Airborne Precautions Research Articles

Vaccine-associated measles in an immunocompromised host: Hospital infection prevention and control and public health response

Introduction: Vaccine-associated measles is generally not considered to be transmissible, as opposed to wild-type measles, which is one of the most highly contagious diseases. Data on contact and exposure management of vaccine-associated measles is limited, with varied approaches to such cases described in the literature. Methods: We report the case of a 2-year-old immunosuppressed child who developed a febrile exanthem with mild conjunctivitis 18 days after receiving the measles-mumps-rubella-varicella vaccine. Results: Given the patient's recent measles-containing vaccination while on immunosuppressive medications, consistent clinical findings and the lack of epidemiological risk factors for wild-type infection, the decision was made to treat this as a presumptive case of vaccine-associated measles virus prior to return of confirmatory genotyping results. After consultation with public health experts, contact tracing was not considered necessary. No secondary measles cases were identified, despite a large exposure potential due to lack of consistent airborne precautions during hospital admission. Discussion: This case highlights the lack of transmissibility of vaccine-associated measles in immunocompromised hosts, adding to the scant body of literature on this topic, with the potential to inform hospital infection prevention and control as well as public health management in similar situations.

A time-motion study on impact of spatial separation for empiric airborne precautions in emergency department length of stay.

To evaluate the impact of spatial separation on patient flow in the emergency department. This was a retrospective, time-and-motion analysis conducted from 15 to 22 August, 2022 at the emergency department of a tertiary hospital in Kuala Lumpur, Malaysia. During this duration, spatial separation was implemented in critical and semi-critical zones to separate patients with symptoms of respiratory infections into respiratory area, and patients without into non-respiratory area. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Patients triaged to critical and semi-critical zones were included in this study. Timestamps of patient processes in emergency department until patient departure were documented. The emergency department length-of-stay was longer in respiratory area compared to non-respiratory area; 527 min (381-698) versus 390 min (285-595) in critical zone and 477 min (312-739) versus 393 min (264-595) in semi-critical zone. In critical zone, time intervals of critical flow processes and compliance to hospital benchmarks were similar in both areas. More patients in respiratory area were managed within the arrival-to-contact ≤30 min benchmark and more patients in non-respiratory area had emergency department length-of-stay ≤8 h. The implementation of spatial separation in infection control should address decision-to-departure delays to minimise emergency department length of stay. The study evaluated the impact of spatial separation on patient flow in the emergency department. Emergency department length-of-stay was significantly prolonged in the respiratory area. Hospital administrators and policymakers can optimise infection control protocols measures in emergency departments, balancing infection control measures with efficient patient care delivery. STROBE guidelines. None. The study obtained ethics approval from the institution's Medical Ethics Committee (MREC ID NO: 20221113-11727). The author has checked and make sure our submission has conformed to the Journal's statistical guideline. There is a statistician on the author team (Noor Azhar).

Not Your Usual Exposure: Tuberculosis Contact Investigation Related to Contaminated Bone Allograft

Background: Mycobacterium tuberculosis transmission through contaminated bone allograft product is unusual and was first described in 2021 with a second outbreak in 2023. In July 2023, Michigan Medicine conducted contact tracing for healthcare personnel (HCP), patients, and visitors following exposure to an immunocompromised patient with surgical site infection and subsequent widely disseminated tuberculosis (bacteremia, pulmonary, lymphadenopathy) following spinal fusion with bone allograft in April 2023. The patient was in the emergency department, operating room (OR), and inpatient units for 9 days prior to initiation of Airborne Precautions (AP). Methods: Michigan Medicine is a 1,107 bed academic hospital. HCP are screened for tuberculosis with interferon-gamma release assay (IGRA) testing upon hire and following tuberculosis exposure. Exposure testing includes baseline IGRA testing and follow-up testing at 10-12 weeks post exposure. Exposure criteria for this investigation was defined as sharing room airspace with the tuberculosis patient prior to initiation of airborne precautions or Central Sterile Processing Department (CSPD) staff involved with instrument decontamination without the use of a respirator. Of note, universal masking with surgical masks was not required during this time for staff and patients/visitors, with the exception of CSPD and OR staff. Contact tracing was performed by Infection Prevention and Occupational Health Services managed all test results and conversions. Results: 176 employees from perioperative care areas (n=30), CSPD (n=7), OR (n=9) and inpatient units (n=130) were IGRA tested. Five employee conversions were identified: one surgeon, one circulating OR nurse, two CSPD decontamination staff, and one respiratory therapist. At time of detection, none of the conversions had evidence of active tuberculosis. Additionally, 46 patients and visitors were tested with zero conversions. HCP compliance with IGRA testing was initially 15% before engagement from hospital and unit leadership and human resources. With intervention, employee compliance reached 100%. Conclusion: Despite standard use of surgical masks for OR and CSPD staff, aerosolization of infected bone graft material played an important role in tuberculosis transmission during surgery and instrument cleaning. Respiratory therapy practices in the ICU setting likely also increased risk for pulmonary tuberculosis transmission. Achieving 100% HCP compliance for baseline and follow-up IGRA testing is challenging and requires engagement of both unit and hospital leadership and human resources to ensure all HCP are tested.

Knowledge and Practices of Airborne Infection Control at the Household Level among Pulmonary Tuberculosis Patients Attending a Tertiary Care Teaching Hospital in Central Karnataka, India

Abstract Background: Airborne transmission of tuberculosis (TB) is a major route of spread. Household contacts of TB patients are at high risk of infection. However, there is limited evidence on airborne infection control knowledge and practices among TB patients in India. This study was done to assess the knowledge and practices related to airborne infection control among pulmonary TB (PTB) patients at the household level and determine associated factors. Subjects and Methods: A cross-sectional study was conducted among 157 smear-positive PTB patients at a tertiary care hospital in Karnataka, India, using a pretested questionnaire. Knowledge and self-reported practices regarding airborne precautions were assessed. Bivariate analysis was done to determine associated factors. P <0.005 was considered significant. Results: Major gaps were found in knowledge about ventilation (50.3%), avoiding visitors (39.5%), and sputum disposal (33.8%). Suboptimal practices were reported for using tissues (19%), handwashing (25%), ventilation (66%), sputum handling (54%), and waste disposal (30%). Good knowledge was associated with younger age, higher education, Hindu religion, family history of TB, intensive phase treatment, and presence of symptoms (P < 0.05). Participants with good knowledge had significantly better preventive practices (P < 0.00001). Conclusion: Tailored education on airborne precautions focusing on identified knowledge gaps and risky practices can help improve the adoption of infection control measures among TB patients at the household level. A multifaceted approach is required to translate improved awareness into optimal preventive behaviors.

Educational needs of community visiting nurses for infection prevention and control: Application of the Borich needs assessment and the Locus for Focus models.

This study aimed to assess the educational needs and analyze the priorities of infection prevention and control (IPC) for community-visiting nurses. This is a cross-sectional descriptive study. This study was conducted with 144 visiting nurses working in public health centers and long-term care facilities in South Korea. A total of 23 questions in five subcategories were used to measure the current knowledge and perceived importance of IPC in community-visiting nursing. Data were collected from June 23 to October 30, 2021, during the COVID-19 pandemic. Data were analyzed paired t-test, the Borich needs assessment, and the Locus for Focus models. Top-priority content was defined as content belonging to two models, the first 10 contents of Borich needs assessment and the contents located in the Quadrant I of the Locus for Focus models. "Reporting in case of infection-related accidents," "Mandatory vaccination for visiting nurses," "Standard precaution," "Airborne precaution," "Contact precautions," "Respiratory infection control," and "Post-visit management." This study suggests that it is necessary to provide visiting nurses with more opportunities for IPC education and to develop standardized IPC programs that consider educational priorities.

Risk factors for transmission of carbapenem-resistant Acinetobacter baumannii in outbreak situations: results of a case-control study

BackgroundAn increase in patients with multidrug-resistant organisms and associated outbreaks during the COVID-19 pandemic have been reported in various settings, including low-endemic settings. Here, we report three distinct carbapenem-resistant Acinetobacter baumannii (CRAB) outbreaks in five intensive care units of a university hospital in Berlin, Germany during the COVID-19 pandemic.MethodsA case-control study was conducted with the objective of identifying risk factors for CRAB acquisition in outbreak situations. Data utilized for the case-control study came from the investigation of three separate CRAB outbreaks during the COVID-19 pandemic (August 2020– March 2021). Cases were defined as outbreak patients with hospital-acquired CRAB. Controls did not have any CRAB positive microbiological findings and were hospitalized at the same ward and for a similar duration as the respective case. Control patients were matched retrospectively in a 2:1 ratio. Parameters routinely collected in the context of outbreak management and data obtained retrospectively specifically for the case-control study were included in the analysis. To analyze risk factors for CRAB acquisition, univariable and multivariable analyses to calculate odds ratios (OR) and 95% confidence intervals (CI) were performed using a conditional logistic regression model.ResultsThe outbreaks contained 26 cases with hospital-acquired CRAB in five different intensive care units. Two exposures were identified to be independent risk factors for nosocomial CRAB acquisition by the multivariable regression analysis: Sharing a patient room with a CRAB patient before availability of the microbiological result was associated with a more than tenfold increase in the risk of nosocomial CRAB acquisition (OR: 10.7, CI: 2.3–50.9), while undergoing bronchoscopy increased the risk more than six times (OR: 6.9, CI: 1.3–38.1).ConclusionsThe risk factors identified, sharing a patient room with a CRAB patient and undergoing bronchoscopy, could point to an underperformance of basic infection control measure, particularly hand hygiene compliance and handling of medical devices. Both findings reinforce the need for continued promotion of infection control measures. Given that the outbreaks occurred in the first year of the COVID-19 pandemic, our study serves as a reminder that a heightened focus on airborne precautions should not lead to a neglect of other transmission-based precautions.

Infection prevention and control measures to reduce the transmission of mpox: A systematic review.

To make inferences regarding the effectiveness of respiratory interventions and case isolation measures in reducing or preventing the transmission of mpox based on synthesis of available literature. The WHO Clinical Management and Infection Prevention and Control 2022 guideline and droplet precautions in healthcare facilities and home isolation infection prevention control measures for patients with mpox. We conducted a systematic review that included a broad search of five electronic databases. In a two-stage process, we initially sought only randomized controlled trials and observational comparative studies; when the search failed to yield eligible studies, the subsequent search included all study designs including clinical and environmental sampling studies. No studies were identified that directly addressed airborne and droplet precautions and home isolation infection prevention control measures. To inform the review questions the review team synthesized route of transmission data in mpox. There were 2366/4309 (54.9%) cases in which investigators identified mpox infection occurring following transmission through direct physical sexual contact. There were no reported mpox cases in which investigators identified inhalation as a single route of transmission. There were 2/4309 cases in which investigators identified fomite as a single route of transmission. Clinical and environmental sampling studies isolated mpox virus in a minority of saliva, oropharangeal swabs, mpox skin lesions, and hospital room air. Current findings provide compelling evidence that transmission of mpox occurs through direct physical contact. Because investigators have not reported any cases of transmission via inhalation alone, the impact of airborne and droplet infection prevention control measures in reducing transmission will be minimal. Avoiding physical contact with others, covering mpox lesions and wearing a medical mask is likely to reduce onward mpox transmission; there may be minimal reduction in transmission from additionally physically isolating patients with mild disease at home.

Awareness of droplet and airborne isolation precautions among General Dental Practitioners after the outbreak of corona virus infection in Libya

Aims and Objective: The purpose of this study is to obtain the level of knowledge and practice among Libyan General Dental Practitioners to wards droplet and airborne isolation precautions in Zawia city, Libya. Material and Methods: A cross sectional survey was conducted among 110 General Dental Practitioners work at dental Hospital in Zawia, Libya. A self-assessment questionnaire composed of queries on two levels, namely knowledge and practices with respect to airborne and droplet isolation precautions was used. The data was collected and statically analyzed. Results the survey was completed by 100 potential respondents. The present study showed aware General Dental Practitioners about knowledge more than practice towards droplet and airborne isolation precautions. Conclusion: General Dental Practitioners seemed to have high levels of knowledge and good practice towards infection control after the outbreak of corona virus infection.

Knowledge, Attitude and Practices Regarding Tuberculosis Infection Control Practices among Health Care Workers at Tertiary Care Centre, Rajnandgaon

Tuberculosis infectious disease owns highest burden of respiratory infection. India being the largest contributor to global Tuberculosis cases. Mycobacterium tuberculosis mode of transmission by respiratory route require airborne precautions to be strictly followed in healthcare settings to minimize the transmission. Research was plan to assess fundamentals of Tuberculosis infection control among healthcare workers. Questionnaire based cross-sectional study which included sociodemographic characteristics, with twenty-five questions on knowledge of Tuberculosis, attitude and practices for Tuberculosis infection control was conducted in Bharat Ratna Late Shri Atal Bihari Vajpayee Memorial Medical College, Rajnandgaon Chhattisgarh from April 2023 to May 2023. 156 HCWs with mean age group 36 ± 9.7 (18-59) years participated in the study. Healthcare workers included were nurses (55.1%) and technicians (44.8%). Knowledge and attitude score observed in our study is 90.3% and 92.3% levelled as good to moderate but at the same time good to moderate practice observed is 59.6%. Certain deficiencies regarding some areas of preventive measures of tuberculosis was observed among participants which require improvement by conducting training sessions.

SIR Flat CAP (Safety In Radiology - Flat-Packed Compact Airborne Precaution): A Low-Cost, Portable, Negative-Pressure Isolation Barrier Shield for Protecting Frontline Healthcare Workers.

Introduction Multiple barrier shields have been described since the start of the COVID-19 pandemic. Most of these are bulky and designed for use in the main anesthetic or radiology departments. We developed a portable, negative-pressure barrier shield designed specifically for portable ultrasound examinations.A novel supine cough generation model was developed together with a reverse qualitative fit test to simulate real-world aerosol droplet generation and dispersion for evaluating the effectiveness of the barrier shield.We report the technical specifications of this design, named "SIR Flat CAP" from Safety In Radiology - Flat-packed Compact Airborne Precaution, as well as its performance in reducing the spread of droplets and aerosols. Methods The barrier shield was constructed using 1 mm acrylic panels, clear packing tape, foam double-sided tape, and surgical drapes. Negative pressure was provided via hospital wall suction. A supine cough generation model was developed to simulate cough droplet dispersal. A reverse qualitative fit test was used to assess for airborne transmission of microdroplets. Results The supine cough generation model was able to replicate similar results to previously reported supine human cough generation dispersion. The use of the barrier shield with negative-pressure suction prevented the escape of visible droplets, and no airborne microdroplets were detected by reverse qualitative fit testing from the containment area. Conclusions The barrier shield significantly reduces the escape of visible and airborne droplets from the containment area, providing an additional layer of protection to front-line sonographers.

Knowledge of Droplet Infection and Airborne Isolation Among Dental Students in South India: A Questionnaire Study.

Background Infections can spread within the dental clinic through many routes. Interrupting this transmission of infection within the dental office is an important part of the dental practice. This study aimed to assess the knowledge, attitude, and practice regarding precautions against droplet and airborne infections among dental students in South India. Methodology A cross-sectional, questionnaire-based survey was conducted among 236 undergraduate dental students in Chennai. The questionnaire consisted of 11 questions in three categories of knowledge, attitude, and practice regarding airborne and droplet isolation precautions. The collected data were compiled and analyzed using SPSS version 13 software (SPSS Inc., Chicago, IL, USA). Results The frequency scores of knowledge, attitude, and practice regarding droplet and airborne isolation precautions showed that dental students were very much aware of the precautions and the guidelines. The mean scores for knowledge, attitude, and practice were 7.70 ± 2.48, 37.22 ± 6.98, and 7.1 ± 1.64, respectively. There were no significant differences among subgroups (third-year students, fourth-year students, and interns) regarding knowledge, attitude, and practice. A positive linear correlation was observed between knowledge and attitude, knowledge and practice, and attitude and practice (p < 0.05). Conclusions According to the results of this study, dental students had adequate knowledge, positive attitudes, and compliance. Training programs on isolation precautions are needed to sustain and update the knowledge according to the changing trends in infectious diseases.

Standard precautions should include 'safe ventilation' to minimise far-afield airborne transmission in health and social care settings.

Standard precautions should include 'safe ventilation' to minimise far-afield airborne transmission in health and social care settings.

A Review on Monkeypox

Monkeypox is a re-emerging zoonotic disease caused by a DNA virus that belongs to the orthopox virus genus of the Poxviridae family. After the eradication of smallpox in 1980, monkeypox has gradually emerged as the most important orthopox virus from a public health perspective. Monkeypox typically causes fever, chills, rash, and lesions on the face or genitals. MPXV (monkeypox virus) is considered a large virus that measures about 200–250 nm with the appearance “brick-like” or ovoid shape, The virus’s original source is wild animals. It can be found in a variety of mammals including squirrels, mangabey monkeys, and Gambian rats. Viral transmission can occur through direct and indirect contact with live or dead animals, including handling wild game, a bite or scratch, or contact with fluids or lesions from an infected animal. Human-to-human transmission likely occurs through contact with lesions, body fluids, contaminated bedding or clothing, and exposure to respiratory droplets from infected persons. Animal-to-human transmission of MPXV may occur via animal bites or scratches by infected small mammals, including rodents and nonhuman primates, or through the consumption of bush meat. Any patient with a fever and disseminated vesicular or pustular rash should be immediately placed on airborne and contact precautions, as these are the classic symptoms of Orthopox virus infections. smallpox antivirals with poxvirus activity, such as cidofovir, brincidofovir, and tecovirimat, are active against the monkeypox virus. Monkeypox is usually a self-limiting disease; however, new-borns, children, and people with underlying immune deficiencies may be at risk of more serious illness and death.

Emerging and re-emerging viral diseases, predisposing risk factors, and implications of international travel: a call for action for increasing vigilance and imposing restrictions under the current threats of recently emerging multiple Omicron subvariants.

Emerging and re-emerging viral diseases, predisposing risk factors, and implications of international travel: a call for action for increasing vigilance and imposing restrictions under the current threats of recently emerging multiple Omicron subvariants.

First case of mpox diagnosed in Queensland, Australia: clinical and molecular aspects.

First case of mpox diagnosed in Queensland, Australia: clinical and molecular aspects.

Health and Safety Regulations for COVID-19: A Policy Analysis.

The COVID-19 pandemic spurred some regulators in the USA to require occupational health and safety programs to prevent COVID-19 transmission in workplaces. The objective of this study was to describe such state and federal regulations enacted between January 2020 and January 2022. Regulations, including emergency temporary standards (ETS) and permanent standards, were identified through a search of Nexis Uni and Bloomberg Law and review of US OSHA websites and the Federal Register. Full texts were reviewed for regulatory scope, hazard and exposure definitions, determination of exposure or risk levels, and control strategies. Four state (California, Michigan, Virginia, and Oregon) and two federal regulations were identified. All regulations described respiratory aerosols as the primary source of SARS-CoV-2 and recognized person-to-person transmission by droplet, airborne, and contact routes. Only the US OSHA ETS for healthcare explicitly stated that inhalation of respiratory particles was the most likely method of COVID-19 transmission. The Virginia, Michigan, and Oregon regulations described different categories of risk defined by exposure frequency and duration or specific workplace activities. California described exposure as places and times when employees come into contact or congregate with other people. The US OSHA ETS for healthcare described exposure as involving close contact with suspected or confirmed COVID-19 patients. While all of the state regulations required strategies from across the hierarchy, only the Virginia regulations specifically incorporated the hierarchy of controls. Only the California and Virginia regulations explicitly linked control strategies to the transmission route, while Virginia demarcated control strategies by risk level. Oregon linked risk level to occupancy levels and physical distancing requirements and referred to the use of a layered approach for transmission control. The US OSHA ETS for healthcare defined droplet and airborne precautions but made no mention of the hierarchy of controls or risk levels. Respirators were discussed in most of the regulations. The first Michigan regulation explicitly required respirators appropriate to exposure risk. The California regulations noted that respirators protect the wearer while face coverings protect people around the wearer. These regulations offer insights for a permanent US OSHA infectious disease regulation, such as the need to consider a range of transmission modes including near- and far-range aerosol inhalation, endemic and novel pathogens, workplaces beyond healthcare settings, factors that contribute to exposure and risk, the hierarchy of controls, the role of vaccination, and the importance of written exposure assessment and infection prevention plans.

Development of a qualitative respirator fit testing program for BSN students

The COVID-19 pandemic has impacted the nursing student clinical experience. At the time of this project, hospitals hosting students for clinical experiences had a high population of COVID-19 positive patients. University and hospital policies at the time prohibited students from caring for COVID-19 patients due to the inability to safely ensure that students could access the proper protective equipment (PPE) necessary when caring for patients in airborne precautions. Infection control guidelines for patients in airborne precautions require a N95 respirator to be always worn by healthcare providers. These respirators require yearly fit test following OSHA (Occupational Safety and Health Administration) standards. Hospitals do have the resources to complete N95 fit tests for nursing students. The solution was to provide qualitative N95 mask fit testing, performed by university faculty, staff, and students using OSHA guidelines and standards. Within 3 months, over 50% of the student population had been fit tested, which increased the clinical opportunities for the students.

A Novel Approach to Emergency Department Readiness for Airborne Precautions Using Simulation-Based Clinical Systems Testing.

Study objectivesEmergency department (ED) COVID-19 preparations required rethinking workflows and introducing the potential for errors. Simulation provides a nimble methodology integrating into situ training and systems testing to prepare staff, detect potential workflow latent safety threats and provide recommendations for mitigation.MethodsWe developed 5 onsite rapid-cycle ED simulation cases using “tipping points” related to new protocols coupled with a structured observation tool. Staff observed simulations, recorded adherence to protocols, identified safety threats, discussed mitigation strategies, and participants completed an evaluation using a 5-point Likert scale. Latent safety threats were prioritized by risk and escalated to leadership.ResultsThrough 44 simulations, 76 staff identified 31 unique latent safety threats in the following categories: job aids 9 (29%), isolation measures 8 (26%), communication and personnel 6 (19%), and technology and equipment 8 (26%). Eleven high-priority safety threats were escalated to ED leadership. Sixty-five staff (86% of participants) completed a web-based evaluation reporting that simulations were worth the time (86% strongly agreed), an effective way to test the system (92% strongly agreed), and an acceptable way to improve (92% strongly agreed).ConclusionOur study demonstrated that simulation-based clinical systems test methods are adaptable for rapid preparedness evaluation and training. In combination with rapid-cycle deliberate practice, many latent safety threats were identified prior to clinical implementation. Our work highlights a novel application of simulation systems to increase system preparedness and reduce the potential for errors which may be applicable in diverse settings for designing, evaluating, and training staff in new protocols and procedures.

Changing Epidemiology: Outbreak of Monkey Pox

Monkeypox is a viral illness endemic to African countries. 20 May 2022, W.H.O alarmed all countries on the outbreak of the monkeypox virus1. Symptoms include headache fever swollen lymph nodes lethargy and the development of rash. Two types of clades (strains) are found that is central and West African clades. A central clade is more infectious than a western clade. A western clade is self-limiting within 2-3 weeks with a case fatality rate of 1% while the central clade is a 10% fatality rate. Monkeypox virus causes monkeypox a zoonotic disease which belongs to the poxviridae family2 which is closely related to the smallpox virus. Indicated from historical data smallpox vaccination with vaccinia virus (orthopoxviral) was 85% protective against monkey pox3. Danish laboratory in 1958 discover the virus in monkeys from where its name monkey pox originates4. The first case was discovered in a 9-month baby for the first time in Congo in 19705. A previous systematic review of the summer of 2018 described the epidemiological outbreak of the monkeypox virus6. United Kingdom’s first case was presented on 16 May 24, 2022, after laboratory confirmation7. The incubation period of monkeypox ranges from 6-13 days with possible extension to 5-21 days. The illness consistently ends by 2-4 weeks. Smallpox vaccines provide adequate protection against the monkeypox virus. World health organization suggests that health workers who are treating or exposed to monkeypox patients or their laboratory samples be immunized against smallpox. Effective laboratory investigation is a significant measure for identification and management. PCR on multiple lesions from various sites can be utilized to diagnose the potential condition. It should be sent to the government public lab and the control &amp; command center must be notified. Refrigerated (2-8c) samples should be sent within 5 days of collection. Sample of swab should be of nylon, polyester, or Dacron swab with plastic, wood, or thin aluminum shaft. International support for increased surveillance and detection is important for monkeypox cases for understanding the changing epidemiology of the resurging disease. In the current environment of pandemic threats, the public health importance should not be underestimated. Outside of African countries appearances of cases highlights the risk of geographical spread. Discontinuation of the smallpox vaccine has created a landscape for monkeypox. Government guidelines for emergency diseases should be used with proper notification of case reports to the directorate. Personal protection equipment with equipped labs should be provided. All children less than 12 should be vaccinated with smallpox vaccines. A combination of standard, contact, droplet and airborne precaution should be used. Place the patient in a single room with a portable HEPA filter or airborne infection isolation room. Staff from equipped laboratories should obtain samples from suspected/confirmed monkeypox virus infection. Appropriate personal protective equipment (PPE) should be provided and disposed of properly before leaving the room. Monitoring and tracing contact must be maintained and recorded. World health organization effective hand hygiene five moments should be performed by healthcare workers frequently. Use guidelines for correct containment and disposal of contaminated waste. Be care full always with the soiled laundry to avoid contact with lesion material and used PPE materials. Ensure procedures are in place for cleaning and disinfecting environmental surfaces in patient care zones. Always use the government of Pakistan’s national health guidelines for emergencies.

Co-infection of COVID-19 and Monkeypox: A Case Report from Florida, USA, 2022

Monkeypox is a re-emerging zoonotic disease of the orthopoxvirus genus presenting with myocutaneous symptoms similar to those caused by smallpox. Patients infected with monkeypox may experience a prodromal period with flulike symptoms lasting between 1-4 days, an asymptomatic incubation period lasting 7-17 days and a symptomatic rash period lasting 14-28 days between the appearance of widespread vesiculopapular lesions and desquamation. Specific risk factors for the current monkeypox outbreak include HIV infection, prior STI infection, male sex, young-adult age (specifically being in the 20’s-30’s age group), engaging in risky behaviors (such as unprotected sex) and men having sex with other men. We report the case of a 38-year old HIV+ patient testing positive for monkeypox, COVID-19 and herpes who presented to the emergency department with widespread vesiculopapular lesions. One week prior to ED presentation, the patient experienced flu-like symptoms including fever and, two days later, developed a vesiculopapular rash beginning on his face and spreading downwards to his extremities, trunk and genitalia. The flu-like symptoms developed twelve days after attending an event where the patient reported having sex with multiple other men. The patient was treated with intravenous fluids and supportive care alongside his HIV medications. Nine days after initial ED presentation, all skin lesions were desquamated and the patient was discharged from the hospital. To our knowledge, this is one of the first reported cases of co-infection with COVID-19 and monkeypox in Florida and the United States more broadly. Despite our patient’s several risk factors for monkeypox infection, and immunosuppressed status, he experienced an uncomplicated clinical course. As vaccination and antiviral treatments become more available for monkeypox patients, our case suggests supportive care with airborne and contact precautions may be adequate in the treatment of future monkeypox patients where these treatments are unavailable.