With the atypical presentation and wide reach of the current mpox outbreak, we recommend that, while in the hospital setting, suspected or confirmed cases should be warded in a single room with dedicated facilities and with droplet and contact precautions. This is to prevent inadvertent nosocomial transmission to other patients and to HCPs. If available, patients with confirmed mpox infection may be placed under negative pressure, airborne isolation. All HCPs interacting with the patient should don PPE, including a full gown, gloves, eye protection with goggles or face shields, and an N95 respirator or equivalent mask. These recommendations are consistent with the PHAC’s and CDC’s interim guidance on infection control for patients with suspected or confirmed mpox.23,24,26 Ideally, staff at high risk of severe disease (e.g., pregnant or severely immunocompromised individuals) should not provide direct care for patients with confirmed mpox.

With possible risk of transmission to HCPs and other patients, or progression to more severe disease, nonurgent surgeries and procedures should be postponed until the patient is deemed noninfectious and/or deisolated. If the surgery is nonurgent or elective, the patient can be discharged for home isolation if deemed safe. The patient can be readmitted for surgery after documentation of recovery from mpox. This can help minimize transmission to HCPs and other inpatients, and save hospital bed resources.

Nevertheless, if the surgery is emergent or essential, full precautions must be observed perioperatively. During transfer from isolation to the OR, the patient should wear a surgical mask, and skin lesions should be covered with a clean sheet or gown. The HCPs accompanying the patient should wear full PPE as described above, with a dedicated cleared route, when possible, to minimize lateral exposure. The receiving OR should ideally be negative or neutral pressure, and HCPs should wear full PPE. The patient should also be extubated and recover in the OR, observed as necessary, and then transported back to the isolation room.

While the primary route of respiratory transmission is due to droplets and not airborne spread, we believe it is prudent for surgeries and anesthesia to be performed in a negative pressure or minimal neutral pressure OR when available, as there is a risk of spread of oral secretions and droplets during AGPs such as bag-mask ventilation, laryngeal mask airway insertion, endotracheal intubation, and extubation. This should be considered whenever possible, as there may be immunocompromised or pregnant patients within the OR complex who may be susceptible to higher morbidity than healthier individuals in the case of inadvertent transmission via possible airborne routes. This is also supported by CDC recommendations.24 Aerosol-generating procedures should be done with the door closed and with minimal HCPs present. If negative pressure rooms are not available the high air exchanges in the OR should be sufficient since the patient is intubated and all staff are wearing N95 masks and full PPE. Procedures can be done under regional anesthesia or sedation to minimize AGPs. Single-use disposable equipment should be used as far as possible to prevent cross contamination.

Gloves should always be worn during direct contact with suspected mpox patients, regardless of skin lesions, along with careful hand hygiene before and after removing the gloves. HCPs should remove their PPE using the proper steps to reduce self- and cross-contamination.27

If an HCP has a breach in PPE while managing a confirmed or suspected case, they should immediately wash the exposed area with soap and water. The breach should be reported as per the hospital occupational health guidelines, with consideration for post-exposure prophylaxis (PEP) if indicated.25

Care is required to avoid or minimize direct contact with the patient’s gown or bedsheets/linen to prevent indirect transmission. Personnel who clean the OR should place all used linen and patient’s clothes in laundry bags while wearing full PPE. The contaminated linen/clothing should never be shaken or tossed as this can disperse infectious material.

If the anesthesiologist is involved in the care and management of pain in mpox patients, similar recommendations of PPE use during interactions with such patients is prudent. Gloves and disposable gowns should be worn. Despite transmission being described as largely contact and droplet based, most countries’ infection-control authorities recommend using at least an N95 respirator.23,24 Proper hand hygiene should be followed after interaction and doffing of the PPE.

Healthcare providers who have interacted with mpox patients should be risk-stratified based on exposure to higher, middle and lower risk groups, and should self-monitor for 21 days after the last exposure. We extrapolate from the CDC’s community exposure risk assessment and the PHAC’s interim guidance for the hospital setting further detailed in Table.26,28

Although appropriate use of PPE largely mitigates the risk of transmission,29 self-monitoring requires little effort beyond education. As long as an avenue is provided for the HCP to seek further clarification and help, self-monitoring even for those with very low risks can serve as a safety net for mitigating further virus transmission. Those who are asymptomatic, with low to middle exposure risks, can continue to work. The presence of any symptoms suggestive of mpox should prompt self-isolation and immediate notification to their hospital infectious diseases (ID) and epidemiologic teams for further follow-up and treatment. Those with high-risk exposures but are asymptomatic should follow up with their local infection control team and self-monitor their symptoms closely. Guidelines generally allow such HCPs to continue working, but PEP is strongly recommended for these individuals.24 Isolation may still be considered for these high-risk exposure HCPs so as to limit possible inadvertent nosocomial transmission or spread through the hospital setting.