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Monkeypox and guidance for health care providers

Background

Monkeypox is a viral illness endemic to parts of Central and West Africa. Since May 2022, several countries in which monkeypox is not endemic, including Canada, have documented clusters of cases of monkeypox virus infection. All infections characterized so far among the recent clusters have been due to the West African clade of the virus which is generally associated with less severe disease and lower transmissibility than the central African clade. Refer to the Ministry of Health Emergency Planning and Preparedness (Government of Ontario) website for further information.

Epidemiology

Monkeypox is a viral infection caused by a virus of the Orthopoxvirus genus related to smallpox. The virus is endemic in certain areas of Central and West Africa with imported cases occurring in other regions most associated with travel. Clinical presentation resembles smallpox but is typically less severe.

Person-to-person transmission occurs primarily through close contact with an infected individual’s body fluids, respiratory droplets or lesions, or through direct contact with items that have been contaminated with the virus (e.g., clothing, bedding). The incubation period is typically 6 to 13 days but can range from 5 to 21 days. Individuals are infectious from symptom onset until all scabs have fallen off and new skin is present. Monkeypox virus can also be transmitted from animals-to-humans (i.e., zoonotic transmission). Historically, there has been limited person-to-person transmission and transmission within health care settings has rarely been reported.

Clinical presentation

Monkeypox should be considered in individuals presenting with compatible symptoms and exposure history (including travel) or other risk factors.

Symptoms

The rash can last for 2 to 4 weeks and progress through the following stages from macules, to papules, to vesicles, and then to pustules which develop a depression in the centre (umbilication) before they begin to crust, form scabs, and fall off. The rash is usually confined to the trunk but can spread to the palms and soles of the feet, occurring in a centrifugal distribution. Lymphadenopathy (swollen lymph nodes) is considered a key feature, distinguishing monkeypox from smallpox. Atypical symptoms including skin lesions on the mouth or genitals have been reported. Clustering of cases among men who have sex with men has been reported in some regions.

Children are at higher risk of severe disease. Potential complications include secondary infections, pneumonia, sepsis, encephalitis, keratitis with vision loss. Mortality differs according to viral strain.

It is important to continue to consider differential diagnoses, which may be hard to distinguish from monkeypox—including syphilis, herpes simplex virus (HSV), chancroid, varicella zoster, and other common infections.

Infection prevention and control

In addition to routine practices the following infection prevention and control measures are recommended as per Public Health Ontario (PHO) Infection Prevention and Control (IPAC) recommendations for Monkeypox in Health Care Settings.

An individual with suspect or confirmed monkeypox is to be placed in a single patient room with the door closed with a dedicated toileting facility. An Airborne Isolation Room (AIR) is not necessary but can be used if available and depending on other IPAC considerations. If a single patient room is not available, then precautions should be taken to minimize exposure to surrounding individuals, such as the patient wearing a medical mask over their nose and mouth as tolerated and covering exposed skin lesions with clothing, sheet, or gown as possible.

Providers are recommended to wear appropriate personal protective equipment, including a fit-tested N95 respirator, eye protection, gloves and a gown, and the patient should wear a medical mask for source control.

Refer to Public Health Ontario recommendations putting on and taking off personal protective equipment for further information.

Testing indications for health care providers

Who to test:

Individuals with a compatible clinical illness, where monkeypox is suspected should be tested. Approval for monkeypox testing is not required, nor is it required to contact the Public Health Ontario (PHO) Customer Service Centre prior to specimen submission. Consult with PHO for questions regarding testing eligibility, specimen collection or transportation. Further information on testing information can be found on the PHOL monkeypox virus test information sheet.

Utilize the PHO General Test Requisition and collect samples with a virus culture kit. Complete all fields of the General Test Requisition, including:

Specimen Collection

A variety of specimen types may be collected depending on clinical presentation. Refer to the PHOL lab testing information sheet for information on the type and number of specimens that should be collected and the guidelines for submission.

Testing for herpesviruses (e.g., herpes simplex, varicella) and enterovirus may be ordered on the same specimens being tested for monkeypox — these will be performed once monkeypox testing is completed. If other tests are required, submit additional specimens, as those submitted for monkeypox virus testing will not be routinely processed for additional tests besides herpesviruses and enterovirus.

Specimen Transport

Transportation of monkeypox specimens requires special considerations according to the Transportation of Dangerous Goods requirement for Category B pathogens. Consult the PHOL test information sheet for specific requirements.

Refer to the PHOL website for information on the turnaround time for specimens submitted for monkeypox testing.

Reporting

Monkeypox is now reportable to the Medical Officer of Health as a newly Designated Disease of Public Health Significance under provincial legislation.

On June 16, 2022, monkeypox was designated a Disease of Public Health Significance (DOPHS) as “Smallpox and other orthopoxviruses including monkeypox” under the Health Protection and Promotion Act (HPPA). Under this legislation, it has been designated as both a communicable disease and a virulent disease. Persons required to report DOPHS and/or communicable diseases under the HPPA are now required to report monkeypox directly to the local Medical Officer of Health in accordance with routine reporting processes.

Health care providers with a patient that meets the monkeypox case definitions must contact Public Health Sudbury & Districts immediately at 705.522.9200, extension 772 toll-free 1.866.522.9200 during business hours, or after-hours at 705.688.4366. In addition please complete the first four pages of the monkeypox investigation tool (Public Health Ontario) and fax to Public Health Sudbury & Districts’ secure fax at 705.677.9618 so that prompt follow-up can be initiated.

Case management

Individuals who meet the any of monkeypox case definitions are to self-isolate at home until monkeypox is ruled out by laboratory testing, or if testing is unavailable, until the end of the infectious period (i.e., until scabs have fallen off and new skin has formed). If being seen for clinical care, they are advised to wear a medical mask and cover their skin lesions while test results are pending. Confirmed cases are to self-isolate until the end of the infectious period (i.e., until scabs have fallen off and new intact skin has formed below which typically takes 2-4 weeks). Public Health will actively monitor confirmed cases.

Antiviral treatment (TPoxx®) is available in limited supply for hospitalized cases with severe infection. Hospital clinicians may request the product by contacting the Ministry of Health Emergency Operations Centre at EOCoperations.MOH@ontario.ca or by calling the Healthcare Provider Hotline at 1.866.212.2272. More information on treatment can be found on the ministry website.

Contact management

Contacts should self-monitor for symptoms for 21 days. They should contact Public Health and a health care provider if they develop symptoms. They do not need to quarantine if they are asymptomatic. A contact is considered at higher risk of exposure if, for example, they are a household member or share indoor common spaces, have had intimate or sexual contact, provide direct physical care to the person without appropriate protective equipment, or otherwise have had direct contact with broken skin or mucous membranes.

Post-exposure prophylaxis (PEP) is recommended for those at high risk of exposure. It may be recommended for those at intermediate risk of exposure based on the public health unit’s assessment of risks and benefits.

Imvamune® is available for PEP and must be ordered from the Ministry of Health by public health. Public health will either administer the vaccine to the individual or provide the vaccine to the clinician to administer. Please refer any contacts of monkeypox cases to public health for assessment of eligibility.

The use of Imvamune® for pre-exposure prophylaxis (PrEP) is also being considered for select persons in areas where confirmed cases have been reported. The decision to offer PrEP will be made in consultation with the ministry and Public Health Ontario in consideration of local epidemiology. Further information on Imvamune® is available on the ministry website.

Eligible individuals who want to receive PrEP should contact Public Health Sudbury & Districts at 705.522.9200, ext. 482 (toll-free 1.866.522.9200, ext. 482) or Réseau ACCESS Network at 705.688.0500. Individuals can also connect with PHSD at extension 772 if seeking PEP.

Additional information on Imvamune® is available on the ministry website.

This item was last modified on July 28, 2022