Defining a population group and the role of the Occupational Health professional in the management of public health and control of emerging zoonotic communicable diseases.
At the end of the first wave of the COVID-19 pandemic, a Belgian systematic review identified the need for a comprehensive risk assessment strategy “more systematic approach to prevent biological risks among non-healthcare employees”.
Never in the history of Public Health (PH) has its sibling’s expertise, Occupational Health (OH), been more important. Following the pandemic planning and response for H1N1 and COVID-19, we need to pull together again to support each other and share applied knowledge and expertise to standardise and manage our response to the re-emergence of an Orthopoxvirus that is spreading more rapidly than our historical experience of the disease has ever predicted.
Monkeypox is the fourth in recent a series of emerging sylvatic zoonotic viruses that have spread with pandemic-type speed. You will by now all have seen headlines about a new Orthopoxvirus that has emerged and spread outside its normal region, host, environment and population.
What is Monkeypox?
Monkeypox is a sylvatic zoonotic disease that is normally found in non-human primates and rodents in Central and the West Coast of Africa. It is an Orthopoxvirus genus of the Poxviridae family. It has an incubation period of between 5 and 21 days and becomes untransmissible once the scabs have fallen off the spots.
There are two distinct genetic clades of the Monkeypox virus – the Central African (Congo Basin) clade (CBC) and the West African clade (WAC). Thankfully this outbreak appears to be the usually self-limiting WAC, which may look like a bad case of chickenpox or a syphilis rash.
At the time of writing, more than 120 confirmed or suspected cases of WAC Monkeypox have been reported in at least 11 non-endemic countries in the last week1, 20 of which are in the UK.
How is it diagnosed?
The first 5 days of infection include the distinctive and diagnostic feature of lymphadenopathy, with the skin eruption appearing on extremities within 1-3 days of fever, which can severely affect the head, genitalia, mucous membranes and conjunctiva. Other symptoms include intense headache, back pain, myalgia and intense asthenia.
The rash evolves sequentially from macules (lesions with a flat base) to papules (slightly raised firm lesions), vesicles (lesions filled with clear fluid), pustules (lesions filled with yellowish fluid), and crusts which dry up and fall off. The number of lesions varies from a few to several thousand. In severe cases, lesions can coalesce until large sections of skin slough off.
Diagnostic testing samples need to be taken from the lesions and subject to Category B transportation. Although PCR testing is possible, it is not sufficiently reliable to provide asymptomatic or pre-rash diagnosis.
How is it transmitted?
Transmission occurs via direct contact with blood, bodily fluids, lesions on the skin or internal mucosal surfaces, such as in the mouth or throat, respiratory droplets (aerosols / aerosol generating activities or procedures AGPs) and objects contaminated with any of the above.
Who is at risk?
Healthcare workers are among the populations currently most at risk of contact with people incubating the disease before definitive symptoms indicate differential diagnosis.
Pregnant workers and their unborn and young children and those with underlying immune deficiencies at the time of infection are at risk of complications and are known to lead to worse outcomes. Risk reduction for vulnerable workers is an important occupational issue, which is explored in the proposed vulnerable worker health risk assessment below.
The World Health Organisation (WHO) reports that health workers caring for patients with suspected or confirmed monkeypox virus infection, or handling specimens from them, should , if possible, be previously vaccinated against smallpox when selected to care for the patient2.
The role of Occupational Health
Whilst our Public Health, Infection Prevention and Control (IPC) and Sexual Health (SH) colleagues will have been busy implementing the WHO’s recommendations for passive surveillance and early differential diagnosis of compatible symptoms, OH professionals need to convene and partner closely with these colleagues to rapidly apply our learnings of the last 3 years. The COVID-19 pandemic has seen the prevalence of mental ill-health increase by more than 25% and we now need to support our healthcare colleagues once again as they deal with a high consequence infectious disease (HCID)3. We now have an opportunity to develop and offer consistent standards of health monitoring, education and support to prevent and manage occupationally acquired infection whilst supporting our health protection colleagues.
Control of pathogens within the workplace falls under the Control of Substances Hazardous to Health Regulations (COSHH) and recent events are an important reminder of the need to maintain our professional knowledge and engage in reflective practice.
A 2018 review4 of the occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak found that they need to be prepared for the potential psychological impact and a supportive workplace environment with specific support in place for those most at risk.
Once again, our role requires us to research, analyse, interpret and apply emerging evidence, to lead on and roll out proactive evidence-based health monitoring including vulnerable worker health risk assessment (VWHRA), screening, immunisation and health education, post-exposure prophylaxis, and case management.
Since writing the UK governments have issued control guidance which can be found here.
2022 Monkeypox timeline:
A case tracker is available here and a new one is being developed by UK scientists.
iOH Members can read more at
https://ioh.org.uk/resources/how-do-we-best-apply-the-learnings-from-covid-19-to-monkeypox/
Sources
1 UBC and Jülich (FZJ), 2022. “Monkeypox Goes Global: Why Scientists Are On Alert”. Nature.Com. https://www.nature.com/articles/d41586-022-01421-8.
2 https://www.who.int/news-room/fact-sheets/detail/monkeypox
3 WHO, 2022; “Introducing Mental Health And Psychosocial Support (MHPSS) In Emergencies”. OpenWHO. https://openwho.org/courses/mental-health-and-psychosocial-support-in-emergencies.
4 Brooks, S; Dunn, R; Amlôt, R; Rubin, G; Greenberg, N; 2018. “a systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak”. Journal of Occupational and Environmental Medicine, Volume 60, Number 3, March 2018, pp. 248-257(10). https://doi.org/10.1097/JOM.0000000000001235
5 Reverse transcriptase polymerase chain reaction, commonly known as PCR in the context of COVID-19 testing
6 British Association for Sexual Health and HIV https://www.bashh.org
7 https://www.bhiva.org/BHIVA-rapid-statement-on-monkeypox-virus
8 MSM: Men who have sex with men
Lucy Kenyon is our immediate past-President and Non-exec Director. She was involved at the start of the COVID-19 response and, mindful of the importance of planning for the emerging evidence, she has drafted this to start the dialogue within OH to reduce risks to and support the healthcare workers that we protect.
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