Interim guidance on infection prevention and control for suspect, probable or confirmed monkeypox within healthcare settings
On November 28, 2022, the World Health Organization began using mpox as the preferred term for monkeypox disease. Well be updating our content to reflect this change.
May 27 2022
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Background
Monkeypox is a rare infectious disease caused by the monkeypox virus (genus orthopox). Monkeypox virus is related to, but distinct from, the viruses that cause smallpox (variola virus) and cowpox. Cases of monkeypox are usually found in central and western Africa and it is rare to find cases outside of that geographic area. There are two genetically distinct clades of monkeypox virus: West African clade monkeypox manifests with limited human-to-human transmission, and a case fatality of 1%, whereas the Congo Basin clade is associated with human-to-human transmission and case fatalities historically reported of 10%.
On 13 May 2022, WHO was notified of laboratory-confirmed human cases of monkeypox in the United Kingdom (UK). The UK has confirmed the West African clade of the monkeypox virus. It is unknown at this time if the virus has mutated, which may lead to a change in the modes of transmission, clinical presentation or severity of disease. Transmission risk to healthcare workers is considered low at this time.
On May 19, the Public Health Agency of Canada confirmed the first two human cases of monkeypox in Canada. Both cases were detected in Quebec and other suspected cases are under investigation. Confirmed and probable monkeypox cases have now been reported in many countries outside of Africa.
Person-to-person spread of monkeypox is uncommon. However, when spread does occur between people, the mode is through close contact with an infected person such as through direct contact with their body fluids, respiratory droplets, and/or monkeypox sores, or by sharing clothing, bedding or common items that have been contaminated with the infected person's body fluids or sores. Sexual transmission has not been previously identified as a mode of transmission, though sexual partners also have close direct contact. It is not known whether airborne transmission of monkeypox occurs, although it does not appear to be the primary mode of transmission. However, given evidence of airborne transmission with smallpox, there is a concern that monkeypox can also be transmitted by the airborne route. At this time, as more information is gathered, healthcare settings should implement droplet and contact precautions, in addition to airborne precautions until more information about the potential for aerosol transmission is known.
At this time, it is not known if a person can transmit the infection just before they develop fever or develop a rash.
If a case is suspected, immediately notify local public health authorities.
Transmission
A person can contract monkeypox when they come into close contact with an infected animal, infected person, or materials contaminated with the virus. The virus can enter the body through broken skin, the respiratory tract, or through mucous membranes. Transmission can occur via direct contact with monkeypox skin lesions, non-intact skin or scabs, indirect contact with clothing or linens used by an infected person, or close contact with the respiratory tract secretions of an individual with monkeypox.
Clinical progression and incubation period
- Incubation period is typically 6-13 days from time of exposure, with a range of 5-21 days.
- In previous clinical descriptions, the febrile stage lasts 1 to 4 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 progress from macule, to papule, to vesicle, to pustule, which will then crust.
- The rash/skin lesion stage can last 2-4 weeks.
- The patient is contagious until the scab crusts have fallen off (about 3-4 weeks) and new skin has formed.
- Most infections last 2-to-4 weeks and self-resolve.
Infection prevention and control
Airborne, droplet, and contact precautions should be used for all suspect, probable, and confirmed cases of monkeypox. Precautions should be used when a patient presents with fever and vesicular/pustular rash (suspected case). 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

# 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, airborne, droplet and contact precautions are recommended.

## Patient:
- Patient should perform hand hygiene
- Patient should wear a medical mask
- Suspect, probable and confirmed cases should be immediately placed into an Airborne Infection Isolation Room (AIIR) or 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 and seal-checked N95 respirator
- Gown (cuffed, long sleeve)
- Gloves
- Eye protection (e.g., 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 patients room. 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
Patient should be placed in an AIIR, when available.
If an AIIR is not available, the patient should be placed in a single room with the door closed. For inpatients, a dedicated patient bathroom is required and commode can be used if dedicated bathroom not available
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. 
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# Laundry (such as linens, towels, clothing, bedding)
- Wear appropriate PPE (gloves, gown, fit-tested and seal-checked N95 respirator 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 workers 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 must wear a gown, gloves, fit-tested and seal-checked N95 respirator and eye protection during cleaning and disinfection.
	+ Use standard housekeeping discharge cleaning and disinfection protocols.
	+ All disposable items in the patients room should be discarded.
	+ Privacy curtains must be changed.
	+ Equipment/supplies that cannot be disinfected must be discarded.
Transportation of suspected monkeypox patients
If a patient with suspect, probable, or confirmed monkeypox requires transportation, the patient should not use public transportation. The patient should be masked and lesions covered during transport. If used, patient transport services should be informed that the patient has suspect, probable, or confirmed monkeypox. The receiving healthcare setting should be informed before the patients arrival of the diagnosis and need for airborne, droplet and contact precautions.
Occupational monkeypox exposures in healthcare settings: July 8, 2022
This section provides guidance in assessing a potential occupational exposure of monkeypox 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 monkeypox.

# Background
Airborne, droplet, and contact precautions should be used for all suspect, probable, and confirmed cases of monkeypox. Any lesions, body fluids or respiratory secretions and contaminated materials, such as bedding, should be considered infectious. At the present time the risk of transmission to a HCW appears to be very low. It is unknown if aerosol transmission can occur, if 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 monkeypox and was not wearing PPE consistent with airborne, droplet, and contact precautions, an assessment of the risk to the HCW should be conducted.

# Defining an exposure
The purposes of this section is to define the HCW exposures and mitigate the risk of transmission to patients.
When adequate PPE is not used (see below), an exposure can be defined as:
- HCW skin/mucosa to skin contact with a case
- HCW skin/mucosa contact with a case's biological fluids, secretions, skin lesions or scabs
- HCW 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
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.
For the purposes of assessing risk of occupational exposures, adequate PPE would be defined, at a minimum, as a medical mask or N95 respirator, and gloves.  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 mucous membrane is a higher risk exposure. If the HCW is wearing a medical mask and not an N95, this is not considered an 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.

# Working post-exposure: Length of time and frequency of active symptom monitoring
A HCW may continue to work post-exposure, if they monitor for  and stop working immediately should symptoms arise. All exposed HCW should wear a medical mask at all times while working.
Monitoring monkeypox depends on risk levels of exposure: 
- 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 monkeypox. Notify occupational health if symptoms develop.  Example of a lower-risk exposure is:
	+ Briefly touching a patient without gloves when both the patients skin and the HCWs skin are completely intact
- For higher-risk exposures 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 monkeypox. Notify occupational health if symptoms develop. Examples of a higher-risk exposures are:
	+ Unprotected contact with a patients active skin lesions
	+ A splash of excretions from a patient into a HCW unprotected eye while suctioning
HCW 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 monkeypox.

# Management of exposed HCWs
In the event a HCW develops symptoms of monkeypox, 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 Public Health and investigated fully.
If any symptoms consistent with monkeypox develop Occupational Health should direct the healthcare worker for assessment and diagnostic testing for monkeypox. Please refer to your local testing guidance for monkeypox. Testing for monkeypox 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. HCWs with higher risk exposure should be discussed with Public Health authorities and considered for post-exposure prophylaxis with the smallpox vaccine.

# HCW with monkeypox
If a HCW subsequently is diagnosed with monkeypox, 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.