MEDICAL ADVISORY: Monkeypox Virus

Issued by:  Emily Groot, MPH, MD, FRCPC, Associate Medical Officer of Health

On May 19, 2022, the Public Health Agency of Canada confirmed two cases of monkeypox in Quebec. Other suspected cases are being investigated in Canada. Prior to these confirmed cases, monkeypox has never been identified in Canada. At this time, Niagara Region Public Health is not aware of any known or suspected cases in our region. The risk to residents is currently considered low.

New Reporting Requirements for Health Care Professionals

• On May 20, 2022, Ontario’s Chief Medical Officer of Health issued a new order under section 77.6 of the Health Protection and Promotion Act that requires health care providers to report patients that meet a case definition of monkeypox (see below) to Public Health Ontario within one business day.
• For patients that meet a case definition below, health care providers must also complete the Ontario Monkeypox Investigation Tool (see Appendix B) and send the information via a secure fax to Public Health Ontario at 647-260-7603.

About Monkeypox

• Monkeypox is a zoonotic infectious disease that is typically found in parts of Central and West Africa. Limited cases have been identified in other regions in the past.
• Monkeypox is typically transmitted from animals to humans. Person to person spread is uncommon.
  • When spread does occur between people, the mode of transmission is usually through close contact with an infected individual, such as through direct contact with their body fluids, respiratory droplets, or monkeypox sores, or by sharing clothing, bedding or common items that have been contaminated with the infected person's fluids or sores.
• The incubation period averages 7 to 14 days (range 5 to 21 days).
• Prior vaccination against smallpox provides some cross-protection against infection with monkeypox.
• Monkeypox infection is typically self-limiting, with most individuals recovering in 2 to 4 weeks. Severe illness can occur in some individuals.

Case Definitions

Confirmed case

• Laboratory confirmation of infection
  • Detection of monkeypox virus DNA by polymerase chain reaction from an appropriate clinical specimen OR
  • Isolation of monkeypox virus in culture from an appropriate clinical specimen

Probable case

• A new onset rash in keeping with monkeypox illness, AND
• At least one other acute sign or symptom of monkeypox illness, AND
• Meets at least one of the following epidemiological criteria within 21 days of their symptom onset:
  • High-risk exposure (which includes living in the same household, having direct physical contact including sexual contact, and direct contact with a skin lesion or bodily fluid without appropriate personal protective equipment) to a probable or confirmed human case of monkeypox OR
  • A history of travel to a region that has reported confirmed cases of monkeypox OR
  • A relevant zoonotic exposure

Suspect Case

• A new onset rash in keeping with monkeypox illness AND
• At least one other acute sign or symptom of monkeypox illness AND
• An alternative diagnosis cannot fully explain the illness

Monkeypox Signs and Symptoms

• Monkeypox illness includes a progressively developing rash that usually starts on the face and then spreads elsewhere on the body
  • The rash can affect the mucous membranes in the mouth, tongue and genitalia. The rash can also affect the palms of hands and soles of the feet.
  • The rash can last for 2-4 weeks, progressing through the following stages: macules, papules, vesicles, pustules, and scabs
  • There are case reports from North America of an atypical monkeypox virus rash that includes painful genital/oral lesions
• Other signs and symptoms include fever, chills, headache, myalgias, swollen lymph nodes (e.g., in the neck and groin), fatigue, typically preceding the rash by 1 to 3 days
• A person is most commonly contagious from the onset of initial lesions (typically on the tongue and in the mouth), until scabs have fallen off and new skin is present. Some cases may be contagious before the rash develops, during their early symptoms (prodrome) such as fever, malaise, and headache.

Infection Prevention and Control Recommendations in Health Care Settings

• In addition to routine practices, use additional airborne/droplet/contact precautions for suspected or confirmed cases
• Personal protective equipment for health care workers includes
  • Fit-tested and seal checked N-95 respirator (or equivalent); perform seal check after donning N-95 respirator
  • Gloves
  • Gown
  • Eye protection (e.g., face shields or goggles)
• For more information see Public Health Ontario’s Infection Prevention and Control (IPAC) Recommendations for Monkeypox in Health Care Settings

More Information

• Join Dr. Karim Ali (Niagara Health) for a virtual, accredited Zoom session on Tuesday, May 31 at 12 p.m. Monkeypox: The what, where, when and the how of an emerging infectious disease. Pre-register here.
• Monkeypox Test Information Index – Public Health Ontario
• Monkeypox virus – Ministry of Health
• Monkeypox – Health Canada