Notice on Printing and Distributing the Guidelines for Diagnosis and Treatment of Monkeypox (2022 Edition)
National Health Office Medical Letter [2022] No. 202
All provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps Health and Health Committees and Administration of Traditional Chinese Medicine:
Since May 2022, monkeypox cases and community transmission have been reported in several non-endemic countries around the world. In order to prepare for the medical treatment of monkeypox in advance and improve the ability of early clinical identification and standardized diagnosis and treatment, the National Health and Health Commission and the State Administration of Traditional Chinese Medicine organized and formulated the "Guidelines for the Diagnosis and Treatment of Monkeypox (2022 Edition)". It is now printed and distributed to you, please refer to the implementation.
Health administrative departments and traditional Chinese medicine management departments at all levels should attach great importance to them, conscientiously organize training related to monkeypox diagnosis and treatment, and effectively improve the ability of "four early mornings". And make every effort to organize the medical treatment work, and effectively protect the lives and health of the people.
General Office of the National Health Commission
Office of the State Administration of Traditional Chinese Medicine
June 10, 2022
Monkeypox diagnosis and treatment guide
(2022 edition)
Monkeypox is a zoonotic viral disease caused by Monkeypox virus (MPXV) infection, and its clinical manifestations are fever, rash, and lymphadenopathy. The disease is mainly endemic in Central and West Africa. Since May 2022, monkeypox cases have also been reported in some non-endemic countries, with community transmission. In order to improve the clinician's ability to identify monkeypox early and standardize the diagnosis and treatment, this diagnosis and treatment guideline is specially formulated.
1. Etiology
Monkeypox virus (MPXV) is classified in the genus Orthopoxvirus of the Poxviridae family and is one of four genus Orthopoxviruses that are pathogenic to humans, the other three being variola virus, vaccinia virus, and vaccinia virus. Under the electron microscope, the monkeypox virus particles are brick-shaped or oval-shaped, with a size of 200nm×250nm, with an envelope, structural proteins and DNA-dependent RNA polymerase in the virus particles, and the genome is double-stranded DNA with a length of about 197kb. Monkeypox viruses are divided into two subclades, the West African clade and the Congo Basin clade. The virus sequencing results of some cases in non-endemic countries this time are West African branches.
The main host of monkeypox virus is African rodents (including African squirrels, tree squirrels, Gambian kangaroos, dormouse, etc.).
Monkeypox virus is resistant to drying and low temperatures, and can survive for several months on soil, crusts, and clothing. Sensitive to heat, it can be inactivated by heating to 56°C for 30 minutes or 60°C for 10 minutes. It can be inactivated by ultraviolet rays and general disinfectants, and is sensitive to sodium hypochlorite, chloroxylenol, glutaraldehyde, formaldehyde and paraformaldehyde.
2. Epidemiology
(1) Source of infection
The main source of infection is rodents infected with monkeypox virus. Primates (including monkeys, chimpanzees, humans, etc.) can also become sources of infection after infection.
(2) Transmission route
Viruses enter the human body through mucous membranes and broken skin. Humans are mainly infected by contact with infected animal lesion exudates, blood, and other body fluids, or by being bitten or scratched by infected animals. It is mainly transmitted through close contact between people, and it can also be transmitted through droplets. Contact with virus-contaminated items may also be infected, and it can also be transmitted vertically through the placenta. Sexual transmission cannot be ruled out.
(3) Susceptible population
The population is generally susceptible. There is a certain degree of cross-protection against monkeypox virus in people who have been vaccinated against smallpox in the past.
3. Clinical manifestations
The incubation period is 5-21 days, mostly 6-13 days. In the early stage of the disease, chills and fever occur, and the body temperature is mostly above 38.5 °C, which may be accompanied by symptoms such as headache, drowsiness, fatigue, back pain and myalgia. Most patients present with swollen lymph nodes in the neck, armpits, and groin. A rash appears 1-3 days after onset. The rash first appeared on the face and gradually spread to the extremities and other parts. The rashes were mostly distributed centrifugally. The rashes on the face and extremities were more common than on the trunk. The rashes could appear on the palms and soles of the feet, and the number of rashes ranged from several to thousands. etc.; can also involve the oral mucosa, digestive tract, genitalia, conjunctiva and cornea. The rash changes from macules, papules, herpes, pustules to scabs. Herpes and pustules are mostly spherical, about 0.5-1 cm in diameter, hard in texture, and may be accompanied by obvious itching and pain. It takes about 2-4 weeks from the onset to the scab shedding. Erythema or hyperpigmentation, or even scarring, may remain after the scab falls off, and the scarring may last for several years. Complications may occur in some patients, including secondary bacterial infection at the site of skin lesions, bronchopneumonia, encephalitis, corneal infection, and sepsis.
Monkeypox is a self-limiting disease with a good prognosis in most cases. Severe cases are common in young children and immunocompromised people, and prognosis is related to the viral branch of infection, the degree of virus exposure, previous health status, and the severity of complications. The case fatality rate in the West African branch is about 3%, and the case fatality rate in the Congo Basin branch is about 10%.
4. Laboratory inspection
(1) General inspection
Peripheral blood leukocytes were normal or elevated, and platelets were normal or decreased. Some patients may have elevated transaminase levels, lower blood urea nitrogen levels, and hypoproteinemia.
(2) Pathological examination
1. Nucleic acid detection: The nucleic acid of monkeypox virus can be detected in specimens such as skin rash, blister fluid, crust, oropharyngeal or nasopharyngeal secretions by nucleic acid amplification detection method.
2. Virus culture: Monkeypox virus can be isolated by collecting the above specimens for virus culture. Virus culture should be carried out in a biosafety laboratory of level 3 or above.
V. Diagnosis and Differential Diagnosis
(1) Diagnostic criteria
1. Suspected cases
Those who have the above clinical manifestations and have any of the following epidemiological history:
(1) A history of travel and residence in the area where monkeypox cases were reported overseas within 21 days before the onset of the disease;
(2) Close contact with a monkeypox case within 21 days before the onset of the disease;
(3) Contact with the blood, body fluids or secretions of monkeypox virus-infected animals within 21 days before the onset of the disease.
2. Confirmed cases
Suspected cases with positive monkeypox virus nucleic acid test or cultured isolated monkeypox virus.
For cases that meet the criteria for suspected or confirmed cases, infectious disease reporting should be made in accordance with relevant requirements.
(2) Differential diagnosis
It is mainly differentiated from other febrile and rash diseases such as chickenpox, herpes zoster, herpes simplex, measles, dengue fever, etc., and also from skin bacterial infections, scabies, syphilis and allergic reactions.
6. Treatment
At present, there is no specific anti-monkeypox virus drug in China, mainly symptomatic support and treatment of complications.
(1) Symptomatic and supportive treatment. Bed rest, pay attention to supplement nutrition and water, maintain water and electrolyte balance. For those with high body temperature, physical cooling is the main method. If the temperature exceeds 38.5 °C, antipyretic analgesics should be given to reduce fever, but attention should be paid to prevent prostration caused by profuse sweating.
Keep the skin, mouth, eyes and nose clean and moist, and avoid scratching the skin at the rash to avoid secondary infection. Analgesics can be given if the pain at the rash site is severe.
(2) Treatment of complications. In the event of secondary bacterial infection of the skin, effective antibacterial drug treatment should be given, and adjustments should be made according to the isolation and identification of pathogenic bacteria and the results of drug susceptibility. Prophylactic use of antimicrobials is not recommended. When corneal lesions appear, eye drops, supplemented with vitamin A and other treatments can be applied. When encephalitis occurs, sedation, dehydration and intracranial pressure reduction, and airway protection are given.
(3) Psychological support treatment. Patients often have psychological problems such as tension, anxiety, and depression. Psychological support, counseling, and related explanations should be strengthened. According to the condition, a psychologist should be consulted and participated in the diagnosis and treatment of the disease in a timely manner. If necessary, corresponding drug adjuvant treatment should be given.
(4) Chinese medicine treatment. According to the principles of TCM "examination and treatment" and "three causes and measures", the treatment is based on syndrome differentiation. Patients with clinical symptoms of fever are recommended to use Shengma Gegen Decoction, Shengma Biejia Decoction, Zixue Powder, etc.; patients with clinical symptoms of high fever, dense acne, sore throat, and multiple lymphadenopathy are recommended to use Qingying Decoction, Shengma Biejia Decoction, Xuanxue Powder, etc. Bai Chengqi Soup, etc.
7. Discharge criteria
Those who meet the following criteria can be discharged from the hospital: normal body temperature, significant improvement in clinical symptoms, and scabs falling off.
8. Infection prevention and control in medical institutions
Suspected and confirmed cases should be placed in isolation wards. Suspected cases are isolated in a single room.
Medical staff should implement standard precautions, take contact precautions, droplet precautions, wear disposable latex gloves, medical protective masks, protective face shields or goggles, disposable isolation gowns, etc., and do good hand hygiene.
Strictly disinfect the patient's secretions, feces and blood pollutants in accordance with the "Technical Specifications for Disinfection in Medical Institutions".