In November 2024, Canada confirmed its first case of clade I mpox. This case was linked to the ongoing outbreak in central and eastern Africa. The risk from clade I remains low. The mpox vaccine is not available to travellers unless they meet the eligibility criteria.
Mpox (formerly known as 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 (subtypes) of mpox: clade I and clade II. Human infections with clade I are typically more severe and have a higher case fatality rate . Illness with clade II is usually self-limiting within two to four weeks with a case fatality rate around one to three per cent.
NOTE: If you see a patient with suspected or confirmed mpox, please ask them to self-isolate and share TPH’s mpox self-isolation guidance with them.
In 2022, clusters of clade IIb mpox virus cases which were not linked to direct travel to Central or West Africa were documented in many countries where mpox is not endemic. Current epidemiological analysis suggests that these infections were spread via close physical contact with an individual who was infectious with mpox, and many (but not all) cases self-identified as men who have sex with men (MSM).
In December 2023, the USA CDC issued alerts to inform health care providers of an accelerating mpox epidemic in the Democratic Republic of the Congo, including the first documented occurrence of sexually transmitted clade I mpox. Clade I has previously been observed to be more transmissible and to cause more severe infections than clade II. In August 2024, the World Health Organization declared the increase of mpox cases in Africa and the emergence of a new strain (clade Ib) a public health emergency of international concern. In November 2024, Canada confirmed its first case of clade I mpox. This case was linked to the ongoing outbreak in central and eastern Africa.
The strain circulating in Toronto is clade II. The introduction of clade I mpox virus in Toronto is possible, however, the risk remains low. To view the latest data on mpox in Toronto, visit Public Health Ontario’s (PHO) Mpox webpage and click on the latest Summary Report.
Prior to the 2022 clade IIb outbreak, mpox infections had been thought to follow a fairly typical pattern, as outlined below. However, some jurisdictions with new outbreaks of mpox have noticed atypical presentations which may include:
The rash may occur before, with or without 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.
This includes, but is not limited to:
For distinguishing infectious causes of vesicular lesions see a case of human mpox in Canada.
Mpox 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. It can also be transmitted indirectly through contact with materials contaminated with the virus, such as bedding and clothing.
Mpox can spread during the prodromal period, but generally starts with the onset of rash until all lesions have crusted, fallen off, and new skin has formed (about two to four weeks). Recent evidence suggests that some individuals may be infectious up to four days before the onset of symptoms.
On January 27, 2025, the Public Health Ontario Laboratory (PHOL) implemented a new assay that can differentiate between the 3 mpox virus clades Ia, Ib and II. Refer to PHO’s Mpox Virus Test Information Sheet for up to date information on who to test and sample collection and submission.
In addition to routine practices, the following measures are recommended for health care workers when interacting with individuals with suspected, probable, or confirmed mpox infection:
More information:
Tecovirimat (TPoxx®) is 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 mpox in Canada. However, a licensed health care professional may request this drug for eligible patients based on their clinical judgement for treating severe mpox infections.
A limited supply of TPoxx® is available in Ontario for individuals who are severely ill/disabled due to mpox infection or at high risk for severe disease.
Given the limited supply of TPoxx® available in Ontario, TPoxx® should be prescribed based on the eligibility criteria described above.
Health care providers should request TPoxx® by contacting the Office of Chief Medical Officer of Health, Public Health at vaccinesupplyandlogistics@ontario.ca. See Appendix A of the Ministry of Health (MOH) – Mpox Antiviral Guidance for Health Care Providers for the information that needs to be provided as part of the request.
For more information, please refer to the following resources:
Imvamune vaccine can be used for protection against mpox before getting exposed to the virus (Pre-Exposure Prophylaxis or PrEP) or after being exposed (Post-Exposure Prophylaxis or PEP). The vaccine is effective for both Clade I and Clade II.
Imvamune is a live-attenuated, non-replicating vaccine which is active against both mpox and smallpox.
Imvamune should be given as a two-dose series, 28 days apart.
See TPH’s public Mpox webpage for vaccination clinic information.
TPH continues to follow federal and provincial guidance on the administration of Imvamune vaccines to protect at-risk populations against mpox virus. Imvamune is not currently available to travellers unless they meet eligibility criteria below.
Based on the MOH guidelines, the vaccine is available for the following eligible groups:
Household contacts of people who are eligible for PrEP listed above AND who are moderately to severely immunocompromised or are pregnant may be considered for pre-exposure vaccination. These individuals should contact a health care provider or TPH for more information.
All suspected and confirmed cases of mpox must be reported to TPH by:
See TPH’s Mpox Self-Isolation Guidance.
More information