Mpox Exposure in Long-Term Care: A Case Study in Infection Prevention Success

Mpox

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Preventing infections in long-term care facilities (LTCFs) is a constant challenge, especially when health care workers unknowingly work while contagious. Protecting the vulnerable patients and the rest of the staff is crucial, whether it is a cold, influenza, or something like mpox.

“LTCFs are a challenging infection prevention environment because of congregate living of older, possibly immunocompromised residents who might have loss of skin integrity,” authors of a recent study wrote. “Additionally, LTCFs frequently face staffing shortages, possibly leading employees to work while infectious with a communicable disease.⁵ Staffing pressures might inadvertently encourage “presenteeism,” the practice of working while sick. Certified nursing assistants (CNAs) work closely with residents, engaging in physical contact through assistance with hygiene, feeding, and dressing.”

The study published in the American Journal for Infection Control titled, “Lack of mpox transmission in an LTCF despite widespread exposure—Kentucky, 2023” highlights a significant infection control challenge in LTCFs involving a CNA who worked 3 shifts while infectious with mpox virus (MPXV). Despite direct contact with nearly all 56 LTCF residents, no secondary infections were detected. This case provides valuable insights for infection prevention and control (IPC) professionals on mitigating transmission risks and reinforcing standard precautions in health care settings. What went right in this case, and how can health care facilities strengthen their defenses against infectious disease threats? Let’s explore the key takeaways.

Key Takeaways for IPC Professionals

1. The Role of Standard Precautions in Preventing Transmission

The absence of secondary cases suggests that consistent adherence to standard precautions, particularly glove use, was crucial in preventing MPXV transmission. To prevent pathogen spread in LTCFs, IPC professionals should emphasize the importance of standard precautions, including hand hygiene, proper glove donning and doffing, and avoiding direct skin-to-skin contact with potentially infected individuals. Routine compliance monitoring and staff education on infection prevention strategies should be prioritized.

2. Infection Risks in Long-Term Care Settings

LTCFs present unique infection control challenges due to shared living spaces, frequent physical contact between staff and residents, and a high prevalence of immunocompromised individuals. Residents often require assistance with personal care, increasing the likelihood of exposure to infectious agents. IPC teams should conduct regular risk assessments to identify potential vulnerabilities in infection prevention protocols, particularly in settings where high-contact care is common.

3. Addressing the Risk of Presenteeism in Health Care Workers

Staffing shortages in health care settings, especially in LTCFs, often lead to “presenteeism”—working while ill due to fear of burdening colleagues or losing income. In this case, the CNA worked multiple shifts while symptomatic, increasing exposure risks. To mitigate this issue, IPC professionals should advocate policies encouraging staff to report symptoms early and take leave when necessary. Clear communication about sick leave policies and ensuring adequate staffing levels can reduce presenteeism and minimize the risk of infectious disease transmission.

4. Timely Identification and Response to Exposures

A 16-day delay between symptom onset and diagnosis highlights the need for improved early detection and reporting mechanisms in LTCFs. IPC teams should implement proactive screening measures, including symptom monitoring and routine skin assessments, particularly during known outbreaks. Staff should be trained to recognize early signs of MPXV and other infectious diseases to facilitate prompt intervention and limit potential spread.

Before the diagnosis, the CNA began experiencing fever and general discomfort 16 days ago (day 1). By day 5, skin lesions had developed on the face and genitals; on day 9, additional lesions appeared on the hands and arms. In total, 16 lesions were noted on the left hand, while fewer lesions were observed on the right. On day 9 of the illness, the CNA was sent home from a day shift due to fever, having previously worked 3 symptomatic shifts on days 5 and 7 and a night shift covering days 9 to 10.

“The CNA was considered infectious from 4 days prior to symptom onset until lesions completely healed,” the authors wrote. “Detailed questioning of the CNA and LTCF leadership was undertaken to identify residents who received care from the CNA. Residents with possible skin-to-skin contact with the CNA were considered at-risk, and those with possible contact to areas of compromised skin integrity were considered high-risk.”

5. The Role of Postexposure Prophylaxis (PEP) in Mitigating Infection Risks

Following exposure and receiving a letter explaining the situation, 50% of the at-risk residents opted to receive the JYNNEOS vaccine as PEP. Vaccination is most effective when given within 4 days of exposure, but the first dose was administered 10 days after the last day of possible exposure and 15 days after the first day of possible exposure. All residents who received the first dose also received a second dose 1 month later.

The lack of secondary infections suggests that either transmission risk was inherently low due to standard precautions or that PEP played a mitigating role. IPC professionals should ensure rapid access to PEP in future exposure incidents and promote its timely administration to maximize effectiveness.

6. Surveillance and Monitoring in Outbreak Response

The LTCF implemented a structured monitoring plan, conducting daily temperature and skin checks for 21 days post-exposure. No secondary infections were identified, reinforcing the importance of active surveillance in containing potential outbreaks. IPC teams should develop and maintain comprehensive outbreak response plans, incorporating timely monitoring, clear resident communication, and standardized infection prevention protocols to detect and manage potential cases efficiently.

Final Thoughts

This case underscores the importance of strict adherence to standard precautions, rapid identification of infectious cases, and effective outbreak response strategies in long-term care settings. While MPXV transmission from health care providers to patients remains rare, IPC professionals must remain vigilant, ensuring that staff are well-trained, adequately protected, and supported in their infection prevention efforts. By reinforcing infection control measures and advocating for proactive interventions, health care facilities can continue to safeguard both staff and residents from emerging infectious threats.