Monkeypox: Public health management of cases and contacts in Canada

June 21, 2022

On this page

• Introduction
• Background
• Public health management of cases
• Public health management of contacts
• Appendix 1: Recommendations for hand hygiene and respiratory etiquette
• Appendix 2: Recommendations for environmental hygiene
• Additional Resources

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 fomites^{Footnote 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:

• Isolation of cases until deemed no longer contagious by the PHA
  • Cases may isolate at home when feasible, or in an alternate dwelling such as a hotel or self-containing accommodation as directed by the PHA, when necessary
    • Note: For the remainder of this document, “home” will be used as an all-encompassing term to refer to the case's place of isolation
  • Identifying and mitigating any barriers to effective isolation at the home , as well as providing appropriate supports as needed
  • PHAs should take into account the unique characteristics of the case and their living situation (e.g., if the case is living in a homeless shelter) and adjust advice accordingly (e.g., recommending isolating the case in an alternative setting, if possible)
• Active monitoring of MPX cases (i.e., through regular communication), recognizing that frequency may vary by PHA and the local context
  • Monitoring activities can support learning about the clinical evolution of the infection, address emerging issues, as well as encourage the appropriate isolation compliance, including by connecting the individual to community support as appropriate
• Providing information on public health measures (PHMs) that the case, along with their caregiver and household members, should follow (see section below)
• Providing general advice on steps to take if symptoms worsen, including instruction on self-care, when to contact their health care provider and how/when to access medical care
• Identifying all contacts during the case's period of communicability, including, persons identified specifically as contacts by the case, or group(s) of individuals potentially exposed during an event or while at a location, depending on the activities practiced while at those sites

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

• Remain in isolation until deemed no longer contagious (i.e., once scabs have fallen off, and the wound is epithelialized and has a light pink / shiny pearl appearance)
• Avoid contact with vulnerable populations (e.g., children under 12 years of age, immunocompromised individuals, pregnant women)^{Footnote 1}, where possible
• Avoid direct touching of other people, including through sexual contact
  • After being deemed no longer contagious, cases should wear a condom during any sexual activity for 12 weeks
• Cover all lesions with clothing or bandages as much as possible
• Do not share clothes, bedding, towels, utensils, toothbrush, razors, sex toys, needles, or any other items that may be contaminated with infectious particles from lesions or body fluids
• Isolate in a separate space (e.g., private room for sleeping and washroom) whenever possible, especially if the case has respiratory symptoms, lesions that are hard to cover (e.g., on the face), or weeping lesions
  • If a private room for sleeping is not possible, the case should maintain as much distance as possible from others(e.g., by sleeping in separate beds)
  • If a separate washroom is not possible, the case should clean and disinfect all surfaces and objects they have had contact with and immediately remove and launder used towels
• Wear a well-fitting medical mask when around others, at all times
  • When this is not possible, other household members should wear a medical mask when in the presence of the case
• Maintain proper hand hygiene and respiratory etiquette (see Appendix 1 for detail)
• Cases should consult their health care provider for advice if breastfeeding
• Avoid contact with animals, including pets, when possible
  • The current spread of MPX in Canada is a result of human-to-human transmission of the virus; the risk of people passing the virus to animals is unknown at this time and is an area that requires further study
  • A number of animals species are susceptible to MPX, especially rodent species, but the full range of animals susceptible to MPX, particularly in North America, remains unknown at this time
  • To prevent possible spread to animals, including pets and livestock, cases should have another member of their household care for their animals
    • If this isn't possible, cases should cover all lesions with clothing or bandages, wear a well-fitting medical mask and gloves when near the animals, and clean and disinfect high-touch surfaces frequently
  • As a precaution and until more is known, cases should 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

Recommendations for interactions with others outside the home

• Only leave isolation to access urgent medical care or for other such emergencies
  • When accessing medical care, cases should, as much as possible, alert health care providers of their infection in advance of the meeting
• Limit contact with others from outside the home during their isolation period
  • This includes not having visitors inside the home, with the exception of a health care provider who follows relevant IPAC measures to provide necessary patient care services
• As much as possible, have necessities delivered to the home, such as medication, groceries, etc.
• Postpone elective medical visits and other elective procedures (e.g., elective dental visits, elective blood tests)
• Do not donate blood or any other body fluid (including sperm) or tissue
• Do not travel to other cities, regions/provinces/territories or to other countries during the isolation period

Recommendations for environmental hygiene

• Avoid areas commonly used by others in the home, where possible
• Surfaces/objects in common spaces that may be accessed by the case should be adequately cleaned and disinfected (see Appendix 2 for details)
• Unless unable to do so, the case should be responsible for handling and laundering their own clothing, bedding, towels, etc. (see Appendix 2 for details)
• Unless unable to do so, the case should be responsible for handling used utensils and dinnerware (see Appendix 2 for details)

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:

• Avoiding close physical contact with the case
  • If close contact is unavoidable, the caregiver should wear a well-fitting medical mask and should cover any skin that could potentially come in contact with the case (e.g., consider wearing long pants, long sleeves, an apron, etc.)
  • If direct contact with lesions is unavoidable, the caregiver should also wear disposable gloves (see Appendix 1 for details on glove use)
• Avoiding contact with clothing, towels, or bedding used by the case; the case should be responsible for handling and laundering these items
  • If this is unavoidable, the caregiver or household member handling these items should follow recommendations outlined in Appendix 2
• Avoiding sharing personal items with the case (e.g., toothbrushes, razors, sex toys, needles, contaminated utensils, etc.)
• Avoid handling utensils and dinnerware that has been used by the case; the case should be responsible for handling and cleaning these items
  • If this is not possible, the caregiver or household member handling these items should follow instructions outlined in Appendix 2
• Frequently cleaning and disinfecting high-touch surfaces and objects in the home, especially those that the case may have had contact with (see Appendix 2 for detail)
• Practicing frequent hand hygiene (see Appendix 1 for detail)

Public health management of contacts

Contact tracing

The purpose of contact tracing is to:

• Ensure contacts are aware of:
  • their potential exposure,
  • expectations of monitoring for any signs and symptoms,
  • risk mitigation measures to practice,
  • and what to do if they develop MPX symptoms (i.e., immediate isolation, advising PHAs)
• If eligible, provide information about post-exposure prophylaxis and referral to their health care provider, to prevent the onset of disease and stop further transmission
• Identify any symptomatic contacts as early as possible
• Facilitate prompt clinical assessment by a health care provider, laboratory diagnostic testing and treatment if signs or symptoms develop

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:

• Cases are considered contagious from onset of symptoms until after the scabs have fallen off, and there is evidence of epithelialization
• The timing, type (e.g. direct skin contact, respiratory route) and duration of exposure to the case
  • Priority for public health management should be given to contacts with a high-risk exposure

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.

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:

• Conduct active (or passive, where appropriate) public health monitoring for signs and symptoms and counselling
• Provide instructions on what to do if symptoms develop
• Instruct contacts to try avoiding medications that are known to lower fever (e.g., acetaminophen, ibuprofen, acetylsalicylic acid) as these medications could mask an early symptom of MPX; if these must be taken, they should advise the PHA
• Provide appropriate information on which PHMs should be followed in order to reduce potential spread to others (see section below)
• Provide information on when and where to access diagnostic testing (where appropriate)
• Explore means of reaching out to high-risk exposure contacts related to events in situations where contacts are unknown (e.g., outreach to communities, stakeholder engagement, awareness campaign, etc.)
• Contacts may be advised to reach out to health care providers for advice on prophylaxis, especially in situations of high-risk exposure

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:

• If a contact has had previous smallpox vaccination
  • If so, PHAs should consider the time since the contact's last vaccine dose
• If the contact has recovered from a previous MPX infection

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% alcohol^{Footnote 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-contamination^{Footnote 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:

• Wear a well-fitting medical mask and disposable gloves^{Footnote 10}
  • The mask and gloves should be properly disposed of after use
• The caregiver should ensure the contaminated laundry does not come into contact with their skin or clothing
  • The caregiver should cover any skin that could potentially come in contact with the contaminated laundry (e.g., consider wearing long pants, long sleeves, an apron, etc.)
  • Any garments from the caregiver that may have come in contact with the contaminated laundry should be removed and cleaned in the same manner as the contaminated laundry
• The caregiver may consider transporting the contaminated laundry in a leak-proof bag or garbage bag
  • The garbage bag used to transport the laundry should be disposed of afterwards, by being placed in another garbage bag that is then closed and disposed of immediately
• The caregiver should avoid shaking or handling the contaminated laundry in a way that may dispense infectious particles in the air or on surrounding surfaces or objects
• Surfaces should be cleaned and disinfected after use

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 furniture^{Footnote 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 soap^{Footnote 13}.

Additional Resources

• National Advisory Committee on Immunization (NACI): Interim guidance on the use of Imvamune^® in the context of monkeypox outbreaks in Canada
• World Health Organization: Monkeypox fact sheet
• World Health Organization: Monkeypox outbreak toolbox
• World Health Organization: Online training module: Monkeypox
• World Health Organization: Online training module: Monkeypox epidemiology, preparedness and response
• World Health Organization: Disease outbreak news
• World Health Organization: Weekly epidemiological record
• Nigerian Centre for Disease Control: Monkeypox
• Nigerian Centre for Disease Control: Update of Monkeypox Outbreak in Nigeria
• Centers for Disease Control and Prevention: Monkeypox in the United States

References