Interim guidance on infection prevention and control for patients with suspected, probable or confirmed mpox within healthcare settings

November 2024

This guidance has been updated to reflect the evolving epidemiological situation and advancements in evidence. Key updates to this guidance include:

• Nomenclature: 'mpox' is the preferred nomenclature as per the World Health Organization as of November 2022. All reference to 'monkeypox' has been changed to 'mpox'.
• Epidemiological data: updated to reflect current global landscape, including details on both clades and subclades of mpox.
• Clinical progression and incubation period of mpox: updated to reflect current evidence.
• Removed recommendation for the use of an airborne infection isolation room (AIIR).

On this page

• Background
• Transmission
• Clinical progression and incubation period
• Recommendations for infection prevention and control
• Additional precautions
• Cleaning and disinfection
• Containment and disposal of contaminated waste
• Discharge environmental cleaning and disinfection
• Transportation of patients with suspected mpox
• Occupational mpox exposures in healthcare settings
• Acknowledgements
• References

Background

Mpox is a viral infectious disease caused by the mpox virus (Orthopoxvirus genus). The mpox virus (MPXV) is related to, but distinct from, the viruses that cause smallpox (variola virus) and cowpox. Mpox is endemic to Central and West Africa.

MPXV has two distinct genetic clades: clade I and clade II. Clade I usually causes a higher percentage of people with mpox to get severely sick or die compared to clade II.

Clade I (formerly known as Congo Basin or Central African clade).

• Clade Ia: is more common among children, and has been reported as having a case fatality rate up to 10%, according to data from endemic regions.
• Clade Ib: is more common among adults and early evidence suggest it is less severe than clade Ia. As of August 2024, clade Ib has been detected outside of endemic areas.

Clade II (formerly known as West African clade): the case fatality rate is approximately 0.1% to 3.6%, with cases occurring outside of endemic regions rarely being fatal.

• Clade IIa
• Clade IIb (implicated in the 2022 multi-country outbreak)

As of May 2022, many non-endemic countries, including Canada, reported an unusually large number of cases of mpox, with sustained chains of local transmission caused by Clade II. In August 2024, the World Health Organization (WHO) declared a public health emergency of international concern regarding the outbreaks and rapid spread of mpox in African countries.

If mpox is suspected, local public health authorities should be notified immediately.

This guidance intends to provide recommendations for IPC professionals in healthcare settings. Recommendations for non-healthcare settings are beyond the scope of this document. For additional information on mpox, refer to Mpox (monkeypox).

Transmission

Mpox infection occurs when the virus enters the body through the skin, respiratory tract, or mucous membranes. MPXV is transmitted primarily by direct contact with lesions or scabs of an infected individual. It may also be transmitted by contact with blood or other body fluids (such as, semen, saliva, respiratory tract secretions). Transmission through indirect contact with environmental surfaces and fomites contaminated with MPXV can also occur. Although spread through the air is possible, current data continue to support a minimal role of spread through the air for clade I or II MPXV. However, this possibility should continue to be examined given ongoing viral evolution.

Healthcare settings should implement droplet and contact precautions, with appropriate PPE for all suspected, probable and confirmed mpox (N95 respirator, gown, gloves, and eye protection), until more information about the potential for aerosol transmission is known.

Transmission risk to healthcare workers is very low and when reported has primarily been associated with sharps injuries occurring when collecting clinical specimens.

Clinical progression and incubation period

• Incubation period is typically 7 to 10 days from time of exposure, with a range of 3 to 21 days.
• People with mpox may be contagious up to 4 days before the start of their symptoms.
• In previous clinical descriptions, the febrile stage lasts 1 to 3 days prior to the first eruption of skin lesions.
• In some recent cases it appears that the initial lesions may precede the development of the febrile stage.
• Lesions can be found on the skin or mucous membranes such as the genitals, anus, rectum, mouth, throat and eyes.
• Lesions progress from macule, to papule, to vesicle, to pustule, which will then crust.
• The rash/skin lesion stage can last 2 to 4 weeks.
• The patient is contagious until the scab crusts have fallen off (about 3 to 4 weeks) and new skin has formed.
• At this time, it is not known with certainty if asymptomatic infections occur.
• Most infections last 2 to 4 weeks and self-resolve.

Recommendations for infection prevention and control

Droplet and contact precautions with appropriate PPE for mpox (N95 respirator, gown, gloves, and eye protection), should be used for all patients with suspected, probable, or confirmed mpox. Precautions should be used when a patient presents with fever and vesicular/pustular rash (suspected patient with mpox). Any lesions or respiratory secretions should be considered infectious material.

Routine practices

Continue to follow routine practices including:

• Point of Care Risk Assessment (PCRA)
• Hand hygiene
• Patient placement
• Respiratory hygiene
• Personal Protective Equipment (PPE)
• Injection and medication safety
• Cleaning and disinfection procedures
• Waste management

Routine practices are the IPC measures used in the routine care of all patients, at all times, in all healthcare settings and are determined by the circumstances of the patient, the environment and the task to be performed. Routine practices and additional precautions are covered in detail in to the Public Health Agency of Canada's (PHAC) Routine Practices and Additional Precautions guidance document.

An assessment should be conducted prior to every interaction to determine the infectious risk posed to oneself and others.

Hand hygiene

Alcohol-based hand sanitizers and soap and water are acceptable methods for hand hygiene. When hands are visibly soiled, soap and water is the preferred method. Hand hygiene should always be performed after the removal of gloves.

Additional precautions

As the modes of transmission in this current outbreak are not well understood, Droplet and contact precautions and appropriate PPE for mpox are recommended.

Patient

• Patient should perform hand hygiene
• Patient should wear a medical mask
• Patients with suspected, probable, or confirmed mpox should be immediately placed in a single room with the door closed, for assessment upon entry to the healthcare setting.
• If the patient must leave the room, a medical mask should be worn, if medically able to tolerate or clinical condition allows.
• Skin lesions should be kept covered with a gown, clothes, sheet or bandage, except during examination.
• Room should be cleaned and disinfected after use (as per directions below).

Health care worker - Personal Protective Equipment (PPE)

• Fit-tested N95 respirator (or equivalent, or higher protection)
• Gown (cuffed, long sleeve)
• Gloves
• Eye protection (such as, face shield or goggles)

All PPE (including respirators) must be discarded after each contact with the patient and hand hygiene performed. All PPE should be donned before entering the patient's room. When doffing PPE after contact with lesions, care should be taken to avoid self-contamination, particularly during removal of gloves. All PPE should be disposed of prior to leaving the isolation room except for the respirator, which should be removed, outside of the room once the door is closed, and hands should again be cleaned.

Room selection/patient placement

The patient should be placed in a single room with the door closed. For inpatients, a dedicated patient bathroom is recommended and commode can be used if dedicated bathroom not available.

Intubation, extubation, and any procedures likely to spread oral secretions should be performed in an AIIR.

Visitors should be restricted to those necessary for care or compassionate grounds.

Cleaning and disinfection

Equipment

• Use standard housekeeping cleaning and disinfection protocols.
• Dedicate patient care equipment to a single patient.
• Clean and disinfect all reusable equipment with Health Canada approved disinfectants (with Drug Identification Numbers (DIN)), as per manufacturers' recommendations immediately after use.

Environmental surfaces

All patient contact surfaces should be cleaned and disinfected with Health Canada approved disinfectants (with Drug Identification Numbers (DIN)), as per manufacturers' recommendations.)

Clean and disinfect all surfaces that could have been touched including chairs in the area and public bathrooms. Attention should be paid to frequently touched surfaces, such as doorknobs, call bell pulls, faucet handles and wall surfaces that may have been frequently touched by the patient.

Use standard housekeeping cleaning and disinfection protocols.

Learn more about surface disinfectants for emerging viral pathogens.

Laundry (such as linens, towels, clothing, bedding)

• Wear appropriate PPE (gloves, gown, fit-tested N95 respirator [or equivalent, or higher protection] and eye protection) during collection and bagging of all linens at the point of use.
• The laundry materials should carefully be placed in a leak-proof bag, sealed or tied and placed inside an impermeable bag for transport to laundry area.
• In ambulatory care settings, standard medical laundry facilities should be used. If not available, the items may be washed in a standard washing machine using hot water (70 degrees Celsius) with detergent and must be completely dried in a commercial dryer.
• When handling soiled laundry (clothing, towels, bedding), care should be taken to avoid contact with the worker's skin and clothing.
• Do not shake laundry, as it disperses contaminated infectious particles into the air and onto the surrounding surfaces.

Containment and disposal of contaminated waste

• Biomedical waste should be contained in impervious waste-holding bags or double bagged according to municipal/regional regulations.
• Contaminated disposable items should be discarded according to jurisdictional protocols.

Discharge environmental cleaning and disinfection

• For discharge environmental cleaning and disinfection:
  • HCW should wear a gown, gloves, fit-tested N95 respirator (or equivalent, or higher protection) and eye protection during cleaning and disinfection.
  • Use standard housekeeping discharge cleaning and disinfection protocols.
  • All disposable items in the patient's room should be discarded.
  • Privacy curtains must be changed.
  • Equipment/supplies that cannot be disinfected must be discarded.

Transportation of patients with suspected mpox

If a patient with suspect, probable, or confirmed mpox requires transportation, the patient should be masked and lesions covered. The patient should make arrangements to avoid public transportation. If patient transport services are required they should be made aware of the necessary IPC precautions. When transferring patients between facilities, the receiving healthcare setting should be informed before the patient's arrival of the diagnosis and need for droplet and contact precautions with appropriate PPE for mpox.

Occupational mpox exposures in healthcare settings

This section provides guidance in assessing a potential occupational exposure of mpox in the healthcare setting. The occupational risk assessment is essential in ensuring the workplace remains safe for staff and for the patients who require diagnosis and care to prevent further transmission of mpox.

Background

Droplet, and contact precautions and appropriate PPE for mpox should be used for all patients with suspected, probable, and confirmed mpox. Any lesions, body fluids or respiratory secretions and contaminated materials, such as bedding, should be considered infectious. The risk of transmission to a HCW is very low, and may be associated with a sharps injury occurring during specimen collection. Aerosol transmission does not appear to occur. It is not known if the risk of transmission is associated with the stage of illness (prodrome, rash, systemic symptoms) or if there are patient-related factors such as pregnancy, immune suppression, or young age that may be associated with how much virus a person excretes or if they are more likely to have transmissible virus in the upper respiratory tract.

Exposure

If a healthcare worker (HCW) had contact with a patient who is diagnosed with mpox and was not wearing mpox-recommended PPE, an assessment of the risk to the HCW should be conducted.

Defining an exposure

The purpose of this section is to define the HCW exposures and mitigate the risk of transmission to patients.

When recommended PPE is not used, an exposure can be defined as:

• HCW skin/mucosa to skin contact with patient with confirmed mpox
• HCW skin/mucosa contact with the biological fluids, secretions, skin lesions or scabs of a patient with confirmed mpox
• HCW skin/mucosa contact with surfaces or objects contaminated by the secretions, biological fluids, skin lesions or scabs of a patient with confirmed mpox and in particular any sharps injury in which an instrument used to unroof or sample an mpox lesion penetrates the skin of the HCW
• Prolonged face-to-face interaction with a patient with confirmed mpox.

All exposures should be considered on a case-by-case basis to determine level of risk.

When assessing the level of risk exposure, consider the length of time (transient versus prolonged) and proximity to the patient, other patient factors (drooling, coughing, immune suppression), use of PPE and any skin/mucosa contact with the person or their environment in the assessment.

• Any bare skin of the HCW exposed to infectious material or fomites is an exposure and a risk assessment should consider length of time, and whether there are active lesions or non-intact skin of either the HCW or the patient. Any splash of potentially infectious material into a HCW's mucous membrane is a higher risk exposure. If the HCW was wearing a medical mask and not an N95 respirator (or equivalent, or higher protection), this is not necessarily considered a risk exposure unless there is a high risk of aerosols.

The risk of exposure to potentially infectious aerosols should be considered in the risk assessment. This should include an assessment of coughing or suctioning, intubation, proximity to the person and length of exposure.

Management of exposed healthcare workers: Length of time and frequency of active symptom monitoring

A HCW may continue to work post-exposure, if they monitor for symptoms and stop working immediately should symptoms arise. All exposed HCWs should wear a medical mask at all times while working.

Monitoring mpox depends on risk levels of exposure. Most transient exposures are likely low risk, given the rarity of nosocomial transmission to date:

• For lower-risk exposures conduct passive monitoring (self-monitoring) of symptoms once a day and prior to any shift for 21 days since the last exposure to a person with mpox. Notify occupational health if symptoms develop. Example of a lower-risk exposure is:
  • Briefly touching a patient without gloves when both the patient's skin and the HCW's skin are completely intact
• For higher-risk exposures, particularly sharps injuries that have occurred while providing care to an mpox patient, conduct active screening of symptoms, once a day with Occupational Health and prior to any shift for 21 days since the last exposure to a person with mpox. Notify occupational health if symptoms develop. HCWs with a higher risk exposure should be discussed with Public Health authorities and considered for post-exposure prophylaxis. Other examples of higher-risk exposures are:
  • Unprotected contact with a patient's active skin lesions
  • A splash of excretions from a patient into a HCW's unprotected eye while suctioning

Refer to the Management of exposed HCWs: HCWs who develop symptoms section below for further direction on higher-risk exposures.

HCWs with higher-risk exposures should not care for those who are immunosuppressed, pregnant, giving birth, or children < 12 years of age for 21 days since the last high(er) risk exposure to a person with mpox.

Management of exposed HCWs: HCWs who develop symptoms

In the event a HCW develops symptoms of mpox, they must stop work and immediately report to Occupational Health and Public Health. An investigation should be conducted to determine if the HCW case was healthcare or community acquired. A potentially healthcare acquired case would be considered a sentinel event and should be reported promptly to the local public health authority and investigated fully.

If any symptoms consistent with mpox develop Occupational Health should direct the HCW for assessment and diagnostic testing for mpox. Please refer to your local testing guidance for mpox. Testing for mpox while asymptomatic is not recommended.

The HCW should be assessed regarding their risk of severe disease and treatment should be discussed with an infectious diseases specialist.

Return to work for HCW with mpox

If a HCW subsequently is diagnosed with mpox, they must not return to work until all of the following criteria are met:

• person has no new lesions for 48 hours, and
• no skin or mucous membrane lesions, and
• all previous lesion scabs have dropped off and intact skin is underneath, and
• occupational health has deemed the person well enough to return to work

Occupational Health or Public Health must inform the HCW of the criteria for returning to work.

Acknowledgements

National Advisory Committee on Infection Prevention and Control: Jennie Johnstone (Chair), Stephanie W. Smith (Vice- Chair), Marina Afanasyeva, Irene Armstrong, Molly Blake, Joanne Embree, Jeffrey Eruvwetaghware, Jennifer Happe, Suzy Hota, Allen Kraut, Marianita Lampitoc, Anne Masters-Boyne, Donna Moore, Matthew Muller, Leighanne Parkes, Patsy Rawding, Suzanne Rhodenizer Rose, Brian Sagar, Patrice Savard, Nisha Thampi, Julie Weir, Titus Wong

PHAC, Infectious Diseases and Vaccination Programs Branch

Office of the Vice President: Marina Salvadori, Marianna Ofner

Infection Prevention and Surveillance Division: Maureen Carew, Natalie Bruce

Current and Past Members of the Healthcare Associated Infection Prevention and Control Section: Ama Anne, Ingrid Brown, Katherine Defalco, Steven Ettles, Amanda Graham, Hannah Hardy, Nisrine Haddad, Maureen McGrath, Toju Ogunremi, Chatura Prematunge, Jennifer Selkirk, Karen Timmerman, Teri Wellon

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