Mpox guidance for health protection teams
Version 1.9

What is mpox?

Mpox is a viral zoonotic disease caused by the monkeypox virus (MPXV).

Prior to 2022 cases were identified primarily in countries with endemic mpox in central and west Africa, with sporadic imported cases to the UK and other countries. Numbers of imported cases were very low.

In May 2022, cases of human mpox were reported in multiple countries that have not previously identified MPXV in animal or human populations, including the UK. Most of these cases are from clade II (non-HCID), specifically clade IIb, lineage B.1.

Almost all mpox cases in the UK since May 2022 have been identified in gay, bisexual and men who have sex with men (GBMSM). Most cases in the UK are in men aged 20 to 50.

In August 2024 there was an increase in clade I (HCID) mpox cases within Democratic Republic of Congo (DRC) and neighbouring countries. A Public Health Incident of International Concern (PHEIC) was declared by WHO on 14 August 2024 in relation to this increase.

Mpox clades

Two clades of MPXV have been identified and have now been named by the World Health Organization as:

• clade I (formerly Congo Basin/Central African clade), consisting of two sub-clades
  • clade Ia
  • clade Ib
• clade II (formerly West African clade), consisting of two subclades:
  • clade IIa
  • clade IIb

Details of the HCID status of the two clades is outlined in the UKHSA guidance on HCID status of mpox.

Public health management of the two clades of mpox differ due to the current evidence on differing severity of infection, and the risk of transmission.

Public health management is differentiated in this guidance between clade I (HCID) and clade II (non-HCID).

Latest updates

For the latest epidemiological updates see UKHSA mpox latest updates for the UK.

Clade II (non-HCID)

Requesting  testing

The designated diagnostic laboratories for non-HCID mpox testing are the:

• Edinburgh Specialist Virology Centre (SVC)
• West of Scotland Specialist Virology Centre (WoSSVC) in Glasgow

Getting tested

Testing decisions should be made by infectious disease specialists. Local pathways should be established including the use of regional networks when required.

HPTs should advise non-specialist enquirers of this recommendation and direct them towards the pathway.

HPTs should promptly add all suspected cases to HPZone in anticipation of a test result being sent.

Travelling for testing

As outlined in principles for mpox control in the UK four nations consensus statement, transport from the community to healthcare facilities and back again for non-HCID cases should be organised to minimise contact between cases and new contacts.

Where it can be operationalised by boards, remote assessment of the need for testing, and provision of testing, of suspected cases at home may be undertaken.

Home-testing staff must wear PPE as outlined in ARHAI guidance for the management of mpox cases and waste should be disposed of into a disposable rubbish bag followed by placing into a second disposable bag, tied securely and then disposed of through the case’s usual domestic waste. 

If otherwise well, suspected and confirmed cases may drive themselves (or cycle, walk) to arrive at, and leave, healthcare settings.

They should ensure they have an arranged appointment before travelling and that they have been provided with clear instructions advising where to report to on arrival. 

This will ensure that the appropriate IPC measures can be implemented. 

Due to the theoretical airborne risk associated with those who have respiratory symptoms, where the case has respiratory symptoms (for example, a cough) any travel other than essential travel should be avoided.

Private transport

Where an individual is required to drive or share a private vehicle with a suspected or confirmed case for the purposes of assessment, testing or urgent care:

• the other individual should preferably be an existing close contact of the case (for example, a household member) and not exposing themselves to new risk of transmission – where possible, share the vehicle with the same person each time
• everyone in the car should wear a well-fitting surgical face mask or double-layered face covering while in the car
• all hard surfaces should be wiped down after the journey using a standard detergent or detergent wipes while still wearing the well-fitting surgical face mask or double-layered face covering
• cleaning waste and face masks/coverings should be double bagged and disposed of as usual with domestic waste – perform hand hygiene using soap and water or an alcohol-based hand rub afterwards

Public transport

Where remote/home assessment or testing is not possible and private transport is not available, public transport can be used as a last resort with a preference for private taxis ahead of communal vehicles.

Lesions, if any, should be covered by cloth (for example, scarves or bandages) and a face covering muse be worn.​

Further mitigations to consider include:

• vehicle adaptations (screen or barrier to separate the driver from passenger)
• avoiding physical contact and maximising the distance between people in the vehicle (for example, the passenger sitting diagonally behind the driver)
• avoiding busy periods to minimise time in the vehicle and contacts exposed

Receiving results

Clade II (non-HCID) laboratory test results will be shared using the Electronic Communication of Surveillance in Scotland (ECOSS) and HPZone.

The specialist virology centres will also advise positive and negative results for mpox by telephone or email to the requesting clinician or person indicated on email accompanying the submission form.

It is the responsibility of the clinician caring for the patient to notify the local HPT, whether samples are positive or negative.

See the section on notification for more detail.

Any results enquiries should be sent to:

Updating public health action

On receipt of a positive test result, the local HPT should inform Public Health Scotland and other relevant parties within their health board, including ensuring that the local NHSScotland diagnostic microbiology and virology laboratory who may be testing other samples are aware.

Upon receipt of a result (positive or negative) HPTs should review their public health actions, for example contact tracing and post-exposure prophylaxis.

When negative results are received the case should be update on HPZone to 'discarded'.

Contact tracing and follow up

When to trace

Contact tracing is required for PCR positive (untyped) mpox cases who meet the HCID (clade 1) case definition on the case definitions page.

Post-exposure vaccination should ideally be given to contacts within 4 days of exposure, therefore contact tracing should commence as soon as possible.

For suspected cases, while awaiting PCR results the HPT should risk assess the need to gather all contacts and provide initial advice to the highest risk contacts, based on the most likely result.

Who to trace

Use the mpox HCID (clade I) contact tracing guidance to identify contacts and classify them for follow-up actions. This guidance is available on SHPIR (login required). 

Note that a wider contact definition and different categories of contact apply for HCID (clade I) mpox, compared to non-HCID (clade II) mpox.

Post-exposure prophylaxis

As advised by the mpox HCID (clade I) contact tracing guidance, ideally within 4 days.

Review Green Book (chapter 29) on smallpox and monkeypox for further details on post-exposure vaccination.

There is no current public health application of antivirals as post-exposure prophylaxis for contacts.

Isolation or restriction on activities

Recommendations for isolation and restriction on activities are dependent on the classification of contact, and are detailed in the HCID (clade I) contact tracing matrix.

Passive or active follow-up

Contacts that require active follow up are:

• high risk (category 3)
• medium risk (category 2)

Contacts that should be managed using passive surveillance are:

• low risk (category 1)

Review the mpox HCID (clade I) contact tracing guidance for further detail. This is available on SHPIR (login required).

The contact follow-up period is 21 days from the last exposure to the confirmed case.

For the purposes of calculating follow-up periods, the last day of exposure should be counted as day 0.

In the case of ongoing contact, the start date for follow-up would typically be the same as the date the case began to isolate away from the household contacts.

Where separation between household contacts and the case cannot be achieved to a level that the HPT assesses as sufficient, contacts may be considered as having ongoing exposure and their follow-up period extended accordingly.

Where a suspected HCID (clade I) mpox cases is subsequently reclassified as a non-HCID (clade II) mpox case, the classification of contacts should be reviewed.

Information for contacts

An information sheet should be sent to the contacts as per the contact’s classification.

Download case and contact information sheets for each category from SHPIR (login required).

Exclusion from work

Review the mpox HCID (clade I) contact tracing guidance for further detail. This is available on SHPIR (login required).

Contacts with symptoms

Any contact who develops mpox symptoms, as set out in their contact information sheet, should be advised to:

• phone their designated HPT contact point straight away
• return home to self-isolate, avoiding contact with others when travelling
• be referred for assessment through local clinical pathways

Cases reporting long-distance or international travel

For any suspected mpox cases who meet the HCID (clade I) case definition on the case definitions page:

• with an international travel history during the infectious or incubation period
• who have travelled by aircraft during the infectious period
• who have travelled by public transport on long journeys (over 4 hours)

Inform PHS (PHS.incident007@phs.scot) so a travel contact tracing assessment can be carried out.

The case should be advised their details may be shared for specific purposes only, such as with an airline for risk assessing the flight contacts or with UKHSA for onward sharing with foreign public health authorities for them to make a public health risk assessment.

PHS should also be notified of any cases or contacts with international or offshore exposures to ensure this information can be passed to National Focal Points.

Contact tracing and follow-up

When to trace

Contact tracing and follow-up is required for the contacts of symptomatic confirmed clade II (non-HCID) cases. 

Who to trace

Offer post-exposure vaccination as per the UKHSA mpox non-HCID contact tracing guidance, based on contact classifications in the UKHSA non-HCID mpox contact tracing guidance.

Note that the UKHSA guidance differentiates between 'high-risk' and 'medium-risk' household contacts.

Classification should be considered on a case-by-case basis

Considerations would include:

• level of physical contact between the case and the contact
• sleeping arrangements
• house layout
• shared facilities
• other shared items, such as towels

Post-exposure prophylaxis

As advised by the UKHSA non-HCID mpox contact tracing guidance.

Refer to the vaccination section of this guidance.

There is no current public health application of antivirals as post-exposure prophylaxis for contacts.

Isolation or restriction on activities

As advised by the UKHSA non-HCID mpox contact tracing guidance.

Passive or active follow-up

There is no requirement for active follow-up of contacts of non-HCID mpox cases, these should be managed using passive surveillance.

They should be given a designated HPT contact point to phone if they develop any symptoms.

HPTs are not required to contact these individuals at the end of their monitoring period, but their follow-up end date should be made clear to them.

The contact follow-up period is 21 days from the last exposure to the confirmed case.

For the purposes of calculating follow-up periods, the last day of exposure should be counted as day 0.

In the case of ongoing contact, the start date for follow-up would typically be the same as the date the case began to isolate away from the household contacts.

Where separation between household contacts and the case cannot be achieved to a level that the HPT assesses as sufficient, contacts may be considered as having ongoing exposure and their follow-up period extended accordingly.

Contact Information

An information sheet should be sent to the contacts as per the contact’s classification.

Download case and contact information sheets for each category from SHPIR (login required).

Exclusion from work

Where occupational exposure or exposure of patients in a healthcare setting may have occurred, occupational health and IPCT should be involved as appropriate.

High-risk contacts (category 3) are to stay away from work for the duration of their follow-up period if work involves contact with:

• immunosuppressed people
• pregnant people
• children aged under 5 years (not limited to healthcare workers), for example, nursery staff or midwives

If clinically well to do so, these contacts may continue to work from home or be reassigned to other work duties where contact with vulnerable groups is not required.

Discuss this with occupational health.

All other contacts can continue to work as usual.

Contacts with symptoms

Any contact who develops mpox symptoms, as set out in their contact information sheet, should be advised to:

• phone their designated HPT contact point straight away
• stop working and return home to self-isolate, ideally by private transport
• be referred for assessment through local clinical pathways

Clade I (HCID)

Where it is identified that a community setting has been visited in the infectious period by a suspected mpox case that meets the HCID (clade I) case definition on the case definitions page, HPTs should consider on a case by case basis whether further action to identify and get in touch with additional contacts, or to provide environmental decontamination advice, would be of public health benefit.

A risk assessment should consider the:

• type and duration of contact during the visit
• any contact or exposure of others to lesions
• vulnerabilities of those exposed
• time elapsed since the exposure

PHS should be notified of any planned communication or follow-up with settings or the public.

Clade II (non-HCID)

Setting with lower risk of transmission

Where it is identified that a community setting has been visited in the infectious period by a confirmed case, settings with lower risk of transmission (for example, case attended restaurant, bar or cinema) do not require further action. 

This means:

• no warn and inform
• no routine communication with setting
• no attempt to identify further contacts by discussing with setting

Setting with higher risk of transmission

Where the exposed setting is assessed as having a higher risk of transmission due to skin-to-skin contact, potential contamination with body fluids or enclosed settings (for example, sex-on-premises venues, massage and saunas, health or social care, prisons, homeless shelters) then the HPT should risk assess whether to attempt to identify exposed persons in the setting and whether to involve environmental health or IPC colleagues.

UKHSA provide additional guidance for clade II (non-HCID) mpox:

• prisons and places of detention
• planning events and mass gatherings – this should be reviewed by HPTs in order to support public health management of local events
• cleaning sex-on-premises venues

A risk assessment should consider the:

• type and duration of contact during the visit
• any contact or exposure of others to lesions
• vulnerabilities of those exposed
• time elapsed since the exposure

Clusters of cases

Where clusters of cases are identified around a single setting then HPT should consider additional actions including the potential for a warn and inform exercise.

PHS should be notified.