EMS Considerations for Mpox: Identify, Isolate, and Inform

Share this article

On July 8-9 a U.S. citizen traveled from Nigeria to Dallas, Texas, via Atlanta, Georgia. On July 13, the patient presented to an emergency department for a rash that had been present since July 7. The patient was diagnosed with mpox and isolated. The Centers for Disease Control and Prevention (CDC) in cooperation with state and local health departments conducted contact tracing to identify over 200 people in 27 states who have had close contact with the patient during travel and after arrival in the United States. Public health authorities are monitoring these close contacts for signs and symptoms of illness. Given the actions of the public health authorities, it is extremely unlikely that EMS clinicians will encounter a person infected with mpox during routine operations; however, it is still advisable at this time for the EMS community to consider a diagnosis of mpox in people who present with a febrile prodrome followed by rash and who may have risk of exposure to the mpox virus.

If EMS personnel suspect a case of mpox, it is advisable to contact the state health department early for possible initiation of special pathogen transport protocols.

NETEC recommends the Identify, Isolate, and Inform strategy for the EMS community.

Identify

• Mpox is a viral illness that is not normally found in the USA, making it extremely unlikely that EMS professionals will encounter a person infected with it during routine operations.
• The signs and symptoms of illness include flu-like symptoms (fever, headache, muscle aches) and swollen lymph nodes. One to three days after the onset of viral symptoms, the patient will develop a rash that becomes vesicular/pustular starting on the face and covering the whole body.
• The person must have traveled to a country that has mpox illness (e.g., Nigeria, Democratic Republic of Congo) and/or otherwise had close contact with a person sick with mpox in the last 5-21 days.

Isolate

• Isolation of the patient is important to prevent transmission of the illness. The mortality for mpox is reported to range from 1-10%. The patient is considered infectious 5 days prior to rash onset until crusting of skin lesions.
• Transmission of the virus is by way of exposure of mucous membranes (eyes, nose, mouth), respiratory tract or non-intact skin by direct or indirect contact with infectious bodily fluids, and/or exposure to respiratory droplets. It is most likely spread from person-to-person by large respiratory droplets (which can be projected e.g., 6 feet). To guard against the possibility of airborne transmission, strict adherence with standard + contact + airborne precautions is recommended for EMS personnel. This includes a NIOSH approved fit-tested N-95 respirator, gown, gloves and eye protection with face shield or goggles.
• Apply a surgical mask to the patient if tolerated and consider covering the patient with an impervious sheet if rash is present.
• Implement a hierarchy of controls:
  • Separate the driver compartment from the patient compartment.
  • Turn the exhaust fan on high in the patient compartment (if so equipped).
  • Adjust air handling to introduce fresh air in both compartments if possible.
  • Driver of ambulance should wear an N-95 respirator if isolation of driver compartment cannot be verified.
  • Limit the number of personnel making patient contact.
  • Use PPE checklists for donning and doffing (ideally with a trained observer).
  • Exercise caution when performing aerosol-producing procedures (e.g., endotracheal intubation, airway suctioning, CPAP/BiPAP, CPR). Only perform these procedures if medically necessary and cannot be postponed.
  • Clean and disinfect all surfaces of the ambulance and equipment with an EPA-registered hospital grade disinfectant. Look for disinfectants with a label claim against vaccinia.
• Mpox contaminated waste must be managed as Category A infectious substances (to determine if this waste may be exempt from category A Infectious Substance Regulations, contact the local public health authorities for further guidance).
• Monitor personnel for signs and symptoms of illness for 21 days after transport if the patient is confirmed to have mpox.
• More guidance can be found in the EMS Infectious Disease Playbook (ASPR, https://asprtracie.hhs.gov/technical-resources/resource/4442/ems-infectious-disease-playbook, Accessed 7/23/21) in the “Special Respiratory Precautions” section.

Inform

• Inform other responding personnel if a risk of mpox is suspected and prevent unprotected exposure to the patient.
• Inform the local and state public health authorities who may initiate special pathogen transport protocols.
• Inform supervisory personnel – some communities may have dedicated transport teams and/or designated facilities for transport and management of patients suspected or confirmed to be infected with special pathogens.
• Inform the receiving facility as soon as possible, that you suspect a patient may be infected with mpox, so that space is made available to properly isolate the patient on arrival (airborne isolation room if available) and that receiving healthcare personnel are in appropriate PPE.