Mpox (monkeypox): Public health management of cases and contacts in Canada

January 4, 2024


January 4, 2024, update

Updates have been made to the last version (February 23, 2023) to:

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:

On this page


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:

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.


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:

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

Recommendations for interactions with others

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:

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:

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:

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:

Public health management of contacts

Contact tracing

The purpose of contact tracing is to:

In Canada, local PHAs are responsible for initiating contact tracing. Once a case is identified, 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:

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:

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.

Table 1: Classification of contacts by exposure risk level
Exposure risk Description Possible examples


Prolonged or intimate contact, including any of the following:

  • skin/mucosa to skin/mucosa contact with a case (regardless of the case’s lesion location)
  • skin/mucosa contact with a case’s biological fluids, secretions, skin lesions or scabs
  • skin/mucosa contact with surfaces or objects contaminated by a case’s secretions, biological fluids, skin lesions or scabs
  • face-to-face interaction with a case, without the use of a medical mask by the case or contact
  • Sexual partner of a case
  • Household member living with a case
  • Roommate of a case in a congregate living setting (such as a group home, student residence, shelter, correctional facility)
  • Person having skin/mucosa contact with a case’s used personal items (for example, bedding, towels, clothing, lesion dressings, utensils, razors, toothbrushes, needles, sex toys)
  • Person having close/intimate interactions with a case in a setting (such as a sex-on-premise venue) or gathering (such as Pride festivals) where there may be a higher likelihood of increased sexual activity


  • Any of the following:
    • limited or intermittent, close proximity exposure to a case without wearing adequate PPE for the type of exposure risk (such as medical mask and gloves)
    • shared living space where there are limited interactions with a case or their personal items
  • Person sitting next to a case on a plane or other mode of transportation
  • Person sharing close proximity workspace with a case for long periods of time

Low or uncertain

  • Any of the following:
    • very limited exposures to a case
    • consistently and appropriately using recommended PPE for the type of exposure risk (such as medical mask and gloves)
  • Person having brief social interactions with a case
  • Colleague not sharing a confined or close-proximity office space with a case


  • PPE: Personal protective equipment

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:

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:

Table 2: Incremental public health measures recommendations for contacts based on exposure risk
Exposure risk Recommendations

For all exposures

  • Should be offered Imvamune® vaccination if they have not received it already and are eligible
  • Can be permitted to continue routine daily activities, with some specific PHMs in place
  • Self-monitor for signs and symptoms of mpox infection, including those that can be mild or go unnoticed
  • Practise proper hand hygiene and respiratory etiquette
  • Reduce the risk of transmitting mpox by having fewer sexual partners and using barrier protection during sexual activity (such as condoms, dental dams, gloves, clothing)
  • Notify the PHA and isolate immediately if signs or symptoms develop
  • Alert any health care providers that provide medical care of the potential exposure
  • Be aware that travelling during the 21-day post-exposure period could lead to unforeseen consequences if symptoms were to develop (for example, the need to isolate abroad, seek medical attention and/or reschedule transportation, as well as the potential for additional financial costs)

For both intermediate- and high-risk exposure contacts

  • Along with the recommendations outlined in the previous section:
    • Avoid high-risk settings (for example, congregate living settings, such as correctional facilities or shelters) and populations at risk of more severe disease (for example, individuals who are immunocompromised, individuals who are pregnant, young children) Reference 1, where possible
      • If this is unavoidable, consider wearing a well-fitting medical mask in these settings or around populations at risk of more severe disease
      • 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, avoid any close contact with animals (such as petting, kissing, cuddling, sharing sleeping areas, sharing food)

For high-risk exposure contacts

  • Along with recommendations outlined in both previous sections:
    • 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 populations at risk of more severe disease

Additional resources


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.

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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.

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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.

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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.

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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.

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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.

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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.

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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/

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Footnote 8

R. S. Salvato et al., "Healthcare Workers Occupational Infection by Monkeypox Virus in Brazil," in Preprints, ed: Preprints, 2022.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Footnote 21

S. Gould et al., "Air and surface sampling for monkeypox virus in a UK hospital: an observational study," (in eng), Lancet Microbe, vol. 3, no. 12, pp. e904-e911, Dec 2022, doi: 10.1016/s2666-5247(22)00257-9.

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Footnote 22

J. A. Pfeiffer et al., "High-Contact Object and Surface Contamination in a Household of Persons with Monkeypox Virus Infection - Utah, June 2022," (in eng), MMWR Morb Mortal Wkly Rep, vol. 71, no. 34, pp. 1092-1094, Aug 26 2022, doi: 10.15585/mmwr.mm7134e1.

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Footnote 23

C. N. Morgan et al., "Environmental Persistence of Monkeypox Virus on Surfaces in Household of Person with Travel-Associated Infection, Dallas, Texas, USA, 2021," (in eng), Emerg Infect Dis, vol. 28, no. 10, pp. 1982-1989, Oct 2022, doi: 10.3201/eid2810.221047.

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Footnote 24

K. Marimuthu et al., "Viable mpox virus in the environment of a patient room," (in eng), Int J Infect Dis, vol. 131, pp. 40-45, Jun 2023, doi: 10.1016/j.ijid.2023.03.016.

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Footnote 25

I. Tanabe and S. Hotta, "Effect of disinfectants on variola virus in cell culture," (in eng), Appl Environ Microbiol, vol. 32, no. 2, pp. 209-12, Aug 1976, doi: 10.1128/aem.32.2.209-212.1976.

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Footnote 26

W. K. Joklik, "The purification of four strains of poxvirus," Virology, vol. 18, no. 1, pp. 9-18, 1962/09/01/ 1962, doi:

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Footnote 27

G. Kampf, "Efficacy of biocidal agents and disinfectants against the monkeypox virus and other orthopoxviruses," (in eng), J Hosp Infect, vol. 127, pp. 101-110, Sep 2022, doi: 10.1016/j.jhin.2022.06.012.

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Footnote 28

G. Kampf, "Efficacy of heat against the vaccinia virus, variola virus and monkeypox virus," (in eng), J Hosp Infect, vol. 127, pp. 131-132, Sep 2022, doi: 10.1016/j.jhin.2022.06.008.

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Footnote 29

A. Wieder-Feinsod et al., "Overlooked monkeypox cases among men having sex with men during the 2022 outbreak – a retrospective study," International Journal of Infectious Diseases, vol. 128, pp. 58-60, 2023/03/01/ 2023, doi:

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Footnote 30

T. Ward, R. Christie, R. S. Paton, F. Cumming, and C. E. Overton, "Transmission dynamics of monkeypox in the United Kingdom: contact tracing study," BMJ (Clinical research ed.), vol. 379, p. e073153doi: 10.1136/bmj-2022-073153.

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Footnote 31

I. Brosius et al., "Presymptomatic viral shedding in high-risk mpox contacts: A prospective cohort study," (in eng), J Med Virol, vol. 95, no. 5, p. e28769, May 2023, doi: 10.1002/jmv.28769.

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Footnote 32

Centers for Disease Control and Prevention, "Science brief : Detection and transmission of mpox (formerly monkeypox) virus during the 2022 clade IIb outbreak," (in eng), 2023. [Online]. Available:

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Footnote 33

World Health Organization, "Surveillance, case investigation and contact tracing for mpox (monkeypox): interim guidance, 22 December 2022," ed, 2022.

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Footnote 34

United Kingdom Public Health Agencies, "Principles for control of non-HCID mpox in the UK: 4 nations consensus statement," ed, 2023.

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Footnote 35

F. Miura et al., Time scales of human monkeypox transmission in the Netherlands. 2022.

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Footnote 36

Z. J. Madewell et al., "Serial Interval and Incubation Period Estimates of Monkeypox Virus Infection in 12 Jurisdictions, United States, May-August 2022," (in eng), Emerg Infect Dis, vol. 29, no. 4, pp. 818-821, Apr 2023, doi: 10.3201/eid2904.221622.

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Footnote 37

V. M. Ferré et al., "Detection of Monkeypox Virus in Anorectal Swabs From Asymptomatic Men Who Have Sex With Men in a Sexually Transmitted Infection Screening Program in Paris, France," (in eng), Ann Intern Med, vol. 175, no. 10, pp. 1491-1492, Oct 2022, doi: 10.7326/m22-2183.

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Footnote 38

N. Cassir et al., "Observational Cohort Study of Evolving Epidemiologic, Clinical, and Virologic Features of Monkeypox in Southern France," (in eng), Emerg Infect Dis, vol. 28, no. 12, pp. 2409-2415, Dec 2022, doi: 10.3201/eid2812.221440.

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Footnote 39

D. Moschese et al., "Isolation of viable monkeypox virus from anal and urethral swabs, Italy, May to July 2022," Eurosurveillance, vol. 27, no. 36, p. 2200675, 2022, doi:

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Footnote 40

I. De Baetselier et al., "Retrospective detection of asymptomatic monkeypox virus infections among male sexual health clinic attendees in Belgium," Nature Medicine, vol. 28, no. 11, pp. 2288-2292, 2022/11/01 2022, doi: 10.1038/s41591-022-02004-w.

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Footnote 41

Public Health Agency of Canada, "Reducing the Health Impact of Sexually Transmitted and Blood-Borne Infections in Canada by 2030: A Pan-Canadian STBBI Framework for Action," ed, 2018.

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Footnote 42

A. Reda et al., "Monkeypox viral detection in semen specimens of confirmed cases: A systematic review and meta-analysis," (in eng), J Med Virol, vol. 95, no. 1, p. e28250, Jan 2023, doi: 10.1002/jmv.28250.

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Footnote 43

N. Paran et al., "Monkeypox DNA levels correlate with virus infectivity in clinical samples, Israel, 2022," (in eng), Euro Surveill, vol. 27, no. 35, Sep 2022, doi: 10.2807/1560-7917.Es.2022.27.35.2200636.

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Footnote 44

D. Lapa et al., "Monkeypox virus isolation from a semen sample collected in the early phase of infection in a patient with prolonged seminal viral shedding," (in eng), Lancet Infect Dis, vol. 22, no. 9, pp. 1267-1269, Sep 2022, doi: 10.1016/s1473-3099(22)00513-8.

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Footnote 45

C. Suñer et al., "Viral dynamics in patients with monkeypox infection: a prospective cohort study in Spain," (in eng), Lancet Infect Dis, vol. 23, no. 4, pp. 445-453, Apr 2023, doi: 10.1016/s1473-3099(22)00794-0.

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Footnote 46

A. Ma, J. Langer, K. E. Hanson, and B. T. Bradley, "Characterization of the Cytopathic Effects of Monkeypox Virus Isolated from Clinical Specimens and Differentiation from Common Viral Exanthems," (in eng), J Clin Microbiol, vol. 60, no. 12, p. e0133622, Dec 21 2022, doi: 10.1128/jcm.01336-22.

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Footnote 47

D. Hornuss et al., "Transmission characteristics, replication patterns and clinical manifestations of human monkeypox virus-an in-depth analysis of four cases from Germany," (in eng), Clin Microbiol Infect, vol. 29, no. 1, pp. 112.e5-112.e9, Jan 2023, doi: 10.1016/j.cmi.2022.09.012.

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