Monkeypox: Public health management of cases and contacts in Canada

June 21, 2022

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Introduction

The Public Health Agency of Canada (PHAC), in collaboration with provincial/territorial (PT) public health authorities (PHAs) and other relevant federal government departments, has developed this document to provide guidance to PHAs working at the federal/provincial/territorial (FPT) level in the event cases of Monkeypox (MPX) virus are suspected or confirmed within their jurisdictions.

The strategy outlined in this guidance relies on rapid case and contact management with the goal of outbreak containment. To achieve this, the objectives for this guidance include rapidly stopping chains of transmission, preventing endemicity of MPX in Canada, and protecting public health and health care in Canada. The ethical principle that is guiding the recommendations in this document, is the protection of vulnerable populations in Canada (e.g., pregnant women, children under 12 years of age, immunocompromised individuals)Footnote 1 .

In addition, because MPX is non-endemic in Canada and the situation is quickly evolving, this document follows precautionary principles and approaches, in an effort to prevent the establishment of endemicity of MPX in Canada.
Guidance pertaining to diagnostic laboratory, specimen handling and transportation, clinical care, and infection prevention and control measures in other settings (e.g., Canadian points of entry, healthcare settings, long-term care facilities) are beyond the scope of this document.

This guidance is informed by the latest available scientific evidence, national and international epidemiological data and expert opinion; it is subject to change as new information becomes available and the situation in Canada evolves.
At the time of publication, the body of evidence surrounding MPX is limited, with little recent scientific data available. PHAC is applying an evidence-informed approach to its case and contact management guidance for MPX; as new scientific information becomes available that triggers a shift in guidance, PHAC will adjust this document accordingly.

This guidance should be read in conjunction with relevant FPT and local legislation, regulations and policies, and adapted to local context as required. This document has been developed based on the Canadian situation and therefore may differ from guidance developed by other countries.

Background

Monkeypox virus in humans

MPX can be spread to humans three ways: animal to human, human to human, and likely through fomitesFootnote 2,Footnote 3,Footnote 4. For more information on the modes of transmission, clinical manifestations, diagnosis and treatment for MPX virus, refer to PHAC's Monkeypox: For health professionals webpage. Information on MPX for the general public is also available.

Current status

The MPX situation in Canada is evolving quickly. For up-to-date information, refer to PHAC's Monkeypox: Outbreak update webpage.

Public health management of cases

Case definitions

National case definitions for MPX have been established and are being used for the context of this document.

Public health activities for case management

PHA's activities for case management may include:

As individual situations vary and are unique, PHA may need to modify isolation approaches used for cases. Modifications in isolation should be designed to maintain the objectives of this guidance (i.e., rapidly stopping chains of transmission, preventing endemicity, and protecting public health and health care in Canada).

Public health measures recommendations for suspected, probable and confirmed cases

Among symptomatic infections, MPX illness is usually self-resolving. However, severe cases can occur and may be fatal Footnote 1. Based on genomic sequencing available to date, the outbreaks occurring in Canada are the result of transmission of the Western African clade of MPX, which historically has reported a case fatality rate of approximately 1-3%, although recent studies of cases in the USA and UK report case fatality rates of 0%Footnote 5,Footnote 6,Footnote 7.

When hospital-level care is not required, cases of MPX are recommended to practice the measures outlined below. These protocols should be followed until scabs have fallen off and there is evidence of epithelialization. This typically takes 2 to 4 weeks, but may take longer.

Recommendations for interactions with others inside the home

Recommendations for interactions with others outside the home

Recommendations for environmental hygiene

Public health measures for caregivers at the home

Ideally, only one individual in the home should provide direct care to the case, if and when needed (referred to as the "caregiver”). Health care providers entering the home to provide medical care should follow appropriate IPAC protocols.

The caregiver should not be someone who is vulnerable to MPX (e.g., pregnant woman, child under 12 years of age, immunocompromised individuals)Footnote 1. Caregivers should self-monitor for signs or symptoms for 21 days since their last exposure to the case (see contact management section below for further details). If signs or symptoms develop, they should immediately notify the PHA and follow their instructions.

Caregivers should be provided instructions by the PHA on how to reduce their risk of MPX infection, which may include:

Public health management of contacts

Contact tracing

The purpose of contact tracing is to:

In Canada, local PHAs are responsible for initiating contact tracing. Once a case is identified, PHAs assess the need to begin contact tracing using the epidemiological and clinical information provided.

In determining the need to initiate contact tracing, the following factors should be taken into consideration:

In addition to traditional contact tracing activities, PHAs should consider proactive, non-stigmatizing communication and outreach strategies to target groups that may be at higher risk of exposure, in collaboration with local community-based stakeholders and organizations. This could also be instituted even before cases appear in the community, as an upstream approach.

Risk assessment of contacts

All individuals who are contacts of a confirmed, probable or suspected case are recommended to be rapidly identified and assessed by PHAs, to determine their risk of exposure and the appropriate public health recommendations to follow.

To facilitate determining the public health recommendations, contacts are classified according to their risk of exposure in Table 1 below. Note that Table 1 provides guidance for classifying contacts as either high, intermediate or low risk, depending on their exposure, for the purposes of determining recommended actions. The information provided in Table 1 is not intended to replace more personalized public health advice provided to contacts, based on clinical judgement and comprehensive risk assessments conducted by PHAs.

Table 1: Classification of contacts by exposure risk level.
Exposure risk Description Examples
High

Prolonged or intimate contact, including any of the following:

  • Skin/mucosa to skin contact with a case (regardless of the case's lesion location)
  • Skin/mucosa contact with a case's biological fluids, secretions, skin lesions or scabs
  • Skin/mucosa contact with surfaces or objects contaminated by a case's secretions, biological fluids, skin lesions or scabs
  • Face-to-face interaction with a case, without the use of a medical mask by the case or contact
  • Sexual partner of a case
  • Household members living with a case
  • Roommate in a group home or student residence living with a case
  • Skin/mucosa contact with a case's unwashed bedding, towels, clothing, lesion dressings, utensils, razors, needles, sex toys, etc.
Intermediate
  • Not meeting high-risk exposure criteria above AND any of the following:
    • Limited or intermittent, close proximity exposure to a case without wearing adequate PPE for the type of exposure risk (i.e., medical mask and gloves)
    • Shared living space where there are limited interactions with a case or their belongings
  • Sitting next to case on plane
  • Person sharing close proximity workspace with a case for long periods of time
Low or Uncertain
  • Not meeting the high- or intermediate-risk exposure criteria above AND any of the following:
    • Very limited exposures to a case
    • Consistently and appropriately using recommended PPE for the type of exposure risk (i.e., medical mask and gloves)
  • Brief social interactions with a case
  • Colleagues not sharing a confined or close-proximity office space with a case
Acronyms:
  • PPE: Personal protective equipment

Note: This guidance is focused on community settings. For health care providers who have had an exposure to MPX, follow occupational health and safety advice or refer to PHAC guidance on infection prevention and control of monkeypox cases in healthcare settings.

Public health activities for contact management

For both high- and intermediate-risk MPX contacts, PHAs may conduct the following activities during the 21-day period since the contact's last exposure to the case:

Public health measures recommendations for contacts

Recommendations in Table 2 below apply for the 21-day period following the last exposure to a known suspected (unless MPX is ruled out), probable or known case.
Note: A risk assessment conducted by the PHA may further inform personalized PHMs recommendations, for example, PHAs may consider the following:

Table 2: Public health measures recommendations for contacts based on exposure risk.
Exposure risk Recommendations
For all exposures
  • Can be permitted to continue routine daily activities, with some specific PHMs in place
  • Self-monitor for signs and symptoms of MPX infection
  • Practice proper hand hygiene and respiratory etiquette (see Appendix 1)
  • Practice safe sex behavioursFootnote a
  • Notify the PHA and isolate immediately if signs or symptoms develop
  • Alert any health care providers that provide medical care of the potential exposure
For both intermediate- and high-risk exposure contacts
  • Avoid high-risk settings (e.g., congregative living settings, such as jails or shelters) and vulnerable populations (e.g., children under 12 years of age, pregnant women, immunocompromised individuals)Footnote 1, where possible
    • If this is unavoidable, consider wearing a well-fitting medical mask in these settings or around vulnerable populations
    • For contacts who work in high-risk settings, refer to occupational health and safety advice or defer to the advice of their local PHA, based on a risk assessment
  • As a precaution to prevent possible spread to animals, including pets and livestock, and until more is known, it is recommended that contacts:
    • Have another member of their household care for their animals
      • If this is not possible, contacts should wear a well-fitting medical mask and gloves when near the animals, and clean and disinfect high-touch surfaces frequently
    • Avoid handling, feeding or working closely with wildlife to prevent any possible spread of the virus – this is to limit risk of creating a wildlife reservoir for this virus in Canada
For high-risk exposure contacts
  • Wear a well-fitting medical mask whenever in the presence of others (including household members)
  • Refrain from sexual contact with others
  • Be especially vigilant when self-monitoring for symptoms if working with vulnerable populations
Table 2 Footnote a

While condom use and reduction of the number of partners is not completely protective in the case of MPX, it could reduce the risk of exposure.

Return to table 2 footnote a referrer

Appendix 1: Recommendations for hand hygiene and respiratory etiquette

Hand hygiene

Proper hand hygiene involves washing one's hands regularly with soap and water for at least 20 seconds or using hand sanitizer containing at least 60% alcoholFootnote 8,Footnote 9. When hands are visibly soiled, soap and water is the preferred method.

Hand hygiene should always be performed before and after any contact with an MPX case or after touching surfaces/objects within the case's environment, especially those that the case has had contact with (i.e., touched with hands, sat on, lied on, skin has touched, mouth has touched, etc.)Footnote 10,Footnote 11. It is important that those around an MPX case (e.g., caregivers, household members) avoid touching their eyes, nose, or mouth with unwashed hands.

If using gloves (e.g., caregiver providing direct care to a case, caregiver handling a case's utensils), they should be disposed of in an open waste container that has a bag in it, then the bag should be tied and disposed of. Hand hygiene should be performed immediately after the removal and disposal of gloves.

Respiratory etiquette

Respiratory etiquette means, when coughing or sneezing, the individual should:

  1. Cough or sneeze into a tissue or the bend of their arm, not their hand
  2. Throw any used tissues into a waste container that has a plastic bag in it, as soon as possible
  3. Perform hand hygiene immediately afterwards

Appendix 2: Recommendations for environmental hygiene

Laundry should be performed prior to cleaning and disinfecting surfaces and objects, to decrease opportunities for cross-contaminationFootnote 10,Footnote 11.

Handling laundry

The case should be responsible for handling their own laundry (e.g., clothes, towels, bed linens, etc.).

Contaminated laundry must be washed in a standard washing machine using hot water (i.e., 70°C) with detergent, and must be completely dried in a drying machine. If the case does not have access to laundry washing and drying machines, the PHA may assist in identifying supports to ensure contaminated items can be laundered appropriately.

If the case is unable to launder their own items and a caregiver needs to handle these items, they should:

Cleaning and disinfecting surfaces and objects

It is recommended that surfaces and objects the case may come into contact with are frequently cleaned and disinfected, with particular attention paid to high-touch surfaces and objects (e.g., tabletops, countertops, toilets, door handles, light switches, computer keyboards, etc.).

If a surface or object is visibly soiled, it should first be cleaned with regular cleaning products followed by disinfection by a standard household disinfectant. Ensure manufacturer's instructions are being followed when using these products. If using household bleach to disinfect (i.e., a 0.1 % sodium hypochlorite solution), instructions on how to dilute bleach are available at the following webpage: Use household chemicals safely - Canada.ca

Single-use disposable cleaning equipment (e.g. disposable towels) is recommended. If disposable cleaning equipment is not available, the cleaning material (cloth, sponge etc.) should be washed (e.g., with rags) or placed in a disinfectant solution effective against viruses, or 0.1% sodium hypochlorite. If neither option is available, the cleaning material should be discarded.

Cleaning furniture and carpets

Vacuum upholstered furniture and carpeted floors using a vacuum cleaner equipped with a high-efficiency particulate air (HEPA) filter. Do not vacuum furniture or carpet with a vacuum cleaner without a HEPA filter as this may spread infectious particles. Clean upholstered furniture and carpets that require removal of visible soil using commercially available cleaning products or professional steam cleaning. Individuals should consult their public health department if they have grossly soiled furnitureFootnote 12.

Cleaning dishware and utensils

Dishes and other eating utensils should not be shared with the case. It is not necessary for the case to use separate utensils if properly washed. Soiled dishes and eating utensils should be washed in a dishwasher or by hand with warm water and soapFootnote 13.

Additional Resources

References

Footnote 1

E. M. Beer and V. B. Rao, "A Systematic Review of the Epidemiology of Human Monkeypox Outbreaks and Implications for Outbreak Strategy," PLOS Neglected Tropical Diseases, vol. 13, no. 10, p. e0007791, 2019.

Return to footnote 1 referrer

Footnote 2

M. G. Reynolds, et al., "Clinical Manifestations of Human Monkeypox Influenced by Route of Infection," The Journal of Infectious Diseases, vol. 194, no. 6, pp. 773-780, 2006.

Return to footnote 2 referrer

Footnote 3

R. H. Doshi, et al., "Epidemiologic and Ecologic Investigations of Monkeypox, Likouala Department, Republic of the Congo, 2017," Emerging Infectious Diseases, vol. 25, no. 2, pp. 273-281, 2019.

Return to footnote 3 referrer

Footnote 4

A. Vaughan, et al., "Human-to-Human Transmission of Monkeypox Virus, United Kingdom, October 2018," Emerging Infectious Diseases, vol. 26, no. 4, pp. 782-785, 2018.

Return to footnote 4 referrer

Footnote 5

E. M. Bunge, et al., "The Changing Epidemiology of Human Monkeypox—A Potential Threat? A Systematic Review," PLOS Neglected Tropical Diseases, vol. 16, no. 2, p. e0010141, 2022.

Return to footnote 5 referrer

Footnote 6

H. Adler, et al., "Clinical Features and Management of Human Monkeypox: A Retrospective Observational Study in the UK," The Lancet Infectious Diseases, 2022.

Return to footnote 6 referrer

Footnote 7

U.S. Centre for Disease Control and Prevention, "Update: Multistate Outbreak of Monkeypox - Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003," Centers for Disease Control and Prevention, 4 July 2003. [Online]. Available: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5226a5.htm#tab [Accessed 2 June 2022].

Return to footnote 7 referrer

Footnote 8

T. Tabie and V. Curtis, "Handwashing and risk of respiratory infections: a quantitative systematic review," Tropical Medicine & International Health, vol. 11, no. 3, pp. 258-267, 2006.

Return to footnote 8 referrer

Footnote 9

A. E. Aiello, R. M. Coulborn, L. Perez and E. L. Larson, "Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis," American Journal of Public Health, vol. 98, no. 8, pp. 1372-1381, 2008.

Return to footnote 9 referrer

Footnote 10

Public Health Agency of Canada, "Interim guidance on infection prevention and control for suspect, probable or confirmed monkeypox within Healthcare settings," 27 May 2022. [Online]. Available: https://www.canada.ca/en/public-health/services/diseases/monkeypox/health-professionals/interim-guidance-infection-prevention-control-healthcare-settings.html. [Accessed 2022 June 3 2022].

Return to footnote 10 referrer

Footnote 11

Public Health Agency of Canada, "Routine practices and additional precautions for preventing the transmission of infection in healthcare settings," 2016. [Online]. Available: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/routine-practices-precautions-healthcare-associated-infections-2016-FINAL-eng.pdf. [Accessed 3 June 2022].

Return to footnote 11 referrer

Footnote 12

U.S. Centre for Disease Control and Prevention, "Interim Guidance for Household Disinfection of Monkeypox Virus," 27 May 2022. [Online]. Available: https://www.cdc.gov/poxvirus/monkeypox/pdf/Monkeypox-Interim-Guidance-for-Household-Disinfection-508.pdf. [Accessed 3 June 2022].

Return to footnote 12 referrer

Footnote 13

U.S. Centre for Disease Control and Prevention, "Infection Control: Proper hand hygiene and cleaning products," 27 May 2022. [Online]. Available: https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-home.html#:~:text=Hand%20hygiene%20(i.e.%2C%20hand%20washing,had%20contact%20with%20lesion%20material. [Accessed 8 June 2022].

Return to footnote 13 referrer

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