Mpox (monkeypox): Public health management of cases and contacts in Canada
January 4, 2024
Note
January 4, 2024, update
Updates have been made to the last version (February 23, 2023) to:
- acknowledge the risk of pre-symptomatic transmission of mpox (monkeypox)
- provide public health authorities with advice for contact tracing for those exposed to a case in the pre-symptomatic period and
- include the latest information on mpox vaccination
February 23, 2023, update
An update was made to the previous version (October 18, 2022) of this document to change the term “monkeypox” disease to “mpox” disease. This change aligns with the World Health Organization's (WHO) preferred nomenclature for the disease. The WHO recommended this change in November 2022 to help reduce stigma and other concerns associated with the previous terminology.
When referring to the virus itself, “monkeypox virus” will be used throughout this guidance to align with the International Committee on Taxonomy of Viruses’ (ICTV) terminology. PHAC will continue to monitor any changes to ICTV terminology and update guidance as needed.
October 18, 2022, update
Updates have been made to the previous version (June 21, 2022). They include the following changes:
- identify populations who may be at greater risk of infection during the current outbreak, while recognizing that risk of exposure to mpox is not exclusive to any group or setting
- clarify advice for condom use following mpox infection
- note that public health authorities may consider developing targeted messaging for gatherings/settings where close physical contact, including sexual activity, may take place (for example, parties, clubs, raves, festivals)
- provide more information related to animals that have been exposed to a human case of mpox, including risk mitigation measures that may be put in place
- provide information on safer sex practices in the context of the mpox outbreak
On this page
- Introduction
- Background
- Public health management of cases
- Public health management of contacts
- Additional resources
- Footnotes
- References
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. It provides guidance to PHAs working at the federal/provincial/territorial (FPT) level in the event cases of monkeypox 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, including among:
- populations at higher risk of exposure to mpox (monkeypox) (such as individuals self-identifying as gbMSM [gay, bisexual and other men who have sex with men] especially those with multiple sexual partners) and/or severe disease (such as individuals who are immunocompromised, individuals who are pregnant, young children)Reference 1 and
- settings where transmission is occurring (such as sex-on-premise venues and congregate living settings)
To achieve this, the objectives for this guidance include rapidly stopping chains of transmission to reduce the spread of mpox and mitigate the impacts in Canada. This will ultimately contribute to the overall goal of eliminating person-to-person transmission of mpox in Canada.
As mpox is not endemic in Canada and the situation continues to evolve, this document also follows precautionary principles and approaches, in an effort to prevent the long-term establishment of mpox in Canada.
Guidance on diagnostic laboratory, specimen handling and transportation, clinical care, and infection prevention and control (IPC) measures in other settings (for example, Canadian points of entry, health care 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 and globally evolves.
Although a significant volume of scientific literature has been published since the introduction of mpox into Canada, there are still several knowledge gaps on the transmission dynamics of the monkeypox virus. PHAC continues to apply an evidence-informed approach to its case and contact management guidance for mpox. We will adjust this document accordingly as new scientific information becomes available.
This guidance should be read in conjunction with relevant FPT and local legislation, guidelines, regulations and policies. It should be adapted to the local context as required.
PHAC has developed this document based on the Canadian situation. Therefore, it may differ from guidance developed by other countries.
Background
Monkeypox virus in humans
Monkeypox virus can be spread to humans in 3 ways: animal to human, human to human and likely through fomites Reference 2 Reference 3 Reference 4 Reference 5 Reference 6 Reference 7 Reference 8. For more information on the modes of transmission, clinical manifestations, diagnosis and treatment for monkeypox virus, refer to PHAC's Mpox (monkeypox): For health professionals web page. Information on mpox for the general public is also available.
Current status
The WHO declared mpox a global outbreak in July 2022. As of May 2023, it announced the outbreak no longer constituted a public health emergency of international concern (PHEIC). It did, however, emphasize the need for a robust long-term response plan for mpox. For Canada’s current response plan, refer to Federal, Provincial and Territorial Public Health Response Plan for the Management of the Monkeypox Outbreak.
Although the outbreak is no longer considered a PHEIC, mpox cases continue to be reported in Canada, as well as globally. PHAC continues to work with PTs and international partners to actively monitor the situation. For up-to-date information, refer to PHAC's Mpox (monkeypox): Outbreak update web page.
At the time of this update, most cases of mpox in Canada are in individuals self-identifying as gbMSM (gay, bisexual and other men who have sex with men), especially those with multiple sexual partners. However, it is important to stress that the risk of exposure to the monkeypox virus is not exclusive to any group or setting.
Mpox illness is usually self-resolving. However, severe cases can occur and may be fatal Reference 1. Based on genomic sequencing available to date, the outbreaks occurring in Canada are the result of transmission of Clade IIb of monkeypox virus, which historically has reported a case fatality rate of approximately 1% to 3% Reference 9 Reference 10 Reference 11. At the time of this update, no fatalities have been reported among mpox cases in Canada. For further details on mpox epidemiology in Canada, refer to PHAC's Mpox (monkeypox) epidemiological update web page.
Mpox vaccination
Imvamune® is a licensed third-generation smallpox vaccine. It is indicated for immunization against smallpox, mpox and related Orthopoxvirus infection and disease in adults 18 years of age and older determined to be at high risk for exposure.
Given the reduced epidemiological activity since summer 2022, vaccine effectiveness studies as well as studies to determine the duration of vaccine protection are limited. Evidence is emerging on the effectiveness of Imvamune®, demonstrating the vaccine reduces risk of mpox and that the 2-dose primary series provides better protection than a single dose. However, estimates vary. The National Advisory Committee on Immunization (NACI) has issued an updated Interim guidance on Imvamune® in the context of ongoing mpox outbreaks in Canada. This interim guidance covers the pre-exposure and post-exposure use of the vaccine. A Summary of NACI rapid response of September 23, 2022, is also available.
Public health management of cases
Case definitions
National case definitions for mpox have been established and are being used in this document.
Public health activities for case management
PHA's activities for case management may include:
- isolating cases until they are deemed no longer contagious by the PHA
- As individual situations vary and are unique, PHAs may need to modify isolation approaches used for cases. Modifications in isolation should be designed to maintain the objectives of this guidance (for instance, rapidly stopping chains of transmission to reduce the spread of mpox and mitigate the impacts in Canada).
- 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 (for example, should encompass health, psychological, material and essential supports needed for adequate living)
- PHAs should take into account the unique characteristics of the case and their living situation (for example, if the case is living in a congregate living setting like a homeless shelter, student residence or correctional facility) and adjust advice accordingly (for example, recommending isolating the case in an alternative setting, when no other option is available)
- active monitoring of mpox cases (such as 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 and 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 (refer to the section on Public health measures recommendations for suspected, probable and confirmed cases)
- 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, and groups of individuals potentially exposed during an event or while at a location, depending on the activities practised while at those sites
Public health measures recommendations for suspected, probable and confirmed cases
When hospital-level care is not required, cases of mpox are recommended to isolate from the start of symptoms until scabs have fallen off and there is evidence of epithelialization. This typically takes 2 to 4 weeks, but may take longer. The full spectrum of recommended PHMs is outlined as follows.
General recommendations for isolation
- Remain in isolation until deemed no longer contagious (once scabs have fallen off, and the wounds are epithelialized and have a light pink/shiny pearl appearance).
- 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.
- When possible, cases seeking medical care should not use public transportation.
- If public transportation is unavoidable, cases should wear a well-fitting medical mask, cover any lesions and maximize their distance from others.
- As much as possible, have necessities such as medication and groceries, delivered to the home.
- Postpone elective medical visits and other elective procedures (such as elective dental visits and 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.
- Maintain proper hand hygiene and respiratory etiquette.
Recommendations for interactions with others
- Avoid touching other people directly, even if they are fully vaccinated against mpox.
- includes avoiding sexual contact
- Avoid all contact with populations at risk of more severe disease (for example, individuals who are immunocompromised, individuals who are pregnant, young children) Reference 1 where possible.
- Limit contact with others from outside the home during the isolation period.
- includes not having visitors inside the home, with the exception of a health care provider who follows relevant IPC measures to provide necessary patient care services
- Isolate cases in a separate space (such as a private room for sleeping and washroom) whenever possible if they live with others, especially if the case has respiratory symptoms (particularly if they have lesions inside the mouth or throat), lesions that are hard to cover (such as on the face, neck, hands) or weeping lesions.
- if a private room for sleeping is not possible, the case should maintain as much distance as possible from others (for example, 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
- Take the following measures when interaction with others is unavoidable:
- cover all lesions with clothing or bandages as much as possible (including when accessing common spaces, even if others are not present)
- wear a well-fitting medical mask
- when this is not possible, other household members should wear a medical mask when in the presence of the case
- Do not share clothes, bedding, towels, utensils, toothbrushes, razors, sex toys, needles or any other items that may be contaminated with infectious particles from lesions or body fluids.
- Consult the health care provider for advice if the case must have close contact with infants (for example, provides care to or breastfeeds an infant), given the potential for severe disease in very young children.
Recommendations for interactions with animals (pets, livestock and wildlife)
The current spread of mpox disease in Canada is a result of human-to-human transmission of the monkeypox virus. However, humans can also spread the virus to animals, which can then spread it back to humans.
Many different animal species are susceptible to monkeypox virus, especially rodent species such as squirrels and rats. However, the full range of animals susceptible to monkeypox virus, particularly in North America, remains unknown at this time. Dogs are now known to be susceptible, following a report in August 2022 of a dog in France that developed mpox infection after close contact with human cases in a household Reference 12. It is prudent to assume that any mammal species could be infected with the monkeypox virus.
Cases should:
- be advised they can transmit mpox to animals and to avoid contact with animals, including pets, when possible
- prevent possible spread to animals, including pets and livestock, by having 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, their food, bedding or other items
- avoid close contact (such as petting, kissing, cuddling, sharing sleeping areas, sharing food)
- clean and disinfect high-touch surfaces frequently
- if this isn't possible, cases should:
- avoid handling, feeding or working closely with wildlife to prevent any possible spread of the virus, to limit risk of creating a wildlife reservoir for this virus in Canada
- avoid having visiting pets inside the home where they are isolating
- be advised that if they have had close contact with animals (for example, petting, kissing, cuddling, sharing sleeping areas, sharing food) during their contagious period, the animal(s) should be monitored for clinical signs for 21 days after the exposure and kept away from other animals and people during this time
- consult a veterinarian if an animal develops clinical signs of mpox (such as fever, depression, not eating, respiratory signs, diarrhea, oral ulcers, skin lesions) within 21 days of close contact with a case
Recommendations for environmental hygiene
The risk of fomite transmission of monkeypox virus remains difficult to characterize. In general, orthopoxviruses are known to be very stable in the environment and remain infectious for prolonged periods in scabs, especially in dark and cold environments Reference 13 Reference 14 Reference 15. Materials contaminated with orthopoxviruses (such as clothes, paper, dust) can remain contagious for months to years if not disinfected Reference 13 Reference 14 Reference 15 Reference 16 Reference 17 Reference 18.
Some limited evidence has found persistent monkeypox virus DNA Reference 19 Reference 20 Reference 21 Reference 22 Reference 23, and in some cases potentially infectious virus Reference 21 Reference 23 Reference 24, on surfaces and fabrics directly touched by cases. However, many unknown factors remain, including the viral load needed for transmission to occur and the stability of infectious virus on surfaces and fabrics in various environmental conditions. Some small experimental studies have shown that despite environmental stability, poxviruses can be inactivated when exposed to standard chemical disinfectants and temperature greater than 50° Celsius Reference 25 Reference 26 Reference 27 Reference 28.
In light of this, PHAs should advise cases and/or caregivers on proper environmental hygiene in the home, including recommendations for:
- handling laundry
- cleaning and disinfecting high-touch surfaces and objects
- cleaning and vacuuming furniture and carpets
- handling and cleaning dishware and utensils
- proper waste management in the home
- for example, contaminated materials should be disposed of in a manner that prevents access by pets or wild animals, rodents in particular
Detailed advice on environmental hygiene is available for cases and their caregivers on PHAC's website.
Post-recovery risk reduction
Cases who have recovered (once scabs have fallen off and the wounds are epithelialized) should be advised by the PHA:
- that using barrier protection (such as condoms, dental dams) may decrease the risk of monkeypox virus transmission through genital fluidsFootnote a
- for additional information on barrier protection, consult PHAC’s Sexually Transmitted and Blood Borne Infections (STBBI) Prevention Guide
- to consult resources on preventing the spread of mpox, such as Mpox (monkeypox): How it spreads, prevention and risks
Public health measures for caregivers at the home
Ideally, only 1 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 IPC protocols.
The caregiver should not be someone who is at risk of more severe disease from mpox (for example, individuals who are immunocompromised, individuals who are pregnant, young children) Reference 1. Caregivers should self-monitor for signs or symptoms for 21 days since their last exposure to the case (refer to the following section on contact management for further details). If signs or symptoms develop, they should immediately notify the PHA and follow their instructions.
The PHA should provide caregivers with instructions on how to reduce their risk of mpox infection. These may include:
- avoiding close physical contact with the case (even if the caregiver is fully vaccinated)
- If close contact is unavoidable, the caregiver should wear a well-fitting medical mask and cover any skin that could potentially come in contact with the case (consider wearing long pants, long sleeves, an apron) .
- follow appropriate steps for removing clothing and handling laundry after providing care
- If direct contact with lesions is unavoidable, the caregiver should also wear disposable gloves.
- If close contact is unavoidable, the caregiver should wear a well-fitting medical mask and cover any skin that could potentially come in contact with the case (consider wearing long pants, long sleeves, an apron) .
- practising frequent hand hygiene
- having the case handle their own laundry, utensils and dishware, and be responsible for cleaning and disinfecting in the home
- The caregiver or household member should follow specific instructions to reduce the risk of infection if this is unavoidable.
Public health management of contacts
Contact tracing
The purpose of contact tracing is to:
- ensure contacts are aware of:
- their potential exposure
- their potential to develop infection even if fully vaccinated,
- expectations of monitoring for any signs and symptoms (including the need to monitor for mild symptoms that can go unnoticed) Reference 29
- risk mitigation measures to practise for 21 days post-exposure, depending on the circumstances (for example, ensure contacts are aware of and can evaluate the risks associated with planned activities including sexual activity, travelling or attending social events/gatherings)
- the importance of consistently practising recommended PHMs, given the potential for pre-symptomatic transmission (details provided in the following section)
- what to do if they develop mpox symptoms (for example, isolate immediately, advise PHAs)
- provide information about post-exposure prophylaxis and refer to their health care provider, if eligible, to prevent the onset of disease and stop further transmission
- identify 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, they 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 considered:
- Recent evidence suggests that some cases may be infectious up to 4 days before the onset of symptoms.
- It is currently unknown what proportion of mpox cases transmit the virus pre-symptomatically and if the likelihood of pre-symptomatic transmission varies by route of transmission Reference 30 Reference 31.
- Cases are considered contagious until after the scabs have fallen off and there is evidence of epithelialization.
- Several factors may influence transmission, such as the timing, type (for example, direct skin contact, respiratory route) and duration of exposure to the case, as well as any mitigation measures used during exposure (for example, if case was wearing a well-fitting medical mask or gloves).
- Priority for public health management should be given to contacts with a high-risk exposure.
Previously, it was recommended that PHAs identify contacts who were exposed to an mpox case between the date of symptom onset and when their scabs fell off (with evidence of epithelialization). Based on the current evidence that pre-symptomatic transmission may occur, PHAs may consider extending contact tracing to certain contacts who were exposed to the case up to 4 days before their symptom onset Reference 30 Reference 31 Reference 32 Reference 33 Reference 34 Reference 35 Reference 36 Reference 37 Reference 38 Reference 39 Reference 40. This tracing may be done based on a risk assessment of the case’s behaviour up to 4 days before their symptom onset. When assessing the risk, PHAs could consider whether the case had engaged in an activity with a greater risk of mpox transmission and/or visited a high-risk setting or event during this pre-symptomatic period. Refer to Table 1 on the classification of contacts by exposure risk level for a description and examples of high-risk exposure contacts.
The decision to trace contacts exposed to a case in the pre-symptomatic period will depend on whether PHAs are opting for a more rigorous contact management approach and if the necessary resources are available.
Proactive communications to potential contacts
Along with traditional contact tracing activities, PHAs should consider proactive, non-stigmatizing communication and outreach strategies to reach groups that may be at higher risk of exposure based on current epidemiological data. They should do so 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.
In particular, PHAs may consider enhancing these types of communications during times where transmission may be expected to increase, such as during periods of:
- increased international travel (for example, spring break, summer vacations, winter holidays), since mpox is still causing active outbreaks in various countries
- increased gatherings where there may be a higher likelihood of increased sexual activity (such as Pride festivals, other large social or cultural events)
PHAs may also find it beneficial to provide targeted messaging and advice on risk mitigation strategies for settings where activities may increase the risk of mpox transmission. Such settings include sex-on-premise venues and congregate living settings, like shelters and correctional facilities. PHAs could also highlight that substance use (drugs and/or alcohol) may also impact individuals' assessment of risk and reduce adherence to safer sex practices Reference 41.
Information can be found at Mpox (monkeypox): How operators can reduce the risk of spread in community settings.
Risk assessment of contacts
It is recommended that all individuals who are contacts of a confirmed, probable or suspected case be rapidly identified and assessed by PHAs. Such assessment will 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. This table provides guidance for classifying contacts as either high, intermediate or low risk, depending on their exposure, for the purpose of determining recommended actions. This information is not intended to replace more personalized public health advice provided to contacts, which is based on clinical judgment and comprehensive risk assessments conducted by PHAs.
Depending on the PHA’s approach to contact tracing (refer to the section on contact tracing), PHAs may classify a contact’s risk of exposure to a symptomatic or a pre-symptomatic case.
Exposure risk | Description | Possible examples |
---|---|---|
High |
Prolonged or intimate contact, including any of the following:
|
|
Intermediate |
|
|
Low or uncertain |
|
|
Acronyms
|
||
Note: This guidance is focused on community settings. For health care providers who have had an exposure to mpox, follow occupational health and safety advice and/or refer to PHAC guidance on infection prevention and control of mpox cases in healthcare settings. |
Public health activities for contact management
For both high- and intermediate-risk mpox contacts, during the 21-day period since the contact's last exposure to the case, PHAs may:
- conduct active (or passive, where appropriate) public health monitoring for signs and symptoms and counselling
- may include informing the contact that symptoms can occur even if vaccinated and can be mild or go unnoticed
- provide instructions on what to do if symptoms develop
- advise contacts that taking certain medications (such as acetaminophen, ibuprofen, acetylsalicylic acid) could mask early symptoms of mpox
- contacts who need to take these medications should advise the PHA
- provide appropriate information on which public health measures (PHM) to follow to reduce potential spread to others (refer to the following section on public health measures recommendations for contacts)
- provide information on when and where to access diagnostic testing (as appropriate)
- explore means of reaching out to high-risk exposure contacts related to events in situations where contacts are unknown (for example, outreach to communities, stakeholder engagement, awareness campaign)
- possibly advise contacts 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 apply for the 21-day period following the last exposure to a known suspected (unless mpox is ruled out), probable or known case.
Note: Along with determining exposure risk level, PHAs may further adjust PHM recommendations based on a thorough individual assessment of a contact’s specific risk factors. For example, PHAs may consider if the contact:
- had previous vaccination against smallpox or mpox, and if so, the time since the last vaccine dose
- PHAs may also take into consideration that the highest protection against disease is provided after 2 vaccine doses.
- Studies on vaccine effectiveness and duration of vaccine protection are limited at this time. Evidence is emerging on vaccine effectiveness of Imvamune®, demonstrating the vaccine reduces risk of mpox and the 2-dose primary series provides better protection than a single dose (estimates vary).
- PHAs may also take into consideration that the highest protection against disease is provided after 2 vaccine doses.
- has recovered from a previous mpox infection
- is at higher risk of severe disease, including individuals who are immunocompromised (for example, HIV with very low CD4 levels), pregnant or young children
Exposure risk | Recommendations |
---|---|
For all exposures |
|
For both intermediate- and high-risk exposure contacts |
|
For high-risk exposure contacts |
|
Additional resources
- National Advisory Committee on Immunization (NACI): Interim guidance Imvamune® in the context of mpox (monkeypox) outbreaks
- Federal, Provincial and Territorial Public Health Response Plan for the Management of the Mpox (monkeypox) Outbreak
- Public Health Ontario – Evidence Brief: Monkeypox Transmission Through Genital Excretions
- U.S. Department of Homeland Security Science and Technology – Evidence Brief: Master Question List for Monkeypox Virus
- World Health Organization: Mpox (monkeypox) Outbreak 2022
Footnotes
- Footnote a
-
Emerging evidence has documented the monkeypox virus in seminal fluid, oropharyngeal and anorectal swabs among people with mpox infection39, 40, 42, 43, 44, 45, 46, 47. The relevance of these findings for transmission is not yet known. At this time, PHAC has taken a precautionary approach to recommendations for barrier protection following infection26.
References
- Footnote 1
-
E. Beer, M and V. Rao, B, "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.
- Footnote 2
-
M. Reynolds, G 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.
- Footnote 3
-
R. Doshi, H 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.
- 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.
- Footnote 5
-
J. P. Thornhill et al., "Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022," (in eng), N Engl J Med, vol. 387, no. 8, pp. 679-691, Aug 25 2022, doi: 10.1056/NEJMoa2207323.
- Footnote 6
-
V. Del Río García, J. G. Palacios, A. M. Morcillo, E. Duran-Pla, B. S. Rodríguez, and N. Lorusso, "Monkeypox outbreak in a piercing and tattoo establishment in Spain," (in eng), Lancet Infect Dis, vol. 22, no. 11, pp. 1526-1528, Nov 2022, doi: 10.1016/s1473-3099(22)00652-1.
- Footnote 7
-
A. M. Tutu van Furth et al., "Paediatric monkeypox patient with unknown source of infection, the Netherlands, June 2022," (in eng), Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin, vol. 27, no. 29, 2022/07// 2022, doi: 10.2807/1560-7917.es.2022.27.29.2200552.
- Footnote 8
-
R. S. Salvato et al., "Healthcare Workers Occupational Infection by Monkeypox Virus in Brazil," in Preprints, ed: Preprints, 2022.
- Footnote 9
-
E. Bunge, M 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.
- Footnote 10
-
H. Adler et al., "Clinical Features and Management of Human Monkeypox: A Retrospective Observational Study in the UK," The Lancet Infectious Diseases, 2022.
- Footnote 11
-
U.S. Centre for Disease Control and Prevention, "Update: Multistate Outbreak of Monkeypox - Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003," ed: Centers for Disease Control and Prevention, 2003.
- Footnote 12
-
S. Seang et al., "Evidence of human-to-dog transmission of monkeypox virus," (in eng), Lancet, vol. 400, no. 10353, pp. 658-659, Aug 27 2022, doi: 10.1016/s0140-6736(22)01487-8.
- Footnote 13
-
S. Essbauer, H. Meyer, M. Porsch-Ozcürümez, and M. Pfeffer, "Long-lasting stability of vaccinia virus (orthopoxvirus) in food and environmental samples," (in eng), Zoonoses Public Health, vol. 54, no. 3-4, pp. 118-24, 2007, doi: 10.1111/j.1863-2378.2007.01035.x.
- Footnote 14
-
F. v. Rheinbaben, J. Gebel, M. Exner, and A. Schmidt, "Environmental resistance, disinfection, and sterilization of poxviruses," in Poxviruses, A. A. Mercer, A. Schmidt, and O. Weber Eds. Basel: Birkhäuser Basel, 2007, pp. 397-405.
- Footnote 15
-
H. Rouhandeh, R. Engler, M. Taher, A. Fouad, and L. L. Sells, "Properties of monkey pox virus," (in eng), Arch Gesamte Virusforsch, vol. 20, no. 3, pp. 363-73, 1967, doi: 10.1007/bf01241954.
- Footnote 16
-
R. W. Sidwell, G. J. Dixon, and E. McNeil, "Quantitative studies on fabrics as disseminators of viruses. I. Persistence of vaccinia virus on cotton and wool fabrics," (in eng), Appl Microbiol, vol. 14, no. 1, pp. 55-9, Jan 1966, doi: 10.1128/am.14.1.55-59.1966.
- Footnote 17
-
R. W. Sidwell, G. J. Dixon, and E. McNeil, "Quantitative studies on fabrics as disseminators of viruses. 3. Persistence of vaccinia virus on fabrics impregnated with a virucidal agent," (in eng), Appl Microbiol, vol. 15, no. 4, pp. 921-7, Jul 1967, doi: 10.1128/am.15.4.921-927.1967.
- Footnote 18
-
A. W. Downie, M. Meiklejohn, L. St Vincent, A. R. Rao, B. V. Sundara Babu, and C. H. Kempe, "The recovery of smallpox virus from patients and their environment in a smallpox hospital," (in eng), Bull World Health Organ, vol. 33, no. 5, pp. 615-22, 1965.
- Footnote 19
-
D. Nörz et al., "Evidence of surface contamination in hospital rooms occupied by patients infected with monkeypox, Germany, June 2022," (in eng), Euro Surveill, vol. 27, no. 26, Jun 2022, doi: 10.2807/1560-7917.Es.2022.27.26.2200477.
- Footnote 20
-
B. Atkinson et al., "Infection-competent monkeypox virus contamination identified in domestic settings following an imported case of monkeypox into the UK," (in eng), Environ Microbiol, vol. 24, no. 10, pp. 4561-4569, Oct 2022, doi: 10.1111/1462-2920.16129.
- Footnote 21
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