RCN position on Mpox infection and the protection of healthcare workers by employers

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 Mpox as a result of their work. This applies to all health and care settings including the community, GP practices, sexual health clinics, hospitals and prisons.

Mpox is a rare zoonotic infection outside of parts of Africa that is now thought to be spreading due to extensive previously unknown levels of human person-to-person transmission. There are two groups or ‘clades’ of Mpox Clade I and Clade II. A ‘clade’ refers to a major genetic strain of the virus.

The current outbreak of international concern relates to the Mpox Clade I which is classified as a High Consequence Infectious Disease. This is different to the Clade II Mpox virus identified as causing outbreaks associated with sexual contact in 2022 in the UK and other countries. Infection with Mpox Clade I may be more serious and is currently at the centre of a major outbreak in some African countries with spread via travel to other parts of the world.

 Those most likely to suffer from more severe infection are immunocompromised individuals, pregnant women, or children.

This is a unique situation and poses significant challenges for preventing the spread of infection and the protection of healthcare workers should suspected cases occur in the UK.

Clade I Mpox infection is classified as a High Consequence Infectious Disease (HCID) and both Clade I and II are a Group 3 Biological hazard in the Approved List of Biological Agents, 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. This is not limited to those working in a laboratory with the virus, and is inclusive of those caring for patients who have the disease.

Healthcare workers are at risk of contracting Mpox (Clades I and II) when they are in close contact with or working in the care environment/home of a person who is suspected, probable or confirmed with the infection.

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 Mpox, healthcare workers must wear personal protective equipment (PPE) to protect themselves from infection as a result of transmission via the airborne route or direct contact. 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 Mpox (UKHSA 2024) describes the minimum standards for suspected/probable cases and confirmed cases of both Clade I and Clade II. Staff will require additional PPE, including FFP3 masks or powered respirators with hoods/helmets in some circumstances including when exposed to suspected or confirmed cases of Clade 1 Mpox or where the Clade is unknown . Updated UKHSA guidance is awaited now available following the recent spread of Clade I Mpox outside of the historical central African region where it has been known to circulate. The employer’s organisational risk assessment remains central in supporting staff to identify and manage local risks as they occur and avoid preventable exposure to infection.

It is foreseeable that as of August 2024 suspected or probable cases will turn out to be positive for Clade I, 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) and do not meet the required standards for PPE as they do not provide suitable and sufficient protection to the worker from micro-organisms spread via the airborne route. 

The RCN position is that where exposure to Mpox may occur regardless of the care setting (for example a person's own home, GP practice or hospital), 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. Members should refer to the national IPC or health protection policies for guidance.

To adequately protect themselves against infection and to prevent the need for post exposure isolation, Health and social care workers should be offered the same level of protection for both suspected/probable and confirmed cases of Clade I infection. It is essential that members have access to readily available, suitable, and sufficient Respiratory Protective Equipment (RPE) for which, unless using a loose fitting facepiece e.g. an air powered hood, healthcare workers must be fit tested prior to use.

RCN members who have any concerns should contact RCN Direct.

Further information

• UKHSA, Mpox: background information
• UKHSA, Principles for control of non-HCID mpox in the UK: 4 nations consensus statement
• NHS England, Mpox
• Scotland NHS Inform, Mpox (monkeypox)
• Public Health Wales, Mpox (monkeypox)
• Northern Ireland, Monkeypox
• European Centre for Disease Control, Mpox factsheet for health professionals
• HSE, The Approved List of biological agents - MISC208