Mpox (monkeypox): For health professionals
On this page
- What's unique to the 2022 multi-country outbreak
- What health professionals need to know about mpox
- Agent of disease
- Clinical manifestations
- Management and treatment
- Reporting an adverse reaction following vaccination
- Infection prevention and control
- Webinars about mpox
- Additional resources
What's unique to the 2022 multi-country outbreak
As of May 2022, many non-endemic countries, including Canada, reported an unusually large number of cases of mpox (monkeypox), with sustained chains of local transmission. Prior to this outbreak, mpox was rarely observed outside of endemic countries of West and Central Africa, except for sporadic cases or clusters of cases, in relation with travel to endemic countries or with importation of reservoir animals.
Currently, transmission occurs mainly through direct and intimate contact (for example, sexual contact) with a person who has mpox. However, cases of transmission not linked to sexual exposure have been reported. It is not known whether airborne transmission of mpox occurs, although it is not the primary mode of transmission.
While mpox can infect anyone, most cases in the 2022 outbreak have been identified in men who reported sexual contact with other men.
On July 23rd, 2022, the World Health Organization (WHO) officially declared mpox to be a Public Health Emergency of International Concern (PHEIC).
During the multi-country 2022 outbreak, not all cases have been presenting in the typical fashion historically described in the literature. Unique manifestations described during this outbreak include:
- asynchronous generalized rash
- exclusively oral, genital, or perianal lesions
- presentation with a single or only a few lesions
- pharyngitis manifesting as sore throat (may be the only initial presentation)
- symptoms of proctitis (for example, rectal pain)
Historically, systemic symptoms were reported to begin prior to skin lesions. However, now they are also reported to begin concurrently with, or after the appearance of skin lesions.
Some of the leading causes of hospitalization include the following complications:
- severe pharyngitis (may compromise airway and swallowing)
- severe proctitis (may hinder defecation)
- uncontrolled genital pain leading to urinary retention
- bacterial superinfection of skin lesions
- corneal infections that can lead to loss of vision
Although rare, death due to mpox infection can occur and has been reported during the 2022 multi-country outbreak.
The monkeypox virus can infect several different animal species. Therefore, although most cases are currently due to human-to-human transmission, there is concern that the virus could spread to animals in non-endemic regions and establish a new reservoir. To date, only a small number of instances of human-to-animal transmission has been reported in household settings, but this is an area that requires further study.
What health professionals need to know about mpox
Mpox is a viral zoonotic infectious disease caused by an Orthopoxvirus. Person-to-person transmission can occur through direct contact with an infected person or shared contaminated objects. Human-to-human transmission is the major driver of the 2022 multi-country outbreak.
While outbreaks have occurred in endemic areas, sustained multi-country outbreaks with very large numbers of affected persons have not been previously reported. Outside of endemic areas, there was a single zoonotic outbreak in 2003 in the United States, linked to pet prairie dogs who were infected after contact with rodents imported from Africa for the pet trade. Historically, mpox has presented with a characteristic rash, which could be preceded by systemic manifestations such as fever. Lymphadenopathy is a feature that helps to differentiate mpox from other diseases with a similar rash (such as varicella zoster, herpes simplex, secondary syphilis, chancroid and hand-foot-and-mouth disease).
Presentation of cases during the current outbreak has not always been typical. Please refer to What's unique to the 2022 multi-country outbreak section for additional details.
Management is mainly focused on supportive care, as there is limited data on the clinical effectiveness of specific treatments for mpox infections in humans. Some existing treatments for smallpox may have a role to play in mpox management. Smallpox vaccines have been used for pre-exposure and post-exposure prevention. According to reports from the 2003 United States outbreak, post-exposure use of smallpox vaccine prevented the diseases among the vaccine recipients.
Agent of disease
The monkeypox virus is part of the Poxviridae family. Specifically, it is a member of the Orthopoxvirus genus, which also includes variola virus (the virus that causes smallpox), vaccinia virus and cowpox virus.
There are 2 known subtypes of monkeypox virus (called clades). On August 12, 2022, the World Health Organization introduced a new nomenclature for the monkeypox virus clades:
- Clade one (I) (formerly known as Congo Basin or Central African clade)
- Clade two (II) (formerly known as West African clade), which is further divided into 2 subclades:
- Clade IIa
- Clade IIb
Compared to clade I, clade II is associated with a relatively less severe symptoms and outcomes.
Clade IIb has been implicated in the 2022 multi-country outbreak.
Mpox has typically been characterized as a zoonotic infection. Its main reservoirs are unknown but are thought to be small mammals from endemic regions of Africa, such as:
- Gambian pouched rats
- rope squirrels
- sun squirrels
Humans and non-human primates are thought to be incidental hosts.
A person with mpox is considered to be infectious from the onset of symptoms until all their lesions have crusted over, the scabs have fallen off and a new layer of skin has formed underneath. This also includes the healing of all mucosal surfaces (mouth, throat, eyes, vagina and anorectal area).
At this time, it is not known with certainty if a person can transmit the infection before they become symptomatic.
Infection is thought to occur when the virus enters the body through skin, the respiratory tract, or mucous membranes.
This can occur through the following routes:
- through direct contact with an infected animal's skin lesions, body fluids (such as blood and saliva) or mucosal surfaces, including:
- contact from providing care and handling
- through bites or scratches
- preparing or eating undercooked meat (for example, bushmeat)
- through direct contact with skin lesions or scabs, body fluids (such as blood, saliva and semen) or mucosal surfaces (such as eyes, mouth, throat, genitalia and anorectal area)
- for example, contact from providing care or sexual contact
- through respiratory transmission such as contact with infected droplets generated by talking, breathing, coughing, and sneezing.
- It is not known whether airborne transmission of mpox occurs, although it is not the primary mode of transmission. More evidence is needed to determine whether airborne transmission occurs.
- from an infected pregnant person to the fetus
- through direct, unprotected contact with:
- materials (for example, clothing or linens and towels),
- objects (for example, razors, utensils, needles, sex toys, toothbrushes) that have been in contact with a person or animal with mpox.
The incubation period can range from 3 to 21 days. During the 2022 multi-country outbreak, the incubation period has generally ranged from 7 to 10 days.
Mpox illness is usually self-resolving within a period of 2 to 4 weeks. The spectrum of severity varies from a single skin lesion to disseminated, multi-organ infection. At this time, it is not known with certainty if asymptomatic infections occur.
Mpox presents with either systemic symptoms, skin or mucosal lesions, or both. Systemic symptoms typically occur 0 to 5 days before the appearance of lesions. However, they may also occur during or after the onset of skin lesions (as documented in the 2022 outbreak).
Signs and symptoms of mpox may include:
- Skin or mucosal lesions (often painful)
- lymphadenopathy (localized or generalized)
- sore throat
- rectal symptoms (for example, rectal pain)
- musculoskeletal manifestations such as myalgia, arthralgia and back pain
- gastrointestinal symptoms (for example, vomiting, diarrhea)
In the 2022 multi-country outbreak, pharyngitis symptoms (for example, sore throat) and proctitis symptoms (for example, rectal pain) have frequently been reported.
Lesions generally (but not always) appear 1 to 3 days after the onset of fever and last for 2 to 4 weeks. Mpox lesions can be painful and may become itchy during the healing phase. Lesions can be located anywhere on the body, including the:
- mouth and pharynx
- anal and perianal area
- hands (including the palms)
- feet (including the soles)
As the illness progresses, lesions change from flat lesions (macules) to raised lesions (papules), to vesicles and then pustules (see Figure 1). At the latest stage, they will form ulcers that eventually scab over. Figure 2 shows photographs of mpox skin lesion progression.
Mpox lesions in the same body area tend to evolve at the same time (synchronously). However, individuals may have an atypical or asynchronous rash.
Photos of mpox rash
Severe cases can occur but are rarely fatal. Notably, mpox infection during pregnancy may increase risk of maternal and fetal morbidity and mortality. Young children and immunocompromised individuals are also more likely to experience severe disease.
Case fatality rate (CFR) depends on viral clade, host factors (such as immune status and age) and structural factors (such as availability of health care and reporting rates).
Clade I has a CFR of around 10%, while clade II, when occurring in endemic areas, has historically had a CFR of approximately 1 to 3%. When outbreaks of clade II have occurred in non-endemic countries, the CFR has been lower (for instance, during the 2003 US outbreak, there were no recorded fatalities).
Young children and immunocompromised individuals might be at increased risk of complications, which may include:
- bacterial superinfection
- corneal infection (may lead to vision loss)
Mpox may present with concurrent sexually transmissible and blood-borne infections (STBBIs). Hence, healthcare providers should be vigilant and offer testing to mpox cases to rule out STBBIs such as syphilis, gonorrhea, chlamydia, herpes simplex and HIV.
To confirm the diagnosis of a monkeypox virus infection, one or more of the following diagnostic markers must be positive:
- presence of monkeypox virus DNA by PCR
- isolation of monkeypox virus from viral culture
Consult your public health laboratory before sending specimens to receive proper instructions on specimen handling and transport. See biosafety advisory: Monkeypox virus (MPXV).
Wear the adequate personal protective equipment when evaluating and sampling the patient.
The best specimens for PCR and isolation are skin lesion material, including:
- swabs of lesion surface or lesion fluid
- lesion crusts (scabs)
- roofs of multiple lesions (no need to de-roof the lesion before swabbing)
Skin lesion material should be placed in an empty, sterile container for transport.
Although the preferred transport container for a monkeypox virus specimen is an empty, sterile container, formalin-fixed tissues and paraffin-embedded tissues can be sent for PCR, but not for viral culture.
Currently, serology is not being used as a diagnostic modality.
Contact the National Microbiology Laboratory (NML) at email@example.com if you are unable to collect lesion swabs to discuss other possible viable sample types. You can also contact your local public health laboratory to inquire about other appropriate specimen types.
Given the evolving situation of the multi-country 2022 outbreak, the NML is relaxing the requirement to demonstrate travel to monkeypox virus endemic areas or contact to travellers or animals from these areas.
Test requisitions forms:
The mpox rash can be difficult to distinguish from a number of other infectious and non-infectious rashes.
A possible distinguishing feature of mpox is the presence of localized or generalized lymphadenopathy. Refer to the What's unique to the 2022 multi-country outbreak section for more information.
Smallpox can be similar to mpox in its presentation, but since its global eradication in 1980, it is not considered in the differential diagnosis unless there has been a serious laboratory breach.
Other infections to be considered in the differential diagnosis can include:
- Varicella zoster (chickenpox, shingles)
- herpes simplex
- lymphogranuloma venereum
- hand-foot-mouth disease
- molluscum contagiosum
- human papillomavirus infection
- orf (rare)
Co-infections of mpox with sexually transmissible and blood-borne infections (STBBIs) have been frequently reported during the 2022 outbreak, therefore clinicians should be vigilant and consider testing for HIV, syphilis, gonorrhea and other STBBIs in anyone suspected to have acquired mpox through sexual contact.
Management and treatment
Supportive care is a central part of mpox management as there is limited data on the clinical effectiveness of specific treatments for mpox infections in humans. Consult an infectious disease physician to discuss therapeutic options for suspected or confirmed cases.
Some existing treatments for smallpox, such as TPOXX (tecovirimat monohydrate capsules) may have a role to play in select instances. TPOXX is an oral antiviral agent that is indicated for the treatment of human smallpox disease in adults and pediatric patients weighing at least 13 kg. It does not currently have an approved Health Canada indication for mpox or other Orthopoxviruses. However, recommendations for its off-label use can be found at: CADTH Health Technology Review on Tecovirimat (Tpoxx): Update (PDF).
It is suggested that a history of smallpox vaccination may provide some protection against mpox. Routine vaccination for smallpox with first or second generation vaccines generally stopped in 1972 in Canada, but some individuals and groups such as healthcare workers, armed forces personnel and migrants may have been vaccinated after 1972.The exact duration of this protection is not clear as immunity may wane over time.
Imvamune is a licensed third generation smallpox vaccine 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.
The National Advisory Committee on Immunization (NACI) has issued an updated Interim guidance on Imvamune in the context of ongoing monkeypox 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.
Learn more about storage temperatures, shelf life, shipment and supportive temperature excursion information for the Imvamune vaccine in Canada.
Access to products
The PHAC National Emergency Strategic Stockpile (NESS) maintains a supply of vaccines and therapeutics and continues to work with provinces and territories to support collective preparedness and, as required, outbreak management. Health care facilities and local or regional health departments should direct requests for these vaccines and therapeutics to their respective provincial or territorial Ministry of Health (MOH).
For more information on these products, refer to the Product Monographs available on Health Canada's Drug Product Database.
Reporting an adverse reaction following vaccination
Healthcare providers are required to report possible reactions following vaccination to their local public health authority. The public health authority then reports them to PHAC.
Learn more about:
- Reporting adverse events following vaccination with Imvamune: Communiqué to healthcare professionals (October 31, 2022)
Infection prevention and control
Airborne, droplet and contact precautions are recommended in a healthcare setting.
For guidance on infection prevention and control for mpox, refer to the Interim guidance on infection prevention and control for suspect, probable or confirmed monkeypox within Healthcare settings – 27 May 2022.
If you suspect a case of mpox, follow your provincial, territorial or local public health authority's reporting requirements. Ensure you're using the correct case report form for your jurisdiction.
Mechanisms are in place for provincial and territorial public health authorities to securely transfer their de-identified forms to PHAC.
Our mpox case report form is available for your reference:
We're working with provincial and territorial public health partners to monitor cases of mpox in Canada. To learn more about this, refer to the Monkeypox: Outbreak updates web page.
To help health professionals and other decision makers respond to mpox, PHAC has commissioned the McMaster Health Forum to produce a rapid living evidence profile. The profile identifies, assesses the quality, categorizes and briefly summarizes the emerging scientific literature. It includes key findings on epidemiology, prevention and control, clinical presentation and treatment.
Webinars about mpox
There is a series of webinars about mpox in Canada that aim to improve awareness of the ongoing outbreak. These webinars are organized and hosted by the National Collaborating Centre for Infectious Diseases (NCCID) in partnership with PHAC and the Association of Medical Microbiology and Infectious Disease (AMMI) Canada.
These webinars are available for health professionals to watch on the NCCID website:
- mpox in Canada: what clinicians need to know
- mpox: Infection prevention and control
- mpox: Diagnostics
- mpox: Perspectives from the US
- Mpox (monkeypox): Public health management of cases and contacts in Canada
- Mpox (monkeypox) vaccination clinic resources
- National case definition
- Mpox (monkeypox) and animals
- World Health Organization: Monkeypox fact sheet
- Centers for Disease Control and Prevention: Mpox
- European Centre for Disease Prevention and Control. Epidemiological update: Monkeypox multi-country outbreak. 25 May 2022
- World Health Organization: Emergency events, monkeypox
- World Health Organization: Weekly epidemiological record (WER) no.11, 16 March 2018, Emergence of monkeypox in West Africa and Central Africa 1970-2017
- Centers for Disease Control and Prevention: 2022 Outbreak Cases and Data
- World Health Organization: Monkeypox outbreak toolbox
- World Health Organization: Online training module: Mpox: Introductory course for African outbreak contexts
- World Health Organization: Online training module: Mpox: Epidemiology, preparedness and response for African outbreak contexts
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