Mpox: background

Mpox is an infectious disease caused by a virus called MPXV. There are 2 main types (called clades) of the virus: clade I MPXV and clade II MPXV. Clade I MPXV may cause more severe disease than clade II MPXV. In the UK, clade I mpox is designated as a high consequence infectious disease (HCID), whereas clade II mpox is not classified as an HCID.

Since May 2022, cases of clade II mpox have been reported in multiple countries that do not have endemic MPXV in animal or human populations, including in the UK. As of 31 October 2024, there have been over 3,900 cases of clade II mpox reported in England since May 2022. Historically, clade I mpox was known to circulate in 5 Central African Region countries. However, in 2024, clade I mpox cases were reported in countries from beyond these 5, and in October 2024, clade I mpox was detected in the UK for the first time.

This guidance is to be used where prisons and places of detention (PPD) healthcare staff suspect or it is confirmed that a prisoner has clade II (non-HCID) mpox. There is separate information available on the case definitions of mpox, including the operational case definition for a clade I (HCID) mpox case.

How mpox spreads

Mpox does not spread easily between people unless there is close contact.

Spread between people may occur through:

• direct contact with rash, skin lesions or scabs (including during sexual contact, kissing, cuddling or other skin-to-skin contact)

• contact with bodily fluids such as saliva, snot or mucus

• contact with clothing or linen (such as bedding or towels) or other objects and surfaces used by someone with mpox

It is possible that mpox may spread between people through close and prolonged face-to-face contact such as talking, breathing, coughing, or sneezing close to one another. However, there is limited evidence to confirm or exclude this as a method of spread at this time. This information will be updated as new evidence is available.

Symptoms of mpox usually appear 5 to 21 days after contact with someone with mpox. Mpox infection usually resolves without treatment, although severe illness can occur. The illness may begin with fever and the symptoms listed on Mpox: background information.

Cases of clade II mpox in the 2022 outbreak were predominantly in gay, bisexual and other men who have sex with men (GBMSM) aged 20 to 59 years.

Clinicians may refer to UKHSA guidance for examples of mpox lesions to aid detection of suspected cases.

Notification of confirmed cases of mpox

The Health Protection (Notification) Regulations 2010 have been amended to include mpox as a notifiable disease in Schedule 1 and mpox virus as a notifiable causative agent in Schedule 2.

The National Health Service (Charges to Overseas Visitors) Regulations 2015 have been amended to include mpox in Schedule 1.

Identifying cases and contacts

Cases or contacts may be identified at reception into PPDs, following presentation within the PPD setting itself or via contact tracing.

Cases or contacts may be concerned about presenting in the PPD setting due to potential stigma. Staff in PPDs settings should be sensitive to the circumstances and be supportive of those concerned.

Reception screening

UK Health Security Agency (UKHSA) health and justice advice is that new receptions into PPDs should be risk assessed for mpox as part of the reception screen.

Suspected, highly probable and confirmed mpox case definitions are available. Highly probable cases are to be treated as confirmed cases.

For new receptions who do not currently have symptoms, it is recommended the following information is recorded in case future symptoms develop:

• do they have any history of travel in the last 21 days (and to where)
• do they think they may have had close contact with a confirmed or possible mpox case

Presentation with symptoms at reception or within the PPD

If a resident presents with symptoms of mpox, healthcare staff should wear appropriate personal protective equipment (PPE) and clinically assess the patient according to mpox diagnostic testing.

Presentation within the PPD setting about concerns of close contact with a case

If an individual presents with concerns they have had contact with an mpox case then healthcare should undertake an initial risk assessment in regards to potential contact informed by the UKHSA contact classification matrix.

Contact tracing

Contact tracing will be undertaken for suspected and confirmed cases. This should be conducted by the health resilience leads (HRL) where available in partnership with healthcare, and this information should be provided to the local UKHSA health protection teams (HPTs).

This should include information on contacts within the infectious period (from date of symptom onset as per case definition) and nature of contact as per current contact risk classification – consider household, visitors (to household or households visited), sexual contacts, community settings (including shops and entertainment venues), healthcare exposures, public transport and so on.

Reporting suspected cases and contacts

When cases and contacts are identified, the local UKHSA HPT should be informed and relevant case and contact management guidance followed.

Testing is advised for suspected cases. Local HPTs should be informed of confirmed, highly probable, or suspected cases as soon as possible. Testing to be confirmed in line with locally agreed pathways.

HPTs are likely to require the following information about cases:

• symptoms (including symptom onset date and symptom progression) and to ask about systemic influenza-like illness symptoms prior to onset of rash to determine infectious period and epidemiological analysis
• full travel history for the 21 days prior to onset of symptoms

Management of cases in the PPD setting

Isolation of cases

If a resident presents with symptoms, healthcare staff should wear appropriate PPE and clinically assess the patient according to the mpox guidance.

Arrangements for individual patients should be considered on a case-by-case basis.

Suspected cases should be isolated in single cell accommodation while HPT advice and further clinical assessment is arranged.

Confirmed and highly probable cases should isolate in a single cell and are able to end isolation once the de-isolation criteria are met.

Isolation within the PPD can be used for clinically well, ambulatory suspected or confirmed cases for whom it is judged safe and clinically appropriate. They should be managed in a single room with separate toilet facilities where possible. If this cannot be arranged, this must be discussed with the HPT. Additional environmental cleaning should minimise the risk of possible transmission via surfaces.

Infection prevention and control (IPC) measures for cases

For ambulatory well suspected or confirmed cases with limited lesions, covering lesions and wearing a face mask reduces the risk of onwards transmission.

If cases need to be transported to hospital, lesions should be covered and a face mask worn. If a possible case has extensive lesions that cannot be readily covered, then ambulance transport will be required.

Infection prevention and control (IPC) requirements for staff including those undertaking escort duties are detailed in the general IPC guidance section.

Management of contacts

Isolation of contacts

See definitions of contacts.

Medium risk (category 2) contacts do not need exclusion or isolation provided they comply with passive monitoring, and should be given advice to avoid sexual or intimate contact and other activities involving skin-to-skin contact for 21 days from last exposure.

High risk (category 3) contacts should comply with passive monitoring, avoid contact with immunosuppressed people, pregnant women, and children under the age of 5 where possible for 21 days from last exposure and be given advice to avoid sexual or intimate contact and other activities involving skin-to-skin contact for the same time period. Following risk assessment, high risk contacts may also be excluded from work for 21 days if work involves skin-to-skin contact with immunosuppressed people or pregnant women and children under the age of 5.

Decisions on contact isolation (including workplace high risk contact) will be advised by the HPT.

IPC measures for contacts

When managing contacts, staff should follow general IPC guidance as outlined below.

Vaccination

Some contacts may be given vaccination as post-exposure prophylaxis; this will be agreed with the HPT. Pre-exposure prophylaxis maybe considered in an outbreak. Information about mpox vaccination is available in the Green Book chapter 29.

IfVaccination must be accessed via out-reach to specific regional sites (which include NHS hospitals and specific sexual health centres). Residents in secure settings must travel to the HPTsite to be vaccinated as there is no provision for transporting or incidentdelivering vaccine elsewhere to the resident.

There are regional leads handling the access pathways for case management teamand advisestreatment thatwho mpoxwill need to liaise with health and justice commissioners if vaccination is required,required. thenHis thisMajesty’s shouldPrison beand deliveredProbation toService residents(HMPPS) ofwill PPDremain settingsresponsible viafor anproviding agreedescort in-reachstaff model.to accompany the resident to the vaccination site.

General IPC guidance

PPE

Staff should receive appropriate training and be competent in the required PPE donning and doffing procedures and hand hygiene. Staff should know their local procedures for reporting any PPE breach or other risk contact with a confirmed or highly probable case so that they can be assessed for follow-up and possible restrictions.

For suspected, highly probable and confirmed clinically well cases managed in residential settings including PPDs, transmission risks should be based on a clinical risk assessment.

For suspected, highly probable and confirmed cases, the minimum PPE is:

• gloves
• fluid-repellent surgical facemask (FRSM) – an FRSM should be replaced with an FFP3 respirator or equivalent if the case has respiratory symptoms, severe disease or extensive vesicular lesions
• apron (the use of long-sleeved single-use disposable gowns should be considered where extensive manual handling, unavoidable skin-to-skin contact or contact with contaminated items such as used bedlinen, is anticipated)
• eye protection, which is required if there is a risk of splash to the face and eyes (for example, when taking diagnostic samples) – a full face visor is advised if the case has respiratory symptoms, severe disease or extensive vesicular lesions

HMPPS escort staff should also follow these PPE guidelines.

In the event of a hospitalised patient requiring ongoing contact escort, PPE may be required for the attending staff and should be risk assessed with support from the HPT and trust IPC team.

Hand hygiene

Hand hygiene is important and should be undertaken by the patient before leaving their room. Staff should follow best practice regarding hand hygiene when removing PPE. Alcohol-based hand sanitiser can be used as an alternative to soap and water for visibly clean, dry hands.

Cleaning and decontamination

Increased cleaning is likely to reduce risk and is recommended. Poxviruses such as MPXV can survive in the environment and on different types of surfaces for up to 56 days depending on the environmental conditions. Evidence on the survival of MPXV itself is limited, but viable MPXV has been detected on household surfaces at least 15 days after contamination of the surface.

While there is limited data on transmission of poxviruses from contaminated objects or materials other than linens such as clothing or bedding, there remains a risk that mpox can be transmitted via this route. Appropriate cleaning and disinfection can help reduce this risk.

All staff who are cleaning and decontaminating in PPD settings should be trained in donning and doffing of PPE, safe disposal of PPE, and in the use of disinfectants as required by COSHH regulations.

Cleaning and decontamination at the end of the isolation period

Once the person is recovered (or left the cell or room) then a final clean should be undertaken while wearing full PPE as outlined below. Cleaning should be carried out in the following order:

1. Clean your hands.
2. Apply PPE. 
3. Collect and dispose of general waste items in the room, including objects such as bandages, paper towels, food packaging, and other common waste items.
4. Remove contaminated clothing and linen from the environment.
5. Clean and disinfect hard surfaces, for example counters, toilets, walls. 
6. Steam clean soft surfaces, for example cushions, cushioned chairs. 
7. Steam clean carpet and wash hard flooring.
8. Remove PPE.
9. Collect waste generated from cleaning (for example, sponges and mops) into impermeable bags, tie securely and dispose of into usual waste stream.
10. Wash your hands.

All objects and waste from cells or shared areas should be disposed of in the general waste stream. Objects and waste from healthcare areas should be disposed of in the category B waste stream.

Personal protective equipment (PPE) for cleaning and decontamination

People cleaning where a confirmed case has spent significant time should wear the PPE listed below to avoid direct contact with contaminated material during the process:

• single pair of disposable gloves
• disposable plastic apron
• FRSM

While wearing PPE, staff should keep their hands away from their faces and the PPE they are wearing. They should change their gloves if they become torn or heavily contaminated.

When taking off (doffing) PPE:

• PPE should be removed in an area where clean equipment cannot inadvertently be contaminated while you are taking it off
• remove your PPE carefully to prevent contaminating yourself – for example, do not touch the outside of your gown, and only touch the ties of your face mask when removing it
• wash your hands with soap and water for at least 20 seconds after cleaning, and make sure to do so immediately after removing gloves

All PPE and disposable materials used for cleaning cells and shared areas should be disposed of in the general waste stream. PPE and disposable materials used in healthcare settings should be disposed of in the Category B waste stream.

Management of contaminated clothing and linen

Contaminated clothing, removable soft furnishings, and linens such as bedding and towels should be collected first before the room is cleaned. These items should not be shaken, sorted or handled in a manner that may disperse infectious particles.

Items that have been in direct contact with the skin of someone with mpox and which are not easily washable in a washing machine, for example duvets, pillows, or blankets, may need to be disposed of. Permission should be obtained from the owner if these are personal or individuals’ items. Contaminated items from cells and communal areas that cannot be washed should be disposed of via the usual waste stream. Contaminated items from healthcare settings should be disposed of in the Category B waste stream.

All other clothing and linen items should be double bagged with an inner soluble alginate bag placed carefully into a polythene bag or impermeable sack before removal from the room. Remove the soluble alginate bag directly into a standard washing machine while wearing PPE. Wash the items with detergent at the highest temperature possible for the material, and set to the longest wash cycle available. Avoid overloading the machine, use plenty of water, and avoid economy cycles.

After all contaminated clothing and linens have been removed, the rooms can be cleaned and disinfected using disposable equipment (for example mops with disposable heads, disposable cleaning wipes).

Cleaning hard surfaces 

It is important to prevent the spread of dust particles that may contain MPXV. To minimise this risk, avoid dry dusting or sweeping, as these actions can release dust into the air. Instead, use wet cleaning methods, such as using disinfectant wipes, sprays, or mopping, which are more effective at containing dust. It is recommended that you do not use vacuum cleaners, as this may disperse dust particles around the environment.

Clean hard surfaces by using detergent, followed by disinfection with a solution of freshly prepared bleach or sodium hypochlorite diluted to 1,000 ppm (0.1%) available chlorine. When using bleach:

• take care to prepare the correct concentration
• it is recommended that the bleach has one minute contact time with the surface being disinfected
• follow the manufacturer’s instructions and do not mix cleaning products
• be aware that bleach may trigger asthma in poorly ventilated spaces
• make sure you comply with the safety data sheets and COSHH regulations
• be aware that bleach may damage some surfaces

Make sure you thoroughly clean frequently touched surfaces like tables, door handles, toilet flush handles and taps.

Cleaning soft surfaces

Soft furnishings, such as carpets, sofas, curtains, mattresses, and vehicle interiors, should be professionally steam cleaned by individuals wearing full PPE as described above; this may need to be carried out professionally. Steam cleaners then need to be disinfected after use following the manufacturer’s instructions.

If an item has been heavily contaminated with body fluids, it may need to be disposed of and replaced. The need for this should be discussed with the owner, and permission obtained prior to disposal.

Waste disposal 

Cleaning equipment and non-reusable equipment in the rooms used by a confirmed HCID mpox case that cannot be cleaned may need to be disposed into the normal waste stream. Equipment used in healthcare areas should be disposed of in the category B waste stream. This also applies to any other waste generated that has not been previously mentioned. Advice can be sought from the local waste contractor, a Dangerous Goods Safety Adviser, or in Health Technical Memorandum 07:01 ‘Safe Management of Healthcare Waste’.

Hand hygiene

Staff undertaking cleaning should wash their hands with soap and water for at least 20 seconds after cleaning, and make sure to do so immediately after removing gloves. Alcohol-based hand sanitiser containing at least 60% alcohol can be used to clean hands that are visibly clean. If hands are visibly dirty they should be washed with soap and water before using hand sanitiser.

More information on hand hygiene can be found on the NHS How to wash your hands page. 

Cleaning communal areas 

If the individual had spent any time in communal areas such as wing landings, gyms or visiting areas these may need to be cleaned. The decision on which communal areas require cleaning should be informed by a risk assessment with the local HPT, considering factors such as the clinical condition of the case (for example, the severity of rash), patient timelines including when they first felt unwell or when a rash developed, type of exposure, and other relevant factors.

For areas where the case has spent limited time, appropriate PPE for cleaning includes a FRSM, eye protection, disposable gloves and long sleeve gown. Pay particular attention to frequently touched surfaces such as tables, door handles, toilet flush handles and taps.

Reducing contact with clinically vulnerable people

Where possible, pregnant women and severely immunosuppressed individuals (as outlined in the Green Book) should not assess or care for individuals with suspected or confirmed mpox. This will be reassessed as evidence emerges.