Smallpox of monkeys, quarantines possible: the circular

Cases rise in Italy: the Ministry of Health updates information on case management, close contacts and tests

The cases of monkeypox in Italy are increasing and the Ministry of Health has launched a new circular with which information on case management, close contacts and tests has been updated (READ).

Monkeypox, it reads, can be transmitted to anyone, regardless of sexual orientation or gender identity, through contact with body fluids, contact with lesions or shared objects.

What to do if you are positive for monkeypox

Cases should be isolated until the scabs of the rash fall, which indicates the end of the infection.

In the presence of signs and symptoms that do not require hospitalization, the confirmed case – if the housing and sanitation conditions allow it – can be followed at home according to the procedures defined locally, in isolation even with respect to cohabitants and any other carers. The subject must be informed about compliance with all hygiene-behavioral measures to be implemented in order to prevent the spread of the disease to other people. A case of MPX must be monitored daily by the territorially competent Prevention Department (via telephone calls).

Cases must:

– remain in isolation in a dedicated room when I am at home;

– use dedicated household items (clothes, sheets, towels, eating utensils,

plates, glasses), which should not be shared with other family members;

– avoid contact with immunocompromised people until the rash heals


– avoid close or intimate contacts (hugs, kisses, prolonged face-to-face contacts in closed spaces)

with other people until the rash has completely healed;

– provide for thorough hand and respiratory hygiene (for the case and for all members of the


– use a surgical mask in case of contact with other people;

– abstain from sexual activity until the scabs fall off. Cases should be aware that condom use alone cannot provide complete protection against MPXV infection, as contact with skin lesions is required for its transmission;

– leave your home only temporarily (to go to medical examinations and to carry out physical exercise necessary for your mental stability), provided that you are wearing a surgical mask and that the rash is covered (clothes with sleeves and long pants) ;

– avoid contact with any pet mammal, in particular with pet rodents and lagomorphs (mice, rats, hamsters, gerbils, guinea pigs, squirrels, rabbits, etc.). Any recent contact with these pets should be recorded and reported to the veterinary authorities in order to ensure the possibility of quarantining and testing animals with symptoms potentially referable to MPX (fever, lack of appetite, cough, nasal discharge or scabs, conjunctivitis, rashes such as pustules and blisters, particularly on the ears and around the lips.

For the management of urban (domestic) waste of monkeypox sick people it is recommended to stop separate collection, regardless of their nature (glass, metal, organic waste, plastic, paper, etc.), with the foresight to pack them in so as not to damage and / or contaminate the bags externally (for example by using disposable gloves).

In the presence of sharp or pointed objects or in any case capable of causing tearing of the casing (glass or metal objects or fragments), it is recommended to carry them out with particular care (e.g. by wrapping them in paper) to avoid producing tearing of the bags with consequent risk of their contents spilling.

It is also advisable to collect all personal waste (such as used handkerchiefs, bandages / gauze that has come into contact with body fluids or skin lesions) and disposable cloths used for cleaning and place them in a separate and closed bag, before being introduced into the bag. of unsorted waste. Finally, at least two bags must be used one inside the other or in a greater number depending on their mechanical resistance. This choice is indicated to limit as much as possible errors in the collection and delivery of waste to safeguard the safety in the home and the health of the ecological operators in charge of waste collection.

Contact tracking

Contact tracing allows the rapid identification of new cases, to stop the transmission of the virus and to contain the epidemic. It also allows for early identification and management of any contacts at a higher risk of developing a serious disease. Different contexts need to be considered when seeking contacts, including family, workplace, school / daycare, sexual contacts, health care, transportation, sports, social gatherings, and any other interactions mentioned. The attendance lists, passenger lists, etc. they can be further used to identify contacts.

Contact tracing should begin as soon as possible after confirming a case of MPX. If laboratory confirmation does not occur promptly, contact tracing should also be considered for probable cases of MPX.

The contagiousness of MPX is mainly linked to the presence of the rash, even if the lesions are few; however, patients with prodromal symptoms (such as fever, myalgia, fatigue and headache) can also transmit the virus. Currently, no available evidence suggests the existence of pre-symptomatic transmission of MPXV. Therefore, in the search for close contacts, individuals who have been exposed to the case in the interval between onset of symptoms and healing / resolution of the rash should be considered.

Therefore, the infectious period must be considered starting from the appearance of prodromal symptoms until the crusting of all lesions and the formation of new skin. If no prodromal symptoms are reported, as is often the case in this outbreak, it can be considered as the start of the infectious period of MPX one day before the onset of the rash

If backward tracing of sexual contacts is also done to identify the index case or site of infection, the reference period should cover 21 days prior to the onset of symptoms.

Close contacts

Close contacts should be identified as early as possible and informed of their exposure and the risk of developing infection. They should also be educated on the symptoms of MPX and when the symptoms may appear.

For close contacts it is recommended:

– self-monitoring of fever (at least twice a day) or other symptoms attributable to MPX (headache, back pain, lymphadenopathy, etc.) or skin rash of unknown cause within 21 days of the last exposure. In this case, promptly inform the Prevention Department and the attending physician, self-isolate and avoid close contacts including sexual activity up to the exclusion of MPX;

– refrain from sexual activities for 21 days after the last exposure or until MPX is excluded;

– practice careful hand and respiratory hygiene (cover mouth and nose when sneezing or coughing, with disposable handkerchiefs to be disposed of correctly and wash your hands often);

– avoid contact with immunocompromised people, children under 12 and pregnant women for 21 days after the last exposure;

– avoid close direct contact with animals, including pets, for 21 days after the last exposure;

– Asymptomatic contacts who adequately and regularly monitor their status can continue routine daily activities such as going to work and attending school (quarantine is not necessary). Local health authorities can choose to exclude preschool children from daycare, preschool or other group settings.

In specific environmental and epidemiological contexts, based on the assessments of the health authorities, the application of quarantine measures may be required.

Low risk contacts

Health authorities can work with event organizers, companies or other venues to provide all attendees with information on potential exposure and guidance as needed. For contacts with low-risk exposures it is possible to adopt passive surveillance, self-check and inform your family doctor and / or local health authorities if symptoms compatible with MPX occur.

For low-risk contacts it is recommended to provide the following information:

– practice careful hand and respiratory hygiene;

– self-monitor MPX-compatible symptoms (fever, rash, lymphadenopathy) for 21 days after exposure; and – call their doctor and / or local health services if they develop symptoms (passive surveillance).

Vaccine therapy and prophylaxis

The adoption of medical-pharmacological countermeasures, including specific antivirals (Tecovirimat authorized by EMA – European Medicines Agency) can be considered in the context of experimental or compassionate use protocols, in particular for those who have severe symptoms or who may be at risk of poor results, such as immunosuppressed people.

Vaccines currently available against smallpox virus may also guarantee some efficacy against monkeypox disease, although data to support this hypothesis are currently still limited. For this reason, the World Health Organization (WHO) has issued interim recommendations regarding their use in the current epidemic context.

According to the WHO: Mass vaccination for monkeypox is currently neither required nor recommended; for case contacts, post-exposure prophylaxis (PEP) with an appropriate second or third generation vaccine is recommended, ideally within four days of first exposure to prevent disease onset; Pre-exposure prophylaxis (PrEP) is recommended for health care workers at risk, laboratory staff handling orthopoxvirus, and those performing diagnostic tests for monkeypox.

Most of the recommendations provided by the WHO relate to off-label use of vaccines. The only smallpox vaccine authorized in the EU by EMA is the modified Ankara live vaccine virus – Bavarian Nordic (MVA-BN), called IMVANEX (Bavarian Nordic A / S) 21.