Dear colleague:

I am writing to notify physicians, nurse practitioners, persons who operate a group practice of physicians or nurse practitioners, hospitals and regulated health professionals who practice at public hospitals and local public health units that the Ministry of Health is closely monitoring the situation concerning monkeypox cases reported in Europe and the US, as well as two confirmed cases in Quebec. I am urging all healthcare providers to be alert for patients presenting with symptoms that are consistent with monkeypox virus infection, especially if they have had travel or contact with a known case.

Monkeypox virus is an orthopoxvirus that causes a disease with symptoms similar to, but less severe than, smallpox. It is typically mild and self-limiting, however severe illness can occur.

Monkeypox virus infection presents with a prodrome that includes fever, chills, headache, myalgias, lymphadenopathy, and fatigue, followed one to three days later by a progressively developing rash. The rash characteristically begins on the face and then spreads to other parts of the body, including the hands, feet and genitals. Early epidemiology on recent cases reported in the US, UK, and Western Europe shows that some cases have been clustered in males who are gay, bisexual, and men who have sex with men. Some of these jurisdictions have noted atypical presentations of cases, such as individuals who have presented with unusual rashes or lesions in the mouth or genital area.

While historically rare, human-to-human transmission occurs primarily through close contact with an infected individual’s bodily fluids, respiratory droplets, or lesions, or through items that have been contaminated with the infected person’s fluids or lesions. The incubation period is typically 6 to 13 days but can range from 5 days to 21 days. Individuals are communicable from symptom onset until all scabs have fallen off and new skin is present.

Please consider the diagnosis of monkeypox in individuals presenting with signs and symptoms that may be compatible, especially with those with history of travel to affected countries or other risk factors. Please do not limit concerns or suspicion for the diagnosis to men who report having sex with other men, as anyone with close personal contact with a person with monkeypox virus infection could be at risk for the disease. Continue to consider the following differential diagnoses, which may be hard to distinguish from monkeypox – including syphilis, herpes simplex virus (HSV), chancroid, varicella zoster, and other common infections. For information on testing, specimen collection and handling, please see the PHO website.
Close contacts of people suspected or confirmed to have monkeypox infection should be advised to self-monitor for symptoms for 21 days after their last exposure. If symptoms develop, they should self-isolate, seek care and get tested.

If you see an individual who has symptoms compatible with monkeypox virus infection, airborne and droplet/contact precautions should be taken. A single room with negative air flow and a closed door is recommended in healthcare settings. If seeing an individual in an outpatient setting, a single room with a closed door is recommended. Providers are recommended to wear appropriate personal protective equipment, including a fit-tested N95 respirator, eye protection, gloves and a gown, and the patient should wear a medical mask for source control. Precautions may be discontinued in consultation with your local public health unit or hospital IPAC staff. In the interim, while monkeypox-specific IPAC resources are being developed, please see PIDAC’s recommendations on precautions for smallpox (variola).

I have issued an Order under section 77.6 of the Health Protection and Promotion Act, requiring all physicians, nurse practitioners, persons who operate a group practice of physicians or nurse practitioners, hospitals and regulated health professionals who practice at public hospitals to report any individual who meets the case definition (in Appendix A) of monkeypox virus to Public Health Ontario (PHO). Please see the attached Order outlining the requirements for reporting of information related to monkeypox to PHO, data collection, and case definition.

Sincerely,  

Kieran Michael Moore, MD, CCFP(EM), FCFP, MPH, DTM&H, FRCPC  Chief Medical Officer of Health

photo: Science Photo Library