Last updated: November 2, 2022
For a concise summary, see Ontario Health’s Testing and Management of Monkeypox: Information for Primary Care Providers.
Monkeypox virus is an orthopoxvirus that causes a disease with symptoms similar to, but less severe than, smallpox and is endemic to parts of Central and West Africa. There are two clades (strains) of monkeypox: the Central African clade and the West African clade. Human infections with the Central African clade are typically more severe and have a case fatality rate around 10%. Illness with the West African clade is usually self-limiting within 2-3 weeks with a case fatality rate around 1%. Previously, cases of monkeypox in countries other than those in Central and West Africa have only been identified as a direct result of travel to these regions.
As of May 2022, many countries where monkeypox is not endemic have documented clusters of cases which are not linked to direct travel to Central or West Africa. For more information see the US CDC 2022 Monkeypox Outbreak Global Map. Current epidemiological analysis suggest that these infections are spreading via close physical contact with an individual who is infectious with monkeypox, and many (but not all) cases self-identify as men who have sex with men (MSM).
For a rapid review of the evidence related to a specific aspect or emerging issue related to the 2022 worldwide monkeypox outbreak review Public Health Ontario’s “What We Know So Far” document.
To view the latest data on Monkeypox in Toronto, visit Public Health Ontario’s Monkeypox webpage and click on the latest Summary Report.
NOTE: If you see a patient with suspected or confirmed monkeypox, please ask them to self-isolate and share Toronto Public Health’s self-isolation guidance with them.
Prior to the current outbreak, monkeypox infections have been thought to follow a fairly typical pattern, as outlined below. However, some jurisdictions with new outbreaks of monkeypox are noticing atypical presentations which may include:
The rash may occur before, with or without the febrile systemic illness. Initial lesions may appear at sites of inoculation, such as the face and neck with kissing, and the penis and perianal region with sexual exposure. Lesions display pleomorphism, presenting in various stages simultaneously. Vesicles and pustules may be smaller than classically described, sometimes noticed only with surrounding pain, pruritis or erythema. Complications have been reported, including myocarditis, proctitis and epiglottitis, but there have been no reported deaths. (A case of human monkeypox in Canada)
This includes, but is not limited to:
For distinguishing infectious causes of vesicular lesions see a case of human monkeypox in Canada.
Monkeypox is spread to people through direct contact with the bodily fluids or lesions of infected animals or people, via respiratory droplets from an infected person, or from mother to fetus. In can also be transmitted indirectly through contact with materials contaminated with the virus, such as bedding and clothing. At this time, it is not known if monkeypox can spread through semen or vaginal fluids. A cautious approach that recommends cases utilize barrier contraception methods during sexual intercourse for 8 – 12 weeks following resolution of their infection should be considered pending the availability of further scientific evidence. For more information, visit Public Health Ontario’s Monkeypox Transmission Through Genital Excretion.
Monkeypox can spread from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. People who do not have monkeypox symptoms cannot spread the virus to others.
Refer to PHO’s Monkeypox Virus Test Information Sheet for up to date information on who to test and sample collection and submission.
In addition to routine precautions, the following measures are recommended for health care workers when interacting with individuals with suspected, probable, or confirmed monkeypox infection:
Tecovirimat (TPoxx®) has recently been authorized for sale and use in Canada, for the treatment of human smallpox disease in adults and pediatric patients weighing at least 13 kg based on limited clinical testing in humans. TPoxx® does not have an approved indication for the treatment of monkeypox in Canada. However, a licensed healthcare professional may request this drug for eligible patients based on their clinical judgement for treating severe monkeypox infections.
A limited supply of TPoxx® is available in Ontario for individuals who are severely ill/disabled due to monkeypox infection or at high risk for severe disease.
TPoxx® should be considered for the following:
significant disability (e.g., proctitis, keratitis or other ocular involvement,
pharyngitis/epiglottitis or other breathing/swallowing compromise).
TPoxx® will initially be provided to clinicians as part of Health Canada’s Special Access Program (SAP). Given the limited supply of TPoxx® available in Ontario, TPoxx® should be prescribed based on the eligibility criteria described above.
Clinicians need to request TPoxx® by contacting the Ministry of Health Emergency Operations Centre (MEOC) at EOCoperations.MOH@ontario.ca or by calling the Healthcare Provider Hotline at 1-866-212-2272. When contacting MEOC, you should include the exact number of patients that have consented to receive the TPoxx® treatment.
Health Canada’s SAP has mandatory reporting requirements for clinicians using the Follow-Up Form (Form C), including treatment response outcomes. This form should be returned to the MEOC at EOCOperations.MOH@ontario.ca. The MEOC will send the forms back to SAP on behalf of the clinician.
For more information, please refer to the following resources:
Imvamune vaccine can be used for protection against monkeypox before getting exposed to the virus (Pre-Exposure Prophylaxis or PrEP) or after being exposed (Post-Exposure Prophylaxis or PEP).
Imvamune is a live-attenuated, non-replicating vaccine which is active against both monkeypox and smallpox.
Imvamune vaccine clinics are being provided by TPH and community partners for both PrEP and PEP (full list of clinic locations).
Based on Ontario Ministry of Health guidelines, the vaccine is available for the following eligible groups:
All suspected and confirmed cases of monkeypox must be reported to TPH by:
See TPH’s Monkeypox Self-Isolation Guidance.