MpoxNon-HCID (monkeypox):mpox: prisons and places of detention

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 monkeypox virus (MPXV) in animal or human populations, including in the UK.

The symptomsAs of 31 October 2024, there have been over 3,900 cases of clade II mpox beginreported 5in toEngland 21since daysMay (average2022. 6Historically, clade I mpox was known to 16circulate days)in after5 exposure.

TreatmentCentral forAfrican Region countries. However, in 2024, clade I mpox iscases mainlywere supportive.reported Thein illnesscountries from beyond these 5, and in October 2024, clade I mpox was detected in the UK for the first time.

This guidance is usuallyto mildbe used where prisons and mostplaces of thosedetention infected(PPD) willhealthcare recoverstaff withinsuspect or it is confirmed that a fewprisoner weekshas withoutclade treatment.II Further(non-HCID) mpox. There is separate information aboutavailable on the clinicalcase featuresdefinitions of mpox, isincluding available.

Seethe currentoperational case definitionsdefinition for a clade I (HCID) mpox. case.

How mpox spreads

TheMpox virusdoes cannot spread ifeasily between people unless there is close contactcontact.

Spread between people andmay theoccur riskthrough:

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• contact years.with Theseclothing groupsor arelinen being(such advisedas tobedding beor alerttowels) toor anyother unusualobjects rashesand orsurfaces lesionsused onby anysomeone partwith ofmpox

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MPXVclose isto dividedone intoanother. 2However, mainthere geneticis groups,limited Cladeevidence Ito andconfirm Cladeor II,exclude withthis Cladeas IIa beingmethod subdividedof intospread Cladeat IIathis andtime. CladeThis IIb.information Mpoxwill causedbe byupdated Cladeas Inew MPXVevidence is classifiedavailable.

Symptoms asof ampox highusually consequenceappear infectious5 diseaseto (HCID),21 whereasdays Cladeafter IIcontact MPXVwith issomeone notwith classifiedmpox. asMpox aninfection HCID.usually resolves without treatment, although severe illness can occur. The virusillness circulatingmay asbegin partwith offever and the outbreaksymptoms whichlisted startedon Mpox: background information.

Cases of clade II mpox in midthe 2022 belongsoutbreak towere Cladepredominantly IIb.in Thisgay, guidancebisexual coversand casesother thatmen arewho nothave HCIDsex with men (GBMSM) cases.aged There20 isto further59 informationyears.

Clinicians onmay therefer HCIDto UKHSA statusguidance for examples of mpox available.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 prisons and places of detention (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 circumstancecircumstances and be supportive of those concerned.

Reception screening

UK Health and 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.

Possible,Suspected, probable, 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,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)(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 possible and probablesuspected cases. Local UKHSA HPTs should be informed of confirmed, highly probable, probableor andsuspected possible 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,symptoms including(including symptom onset date and symptom progressionprogression) –and to ask about systemic influenza-like illness symptoms prior to onset of rash,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, symptoms, healthcare staff should wear appropriate appropriate PPE and clinically assess the patient according to the mpox guidance.guidance.

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

PossibleSuspected and probable 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 contacts (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. See vaccination guidance. Pre-exposure prophylaxis maybe considered in an outbreakoutbreak. Information about mpox vaccination is available in the Green Book chapter 29.

Vaccination 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 site to be vaccinated as there is no provision for transporting or delivering vaccine elsewhere to the resident.

There are regional leads handling the access pathways for case management and treatment who will need to liaise with health and justice commissioners if vaccination is required. His Majesty’s Prison and Probation Service (HMPPS) will remain responsible for providing escort staff 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 suspectedsuspected, highly probable and confirmed clinically well cases managed in residential settings including PPDs, transmission risks should be based on a clinical risk assessment.

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

• gloves
• fluidfluid-repellent repellent surgical facemask (FRSM) – an FRSM should be replaced with an FFP3 respirator andor eyeequivalent protection if the case presentshas with a lower respiratory tractsymptoms, infectionsevere withdisease aor coughextensive and/orvesicular changes on their chest X-ray indicating lower respiratory tract infectionlesions
• 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 exampleexample, 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, enhanced 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

ItIncreased remainscleaning importantis likely to reduce risk and is recommended. Poxviruses such as MPXV can survive in the riskenvironment and on different types of transmissionsurfaces for up to 56 days depending on surfaces.the Theenvironmental riskconditions. canEvidence beon substantiallythe reducedsurvival byof followingMPXV agreeditself cleaningis methodslimited, basedbut viable MPXV has been detected on standardhousehold cleaningsurfaces andat disinfectionleast using15 chlorine-baseddays products.after contamination of the surface.

IncreasedWhile cleaningthere is likelylimited todata reduceon 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 isdisinfection recommended.can Anyonehelp reduce this risk.

All staff who are cleaning aand contaminateddecontaminating areain PPD settings should wearbe fulltrained in donning and doffing of PPE, consistingsafe disposal of an FRSMPPE, non-sterile disposable gloves, and ain disposablethe apron. Anyuse usedof clothsdisinfectants andas moprequired headsby mustCOSHH beregulations.

Cleaning disposedand ofdecontamination andat shouldthe beend putof intothe wasteisolation bags.

period

Once the person is recovered (or left the cell or room) then a final clean should be undertaken while wearing full full PPE as (FRSM,outlined non-sterilebelow. disposableCleaning gloves,should andbe acarried disposableout plasticin apron). Using the standardfollowing cleaning detergent and disinfection products:order:

1. removeClean allyour disposablehands.
2. Apply itemsPPE. 
3. Collect and dispose of general waste items in the room, including objects such as bandages, paper towels, food packaging, and other common waste bagsitems.
4. bagRemove laundrycontaminated packsclothing and removelinen asfrom describedthe environment.
5. Clean and disinfect hard surfaces, for contaminatedexample laundrycounters, toilets, walls. 
6. Steam clean allsoft hardsurfaces, surfacesfor example cushions, cushioned chairs. 
7. Steam clean carpet and touchwash pointshard includingflooring.
8. Remove walls,PPE.
9. Collect floors,waste chairs,generated bedfrom frame,cleaning mattress(for example, sponges and ensuitemops) facilitiesinto adheringimpermeable tobags, localtie policysecurely and dispose of processinto includingusual colourwaste codingstream.
10. Wash your hands.

All objects and waste from cells or shared areas should be disposed of mopsin the general waste stream. Objects and cloths

• anywaste softfrom furnishingshealthcare areas should be steamdisposed cleanedof orin vacuumed.the Ifcategory usingB awaste vacuum,stream.

  Personal useprotective onlyequipment (PPE) for cleaning and decontamination

  People cleaning where a machineconfirmed withcase HEPAhas filtrationspent –significant fulltime should wear the PPE listed below to beavoid worndirect whencontact emptyingwith vacuumcontaminated intomaterial aduring wastethe bagprocess:

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

  Waste management

  AllWhile wastewearing producedPPE, bystaff suspectedshould keep their hands away from their faces and the PPE they are wearing. They should change their gloves if they become torn or confirmedheavily casescontaminated.

  When whiletaking inoff isolation(doffing) PPE:

  • PPE should be baggedremoved in thean cellarea orwhere room.clean Thisequipment bagcannot shouldinadvertently be placedcontaminated intowhile anotheryou wasteare bagtaking outsideit theoff
  • remove roomyour forPPE transportcarefully to prevent contaminating yourself – for example, do not touch the appropriateoutside wasteof collectionyour bingown, forand usualonly domestictouch wastethe managementties inof accordanceyour face mask when removing it
  • wash your hands with localsoap policy.
    and water for at least 20 seconds after cleaning, and make sure to do so immediately after removing gloves

  UsualAll protectivePPE equipmentand shoulddisposable bematerials wornused byfor peoplecleaning handlingcells waste and handsshared washedareas onshould disposalbe disposed of in the general waste stream. PPE.

  Waste generatedand bydisposable materials used in healthcare settings should be disposed of asin healthcarethe Category B waste accordingstream.

  Management toof thecontaminated Nationalclothing infectionand preventionlinen

  Contaminated clothing, removable soft furnishings, and controllinens manual.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.

  Contaminated linen

  MpoxItems canthat behave spreadbeen viain direct contact with clothingthe orskin linensof (suchsomeone aswith beddingmpox and which are not easily washable in a washing machine, for example duvets, pillows, or towels)blankets, usedmay byneed anto infectedbe persondisposed thereforeof. handlingPermission should be minimised.obtained Linenfrom the owner if these are personal or individuals’ items. Contaminated items from cells and beddingcommunal areas that cannot be washed should be carefullydisposed liftedof andvia rolledthe tousual preventwaste dispersionstream. Contaminated items from healthcare settings should be disposed of infectiousin particlesthe fromCategory lesionsB andwaste bodystream.

  All fluids.other Anyclothing suchand linen items should be double bagged (preferablywith inan ainner water-solublesoluble bag)alginate inbag cellplaced carefully into a polythene bag or room,impermeable ideallysack bybefore removal from the infectedroom. person.Remove Thisthe bagsoluble shouldalginate bebag placeddirectly into a plasticstandard bagwashing outsidemachine while wearing PPE. Wash the cellitems orwith roomdetergent at the highest temperature possible for the material, and transportedset to laundry.

  Wherethe possible,longest wash laundrycycle itemsavailable. separatelyAvoid fromoverloading the restmachine, use plenty of water, and avoid economy cycles.

  After all contaminated clothing and linens have been removed, the residentialrooms accommodation’scan laundrybe cleaned and disinfected using disposable equipment (for example mops with disposable heads, disposable cleaning wipes).

  Cleaning hard surfaces 

  It is important to prevent the normalspread detergent,of followingdust particles that may contain MPXV. To minimise this risk, avoid dry dusting or sweeping, as these actions can release dust into the manufacturer’sair. instructions.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.

  WhereClean hard surfaces by using detergent, followed by disinfection with a residencesolution 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 off-siteone laundryminute facilities,contact eachtime premisewith shouldthe discusssurface being disinfected
  • follow the requirementsmanufacturer’s forinstructions safeand pre-launderingdo storage,not transfermix cleaning products
  • be aware that bleach may trigger asthma in poorly ventilated spaces
  • make sure you comply with the safety data sheets and processingCOSHH ofregulations
  • be contaminatedaware laundry.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

  Ideally,Soft laundryfurnishings, such as carpets, sofas, curtains, mattresses, and vehicle interiors, should be washedprofessionally atsteam temperaturescleaned aboveby 65°Cindividuals andwearing dried.full Usual PPE shouldas described above; this may need to be worncarried byout peopleprofessionally. handlingSteam usedcleaners laundry,then andneed handsto washedbe disinfected after disposinguse offollowing PPE.the manufacturer’s instructions.

  If prisonan staffitem handlehas MPXVbeen heavily contaminated laundry,with theybody fluids, it may need to be disposed of and replaced. The need for this should wearbe fulldiscussed PPEwith –the specificallyowner, anand FRSM,permission non-sterileobtained disposableprior gloves,to disposal.

  Waste disposal 

  Cleaning equipment and non-reusable equipment in the rooms used by a disposableconfirmed apron.HCID Thempox usecase that cannot be cleaned may need to be disposed into the normal waste stream. Equipment used in healthcare areas should be disposed of long-sleevedin single-usethe disposablecategory gownsB 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 worn whereused skinto contactclean hands that are visibly clean. If hands are visibly dirty they should be washed with contaminatedsoap laundryand iswater anticipated.before using hand sanitiser.

  WhereMore laundryinformation ison processedhand offhygiene site,can nobe additionalfound decontaminationon stepsthe areNHS requiredHow forto disinfectedwash linensyour 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 returnedcleaned. forThe re-usedecision providingon which communal areas require cleaning should be informed by a risk assessment with the laundrylocal processorHPT, 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 validatedspent disinfectionlimited processestime, appropriate PPE for cleaning includes a FRSM, eye protection, disposable gloves and long sleeve gown. Pay particular attention to frequently touched surfaces such as parttables, ofdoor theirhandles, BStoilet ENflush 14065handles procedures.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.