Monkeypox: guidelines for health professionals

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With the rapid spread between countries and the first confirmations in Brazil, cases of monkeypox (monkey pox) have become a major global public health concern. If previously limited to some African countries, the virus infection currently has epidemic and even pandemic potential.

In addition to the lack of epidemiological link in many cases, the atypicality of skin lesions has been drawing attention, with cases presenting as unique lesions of genital and perianal location, making their diagnosis difficult.

In this scenario, it is important that health professionals who may come into contact with these patients know not only to recognize a suspected case, but also the control and protection measures recommended.

Read too: Monkeypox: what do we need to know about monkeypox?

monkeypox (monkey pox)

Transmission Forms

monkeypox is considered a viral zoonosis. Although initially described in monkeys (hence the name “monkey pox”), other animals are probably more important as reservoirs in maintaining the circulation of the virus in nature.

Among humans, transmission occurs by direct close contact with respiratory secretions and skin lesions of people with the disease in the active phase or with contact with contaminated surfaces. Transmission by contact is considered to be the main form and can last for the entire duration of the disease.

Unlike other viral infections with a cutaneous manifestation, such as chickenpox or shingles, the transmission period ends only when all the scabs disappear. Respiratory transmission is by droplet and associated with prolonged contact.

suspicious case

The current definition of a suspected case is as follows:

– An individual of any age who, as of March 15, 2022, has a sudden onset of an acute rash suggestive of monkeypoxsingle or multiple, in any part of the body (including genital region), whether or not associated with adenomegaly or fever.

AND

– History of travel to an endemic country or with confirmed cases of monkeypox in the 21 days prior to the onset of symptoms.

OR

– Have an epidemiological link with people with a history of travel to an endemic country or country with confirmed cases of monkeypoxsince March 15, 2022, in the 21 days prior to the onset of signs and symptoms.

OR

– Have an epidemiological link with suspected, probable or confirmed cases of monkeypoxsince March 15, 2022, in the 21 days prior to the onset of signs and symptoms.

OR

– History of intimate contact with a stranger and/or casual partner(s) in the last 21 days prior to the onset of signs and symptoms.

They are considered to be skin rashes suggestive of monkeypox: deep and well-circumscribed lesions, often with central umbilication; and progression of the lesion through sequential stages (macules, papules, vesicles, pustules and crusts).

For epidemiological link, close and prolonged exposure without respiratory protection is considered; direct physical contact, including sexual contact, even with condom use; or contact with contaminated materials such as clothing or bedding.

Every case considered suspicious must be notified to the health authorities, within 24 hours, as established by the Ministry of Health. The notification form is available at: https://www.gov.br/saude/pt-br/composicao/svs/resposta-a-emergencias/sala-de-situacao-de-saude/sala-de-situacao- de-monkeypox/case-notification

Differential diagnoses

The main differential diagnoses to consider include varicella, shingles, measles, bacterial skin infections, scabies, syphilis, allergic reactions and infections by herpes simplex.

precautionary measures

In the face of a suspected or confirmed case of monkeypox, in addition to universal standard precautionary measures, specific precautionary measures must be instituted. Thus, for the care and provision of care for these patients, contact and respiratory precautions must be respected, with the proper use of PPE and isolation.

Between the recommended measures by Anvisa, are:

– Contact precautions: patient isolation, use of gown and gloves when handling the patient and products and surfaces used by the patient.

– Respiratory precaution by droplets: patient isolation, use of a surgical mask by the professional when entering the bed or isolation area and when providing assistance less than 1m away from the patient.

– Aerosol respiratory precaution: for specific situations, with the potential to generate aerosols (such as intubation or tracheal aspiration, non-invasive mechanical ventilation, cardiopulmonary resuscitation, collection of respiratory samples, among others), the use of a N95/PFF2 mask is recommended or equivalent replacement for the surgical mask. Ideally, these procedures should be performed in properly engineered locations with negative pressure and a HEPA filter. In the absence of this structure, they must be conducted in a well-ventilated single room, with the minimum number of professionals necessary and with closed doors.

Other important measures to remember:

– Use of goggles or face shield when there is a possibility of contact of secretions with the ocular mucosa.

– During transport or when in common areas, the patient must wear a surgical mask.

– As in all situations of health care, attention should be paid to performing hand hygiene with proper technique and at the recommended times.

– Individuals with suspected or confirmed cases and who require hospitalization should preferably be allocated in a single, well-ventilated room, which must remain with the doors closed.

– In the situation where the number of cases exceeds the number of individual rooms available, it is possible to establish cohort areas, taking care to allocate suspected and confirmed cases in different locations, as well as adopting a cohort of professionals.

– For the cohort area, it is necessary to maintain a minimum distance of 1m between beds and minimum movement of people, including restrictions on visits and companions.

– Even within isolation or cohort areas, professionals must change PPE between one patient and another, and the same coat and/or the same pair of gloves should not be used to care for different patients. At each change of PPE, the professional must sanitize their hands. This measure is essential to prevent cross-transmission of other infectious agents.

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# ANVISA. TECHNICAL NOTE GVIMS/GGTES/ANVISA No. 03/2022. GUIDELINES FOR PREVENTION AND CONTROL OF MONKEYPOX IN HEALTH SERVICES. Brasilia, May 31, 2022.

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