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Information for clinicians on testing semen for monkeypox DNA.

There is a body of evidence documenting the detection of RNA and DNA viruses in semen after acute infection. Monkeypox DNA has been detected in semen up to day 11 after acute infection in men in Italy, although longitudinal sampling after this point was not carried out.

It remains unclear whether this is from seminal carriage as the testes are immunologically-protected sites (as with other viral infections such as Ebola virus disease), or from resolving meatal or urethral lesions that disappear as the skin lesions resolve.

However, in view of this, current UKHSA advice takes a cautious approach and recommends that men who have had a confirmed or highly probable diagnosis of monkeypox according to the UKHSA case definition should use condoms during sex for 12 weeks after complete recovery from monkeypox infection. This is in line with advice from the World Health Organization (WHO).

It should be recognised that there is currently no evidence to support this or any alternative advice.

Following the initial 12 weeks and up to 6 months after recovery from infection, UKHSA therefore recommends performing a monkeypox PCR on semen samples (and where necessary, oropharyngeal and/or rectal swabs) if the patient:

Testing can also be offered on patient request following discussion with the local infection/genitourinary team and then with the Rare and Imported Pathogens Laboratory (RIPL).

A single negative PCR after 12 weeks post recovery is considered adequate, with recognition that this is based on expert opinion in the absence of a clear evidence base.

It should also be noted that a positive PCR does not necessarily indicate that the patient is potentially infectious, only that fragments of DNA have been detected. However, since viral culture is not feasible for clearance testing, if the PCR is positive it is prudent to consider the patient potentially infectious.

Repeat samples should be submitted every 2 weeks thereafter, and the patient should continue to use condoms until a negative test result is obtained.

Any samples sent without a minimum serial interval of 2 weeks will not be processed without prior discussion with RIPL.

Any testing that is requested prior to 12 weeks post recovery must first be discussed and agreed with RIPL prior to sending. Samples received without discussion will not be processed. For semen tested prior to 12 weeks post-recovery, 2 samples collected at least 48 hours apart should be tested, and both need to be negative to be deemed clear.

Sample collection must take place in a facility capable of arranging transport of a Category B sample. These are usually hospitals where cases of monkeypox are cared for and not genitourinary medicine (GUM) clinics.

Samples should be submitted in a universal sterile container and sent to:

High Containment Microbiology FAO Marian Killip / Matthew Jones UKHSA Colindale 61 Colindale Avenue London NW9 5EQ

Samples must be packaged and sent as a Category B infectious substance. Please ensure that samples are properly packaged and sealed. Leaking samples will not be processed. Samples will only be tested during working hours Monday to Friday.

Appropriate counselling from clinicians should include that this is an unvalidated diagnostic test.

It is expected that evidence will emerge for duration of monkeypox DNA detection in semen which will allow this guide to be updated, and earlier testing may be offered if the evidence supports this.

Amended to extend recommendations to highly probable as well as confirmed cases.

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