Screening
Management of asymptomatic contacts
Monitor asymptomatic contacts of confirmed cases for symptoms after their last exposure to the case. Guidelines for contact monitoring may vary between regions. Guidelines from the World Health Organization (WHO), the UK Health Security Agency (UKHSA), and the Centers for Disease Control and Prevention (CDC) are presented here. Consult your local public health authority for the most current guidance.
World Health Organization (WHO)
The WHO defines a contact as a person who has been exposed to a suspected, probably, or confirmed case during the infectious period (i.e., the period beginning with the onset of the index case’s first symptoms, or if relevant up to 2 days before the onset, and ending when their skin lesions have crusted, the scabs have fallen off, and a fresh layer of skin has formed underneath) and has had one or more of the following exposures (including health workers potentially exposed in the absence of proper use of appropriate protective personal equipment [PPE]):[90]
Direct contact: direct skin-to-skin and skin-to-mucosal or mouth-to-mucosal physical contact (e.g., touching, hugging, kissing, intimate oral or other sexual contact).
Indirect contact: contact with items contaminated by the case (e.g., clothing or bedding, handling contaminated materials such as laundry, cleaning rooms).
Nonphysical contact: close and prolonged conversation with a symptomatic case, especially if they have visible mpox ulcers.
Mother-to-child contact: transmission can occur during pregnancy through the placenta or during delivery.
The WHO offers the following recommendations for asymptomatic contacts.[90]
Monitor asymptomatic contacts daily for the onset of signs and symptoms for a period of 21 days from the last contact with a case or their contaminated materials (or up to 2 days before the onset of symptoms if feasible and appropriate). Contacts can be monitored passively (i.e., self monitoring), actively, or directly, depending on available resources. Contacts should monitor their temperature twice daily, irrespective of symptoms.
A contact who develops prodromal symptoms or lymphadenopathy should be isolated and closely examined as a suspected case for signs of a rash. The patient should be tested (oropharyngeal, anal/rectal swabs may be done if no skin/mucosal lesions). If the test is negative, the contact should continue to monitor for the signs of rash for the next 5 days. If no rash develops, the contact may return to temperature monitoring for the remainder of the 21 days. If the contact develops skin or mucosal lesions, they must be isolated and evaluated as a probable case. A specimen from the lesions should be collected for laboratory analysis.
Asymptomatic contacts that adequately and regularly monitor their status can continue routine daily activities (e.g., going to work, attending school) and no quarantine is necessary. Contacts should regularly practice hand hygiene and respiratory etiquette, and avoid sexual contact with others for 21 days.
Asymptomatic contacts should not donate blood, cells, tissue, organs, breast milk, or semen while they are under symptom surveillance.
Asymptomatic contacts should try to avoid or minimize physical contact with children, pregnant women, immunocompromised people, and animals (including pets).
Health workers with an occupational exposure should notify infection control, occupational health, and public health authorities to receive an assessment and management plan of the potential infection. Health workers who have unprotected exposure (i.e., not wearing appropriate PPE or a breach of PPE) to patients (or possibly contaminated materials) do not need to be excluded from work if they are asymptomatic, but should undergo active surveillance for symptoms for 21 days and not work with vulnerable patients during this period. Follow local and national infection control guidance.
Nonessential travel should be avoided until the case is determined to no longer constitute a public health risk to others.
For more detailed information, see the following guidance:
UK Health Security Agency (UKHSA)
The UKHSA recommends categorizing contacts of confirmed cases of mpox, irrespective of clade, based on their exposure risk.[269]
High risk (category 3): unprotected direct contact or high-risk environmental contact. The following public health advice is recommended for this group:
Passive monitoring
Self-isolation is not required
Avoid contact with other people within their household
Avoid sexual or intimate contact and other activities involving skin-to-skin contact for 21 days from last exposure
Avoid contact with immunosuppressed people, pregnant women, or children ages <5 years for 21 days from last exposure
Consider redeployment or exclusion from work for 21 days following a risk assessment if work involves direct contact with immunosuppressed people, pregnant women, or children ages <5 years
Children ages <5 years should be excluded from all settings attended by other children ages <5 years for 21 days from last exposure; children ages ≥5 years may not require exclusion from an educational setting depending on risk assessment
International travel is not advisable for 21 days after last exposure
Postexposure vaccination is recommended as soon as possible after exposure and within 4 days from first exposure (up to 14 days in those at higher risk of severe infection)
Medium risk (category 2): unprotected exposure to infectious materials including droplet or airborne potential route. The following public health advice is recommended for this group:
Passive monitoring
Self-isolation is not required
Avoid sexual or intimate contact and other activities involving skin-to-skin contact for 21 days from last exposure
Avoid contact with immunosuppressed people, pregnant women, or children ages <5 years, where possible, for 21 days from last exposure
A risk assessment is recommended to consider the implications for the contact’s work, which may include redeployment or exclusion
Children do not routinely require exclusion from an educational setting
International travel is not advisable for 21 days after last exposure
Postexposure vaccination is not routinely recommended but may be considered if there is a high concern about respiratory transmission, or if the contact is at higher risk of serious infection (e.g., immunosuppressed people, pregnant women, children ages <5 years)
Low risk (category 1): protected physical or droplet exposure, or no physical contact or unlikely droplet exposure.
There are no public health recommendations for this group. Can continue with routine activities and travel as long as asymptomatic. Follow-up and postexposure vaccination is not required.
For more detailed information, see the following guidance:
Centers for Disease Control and Prevention (CDC)
The CDC recommends categorizing contacts based on their exposure risk.[270]
High risk of exposure: require monitoring for signs and symptoms for 21 days after last exposure. Postexposure vaccination is recommended.
Intermediate risk of exposure: require monitoring for signs and symptoms for 21 days after last exposure. Postexposure vaccination may be considered on an individual basis if the benefits outweigh the risks (no additional doses are required if the person previously received all recommended doses of mpox vaccine).
Uncertain to minimal risk of exposure: require monitoring for signs and symptoms for 21 days after last exposure at discretion of facility and public health authority. Postexposure vaccination is not recommended.
No identifiable risk of exposure: no monitoring or postexposure vaccination is recommended.
Contacts who remain asymptomatic do not need to be isolated but should be monitored, at least daily, for 21 days after last exposure. Monitoring includes assessing the patient for signs and symptoms of mpox and should include a thorough skin exam. If any new symptom develops during the 21-day monitoring period, patients should be placed on empiric isolation precautions and contact their healthcare provider for further assessment.[270]
If a rash develops: empiric isolation precautions are recommended until the rash is evaluated, testing is performed (if indicated), and the result is negative.
If other symptoms develop but there is no rash: empiric isolation precautions are recommended for 5 days after the development of any new symptom (even if the 5-day period extends beyond the original 21-day monitoring period). Isolation precautions can be discontinued if no further symptoms develop in the 5-day period and there are no new rashes or lesions. Isolation precautions can be discontinued prior to 5 days if mpox is ruled out. If new symptoms develop again at any point during the 21-day monitoring period, the patient should be placed on empiric isolation precautions again and a new 5-day isolation period should begin.
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