Mpox guidance for health protection teams
Version 1.7

Purpose and scope

In scope

This guidance aims to support those working in health protection teams (HPTs) across Scotland in managing mpox cases and contacts.

It covers the public health management of both clade I (high consequence infectious disease [HCID]) and clade II (non-HCID) cases.

This guidance was updated in response to increased clade I (HCID) mpox cases in Central Africa. The HCID aspects of this guidance are aligned with the ongoing incident guidance being maintained by the UK Health Security Agency (UKHSA) and published in their Mpox (monkeypox) guidance.

This guidance does not replace individual expert clinical judgment nor local response arrangements.

It is designed to support the development of those arrangements and assist in that response, while maintaining a reasonable expectation that agreed health protection principles and national policy are supported and implemented to good effect in line with the Public Health etc. (Scotland) Act 2008.

This includes exercising functions in a manner which encourages equal opportunities and in observance of equal opportunities requirements.

Employers should be advised to consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.

Out of scope

The guidance does not cover the clinical management of mpox.

Additional resources

This document should also be considered alongside:

• Public Health Scotland mpox resources and links
• HCID contact tracing matrix and related information sheets on SHPIR (log-in required)
• ongoing outbreak guidance from UKHSA in relation to any clade I (HCID) cases of mpox: UKHSA guidance
• Antimicrobial Resistance and Healthcare Acquired Infections (ARHAI) Scotland mpox IPC advice for healthcare settings – this guidance has been updated in response to the outbreak of clade I mpox
• guidance on the management of public health incidents (MPHI)
• information for the public on NHS inform
• locally agreed pathways for clinical management

The latest version should always be referred to by checking the PHS mpox page for any updates or related guidance.

Guidance production

Guidance on clade I HCID mpox has been developed by PHS based on published evidence in mpox: background information and the emerging evidence published in mpox outbreak: technical briefings. Aligning PHS and UKHSA guidance is intended to ensure a co-ordinated response across the UK.

The clade I aspects of the guidance are likely to be updated frequently.

Guidance for non-HCID mpox is based on the published principles for control of non-HCID mpox in the UK: 4 nations consensus statement 2023 from the UK Health Security Agency (UKHSA) and associated UKHSA mpox guidance.

The non-HCID guidance was produced in collaboration with a provisional guidance development group (GDG). HPTs and other stakeholders contributed to its ongoing development through regular feedback and comments.

Feedback on this guidance

Comments on how to improve this guidance are welcome and can be sent to the PHS Guidance Team at phs.guidance@phs.scot

Background

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.

Case definitions

Due to the ongoing situation the mpox case definitions are being frequently updated.

Refer to the latest UKHSA mpox guidance on when to suspect a case of mpox for suspected and confirmed case definitions.

Critical to classifying cases as clade I (HCID) mpox is the operational mpox HCID (Clade I) case definition which specifies that suspected cases must have at least one of:

• travel history to the Democratic Republic of the Congo (DRC) or specified countries where there may be a risk of clade I (HCID) exposure, or a link to a suspected case from those countries, within 21 days of symptom onset

or

• epidemiological link to a case of clade I (HCID) mpox within 21 days of symptom onset

Suspected or confirmed mpox cases are not considered as having a HCID when they:

• have a laboratory confirmed clade II (non-HCID) infection

or

• are of an unknown clade but have none of the epidemiological characteristics listed in the operational mpox HCID (Clade I) case definition.

Countries are specified in the operational mpox HCID (clade I) case definition and are subject to frequent update.

Notification

HPTs should communicate with all local clinicians and health services to be alert to the potential diagnosis, and be aware that under the provisions of the Public Health etc. (Scotland) Act 2008 mpox is a notifiable disease and should be reported as outlined in CMO letter (2022)26.

In practice, this means where a registered medical practitioner has reasonable grounds to suspect that a patient whom the practitioner is attending has mpox they should notify the HPT immediately.

Medical practitioners should consider all mpox as an urgent notification.

Health protection teams are asked to advise PHS immediately of:

• all confirmed mpox cases of unknown clade, regardless of travel or epidemiological link to previous cases
• all suspected mpox cases that also meet the operational mpox HCID (clade I) case definition

See sections on notification under public health management for clade I (HCID) and clade II (non-HCID).

Transmission

Mpox does not spread easily between people unless there is close contact.

Spread between people may occur through:

• direct contact with rash, skin lesions or scabs (including during sexual contact, kissing, cuddling or other skin-to-skin contact)
• contact with bodily fluids such as saliva, snot or mucous
• contact with clothing or linens (such as bedding or towels) or other objects and surfaces used by someone with mpox

It is possible that clade I mpox may spread between people through close and prolonged face-to-face contact such as talking, breathing, coughing, or sneezing close to one another. However, there is currently limited evidence so this will be updated as new information is available.

Spread of mpox may also occur when a person comes into close contact with an infected animal (rodents are believed to be the primary animal reservoir for transmission to humans), or materials contaminated with the virus. Mpox has not been detected in animals in the UK.

Infectious period

This section applies to both clade I (HCID) and clade II (non-HCID) mpox.

An individual with mpox (all clades) is considered infectious from when their symptoms start until:

• their lesions have scabbed over
• all the scabs have fallen off
• a fresh layer of skin has formed underneath

This may take several weeks.

Note that the scabs may also contain infectious virus material.

Health professionals undertaking a risk assessment should consider the extent of lesions at the time of exposure.

The risk of transmission will be higher if:

• there are widespread lesions on uncovered areas – for example, hands or face
• the case was displaying respiratory symptoms at the time of contact

The risk of transmission will be lower if the case:

• had a small number of localised genital lesions
• was asymptomatic or pre-symptomatic

Testing

Clinical diagnosis of mpox can be challenging and a definitive diagnosis (confirmed case) requires polymerase chain reaction (PCR) testing. 

Detailed advice on testing, including sample requirements and transport and packaging can be found in the PHS laboratory information note for mpox testing in Scotland.

Clade I (HCID)

Requesting testing

The designated diagnostic laboratory for HCID mpox testing is the West of Scotland Specialist Virology Centre (WoSSVC) Glasgow.

Prior to testing, discuss the case with Imported Fever Service and local Infectious Diseases physician. Samples should be sent directly to WoSSVC.

The laboratory should be notified by email that the case meets the operational mpox HCID (clade I) case definition before samples are sent.

HPTs should add all suspected cases to HPZone once samples are submitted using the following context:

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.

Travelling for testing

Due to the current uncertainty associated with suspected clade 1 (HCID) mpox, any travel other than essential travel – for example, to seek urgent medical care – should be avoided.

Travel arrangements for testing should be discussed by clinical teams, infection prevention control teams, HPTs and Scottish Ambulance Service (if required) on a case-by-case basis, balancing risk of onward transmission against the practicalities of assessment.

Receiving results

Clade I (HCID) laboratory test results will be shared with Electronic Communication of Surveillance in Scotland (ECOSS).

SVC/WOSSVC will advise of positive and negative results by telephone or email to the requesting clinician or person indicated on the email.

If a PCR positive clade I case is identified, UKHSA will be informed by the WoSSVC/SVC.

In addition, the reference laboratory will inform the IFS of all MPXV samples being tested and of all clade I (HCID) results either positive or negative.

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

Notification should be made promptly on receipt of the result and should include full patient details. This will enable appropriate public health actions to be taken for positive results, or to be stood down for negative results, without delay.

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.

This includes 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) from a suspected mpox case, HPTs should review their public health actions, for example contact tracing and post-exposure prophylaxis.

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

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'.

Enhanced surveillance

Enhanced surveillance is required for:

• confirmed clade I (HCID) cases
• confirmed clade II (non-HCID) cases

Download the surveillance questionnaire from SHPIR (login required).

HPTs should aim to return the enhanced surveillance form for:

• clade I (HCID) – within 24 hours of case confirmation, including out of hours
• clade II (non-HCID) – within 48 hours

The form should be returned to phs.bbvsti@phs.scot and phs.incident007@phs.scot

There is significant overlap between enhanced surveillance and contact tracing, therefore these activities should be combined in as efficient manner as possible to reduce burden on the case.

Contact tracing and enhanced surveillance may involve taking a detailed sexual history. Further advice on sexual history taking is available in the British Association for Sexual Health and HIV (BASHH) guidance on taking sexual histories.

Additional support and input should be sought from local board sexual health colleagues. Delegation of contact tracing and enhanced surveillance may be preferred, especially if the case has co-existing STI diagnoses.

This work division is to be determined by local teams on a case-by-case basis.

Gathering the necessary information as efficiently as possible is preferred by both the case and the teams involved. 

Clinical management

Clinical pathways for suspected cases of clade I (HCID) mpox guides clinicians to distinguish between clade I (HCID) and clade II (non-HCID) mpox, for the purposes of clinical management.

Normal clinical pathways should be followed for clade II (non-HCID) mpox.

For HCID cases, remote initial assessment via primary care is recommended. Primary and community care should then seek local infectious diseases specialist advice via their usual pathways. Specialist clinicians should be advised to discuss any patient with suspected mpox with the Imported Fever Service (0844 778 8990).

See the section on infection prevention and control for advice on PPE.

Public health management for clade I (HCID)

For suspected mpox cases who meet the operational mpox HCID (clade I) case definition, an enhanced public health response is required.

Undertake public health management of the case as HCID unless the case no longer meets the HCID case definition – for example, sequencing data confirms clade II.

If there are any questions about the management of any HCID case or associated contacts, then contact PHS on PHS.incident007@phs.scot or phone PHS on call if out of hours.

Travel and contact history

Wherever a case first presents, a thorough travel and contact history, including sexual contacts, should be taken.

If the receiving clinician has not done so HPTs should ensure this is completed as a priority.

This is essential to public health management.

Clinicians and HPTs should discuss the suspected mpox case with the Imported Fever Service to reach a consensus on whether the case meets the operational mpox HCID (clade I) case definition.

Notify PHS

Upon identification of a suspected clade I (HCID) case or on receiving any related clade I (HCID) case test result

Health protection teams should

Notify PHS by phone and email:

• during office hours phone the PHS blood borne virus team
• out of hours phone the on-call PHS Consultant
• follow up notification by email to PHS.incident007@phs.scot

Enter the case on HPZone:

• using the HPZone context: Clade I mpox
• if negative tests are received the case should be updated to discarded and the context removed
• if tests confirm a clade II (non-HCID) infection, HPZone records should be updated.

Upon receipt of confirmed HCID result

HPTs should:

• review their public health actions to ensure changes are not required, for example, contact tracing and post-exposure prophylaxis
• notify PHS by email at PHS.incident007@phs.scot
• out of hours, the PHS on call consultant should be contacted by phone

Case isolation

Mpox clade I (HCID) cases should be isolated in a negative-pressure single room as per the National Infection Prevention and Control Manual (NIPCM) until they meet the criteria for ending isolation.

Cases should isolate until they meet the criteria for ending isolation.

The local infection specialist service will determine transport options for a suspected mpox case that meets the operational mpox HCID (clade I) case definition for further assessment.

Patients with clinically suspected HCID mpox should not travel:

• on public transport
• in private hire taxis

Guidance for HCID management is available in the National Infection Prevention and Control Manual (NIPCM).

Pregnant women and severely immunocompromised individuals (as outlined in the Green book) should not clinically care for individuals with mpox.

Contact tracing and follow up

When to trace

Contact tracing is required for PCR positive (untyped) mpox cases who meet the operational mpox HCID (Clade I) case definition.

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 operational mpox HCID (clade I) case definition

• 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.

Public health actions for clade II (non-HCID) mpox

There is no change to the public health management of HCID (clade II) mpox cases.

The approach is set out here and follows the same process as the previous guidance

Travel and contact history

Wherever a suspected case first presents a travel and contact history, including sexual contacts, should be taken.

If the receiving clinician has not done so HPTs should ensure this is completed as a priority.

Through discussion with the clinician, HPTs should ensure that the case has been appropriately classified, as per the case definition, as either a:

• clade I (HCID) case
• clade II (non-HCID) case

Notify PHS

All suspected clade II (non-HCID) mpox cases should be entered on HPZone and these will be extracted by PHS.

If negative tests are received the case should be updated to discarded.

Confirmed PCR positive clade II (non-HCID) cases should be notified to PHS by email (phs.bbvsti@phs.scot and phs.incident007@phs.scot and by phone in-hours (ask for the Blood Borne Virus Team).

There is no need to notify PHS out-of-hours of clade II (non-HCID) cases unless additional advice is required.

Case isolation

Suspected cases awaiting assessment or test results should avoid close contact with others.

The large majority of clade II (non-HCID) cases can isolate at home.

Cases should isolate until they meet the criteria for ending isolation.

There should be locally agreed monitoring and review mechanisms in place to support people at home. These arrangements should be agreed with local health protection teams with input from stakeholders who may include:

• infectious disease services
• sexual health
• GP sub-committee
• local authority partners
• health and social care partnerships

Visit SHPIR for advice for mpox cases isolating at home (login required).

Where admission to a health or social care setting is required, guidance for management is available in the National Infection Prevention and Control Manual (NIPCM) A-Z of pathogens.

Where possible, pregnant women and severely immunocompromised individuals (as outlined in the Green Book chapter 7) should not clinically care for individuals with mpox.

They should take additional precaution to avoid contact within the home.

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

Blood, tissue, cell or organ donation

This section applies to both clade I (HCID) and clade II (non-HCID) mpox.

Where it is identified that a confirmed case (of any clade) has made a blood, tissue or cell donation at any point during their infectious period then the Scottish National Blood Transfusion Service (SNBTS) should be advised by:

• email at nss.snbtsdcst@nhs.scot
• telephone on 0131 314 7391 or 0131 314 5520 (business hours)
• calling the SNBTS on call consultant on 0131 314 1794 (out of hours)

Donation or receipt of organs or other medical donations – for example sperm donation – should be followed up with the clinicians or services responsible.

A full position and evidence statement on mpox and blood, tissue, cell or organ donation is available from the Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee.

Venue or setting notification

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 operational mpox HCID (clade I) case definition, 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.

Household pets

This section applies to both clade I (HCID) and clade II (non-HCID) mpox.

There is a risk that animals could become infected or contaminated with the virus through close contact with an infected person and spread the virus to others. 

For this reason, cases should:

• avoid close contact with pets and other animals as much as possible
• practice good hygiene before and after any contact

Contacting APHA

The Animal and Plant Agency (APHA) should be contacted by the HPT if any animals are present within a household (or in other regular contact with) a suspected or confirmed case of mpox. The local Field Services offices should be the initial point of contact.

View the contact details for all offices in Scotland.

HAIRS risk assessment

The Human Animal Infections and Risk Surveillance (HAIRS) risk assessment prepared for the 2022 mpox outbreak is available online.

View the qualitative assessment of the risk to the UK human population of mpox infection in a canine, feline, mustelid, lagomorph or rodent UK pet.

Compensation

This section applies to both clade I (HCID) and clade II (non-HCID) mpox.

Provision of compensation to provide for any loss incurred in complying with a request or order made by a board should be processed in line with sections 56, 57 and 58 of the Public Health etc. (Scotland) Act 2008 as required.

Where contacts of confirmed cases are identified through other routes – for example, sexual health – they should be referred to the health protection team for follow-up.

Where exclusion is required – for example for high risk contacts who are either voluntarily or legally excluded from work with vulnerable groups – these exclusions must be undertaken by Competent Persons in line with sections 56, 57 and 58 of the Public Health etc. (Scotland) Act 2008.

Isolation should not prevent access to any required clinical care.

Travel while isolating

Travel is not advised for any contacts or cases who have been advised to isolate at home.

Travelling against advice

Clade I (HCID)

Serious consideration should be given to the use of the public health act to restrict the movements of cases who meet the operational mpox HCID (clade I) case definition.

If an isolating case or contact discloses that they do intend to travel, HPT should inform PHS as soon as possible by telephone and email (phs.travelteam@phs.scot).

The notification should include the:

• name of the individual
• date of birth
• email or phone contact details
• travel plans
• destination in country (if known)
• brief case or contact history for context

Clade II (non-HCID)

Where a case or contact does advise that they plan to travel regardless of the public health advice the HPT should try to discourage this, and failing that, to mitigate the risk to others.

Contacts traveling against public health advice should be advised to:

• discuss any travel plans with their travel insurance company
• disclose the fact they have been identified as a contact of a mpox case
• consider the accessibility of appropriate health care services in the country they are visiting, in the event they were to develop symptoms whilst overseas

If a confirmed case or symptomatic contact intends to travel against public health advice HPTs may wish to consider the use of the Public Health Act to restrict travel on a case-by-case basis.

If a case or contact declares they intend to travel, HPT should inform PHS as soon as possible by telephone and email (phs.travelteam@phs.scot). This is in order that PHS can liaise with the National Focal Point of the country that they are visiting.

The notification should include the:

• name of the individual
• date of birth
• email or phone contact details
• travel plans
• destination in country (if known)
• brief case or contact history for context

Pre and post-exposure vaccination

Vaccination guidance is based on the Green Book chapter 29.

Guidance on the use of vaccination as pre- and post-exposure prophylaxis is available in the UKHSA mpox vaccination recommendations.

This guidance is updated frequently, and the latest version should be checked on the GOV.UK page.

Pre-exposure vaccination

Individuals in the priority groups should be offered pre-exposure vaccination.

This is outlined in the CMO(2022)29 letter.

Post-exposure vaccination

Post-exposure vaccination for community or occupational contacts should be considered for those with the highest exposure risks defined in the contact tracing guidance for HCID and non-HCID Clades of MPXV.

Post exposure vaccine is currently offered to those who have had a:

• category 3 or category 2 exposure to clade I MPXV
• category 3 exposure to clade II MPXV

In severe supply constraints, post exposure vaccine may be restricted to category 3 exposures.

PHS does not need to be informed before arranging access to post-exposure vaccination for contacts.

Full recommendations available in:

• Green Book chapter 29, smallpox and mpox
• UKHSA mpox vaccination recommendations
• UKHSA non-HCID mpox contact tracing guidance
• UKHSA HCID contact tracing matrix on SHPIR (login required)

PHS does not need to be informed before arranging access to post-exposure vaccination for contacts.

Indications

Previous mpox infection is not a contraindication to vaccination.

However, while there is constrained vaccine supply, vaccination of confirmed cases at on-going risk should be deferred until they are fully recovered and vaccine supply allows.

Whether prior mpox infection protects against future infection is currently unknown, but based on analogy from smallpox infection and from live smallpox vaccine, it seems likely that re-infection will be unusual, particularly in the short term.

Vaccinations delivered in sexual health services should be recorded on the national sexual health system (NaSH), where available.

In sexual health services where NaSH is not available, and in other settings where vaccine is being administered – such as occupational health – vaccination should be recorded using the PHS template and submitted weekly.

Find out about the process for requesting vaccine on SHPIR (login required).

Workforce education resources

Healthcare professionals can access vaccine specific training and other education resources for mpox on TURAS.

Public vaccination information

Members of the public can access:

• vaccination information for mpox on NHS inform
• a PHS information leaflet

Infection prevention and control

Healthcare settings

Infection Prevention and Control (IPC) precautions for healthcare settings are those as outlined in mpox guidance in the National Infection Prevention and Control Manual (NIPCM) A-Z of pathogens.

Advice for non-HCID mpox cases isolating at home, including disposal of household waste, is available in the information sheets for people with mpox isolating at home on SHPIR (login required) and on the PHS mpox webpage.

Sex-on-premises venues

UKHSA advice specifically for owners, managers and staff of sex-on-premises venues is available for clade II (non-HCID) mpox.

Handling the deceased

For managing infection risks when handling the deceased, see Health and Safety Executive (HSE) guidance for the mortuary, post-mortem room and funeral premises, and during exhumation.

Public information

Public information on mpox is maintained on NHS inform.

Advice on mpox and international travel is on Fit for Travel.

Other public facing information on mpox can be found on the Public Health Scotland website.

Abbreviations