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EMS Response to the Current Outbreak of Mpox 

Update 8/19/22

The guidelines on managing mpox contaminated waste have changed since this post was first published. The recommendations have been updated to reflect requirements for the clade (or variant) currently in circulation. Clade II (previously called West African clade) waste can be managed as regulated medical waste. See the section on infection prevention and waste management below for more information.

Mpox is a rare, pox-like viral disease found mainly in Central and Western Africa. In the past several years, cases of Mpox have been detected outside of Africa, typically linked to international travel or imported animals. On May 18, the Massachusetts Department of Public Health (DPH) confirmed a single case of mpox virus infection in an adult male with recent travel to Canada. The CDC has been tracking the U.S. case as well as multiple clusters of mpox reported in several countries that typically do not see mpox cases including Portugal, Spain, Sweden, Italy, and the United Kingdom (CDC, https://www.cdc.gov/media/releases/2022/s0518-monkeypox-case.html, Accessed 2022). 

EMS Strategies for Preventing the Spread of Mpox 

• Given the actions of the public health authorities, it is very unlikely that EMS clinicians will encounter a person infected with mpox during routine operations. However, EMS professionals should follow an identify, isolate, and inform strategy, as outlined in NETEC’s webinar The I’s Have It: Identify, Isolate, and Inform to stop the spread of illness. 
• Find additional resources on clinical care and infection control related to mpox.  
• If you suspect a case of mpox, contact your state health department (CDC, https://www.cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html, Accessed 5/19/2022) for possible initiation of special pathogen transport protocols.

Identifying the Signs, Symptoms, and Risk Factors for Mpox 

• The signs and symptoms of mpox include flu-like symptoms (fever, headache, muscle aches) and swollen lymph nodes. Learn more about the signs and symptoms of mpox. 
• 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. 
• An individual who has recently traveled to a country where mpox is endemic, including Central and Western African countries such as Nigeria or the Democratic Republic of Congo, parts of Europe where mpox has been reported, other areas reporting mpox, cases or had close contact with a person sick with mpox in the last 5-21 days. 

How to Prevent Person-to-Person Transmission of Mpox 

• A patient is considered infectious 5 days prior to rash onset until crusting of skin lesions. 
• Person-to-person transmission occurs through exposure to large respiratory droplets, which can be projected as far as 6 feet. It can also be transmitted by way of exposure to mucous membranes (eyes, nose, mouth), direct contact with body fluids or lesions, and indirect contact with lesions, such as through contaminated clothing or linens.  

PPE for EMS Personnel Managing Patients Suspected of Infection with Mpox 

• To guard against the possibility of airborne transmission, EMS personnel should strictly adhere to standard, contact, and airborne precautions. This includes a NIOSH-approved, fit-tested N-95 respirator, gown, gloves, and eye protection with face shield or goggles. 

Implementing a Hierarchy of Controls in EMS Care 

• 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. See NETEC’s guide on the role of the trained observer. 
• Exercise caution when performing aerosol-generating 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. 

Infection Prevention and Waste Management When Caring for a Patient with Mpox 

• Apply a surgical mask to the patient if tolerated and consider covering the patient with an impervious sheet if rash is present. 
• 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 in the “Special Respiratory Precautions” section. 
• Mpox contaminated waste management practices can differ depending on the strain of mpox virus. Clade II (previously referred to as the West African clade) of mpox viruses can be managed as regulated medical waste. See the Department of Transportation website for more information (page 94). Facilities should also comply with state and local regulations (Hercenter, Accessed 2025, https://www.hercenter.org/rmw/rmwlocator.php) for handling, storage, treatment, and disposal of waste. (CDC, Accessed 2022, https://www.cdc.gov/monkeypox/hcp/infection-control/healthcare-settings.html)
• View the CDC’s Guide, “Managing Solid Waste Contaminated with a Category A Infectious Substance,” to learn more. 

Have a question about infection control and management, how to effectively use your PPE, or waste management for an mpox case? Get an answer from a NETEC expert: send us your question today! 

Informing Health Care Personnel and Public Health Authorities of a Suspected Case of Mpox 

• If you suspect a case of mpox, contact your state health department (CDC, https://www.cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html, Accessed 5/19/2022) for possible initiation of special pathogen transport protocols. 
• Inform other responding personnel if a risk of mpox is suspected and prevent unprotected exposure to the patient. 
• 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. 

Need more help? Get in touch with a NETEC expert today!