Safety: Protect Providers From Monkeypox Exposure

Monkeypox continues to pose a threat since an outbreak of cases began in the U.S. earlier this year. As of Sept. 29, the CDC reported 26,631 confirmed cases with California (4,886), New York (3,914) and Florida (2,520) reporting the highest number of infections. On Aug. 4, U.S. Department of Health and Human Services Secretary Xavier Becerra announced that the ongoing spread of the monkeypox virus in the United States is a public health emergency. Last month, Rochelle Walensky, MD, MPH, director of the CDC, said the virus continues to rapidly spread in certain pockets of the country, but overall infection rates appeared to be slowing. The latest information about monkeypox cases and distribution in the U.S. can be found on the CDC’s website. 

Monkeypox often begins with initial symptoms that can include fever, headache, myalgia, back pain, upper respiratory congestion, cough and lymphadenopathy. Following these initial symptoms, a skin rash typically develops within five days and develops into lesions, which are considered contagious until completely healed, a process that may require two to four weeks after the initial appearance of the rash.

The monkeypox virus is mainly transmitted through direct contact with the skin lesions; but transmission may also occur following contact with infected bodily fluids or by touching clothing, bed linens or other objects or surfaces contacted by someone with the disease. Importantly for surgical professionals, spread can also occur through exposure to aerosolized droplets and small liquid particles expelled by infected individuals.

The American Society of Anesthesiologists (ASA) and the American Patient Safety Foundation (APSF) support the CDC’s following recommendations for protecting healthcare providers from exposure to monkeypox: 

• Wear proper PPE. Surgical professionals should wear gloves, a well-fitting N95 mask, full eye protection and a gown when in the same room as a patient known to be infected or suspected of infection. The goal is to minimize potential exposure of the skin, mucosa and eyes to expelled liquid particles. These measures are especially important during aerosolizing procedures. The ASA and APSF say the spread of monkeypox by aerosolized liquid respiratory particles is less likely as compared to COVID-19, but can still occur. 

Infectious liquid particles might become aerosolized when providers perform laryngoscopy, intubation, extubation, bronchoscopy and an upper gastrointestinal endoscopy using a laryngeal mask. Aerosolized particles travel in air currents and can bypass poorly fitted masks or masks that do not block fine liquid particles. A well-fitted N95 mask will provide the most protection.

• Isolate infected individuals. Patients with monkeypox should be placed in negative pressure rooms during aerosolizing procedures, including intubation, extubation, tracheobronchoscopy or non-invasive airway interventions such as nebulized treatments or initiation of bilevel positive airway pressure. Respiratory particles are removed from negative pressure rooms and do not escape into adjacent areas. The air that is pulled out of negative pressure rooms passes through HEPA filters, clearing it of potentially infectious particles.

• Postpone elective procedures. If possible, delay performing surgery on patients infected with monkeypox. Decisions regarding urgent surgery should be made after consideration of the risks and benefits of moving ahead with the procedure. During emergency surgery, efforts should be made to limit the number of perioperative staff exposed to the patient.

• Consider vaccination. Within a brief period following exposure to monkeypox, vaccination may help prevent or decrease the severity of disease manifestations. Staff members who are exposed to infected patients should immediately consult an infectious disease clinician. The CDC recommends that the antigen vaccine be given as soon as possible post-exposure and at least within four days. It takes time to develop an immune response to the vaccine. If the disease is incubating at the same time, vaccination may prepare the immune system before the infection reaches a more advanced stage and prevent the development of more severe symptoms. If the vaccination is administered between four to 14 days after exposure, it can reduce the symptoms of disease, but might not prevent it.

There may be some crossover protection from the smallpox vaccine, which was widely administered to those born before 1972 in the U.S. The extent of protection 40 or more years after smallpox vaccination is not known.

• Provide support. Give appropriate paid medical leave for healthcare workers who require quarantine or isolation due to monkeypox exposure or infection. If a provider is exposed and gets the disease, they would need to be out on leave until the skin lesions are healed over, which can take four to six weeks. This is a heavy burden for the worker and often hugely problematic for facilities that are already struggling with staff shortages.

The COVID-19 pandemic helped prepare healthcare providers for future infectious threats spread by airborne means. While all providers, and in particular anesthesia professionals, are at a higher risk than the general population of contracting monkeypox, they understand that proper protection and effective practices will help them avoid exposure and continue to safely care for patients. OSM