New monkeypox management protocols

The Ministry of Health published the new manual for the management of patients infected with monkeypox, dedicated to healthcare professionals. The new document was prepared by the Presentation on alerts and preparedness and response plans, in collaboration with scientific societies in order to guarantee a diagnosis, treatment and prevention best among patients hospital, outpatient and even includes recommendations for pediatric cases.

Spain is currently one of the most affected countries in the world. The vast majority of autonomous communities have reported cases, although with great differences between them. Therefore, from the ministry, they allege that “the sustained transmission that is currently observed must be controlled to prevent it from moving to other population groups by the same transmission mechanism.

With regard to appropriate measures for the management of experimental or confirmed monkeypox patients, until now there were discrepancies in the protocol to be followed. Now, to avoid a possible airborne transmission they should use FPP2 masksas good as individual protection equipment (PPE) in case of close contact. To obtain clinical samples, they must also use PPE to minimize the possibility of exposure to pathogens.

When it is necessary to transport the patient, this will be done in a conventional ambulance and the personnel involved in the transport must be informed beforehand and must use personal protective equipment.

In the case of medical acts, in particular those which generate aerosols and any other type of procedure on the respiratory tractsuch as tracheal intubation, bronchoalveolar lavage, manual ventilation, require special protective measures, during the procedure they must be minimize the number of people in the room and everyone must use: FFP3 mask, fitted eye protection or full face shield, gloves, long-sleeved gowns and waterproof leggings.

The protocol also calls forhave a list of all staff handling cases. Its evaluation and follow-up will be provided by the Occupational Risk Prevention Service of your health centre.

On the other hand, if necessary transport the patient will be done in a conventional ambulance and the personnel involved in the transport must be informed beforehand and must use individual protection equipment already named.

During hospitalization, admission should be carried out in rooms with negative pressure. Otherwise, in a single room with bathroom included and good air conditioning

In addition, contaminated surfaces and objects must be cleaned and disinfected with hospital grade disinfectant when it comes to this area or with sodium hypochlorite (bleach) for household use at a concentration of 0.1%.

During hospitalizationthe entry must be made in negative pressure rooms. Otherwise, in a single bedroom with bathroom included and good air conditioning and isolation should be maintained until all lesions have disappeared.

Regarding the collection of samples, “there must be no other patient in the room and essential personnel must be available. In addition, it is recommended to study Specific PCR for Monkeypox suspicious lesions to confirm the diagnosis. Likewise, they assure that the best option to obtain a correct diagnosis is collect samples from more than one lesion (skin lesions or in other mucosal localizations).

Regarding the collection of samples, “there must be no other patient in the room and there must be the essential staff

It also includes the option of other samples according to the differential diagnosis, through medical criteria taking into account the clinical picture, the characteristics of the lesions and the epidemiology. The protocol specifies the sampling methods according to the type of lesion (vesicular lesions, pustular lesions or ulcerated lesions).

In the case of patients with risky sexual practicesespecially if they have suspicious symptoms of another sexually transmitted infection, they should consider the presence or co-infection of STIs.


The experts devoted an entire chapter to the treatments which should be used in case of monkeypox. Of course, this ensures that each drug must be adapted to the individual characteristics of each patient. To treat fever, it is recommended to take Paracetamol; while for pain this drug is also recommended, Ibuprofen or Tramadol. To treat the itch (itchy skin), you must take loratadine. For those who feel anxietythe Lorazepam is the recommended option.

The manual also considers the option of use specific antiviral treatmentsspecially in hospitalized or at-risk patients, although “specific antiviral treatments have limited availability, limited clinical experience and, in some cases, non-guideline indications and with a risk of specific adverse effects”. Therefore, they establish treatment priorities in the following cases:

  • Pneumonia, encephalitis or meningoencephalitis. Corneal ulcers or other ocular lesions with a risk of permanent sequelae affecting vision. Pharyngeal lesions preventing the swallowing of liquids and/or showing total or partial impairment of the respiratory tract.
  • severe proctitis. Severe cellulite or with risk of permanent sequelae. Also for immunocompromised patients with persistent fever or disseminated disease with generalized involvement.
  • All other patients infected with monkeypox who have no contraindication.

In this context, antivirals such as Tecovirimat as the first optionas long as there is stock available; Brincidofovir, Cidofivir and Immunoglobulin smallpoxalthough the latter has very limited availability worldwide, has no approved indication and its in vivo efficacy is unknown. Therefore, its emergency administration may be considered in first-priority severe cases that do not respond to treatment.

On the other hand, they also devote a section to the treatment of skin diseases. For example, they recommend cut nails to avoid scratches and the use of topical antiseptic. For ulcerated genital lesions, it is recommended sitz baths with warm salt water and for oral lesions the use of a antiseptic mouthwash and mouthwashes with 1% lidocaine.

Antivirals such as Tecovirimat should be used as a first option, as long as supplies are available; Brincidofovir, Cidofivir and smallpox immunoglobulin, although the latter has very limited availability worldwide

For the eye conditionsAlthough “previous studies suggest that corneal infection may be a relatively infrequent complication of monkyle pox,” he explains, topical and oral antibiotics they have been used as a treatment against bacterial superinfection of the conjunctiva or cornea.

In the case of inflammation of the rectal mucosathe treatment will be symptomatic onsetwith the contribution of oral anti-inflammatories, topical or systemic corticosteroidstopical or oral antibiotics for bacterial superinfection of perianal lesions and topical solution containing zinc sulphates and copper for perianal skin lesions.


In these protocols, an entire section is devoted to the situation of kids infected with this infection. It is true that the cases of monkeypox in children is less commonbut the Ministry of Health has put in place new measures for the treatment of minors.

There are no contraindications for children to the Imvanex vaccine, as long as there are sufficient doses to administer to all close contacts.

The first, experts recommend hospitalize immunocompromised children and with severe symptoms of vomiting, gastrointestinal intolerance, dehydration, neck pain due to extensive lymphadenopathy, dysphagia, suspected bacterial superinfection, respiratory distress, pneumonia, elevated transaminases, thrombocytopenia or significant decline. They will also be entered newborns or infants under 3 months old.

Second, the document advise against breastfeeding in case of contagion by the mother, since it is not known if the transmission can be rebroadcast in this way.

Despite this, he pointed out that, for the moment, there are no contraindications for children imvanex vaccinealways and when there are sufficient doses to administer to all close contacts.

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