RCN position on Monkeypox infection and the protection of healthcare workers

The RCN is reminding all health and care employers of their legal duty to undertake suitable and sufficient risk assessment in order to ensure healthcare workers are adequately protected from the risk of contracting Monkeypox as a result of their work.

Monkeypox is a rare zoonotic infection that until recently has not been associated with human person-to-person transmission. An ongoing global outbreak is affecting multiple countries, with cases continuing and expected to rise. This is unique and poses significant challenges for preventing the spread of infection and the protection of healthcare workers. Current knowledge of Monkeypox is based on small outbreaks in Africa where it remains endemic, often associated with contact with animals or bushmeat.

Monkeypox is classified as a Group 3 Biological hazard, therefore the Control of Substances Hazardous to Health (COSHH) Regulations apply. This places a legal duty on employers to ensure that the risk of their employees being exposed to the disease is either prevented or adequately controlled, so far as is reasonably practicable.

No deaths have been reported to date in the UK as part of this latest outbreak and the risk of mortality is estimated to be low. Those most likely to suffer from more severe infection are immunocompromised individuals, pregnant women, or children.

Healthcare workers are at risk of contracting Monkeypox when they are in close contact or working in the care environment/home of a person who is suspected, probable or confirmed with the infection. Whilst direct contact is the predominant mode of transmission, airborne transmission can occur if respiratory symptoms are present, or when healthcare workers handle the bedlinen or clothes of infected individuals.

Staff who have been in contact with confirmed cases of infection may be required to self-isolate for up to 21 days. If staff are required to isolate, this will place an additional burden on an already and overstretched workforce, thereby impacting on services and the care of patients.

When caring for people who are suspected or confirmed with Monkeypox, Healthcare workers must wear personal protective equipment (PPE) to protect themselves from infection. Underpinning the selection of appropriate PPE, is the employers organisational risk assessment, enabling staff who are most at risk to be adequately protected.

Current UK guidance for the management of Monkeypox (UKHSA 2022) describes the minimum standards for suspected/probable cases and confirmed cases. However, some staff will require additional PPE, including FFP3 masks in some circumstances. The employers organisational risk assessment is central in supporting staff to identify and manage local risks as they occur and avoid preventable exposure to infection.

The RCN is concerned however, that different standards are being advised for suspected/probable and confirmed cases of infection, leading to confusion and ambiguity. It is foreseeable that suspected or probable cases will turn out to be positive, placing healthcare workers caring for suspected/probable cases at risk of exposure if they do not have access to adequate respiratory protective equipment (RPE). Fluid resistant surgical masks (FRSM) are not classified or appropriate to be used as Respiratory Protective Equipment (RPE).

The RCN position is that where exposure to Monkeypox may occur, the employing organisation should undertake a suitable and sufficient risk assessment, in line with the requirements of COSHH and communicate the significant findings of that risk assessment to all relevant staff. 

To adequately protect themselves against infection and to prevent the need for post exposure isolation, Healthcare workers should be offered the same level of protection for both suspected/probable and confirmed cases of infection. Where the risk assessment identifies healthcare workers are at risk of coming into contact with people who have or are suspected of having the infection, this should include having readily available, suitable, and sufficient Respiratory Protective Equipment (RPE).