List of APHOs/PHOs/LPHOs

Airport Health Organization (APHO)

1. APHO Ahmedabad 26. APHO Srinagar

2. APHO Amritsar 27. APHO Trichy
3. APHO Bagdogra 28. APHO Trivandrum
4. APHO Bangalore 29. APHO Varanasi
5. APHO Bhubaneswar 30. APHO Visakhapatnam
6. APHO Calicut
7. APHO Chandigarh Port Health Organization (PHO)
8. APHO Chennai
9. APHO Cochin 31. PHO Chennai
10. APHO Delhi 32. PHO Cochin
11. APHO Gaya 33. PHO Goa
12. APHO Goa 34. PHO JNPT Sheva
13. APHO Guwahati 35. PHO Kandla
14. APHO Hyderabad 36. PHO Kolkata
15. APHO Jaipur 37. PHO Mangalore
16. APHO Kannur 38. PHO Mumbai
17. APHO Kolkata 39. PHO Paradeep
18. APHO Kushinagar 40. PHO Tuticorin
19. APHO Lucknow 41. PHO Vizag
20. APHO Mangalore
21. APHO Mumbai Land Port Health Organization (LPHO)
22. APHO Nagpur
23. APHO Patna 42. LPHO Agartala
24. APHO Pune 43. LPHO Amritsar
25. APHO Port Blair 44. LPHO Petrapole
GUIDELINES FOR MANAGEMENT
OF MONKEYPOX DISEASE

Ministry of Health and Family Welfare

GOVERNMENT OF INDIA

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1. Introduction
Monkeypox (MPX) is a viral zoonotic disease with symptoms similar to smallpox, although
with less clinical severity. MPX was first discovered in 1958 in colonies of monkeys kept for
research, hence the name ‘monkeypox.’ The first human case of monkeypox was reported from
Democratic Republic of the Congo (DRC) in 1970.

Monkeypox Virus primarily occurs in Central and West Africa. In 2003, the first monkeypox
outbreak outside of Africa was reported in the United States of America which was linked to
contact with infected pet prairie dogs. These pets had been housed with Gambian pouched rats
and dormice that had been imported into the country from Ghana.

1.1 Global Scenario

According to World Health Organization (WHO), in the present series of outbreaks being
reported, this is the first time that chains of transmission are reported in Europe without known
epidemiological links to West or Central Africa. Monkeypox has been reported as endemic in
several other central and western African countries such as: Cameroon, Central African
Republic, Cote d’Ivoire, Democratic Republic of the Congo, Gabon, Liberia, Nigeria, Republic
of the Congo, and Sierra Leone. This has been also reported in certain non-endemic countries
e.g. USA, UK Belgium, France, Germany, Italy, Netherlands, Portugal, Spain, Sweden,
Australia, Canada, Austria, Canary Islands, Israel and Switzerland.

There are no reported cases of monkeypox virus in India till date as on 31st May 2022.
However, India needs to be prepared in view of the increasing reports of cases in non-endemic
countries.

2. Epidemiology

2.1 Agent
Monkeypox virus (MPXV) is an enveloped double-stranded DNA virus that belongs to
the Orthopoxvirus genus of the Poxviridae family. There are two distinct genetic clades of the
monkeypox virus – the Central African (Congo Basin) clade and the West African clade. The
Congo Basin clade has historically caused more severe disease and was thought to be more
transmissible. The geographical division between the two clades has so far been in Cameroon
- the only country where both virus clades have been found.

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2.2 Host:
Natural reservoir is yet unknown. However, certain rodents (including rope squirrels, tree
squirrels, Gambian pouched rats, dormice) and non-human primates are known to be naturally
susceptible to monkeypox virus.

2.3 Incubation period: The incubation period (interval from infection to onset of symptoms)
of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days.

2.4 Period of communicability: 1-2 days before the rash to until all the scabs fall off/gets
subsided.

2.5 Mode of transmission:

 Human-to-human transmission is known to occur primarily through large respiratory
droplets generally requiring a prolonged close contact. It can also be transmitted through
direct contact with body fluids or lesion material, and indirect contact with lesion material,
such as through contaminated clothing or linens of an infected person.
 Animal-to-human transmission: may occur by bite or scratch of infected animals like small
mammals including rodents (rats, squirrels) and non-human primates (monkeys, apes) or
through bush meat preparation.

3. Case definition
3.1 Suspected case:
A person of any age having history of travel to affected countries within last 21 days
presenting with an unexplained acute rash AND
one or more of the following signs or symptoms
 Swollen lymph nodes
 Fever
 Headache
 Body aches
 profound weakness

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3.2 Probable case:
A person meeting the case definition for a suspected case, clinically compatible illness and has
an epidemiological link (face-to-face exposure, including health care workers without
appropriate PPE; direct physical contact with skin or skin lesions, including sexual contact; or
contact with contaminated materials such as clothing, bedding or utensils is suggestive of a
strong epidemiological link).

3.3 Confirmed case:

A case which is laboratory confirmed for monkeypox virus (by detection of unique sequences
of viral DNA either by polymerase chain reaction (PCR) and/or sequencing).

4. Surveillance Strategies
The aims of the proposed surveillance strategy are to rapidly identify cases and clusters of
infections and the sources of infections as soon as possible in order to:

a) isolate cases to prevent further transmission

b) provide optimal clinical care
c) identify and manage contacts
d) protect frontline health workers
e) effective control and preventive measures based on the identified routes of transmission.

4.1 Surveillance outline

a) Use Standard Case Definitions by all District Surveillance Units (DSUs) under Integrated
Disease Surveillance Programme (IDSP) and at Points of Entry (PoEs).
b) Even one case of monkeypox is to be considered as an outbreak. A detailed investigation
by the Rapid Response Teams need to be initiated through IDSP.
c) Report any suspected case immediately to the DSU/State Surveillance Units (SSUs) and
CSU (Central Surveillance Unit), which shall report the same to Dte. GHS MoHFW.
d) Send the samples as per the guidelines to the designated laboratories.

4.2 The salient features include:

a) Targeted surveillance for probable case or clusters.

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b) Initiate contact tracing and testing of the symptomatic after the detection of the
probable/confirmed case.

4.3 Core Surveillance Strategy

a) Hospital based Surveillance: - Health facility-based surveillance & testing – in
Dermatology clinics, STD clinics, medicine, paediatrics OPDs etc.
b) Targeted Surveillance: This can be achieved by:
i) Measles surveillance by Immunization division
ii) Targeted intervention sites identified by NACO for MSM, FSW population

4.4 Reporting
Reporting of cases to be done in the format as placed in Annexure 1.

5. Clinical Features
Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks.
Severe cases occur more commonly among children and are related to the extent of virus
exposure, patient health status and nature of complications. The extent to which asymptomatic
infection occurs is unknown. The case fatality ratio of monkeypox has historically ranged from
0 to 11% in the general population and has been higher among young children. In recent times,
the case fatality ratio has been around 3-6%.

5.1 Common symptoms and signs

 Prodrome (0-5 days)
a. Fever
b. Lymphadenopathy
 Typically occurs with fever onset
 Periauricular, axillary, cervical or inguinal
 Unilateral or bilateral
c. Headache, muscle aches, exhaustion
d. Chills and/or sweats
e. Sore throat and cough
 Skin involvement (rash)
a. Usually begins within 1-3 days of fever onset, lasting for around 2-4 weeks
b. Deep-seated, well-circumscribed and often develop umbilication

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 c. Lesions are often described as painful until the healing phase when they become
itchy (in the crust stage)
d. Stages of rash (slow evolution)
 Enanthem- first lesions on tongue and mouth
 Macules starting from face spreading to arms, legs, palms, and soles (centrifugal
distribution), within 24 hours
 The rash goes through a macular, papular, vesicular and pustular phase. Classic
lesion is vesicopustular
 Involvement by area: face (98%), palms and soles (95%), oral mucous
membranes (70%), genitalia (28%), conjunctiva (20%).Generally skin rashes
are more apparent on the limbs and face than on the trunk. Notably the genitalia
can be involved and can be a diagnostic dilemma in STD population
 By 3rd day lesions progress to papules
 By 4th to 5th day lesions become vesicles (raised and fluid filled).
 By 6th to 7th day lesions become pustular, sharpy raised, filled with opaque fluid,
firm and deep seated.
 May umbilicate or become confluent
 By the end of 2nd week, they dry up and crust
 Scabs remain for a week before falling off
 The lesion heals with hyperpigmented atrophic scars, hypopigmented atrophic
scars, patchy alopecia, hypertrophic skin scarring and contracture/deformity of
facial muscles following healing of ulcerated facial lesions
 A notable predilection for palm and soles is characteristic of monkey pox
e. The skin manifestation depends on vaccination status, age, nutritional status,
associated HIV status. Monkeypox chiefly occurs in communities where there is
often a high background prevalence of malnutrition, parasitic infections, and other
significant heath-compromising conditions, any of which could impact the prognosis
of a patient with MPX.
f. The total lesion burden at the apex of rash can be quite high (>500 lesions) or relatively
slight (<25).

5.2 Differential Diagnosis

Varicella (Chicken pox), disseminated herpes zoster, disseminated herpes simplex, measles,
chancroid, secondary syphilis, hand foot mouth disease, infectious mononucleosis, molluscum
contagiosum.

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5.3 Complications
 Secondary infections
 Pneumonia, sepsis, encephalitis
 Corneal involvement (may lead to loss of vision)

6. Diagnosis
6.1 Personal Protective Equipment for handling the clinical specimens:
PPE to be donned before collecting the specimens should include- Coveralls/Gowns, N-95
mask, Face shield/safety goggles, double pair of gloves. Donning & doffing of PPE should be
carefully performed as per the standard procedure. Procedure for sample collection and
transport of the clinical specimen are placed as Annexure 2. Instructions on sample packaging
and transport are provided in detailed in Annexure 3.

6.2 Clinical samples to be collected from the cases as per the criteria mentioned below
at Table 1:

Traveller from outbreak /endemic region or Community Transmission

Asymptomatic  Observe for the development of any signs and symptoms for 21 days’
post exposure
 If signs and symptoms develop, collect specimens as per the duration
of illness as mentioned below

Rash phase** Recovery phase

 Blood collected in SSGT
 *Lesion roof- with scalpel or plastic
Symptomatic (4-5 ml)
scrapper collected in plain tube
 *Lesion fluid with intradermal syringe Urine in sterile urine
 *Lesion base scrapings with sterile container (3-5ml)
polyester swab collected in plain tube
 *Lesion crust in plain tube
 NPS/OPS in dry plain tube [without
any bacterial medium or VTM]
 Blood collected in SSGT (4-5 ml)
 Blood collected in EDTA (2-3ml)
 Urine in sterile urine container (3-5ml)
* The specimens from lesion should be collected from multiple sites
** A clear lesion images should be sent along with the case record form (preferably on the email ID
mentioned below)

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6.3 Diagnostic modalities for Monkeypox with ICMR NIV Pune
For the confirmation of Monkeypox on the suspected clinical specimens:
a) PCR for Orthopoxvirus genus [Cowpox, Buffalopox, Camelpox, Monkeypox] will be done
b) If specimen will show positivity for the Orthopoxvirus, it would be further confirmed by
Monkeypox specific conventional PCR or real time PCR for Monkeypox DNA
c) Additionally, virus isolation and the Next Generation Sequencing of clinical samples
(Miniseq and Nextseq) will be used for characterization of the positive clinical specimens
All the clinical specimens should be transported to the Apex laboratory of ICMR-NIV
Pune routed through the Integrated Disease Surveillance Programme network of the
respective district/state

6.4 Contact Persons from ICMR-National Institute of Virology Pune Maharashtra, India
for further queries related to collection and transportation of the clinical specimens
Primary contact person Secondary contact person
Dr. Pragya D. Yadav, Dr. Rima R. Sahay,
Scientist-‘F’ & Group Leader, Scientist ‘C’,
Maximum Containment Facility, Maximum Containment Facility,
ICMR-NIV, Microbial Containment Complex, ICMR-NIV, Microbial Containment Complex,
130/1, Sus Road, Pashan, Pune 411021 130/1, Sus Road, Pashan, Pune-411021.
Tel: Office: 020-26006111; Tel: Office: 020-26006160;
Email id: [email protected] Email id: [email protected]

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7. Management
7.1 Principles of Management
 Patient isolation
 Protection of compromised skin and mucous membranes
 Rehydration therapy and Nutritional support
 Symptom alleviation
 Monitoring and treatment of complications

7.2 Patient Isolation

 Isolation of the patient in an isolation room of the hospital/ at home in a separate room
with separate ventilation
 Patient to wear a triple layer mask
 Skin lesions should be covered to the best extent possible (e.g. long sleeves, long pants)
to minimize risk of contact with others
 Isolation to be continued until all lesions have resolved and scabs have completely fallen
off

Table 2: Supportive management of Monkeypox

Component of Symptoms/Signs Management
management
Protection of Skin rash  Clean with simple antiseptic
compromised skin  Mupironic Acid/Fucidin
and mucous  Cover with light dressing if extensive lesion present
membranes  Do not touch/ scratch the lesions
 In case of secondary infection relevant systematic
antibiotics may be considered
Genital ulcers  Sitz bath
Oral ulcers  Warm saline gargles/ oral topical anti-inflammatory
gel
Conjunctivitis  Usually, self-limiting
 Consult Ophthalmologist if symptoms persist or there
are pain/ visual disturbances
Rehydration therapy Dehydration can occur in  Encourage ORS or oral fluids
and nutritional association with poor appetite,  Intravenous fluids if indicated
support nausea, vomiting and diarrhoea  Encourage nutritious and adequate diet
Symptom alleviation Fever  Tepid sponging
 Paracetamol as required
Itching/Pruritus  Topical Calamine lotion
 Antihistaminics
Nausea and vomiting  Consider anti-emetics
Headache/ malaise  Paracetamol and adequate hydration

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7.3 Monitoring and treatment of complications
The patient should closely monitor for the appearance of any of the following symptoms during
the period of isolation:

 Pain in eye or blurring of vision

 Shortness of breath, chest pain, difficulty in breathing
 Altered consciousness, seizure
 Decrease in urine output
 Poor oral intake
 Lethargy

In case any of the above symptoms appear, the patient should immediately contact nearby
healthcare facility/ specialist.

8. Contact tracing
8.1 Definition of a contact
A contact is defined as a person who, in the period beginning with the onset of the source case’s
first symptoms, and ending when all scabs have fallen off, has had one or more of the following
exposures with a probable or confirmed case of monkey pox:
 face-to-face exposure (including health care workers without appropriate PPE)
 direct physical contact, including sexual contact
 contact with contaminated materials such as clothing or bedding

8.2 Contact identification

Cases can be prompted to identify contacts across household, workplace, school/nursery,
sexual contacts, healthcare, houses of worship, transportation, sports, social gatherings, and
any other recalled interactions.

8.3 Contact monitoring

a) Contacts should be monitored at least daily for the onset of signs/symptoms for a period
of 21 days (as per case definition above) from the last contact with a patient or their
contaminated materials during the infectious period. In case of occurrence of fever
clinical/lab evaluation is warranted.
b) Asymptomatic contacts should not donate blood, cells, tissue, organs or semen while they
are under surveillance.
c) Pre-school children may be excluded from day care, nursery, or other group settings.

10
d) Health workers who have unprotected exposures to patients with monkeypox or possibly
contaminated materials do not need to be excluded from work duty if asymptomatic, but
should undergo active surveillance for symptoms for 21 days.

Advisory for International Passengers and surveillance at Airports and Role of APHOs/PHOs
is also elaborated in Annexure 4.

9. Risk Communication and Preventive Measures

Raising awareness of risk factors and educating people about the measures they can take to
reduce exposure to the virus is the main prevention strategy for monkeypox. There are number
of measures that can be taken to prevent infection with monkeypox virus:

 Avoid contact with any materials, such as bedding, that has been in contact with a sick
person.
 Isolate infected patients from others.
 Practice good hand hygiene after contact with infected animals or humans. For example,
washing your hands with soap and water or using an alcohol-based hand sanitizer.
 Use appropriate personal protective equipment (PPE) when caring for patients.

9.1 Reducing the risk of human-to-human transmission

Surveillance and rapid identification of new cases is critical for outbreak containment. During
human monkeypox outbreaks, close contact with infected persons is the most significant risk
factor for monkeypox virus infection. Health workers and household members are at a greater
risk of infection. Health workers caring for patients with suspected or confirmed monkeypox
virus infection, or handling specimens from them, should implement standard infection control
precautions. Samples taken from people and animals with suspected monkeypox virus infection
should be handled by trained staff working in suitably equipped laboratories. Patient specimens
must be safely prepared for transport with triple packaging in accordance with WHO guidance
for transport of infectious substances.

9.2 Infection Prevention and Control (IPC)

A combination of standard, contact, and droplet precautions should be applied in all healthcare
settings when a patient presents with fever and vesicular/pustular rash. In addition, because of
the theoretical risk of airborne transmission of monkeypox virus, airborne precautions should
be applied as per risk assessment.

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Clinical triage includes early recognition and immediate placement of patient in separate area
from other patients (source control). All individuals, including family members, visitors and
HCWs should apply standard, contact and droplet precautions.

9.2.1 Patient isolation

Patient should be managed in isolation, precautions should be taken to minimize exposure to
surrounding persons, which include placing a surgical mask over the patient’s nose and
mouth—if tolerable to the patient—and covering any of the patient’s exposed skin lesions with
a sheet or gown.

9.2.2 Ambulance Transfer

 When a case has to be transported, the personnel accompanying the patient should wear
PPE (long sleeved gown, N95 mask, gloves, and goggles).
 Give prior information to the hospital of the admission/transfer of a potentially infectious
person.
 Request patient to wear a mask (if tolerated) and advise on Respiratory Hygiene and Cough
Etiquette.
 If lesions are present, cover them with long sleeved clothing/pant or a clean sheet to
minimize contact with others. In the ambulance use disposable linen if available.
 The ambulance should be cleaned and disinfected before using for the other patients. After
wearing PPE, surfaces (stretcher, chair, door handles etc.) should be cleaned with a freshly
prepared 1% hypochlorite solution or equivalent. Carefully place reusable blankets in a bag
without shaking or fluffing them, then put into a laundry bag and send for laundering clearly
labelling it so that person in the laundry wears appropriate PPE before handling or
autoclaves it before opening. Follow manufacturer’s instructions for cleaning/disinfecting
reusable equipment in the ambulance. All masks and any waste contaminated with crusts,
secretions, serum or body fluids should be disposed of as infectious waste in yellow bag.
In the ambulance, if the driver’s chamber is not separate, driver should also use PPE.

9.2.3 Additional Precautions

 PPE (Disposable gown, gloves, N95 mask, Eye goggles) should be donned before entering
the patient’s room and used for all patient contact. All PPE should be disposed of prior to
leaving the isolation room where the patient is admitted.
 Hand hygiene (following standard steps of hand hygiene) after all contact with an infected
patient and/or their environment during care.

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 Correct containment and disposal of contaminated waste (e.g., dressings) in accordance
with Biomedical Waste Management guidelines (2016 & subsequent amendments) for
infectious waste.
 Care when handling soiled laundry (e.g., bedding, towels, personal clothing) to avoid
contact with lesion material.
 Soiled laundry should never be shaken or handled in manner that may disperse infectious
particles.
 Care when handling used patient-care equipment in a manner that prevents contamination
of skin and clothing.
 Ensure that used equipment has been cleaned and reprocessed appropriately.
 Ensure provisions are in place for cleaning and disinfecting environmental surfaces in the
patient care environment.
 Hospital disinfectant currently used for environmental sanitation may be used as per
recommendations for concentration, contact time, and care in handling.

9.2.4 IPC at home

Patients who do not require hospitalization may be managed at home taking following
preventive measures:
 Patients should be isolated in a room or area separate from other family members. Healthy
household members should limit contact with the patient.
 Patients should not leave the home except for medical care.
 No visitors should be allowed at home.
 Patients, especially those who have respiratory symptoms (e.g., cough, shortness of breath,
sore throat) should wear a surgical mask. If this is not feasible, other household members
should consider wearing a surgical mask when in the presence of the patient.
 Disposable gloves should be worn for direct contact with lesions and disposed of after use.
 Skin lesions should be covered to the best extent possible (e.g., long sleeves, long pants) to
minimize risk of contact with others.
 Contain and dispose of contaminated waste (such as dressings and bandages) in the
Biomedical waste disposable bag Do not dispose of waste in landfills or dumps.
 Proper hand washing with soap and water (or use of an alcohol-based hand rub) should be
performed by the patient and other household members after touching lesion material,
clothing, linens, or environmental surfaces that may have had contact with lesion material.
 Laundry (e.g., bedding, towels, clothing) may be washed with warm water and detergent;

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 o Care should be used when handling soiled laundry to avoid direct contact with
contaminated material.
o Soiled laundry should not be shaken or otherwise handled in a manner that may
disperse infectious particles.
 Dishes and other eating utensils should not be shared. Soiled dishes and eating utensils
should be washed with warm water and dish washing soap.
 Contaminated surfaces should be cleaned and disinfected. Standard household
cleaning/disinfectants may be used in accordance with the manufacturer’s instructions.
 Pets and domestic animals should be excluded from the patient’s environment.

9.2.5 Duration of Isolation Procedures

Affected individuals should avoid close contact with immunocompromised persons and
pregnant women until all crusts are gone. Isolation precautions should be continued until all
lesions have resolved and a fresh layer of skin has formed.

10. Risk communication

This includes providing public health advice through the channels that target audiences use on
how the disease transmits, its symptoms, preventive measures and what to do in case of suspect
or confirmed infection. This should be combined with targeting community engagement to the
population groups who are most at risk, working closely with health care providers, including
STD clinics, and civil society organizations.

Risk communication should be informed by insights from social listening detecting public
sentiment and should timely address possible rumours and misinformation. Health information
and advice should be provided avoiding any form of stigmatization of certain groups such as
men who have sex with men (MSM).

The key measures that can be taken to prevent infection with monkeypox virus:
 Isolate infected patients from others who could be at risk for infection.
 Avoid contact with any materials, such as bedding, that has been in contact with a patient
of Monkeypox.
 Practice good hand hygiene after contact with infected persons. For example, washing your
hands with soap and water or using an alcohol-based hand sanitizer.
 Use masks and gloves when caring for patients.

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ANNEXURE-1: Case Reporting Format

15
16
ANNEXURE 2- Procedures for the clinical specimen collection:
 Nasopharyngeal and Oropharyngeal swabs in screw capped plain tube:
 Explain the procedure to the patient
 Remove the polystyrene swab. Don’t let anything touch the sterile swab on the end of
the stick
 Ask patient to open mouth and stick their tongue out
 Use tongue spatula to press the tongue downward to the floor of the mouth.
 Use sterile polystyrene swab to swab both of the tonsillar arches and the posterior
nasopharynx, without touching the sides of the mouth.
 Reach behind the uvula and swab: a. tonsillar fauces, b. the posterior pharynx, and c.
any ulceration, exudate, lesion, or area of inflammation.
 Don’t let the sterile swab touch the patient’s tongue, gums, or teeth as you gently
remove it from his/her mouth
 Place the swab into the screw-capped plain plastic tube [without any medium or VTM]
 Similarly, tilt patient's head back 70 degrees. Gently and slowly insert a polystyrene
swab with a flexible shaft through the nostril parallel to the palate until resistance is
encountered.
 The distance is equivalent to that from the nostril to the ear of the patient, indicating
contact with the nasopharynx
 Gently rub and roll the swab, leaving it in place for several seconds to absorb
secretions. If a deviated septum or blockage creates difficulty in obtaining the
specimen from one nostril, use the same swab to obtain the specimen from the other
nostril
 Slowly remove swab while rotating it. Specimens can be collected from both nostrils
 Place the swab into the same screw-capped plain plastic tube [without any medium or
VTM] in which the OPS swab was kept
 Break the excess stick and recap the tube tightly.
 Keep the tube in an upright position in the stand.
 Surface decontaminate the tube using 2% Lysol or 0.5-1% Sodium hypochlorite wipes

 Venous Blood Collection in SSGT and EDTA tube:

 Explain the procedure to the patient
 Check the patient’s fore-arm/median cubital fossa for a prominent vein of good size.
Use the median cubital vein wherever feasible.
 Apply the tourniquet 4-5 fingerbreadths above the site of venipuncture.
 Perform hand hygiene by using an alcohol-based hand rub on the outer pair of gloves.

17
  Disinfect the skin site using a wipe containing 70% alcohol, in a circular motion, from
the centre to periphery. Allow the skin to dry.
 Do not re-touch the site of puncture again. In case of accidental touch, repeat the skin
disinfection as above.
 Anchor the vein by holding your thumb below the puncture site.
 Ask the patient to make a fist so as to make the veins prominent.
 Insert the needle (vacutainer or syringe needle) into the vein, bevel side up, at an angle
of about 30⁰ and advance the needle into the vein.
 Collect 5 mL of blood (into the syringe or into tubes) and aliquot 2 ml in EDTA (Purple
top) 3 ml in SSGT (Yellow top) for serum separation.
 Release the tourniquet.
 Withdraw the needle gently and apply a piece of sterile gauze to the puncture site
 Ask the patient to gently press down on the gauze on the puncture site, keeping the arm
folded
 If a syringe and needle were used for collection, transfer the blood inside the tube by
piercing the stopper of the tubes placed firmly on a rack.
 Invert EDTA tubes gently 4-5 times to ensure proper mixing of the additives
 Keep the tubes in an upright position in the stand.
 Discard the syringe and needle into the sharp’s container
 Surface decontaminate the SSGT and the EDTA tube using 2% Lysol or 0.5-1%
Sodium hypochlorite wipes

 Urine sample collection in the screw capped sterile urine container:

 Explain the procedure to the patient
 Provide privacy to the patient
 First ask patient to wipe/clean the genitals
 Ask patient to urinate a small amount into the toilet bowl, and then stop the flow of
urine.
 Then collect a sample of urine into the clean or sterile container provided
 Ask the patient to collect about 3 to 5 mL of mid-stream urine sample into the
collection tube provided, taking care not to contaminate the outside of the container
 Ask patient to finish urinating into the toilet bowl
 Close the lid carefully and keep the container standing position
 Surface decontaminate the SSGT and the EDTA tube using 2% Lysol or 0.5-1%
Sodium hypochlorite wipes

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 Lesion roof, base scrapping, fluid and crust/scab collection [collect from multiple
sites]:
 Explain the procedure to the patient
 Sanitize the skin covered with lesion with 80% alcohol wipes to start the collection
 Remove the lesion roof using sterile scalpel or plastic scrapper
 Place the roof in the screw cap plain tube.
 Similarly, use 1ml intradermal syringe to collect the pustule/ vesicular fluids from
multiple lesions and collect in fresh screw cap plain tube
 Use the polystyrene swab to collect the scrapings from the base of the lesions by gentle
scrapping and put it in fresh screw cap plain tube
 The scab/crust if formed using polystyrene swab, should also be collected in fresh
screw cap plain tube

Procedures for the transport of the clinical specimens:

 Keep the samples immediately in +4 degree Celsius as soon as they are collected
 After collection of samples, appropriately labelled sample tubes need to be sealed with
parafilm
 Centrifuge the serum tube before shipment
 Tubes need to be wrapped with the absorbent tissue paper/cotton and paced in Zip lock
bags/Secondary receptacle
 Samples should be transported in dry ice as per the instruction provided in Annexure-
3 (adapted from the WHO Guidance on regulations for the transport of infectious
substances 2021-2022) along with the case record form provided with this document.

19
 ANNEXURE 3: INSTRUCTIONS ON SAMPLE PACKAGING AND TRANSPORT
*This is just visual representation. Use appropriate PPE and collection tubes as described
earlier in this document

STEP 1: ARRANGING THE SAMPLE VIALS

A B C

*Wear full set of appropriate *Seal the neck of the sample Cover the sample vials using
Personal Protective Equipment vials using parafilm to prevent absorbent material to contain
and identify the labelled sample leakage during transit. leakage, in the event of a
tubes breakage.

STEP 2: ARRANGING THE PRIMARY VIALS WITHIN A STURDY, LEAK-PROOF

SECONDARY CONTAINER

A B

20
 Option 1: Using a cryo-box as a secondary Option 2: Using a 50-mL centrifuge tube as a
container. (Seal the lid of the box after secondary container. (Seal the neck of the tube
arranging the samples, using cello.) using cello.)

C D

Placing the centrifuge tube inside a zip-lock Placing the zip-lock pouch inside a sturdy plastic
pouch container. (Seal the neck of the container using
cello.)

[Note: Sample vials can also be placed inside a zip-lock pouch, covered in absorbent
material and secured by heat-sealing or rubber bands. Then, the zip-lock pouch should be
placed inside another plastic pouch and secured.]

STEP 3: ARRANGING THE OUTER CONTAINER

A B C

21
Option 1: Option 2: Placing the completed Case
Report Form/Request Form
Using a thermocol box as an Using a hard-board box as an
inside a leak-proof, zip-lock
outer container and placing the outer container and placing the
pouch
secondary container within it, secondary container and the gel
surrounded by hard-frozen gel packs
packs

D E

Documents to accompany:
1) Packing list/Proforma
Invoice
2) Air way bill (for air transport)
(to be prepared by sender or
shipper)
3) Value equivalence
document (for road/rail/sea
transport)

Securing the zip-lock pouch with Attaching the labels:

the Case Report Form on the
 Sender’s Address and contact
outer container
number;
 Consignee’s Address and
contact number;
 Emergency Contact’s name
and number

22
ANNEXURE 4 -Advisory for International passengers
 Travelers should AVOID:
o Close contact with sick people, including those with skin lesions or genital lesions.
o Contact with dead or live wild animals such as small mammals including rodents (rats,
squirrels) and non-human primates (monkeys, apes).

o Eating or preparing meat from wild game (bushmeat) or using products derived from
wild animals from Africa (creams, lotions, powders).

o Contact with contaminated materials used by sick people (such as clothing, bedding, or
materials used in healthcare settings) or that came into contact with infected animals.

 Consult the nearest health facility if you develop symptoms suggestive of monkey pox
like fever with rash &
o You were in an area where Monkey pox has been reported
o You had contact with a person that might have had Monkey pox.

Role of APHOs/PHOs:
a. Remain in a state of alert, particularly for the passengers arriving from countries
reporting monkey pox outbreaks,
b. Familiarize with clinical presentation of monkey pox,

c. Undertake strict thermal screening and history of travel to affected countries in last 21
days,
d. Establish/strengthen referral arrangements from airport/port to identified link hospital.

e. Also, familiarize Bureau of Immigration personnel, airline personnel and any State
health personnel deployed with them about the disease,
f. Inform concerned airlines about detection of a suspect case for the purpose of
disinfection procedure to be followed as per standard guidelines.

23
 $EAI qFKI s{tDTT
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qil+d firi Government of lndia
Department of Health and Family Welfare

RAJESH BHUSHAN, IRS

7*
Nzadi6"
Ministry of Health and Family Welfare

D.O No. 2.2801 5123312022:.DMCel I

Amnt Mahotsav 14th July, 2022
SECRETARY

Dear- CZu,y-ort-,
This is in dntinuation of this Ministry's earlier communication vide DO No.
2.2801510612022; dated 31st May 2022 wherein a comprehensive 'Guidelines for
Management of Monkeypox Disease' issued by this Ministry was shared with all States/UTs.

2. As reported by World Health Organization (WHO), Since 1 January 2022 and as of

22 June2022, a total of 3413 laboratory confirmed cases of Monkeypox and one death have
been reported to WHO from 50 countries/territories. Majority of these cases have been
reported from the European Region (86%) and the Americas (11%). This points to a slow
but sustained increase in spread of cases globally. Considering this is the first time that
cases and clusters are being reported concurrently in five WHO Regions, WHO has
assessed the overall risk of spread of cases as "Moderate" at global level.

3. Continued expansion of spread of Monkeypox disease globally calls for proactive

strengthening and operationalization of requisite public health actions for preparedness and
response against the disease in lndia also.

4. I would, therefore, Iike to reiterate some of the key actions that are required to be
taken by all States/UTs in line with MoHFW's guidance issued on the subject:

a) Orientation and regular re-orientation of all key stakeholders including health

screening teams at Points of Entries (PoEs), disease surveillance teams, doctors
working in hospitals about common signs and symptoms, differential diagnosis, case
definitions for suspecUprobable/confirmed cases and contacts, contact tracing and
other surveillance activities that need to be undertaken following detection of a case,
testing, IPC protocols, clinical management etc.

b) Screening and testing of all suspect cases at points of entries, and in the community
(either through hospital based surveillance and targeted surveillance under measles
surveillance or intervention sites identified by NACO for MSM, FSW population)

c) Patient isolation (until all lesions have resolved and scabs have completely fallen off),
protection of ulcers, symptomatic and supportive therapies, continued monitoring and
timely treatment of complications remain the key measures to prevent mortality.

d) lntensive risk communication directed at healthcare workers, identified sites in health

facilities (such as skin, paediatric OPDs, immunization clinics, intervention sites
identified by NACO etc.) as well as general public about simple preventive strategies
and need for prompt reporting of cases needs to be undertaken.

e) Hospitals must be identified and adequate human resource and logistic support
should be ensured at identified hospitals equipped to manage suspecUconfirmed
cases of Monkeypo-
Room No. 156, A-Wing, Nirman Bhawan, New Delhi'110 011
Tele : (O) 011-23061863,23063221, Fax : 011-23061252, E-mail : [email protected]
 :2:

5. As COVID-19 pandemic continues to pose challenges, it is vitalwe remain aware and

alert about other public health threats and proactively prepare ourselves to tackle them.

6. I am sure, States/UTs shall make all efforts to ensure effective preparedness and
take required action as per the guidelines. Union Ministry of Health shall continue to monitor
the situation closely and will extend all requisite support in this regard.

,Aho- Yours sincerely

(Rajesh Bhushan)
=a
Additional Chief Secretary / Principal Secretary / Secretary (Health) of all States/UTs