De-isolation and discharge of mpox-infected patients

Scope

This guidance has been produced by the UK Health Security Agency (UKHSA) to support NHS Trusts in managing the de-isolation and discharge of patients with mpox. Arrangements for individual patients should be considered on a case-by-case basis. This guidance applies to all mpox cases, irrespective of HCID status, and will be updated in due course.

Hospital de-isolation criteria

Clinical criteria

The patient is judged clinically well enough for safe de-isolation as judged by the clinical team managing the patient.

Laboratory criteria

The patient is polymerase chain reaction (PCR) negative on all 3 of the following samples:

• EDTA blood*
• urine
• throat swab

*It is acceptable not to send EDTA blood if no sample was sent previously because the patient was well throughout admission.

Lesion criteria

The following criteria all apply:

• there have been no new lesions for 48 hours
• there are no mucous membrane lesions
• all lesions have crustedscabbed over, all scabs covering the lesions have dropped off, and intacta fresh layer of skin remainshas formed underneath

Discharge from an isolation facility or isolation ward to another hospital ward, a different in-patient facility or a residential facility (including care homes and prisons)

Discharge from an isolation facility or ward to another hospital ward, different inpatient facility or residential facility can only be considered if the de-isolation criteria in the clinical, laboratory and lesion criteria sections above are all met.

If there is any doubt, clinicians should discuss virological testing of persistent lesions with the UKHSA Rare and Imported Pathogens Laboratory (RIPL).

Transfer of patients from an isolation unit in one hospital to an isolation unit in another hospital may be necessary in certain circumstances prior to the patient meeting all of the above criteria. Such arrangements must be made following case-by-case discussion and agreement between specialists at both institutions.

Discharge from hospital to home

Patients meeting the clinical, laboratory and lesion criteria as stated above can be discharged from hospital to home without requirement for ongoing isolation (that is, full de-isolation).

Patients meeting the clinical criteria but not meeting either laboratory or lesion criteria may be discharged from hospital to continue isolation at home where it is safe to do so after assessment by their treating clinician. They must be able to isolate away from any members of their household who are:

• children aged under 12 years
• pregnant women
• immunosuppressed individuals as per green book definition

They must not go to work, school or public areas and should avoid close contact with other people in their household.

For patients with HCIDclade I mpox, the safety of this approach must be discussed and agreed with the HCID network and the health protection team (HPT) on a case-by-case basis, including an agreed plan for monitoring clinical progress and criteria for deisolation.

Patients with any lesions should remain in regular contact with their clinician until all lesions have crustedscabbed over and all scabs have dropped off. Ongoing contact may be required after de-isolation.

Complex and severe cases, with slow clinical and virological resolution may require additional specialist guidance on risk management following discharge from hospital on a case-by-case basis.

Caring for mpox at home

Patients should be given clear safety-netting guidance, including resources detailing what expected symptoms are and how to treat these. They should also map out what the concerning symptoms to look out for are, and when, where and how to escalate and get help at all time periods. Symptom diaries and strategies for monitoring progress and recovery should also be shared, including where appropriate monitoring tools, for example thermometers, oximeters.

There is guidance available for people diagnosed with non-HCID mpox who have been advised to isolate at home, which includes information on resuming sexual activity.

De-isolation in household settings for clade II (non-HCID) mpox

This guidance relates to patients who have been diagnosed with clade II mpox only, and either managed at home throughout their illness, or who have been discharged from hospital to isolate at home.

There are 2 stages to de-isolation of patients with clade II mpox in household settings.settings: ending self-isolation, and full de-isolation.

When self-isolation ends, patients no longer need to isolate away from other household members (as long as they are not vulnerable at higher risk of severe disease; see below). They should keep any remaining lesions covered when in contact with others. At this stage they can also leave the house, provided they take the precautions listed below.

When the patient meets the full de-isolation criteria, they are able to resume all normal activities with no restrictions.

Patients who have had mpox are advised to follow the advice regarding using a condom during sex for 12 weeks after complete recovery from their infection.

Stage 1: Ending self-isolation

Patients are able to end self-isolation at home once the following lesion criteria have been met.

Lesion criteria

The following criteria must all be met:

• there have been no new lesions for 48 hours
• there are no oral mucous membrane lesions
• all lesions have crustedscabbed over
• all lesions on exposed skin (including the face, arms and hands) have scabbed over, the scabs have dropped off, and a fresh layer of skin has formed underneath

The patient can now leave the house; however any lesions inthat otherthey areashave on normally covered skin should remain covered throughout thetheir patient’s time outside of their home or when they are in contact with other people people.

Patients should continue to avoid close contact with immunosuppressed people, pregnant women, and children aged under 12 years until the criteria for full de-isolation are met (see stage 2 below). This means patients should continue to be excluded from work if their work requires close contact with any of these groups. They should be advised to speak to their employer before returning to work as a risk assessment may be required for people who work in vulnerable settings and consideration given to redeployment or continued exclusion until the criteria for full de-isolation are met.

Stage 2: Full de-isolation

The patient can resume full normal activities with no restrictions when they meet the following lesion criteria:

• there have been no new lesions for 48 hours
• there are no mucous membrane lesions
• all lesions (for both exposed and unexposed areas) have crustedscabbed over, all scabs have dropped off, and intacta fresh layer of skin remainshas formed underneath

De-isolation in household settings for clade I (HCID) mpox

For patients with clade I mpox, there is only one stage to de-isolation.

Patients with confirmed clade I mpox are able to fully de-isolate and resume normal activities with no restrictions when they meet the following criteria:

• there have been no new lesions for 48 hours
• there are no mucous membrane  lesions
• all lesions (for both exposed and unexposed areas) have scabbed over, all scabs have dropped off, and a fresh layer of skin has formed underneath

Patients who have had mpox are advised to follow the advice regarding using a condom during sex for 12 weeks after complete recovery from their infection.