Viruses monkeying around with surgical safety: Monkeypox preparedness in surgical settings

Abstract

Since March 2020, coronavirus disease 2019 (COVID-19) has drastically affected the provision of surgical care. Two years of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have taken a toll on operating volumes, patients' outcomes, and surgical training.1 Spring 2022 marked a reopening of societies and, alongside them, surgical wards. Since then, reports about the emergence of Monkeypox (MPX) in Europe and the United States have ignited fears of a new public health emergency.2 Currently, international and regional health organizations are monitoring the situation, while health authorities are focusing on contact tracing and infection control. While national and international mobility together with hygienic strategies in the community are widely discussed, the discourse on surgical care is limited. An MPX outbreak can have a detrimental impact on surgery. MPX poses a threat to patients with surgical conditions. Patients operated for malignancies, transplant recipients and individuals sustaining heavy injuries and burns have a particularly high risk of developing systemic and life-threatening MPX symptoms if infected.3 However, what is most concerning is the possibility of a new hiatus in surgical care provision due to a new set of social distancing measures or due to increased transmission among patients and health-care workers. A decrease in surgical volumes would further prolong waiting times and associated morbidity and mortality while pushing surgical education to a record low. Although one can only speculate the development of the situation, it is high time we acted for the continuity of surgical care. MPX preparedness in surgical settings can be achieved through adaptation and innovation. During the preoperative infectious control, attention should be paid to flu-like symptoms in the anamnesis and skin lesions during the clinical examination. In elective surgery settings, people with suspicious symptoms or contact history should be instructed to inform the hospital before being admitted. Surgeons should be able to decide whether the patient will be examined and tested for MPX or the operation will be postponed. If an examination is deemed necessary, this should not put health-care personnel and patients at risk of infection. To minimize the exposure, examination can be performed in outpatient or primary care settings outside the surgical wards and the premises used for preoperative assessments. For surgical emergencies, personal protective equipment and separated patients' rooms should be provided. Inpatients' interaction with nonessential personnel and caregivers should be minimized. Depending on the local epidemiological conditions, surgical wards should consider restricting access to visitors. With regard to logistics, availability of disinfection means and personal protective equipment (PPE) should be ensured, while laundry and disinfection facilities should undergo regular quality control. Health-care workers with suspicious symptoms or a contact history should be able to abstain from work. If their presence is essential, they will need to use masks, gloves, and long-sleeved clothing and minimize their interaction with patients and objects that may act as fomites.4 In perioperative settings, the World Health Organization (WHO) Surgical Safety Checklist can serve as a guide for infection control.5 The same has been previously adapted to COVID-19.6 In principle, before the patient arrives at the operating room (OR) the absence of symptoms and enanthemes or exanthemes should be confirmed. Once the patient arrives in the OR, nonessential personnel should leave the room, logistics for additional supplies with minimal involvement of personnel and disinfection of the patients' trolley are necessary. At the end of the operation, it should be arranged for patients to be transferred by porters wearing PPE. After the patient has left the OR, surgical waste should be safely disposed and the OR should be disinfected. A proposed adaptation of this framework is presented in Figure 1. Although we used these recommendations referring to patients with MPX they can also protect patients not suffering from MPX from other postoperative and nosocomial infections (Figure 1). Innovative countermeasures to the risk of contracting MPX may be employed as well. A growing body of research has investigated textiles with antiviral properties7 that can be used as an alternative to conventional bedlinen, white coats, and surgical scrubs. Digital health can also contribute to MPX infection control. Diverse applications, from teleconsultations for patients with contact history, to image recognition software, can minimize the exposure of patients and health-care workers to the virus, and improve patients' screening and diagnosis.8 Digital education tools and interfaces can substitute surgical training, while educating health-care personnel and patients about hygiene. Developing an MPX surgical safety protocol can help ensure the continuity of surgical safety in areas with high transmission rates. Christos Tsagkaris conceptualized the manuscript and wrote the first draft, Anna Eleftheriades, Lily Laubscher, and Valeriia Vladychuk contributed to the literature search and critically edited the first draft, Marios Papadakis supervised the writeup and critically edited the manuscript before submission. The authors declare no conflict of interest. No data were generated during the preparation of this article.

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