Updated August 15, 2022
NCCID Disease Debriefs provide Canadian public health practitioners and clinicians with up-to-date reviews of essential information on prominent infectious diseases for Canadian public health practice. While not a formal literature review, information is gathered from key sources including the Public Health Agency of Canada (PHAC), the USA Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and peer-reviewed literature.
This disease debrief was prepared by Heather Long and Wendy Xie. Questions, comments, and suggestions regarding this disease brief are most welcome and can be sent to firstname.lastname@example.org
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Questions Addressed in this debrief:
- What are important characteristics of the Monkeypox virus?
- What is happening with current outbreaks of Monkeypox?
- What is the current risk for Canadians from Monkeypox?
- What measures should be taken for a suspected Monkeypox case or contact?
What are important characteristics of the Monkeypox virus?
Monkeypox virus is a double-stranded DNA virus belonging to the Orthopoxvirus genus in the family Poxviridae, which includes human variola (VAR), cowpox (CPV), and vaccinia (VAC) viruses. Monkeypox virus is a zoonotic disease, meaning it can be transmitted from animals to humans. Squirrels, Gambian pouched rats, dormice, and non-human primates have been found to be susceptible to monkeypox virus, but further research is required to identify the true natural reservoir(s). There are two genetic clades of the monkeypox virus – the Central African (Congo Basin) and West African clades. The Congo Basin clade has caused more severe disease and is thought to be more transmissible.
Monkeypox virus transmission occurs when a person comes into direct or indirect contact with the body fluids or lesion materials of infected animals and humans, including contaminated materials. Animal-to-human transmission may occur by bite or scratch, or through the preparation of bush meat. Human-to-human transmission of monkeypox virus is thought to occur primarily through respiratory droplets during sustained face-to-face contact, but may also be sexually transmitted through contact with the body fluids of an infected person. The virus may enter the body through broken skin (even if not visible), the respiratory tract, or mucous membranes of the eyes, nose, or mouth.
Signs and Symptoms, and Severity
The symptoms of monkeypox virus are milder than, but similar to those of smallpox. One key difference is that monkeypox causes swollen lymph nodes (lymphadenopathy) while smallpox does not. The swelling can occur in many different locations on the body, or be localized, including lymph nodes of the neck and armpit. The incubation period (time from infection to onset of symptoms) for monkeypox is usually 7−14 days but can range from 5−21 days. In addition to swollen lymph nodes, early signs and symptoms may include fever, headache, muscle aches, exhaustion, backache, and chills. A rash develops on the body within 1 to 3 days (sometimes longer) after the appearance of fever, usually first on the face, then spreading to other parts of the body. The lesions progresses through the stages of macules, papules, vesicles, pustules, and finally scabs before falling off.
At the Meeting of the International Health Regulations Emergency Committee held on June 23, 2022, it was noted that the clinical presentation in the current monkeypox outbreak is often atypical. There are fewer lesions observed, and the lesions are often localized to the genital, perineal/perianal or peri-oral area. Some cases involve an asynchronous rash appearing prior to the prodromal phase (lymphadenopathy, fever, malaise).
Illness can last for 2-4 weeks depending on the health of the infected individual, the clade of the infecting virus, and the route of exposure. In Africa, the disease has been shown to cause death in as many as 1 in 10 people. Pregnant or breastfeeding women, children, persons with underlying medical conditions or immunocompromised individuals may be at higher risk for severe illness due to monkeypox infection.
Since the discovery of monkeypox virus in 1958, infections have been reported in people in central and western African countries: Cameroon, Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Gabon, Liberia, Nigeria, Republic of the Congo, and Sierra Leone, with most infections occurring in the Democratic Republic of the Congo. Outside of Africa, most monkeypox cases in humans have been linked to international travel or exposure to imported animals, including cases in the United States, Israel, Singapore, and the United Kingdom. Many recently reported cases of monkeypox from Sweden, Italy, Belgium, USA and Canada are not linked to travel to the endemic areas of West/Central Africa, suggesting that there is local transmission within communities. In the UK, Spain and Portugal, cases of monkeypox have been reported amongst, but not exclusively in, men who have sex with men (MSM).
A confirmed diagnosis of a monkeypox infection requires positive presence of monkeypox virus DNA detected using polymerase chain reaction (PCR) and isolation of monkeypox virus. The best specimens for PCR and isolation are skin lesion material, including swabs of lesion surface or fluid, crusts/scabs, and roofs of multiple lesions. Lesion material should be transported in an empty, sterile container.
Serology is not the preferred method due to cross-reactivity with previously smallpox vaccinated individuals and other Orthopoxviruses.
Prevention and Control
The Public Health Agency of Canada (PHAC) provided Interim Guidance on infection prevention and control for suspect, probable or confirmed monkeypox within Healthcare settings, dated May 27, 2022 advisesany lesions or respiratory secretions should be considered infectious material. Routine practices should include:
- Point of Care Risk Assessment (PCRA)
- Hand Hygiene (alcohol-based hand sanitizers and soap, washing hands after removing gloves)
- Patient Placement
- Respiratory hygiene
- Personal Protective Equipment (PPE)
- Injection and Medication Safety
- Cleaning and Disinfection Procedures
- Waste Management
Airborne, droplet, and contact precautions are recommended as follows:
- Wash hands
- Wear a medical mask
- Upon entry to a healthcare setting, suspect, probable and confirmed cases should be immediately placed into an Airborne Infection Isolation Room (AIIR) or single room with the door closed.
- If clinically tolerable, patient must wear a medical mask when leaving the room.
- Cover skin lesions with a gown, clothes, sheet or bandage, except during examination.
- Disinfect room after use
Health care worker – Personal Protective Equipment (PPE):
- N95 respirator
- Cuffed, long sleeve gown
- Eye protection
Discard all PPE including respirators after contact with the patient. Perform hand hygiene. Wear all PPE entering the patient’s room and dispose of all PPE prior to leaving the isolation room except for the respirator. Remove respirator outside of the room once the door is closed. Perform hand hygiene again.
Room Selection/Patient Placement:
Place patient in an AIIR, when available or place patient in a single room with the door closed. Inpatients should have their own bathroom or a commode can be used if a dedicated bathroom is not available.
Restrict visitors to those necessary for care or compassionate grounds.
Cleaning and Disinfection:
- Standard disinfection protocols.
- Dedicate patient care equipment to a single patient.
- Disinfect all reusable equipment with hospital-approved disinfectants immediately after use.
Disinfect all contact surfaces with hospital-approved disinfectants including chairs, doorknobs, call bell pulls, faucet handles, wall surfaces and public bathrooms. Use standard housekeeping cleaning and disinfection protocols.
Laundry (such as linens, towels, clothing, bedding):
- Wear appropriate PPE (gloves, gown, fit-tested and seal-checked N95 respirator and eye protection) during collection and bagging of all linens.
- Laundry should be transferred to a sealed and tied into a leak-proof bag and placed inside an impermeable bag for transport to laundry area.
- In ambulatory care settings, standard medical laundry facilities should be used however it not available, laundry may be washed in a standard washing machine using hot water (70 degrees Celsius) with detergent and must be completely dried in a commercial dryer.
- avoid contact with the worker’s skin and clothing when handling soiled laundry (clothing, towels, bedding)
- Do not shake laundry, as it disperses contaminated infectious particles into the air and onto the surrounding surfaces.
Containment and Disposal of Contaminated Waste:
- Biomedical waste should be contained in impervious waste-holding bags or double bagged.
- Contaminated disposable items should be discarded according to jurisdictional protocols.
Discharge environmental cleaning and disinfection:
- HCW must wear a gown, gloves, fit-tested and seal-checked N95 respirator and eye protection during cleaning and disinfection as per disinfection protocols.
- Discard all disposable items in patient’s room.
- Change privacy curtains.
- Discard any equipment/supplies that cannot be disinfected.
Transportation of suspected monkeypox patients:
Patient should not use public transportation and should wear a mask and cover all lesions during transport. Patient transport services should be informed that the patient has suspect, probable, or confirmed monkeypox beforehand and the receiving healthcare setting should be informed of the need for airborne, droplet and contact precautions.
According to the World Health Organization an exposed health care worker who is asymptomatic does not need to isolate and can remain on the job, however will need to actively monitor themselves for 21 days, monitoring one’s temperature twice per day and should have an interview with their local occupational health office before returning to work. If the health care worker becomes symptomatic, they should not return to work and will need to isolate at home until they are no longer considered contagious, when all symptoms have subsided and all scabs are completed healed over. This can take between 2 to 4 weeks.
Treatment and Vaccination
Most cases of monkeypox infection are self-limiting and symptoms will resolve on their own if rashes are left to dry or covered with a moist dressing to protect the area. There is currently no proven and safe treatment for monkeypox virus infection, however, vaccinia immune globulin (VIG) and antivirals may be recommended for severe cases. Tecovirimat (or TPOXX) is an antiviral that was developed to treat smallpox and has also been approved for the treatment of monkeypox in January 2022. Relevant adverse events related to TPOXX can be directly reported to the Canada Vigilance Program through the Health Canada website. Other antivirals including Cidofovir, Brincidofovir and Tecovirimat are all currently being tested for activity against monkeypox virus.
Imvamune is a 3rd generation smallpox vaccine licensed for active immunication against smallpox, monkeypox, and related Orthopoxvirus infection and disease in adults 18 years and older with high risk for exposure. Provincial and territorial public health authorities have started vaccinating populations at higher risk. To date, human-to-human spread of monkeypox can be controlled via early diagnosis and treatment of symptoms, isolation of patient and contact tracing. For individuals who are contacts of cases, post-exposure prophylaxis (PEP) with a second- or third-generation vaccine is recommended. To prevent the onset of disease, this vaccine should be provided within four days of first exposure and up to 14 days in the absence of symptoms.
For health care workers and laboratory staff at high risk of exposure to monkeypox cases, pre-exposure prophylaxis (PrEP) is recommended.
On August 12, 2022, PHAC released a Statement from the Chief Public Health Officer of Canada which stated that to date, the Government of Canada has deployed over 99,000 doses of Imvamune vaccine to provinces and territories and is working to secure future supplies of both vaccines and therapeutics while providing treatment for case management. As of August 11 2022, over 50,000 Canadians have now been vaccinated.
What is happening with current outbreaks of Monkeypox?
At the press conference following the 2nd Emergency Meeting on July 23, 2022, the Director of the World Health Organization (WHO) declared the current monkeypox outbreak to be a public health emergency of international concern (PHEIC). The Public Health Agency of Canada (PHAC) provides the most recent update of reported monkeypox cases across provinces and territories in Canada. The Centers for Disease Control and Prevention (CDC) provides a summary of the confirmed cases in the United States and worldwide.
What is the current risk for Canadians?
As of July 23, the World Health Organization (WHO) maintains the risk to be moderate at the global level, apart from the European region, where the risk is high. The WHO recommends that all countries work closely with the men who have sex with men (MSM) community and HIV patients to communicate information and services available to protect the health of those affected and fight against stigma. The Director of the WHO has made recommendations for regions based on their current epidemiological situation, patterns of transmission and capacities, which can be found here.
On August 12, the Canadian Centre for Disease Control stated that although it is still not known whether those living with HIV are at an increased risk to acquire monkeypox, those with advanced HIV might be at a higher risk for severe monkeypox. They emphasize the importance of prompt diagnosis and treatment in this population and are recommending post-exposure prophylaxis and antiviral treatments for those living with HIV.
There is added risk to health workers if they are not using adequate infection prevention and control (IPC) measures or wearing appropriate personal protective equipment (PPE) to reduce the risk of transmission. In Canada, cases of human transmission have involved close contact with an infected individual, but the risk to the general public remains low. However, this is an ongoing investigation in Canada and around the world, and more information is needed to determine the risk to Canadians. The Public Health Agency of Canada (PHAC) will continue to release recommendations to minimize the risk of infection and provide updates related to confirmed cases. Given that the monkeypox virus is spread through close contacts, PHAC advises physical distancing, handwashing, and wearing masks to reduce the risk of infection. While the risk of infection for the general population is low, PHAC recommends that Canadians and health care providers should be aware of the symptoms of monkeypox regardless of travel history. PHAC also recommends that using condoms, practicing safe sex, and having fewer sexual partners (anonymous partners in particular) even when they do not have symptoms can also reduce the risk of becoming infected with monkeypox.
The Centers for Disease Control and Prevention (CDC) does not see any evidence to date that monkeypox poses a high risk to domestic pets. In a past outbreak in the United States in 2003, there was no evidence to suggest the disease was spread from humans to their domestic pets. Regardless, the CDC recommends anyone with monkeypox to avoid contact with their pets and make arrangements for someone to care for their pets until they recover.
Until more is known about which mammals are susceptible to infection it is best to assume that any mammal can be infected with monkeypox. For the most recent information about monkeypox in animals please refer to the Canadian Centre for Disease Control’s update here.
On July 15, 2022, the Public Health Agency of Canada (PHAC) released a Level 2 (Practice Enhanced Health Precautions) travel advisory indicating an increased risk to travelers, or certain groups of travelers including pregnant women, campers, and people visiting friends and relatives. In addition to following the usual health precautions specific to their travel destination, people are reminded to use appropriate personal protective equipment, consider delaying travel until risk is lower, keep up to date on vaccination recommendations and avoid high-risk activities.
As reported on June 27, 2022, the World Health Organization (WHO) does not recommend adopting any measures restricting international traffic for either incoming or outgoing travelers. They advise anyone who is symptomatic, suspected, or confirmed case to avoid non-essential travel. Anyone who becomes symptomatic upon returning from travel or while travelling should report to a health professional providing all recent travel information, immunization history and information about close contacts. Public health officials will need to work with travel operators and public health to perform appropriate contact tracing and case investigation.
What measures should be taken for a suspected Monkeypox case or contact?
Canadians should be made aware of the symptoms of monkeypox and are advised to report any concerns to their health care provider without delay. The Public Health Agency of Canada has sent alerts to public health authorities to assist health care providers to identify patients showing signs or symptoms consistent with monkeypox, regardless of any reported travel or any specific risk factors.
Health care providers should ensure patients with suspected cases of monkeypox isolate from other family members and pets and should only leave home to seek medical care. The receiving healthcare setting should be notified prior to the patient’s arrival, and patients with suspected, probable, or confirmed monkeypox infection should not use public transportation. Lesions should be covered with long sleeves and pants, and surgical masks should be worn by the patient and all family members in the household. Surgical gloves should be worn when in direct contact with lesions and disposed of immediately in accordance with the local health regulations.