What healthcare providers should look out for with suspected monkeypox cases appearing in Canada

Last week, Toronto Public Health began investigating the first suspected case of monkeypox in Toronto. The adult male, who lives in Toronto, had recent contact with an individual who had travelled to Montreal.1,2 This case is now considered a probable case of monkeypox.3 On May 25, two new suspected cases of monkeypox and one new probable case of the virus (all in adult men) were reported in Toronto, bringing the total number of cases being investigated in the city to four.3 Toronto Public Health is recommending that healthcare providers be alert for patients presenting with symptoms that are consistent with monkeypox virus infection, especially if individuals have had contact with a known case. Conditions such as syphilis, herpes simplex virus, chancroid and varicella zoster should be considered in the differential diagnoses, as they may be difficult to distinguish from monkeypox.1 Monkeypox typically begins with a prodromal systemic illness with one or more of the following symptoms: fever, headaches, intense fatigue, sweating, lymphadenopathy, myalgias and arthralgias. Within one to three days of the prodromal illness, a rash usually develops; however, lesions may appear before or without systemic symptoms. The rash tends to concentrate more on the face and extremities rather than on the trunk. It evolves from macules to papules, vesicles, pustules, and then crusts, which dry up and fall off.1 Monkeypox is primarily transmitted person-to person through respiratory secretions following prolonged face-to-face contact, through body fluids, and by direct contact with skin lesions or a patient’s contaminated items (e.g., clothing/bedding). The incubation period averages seven to 14 days (range 5 to 21 days). The infection can be transmitted anytime from the onset of lesions until all the lesions have cleared. Some individuals may be contagious during the prodrome phase when they have nonspecific symptoms (fever, malaise, headache), before the rash develops.1,2 For suspected cases in Ontario, information on testing, specimen collection and handling, and reporting is available on the Public Health Ontario website.4 Any individual in Ontario who meets the case definition (see Appendix A, available on page 4) must be reported to Public Health Ontario within one business day. Healthcare providers should use the Ontario Monkeypox Investigation Tool to report cases (see pages 6 through 9 available here). Monkeypox is usually a self-limited disease with the symptoms lasting from two to four weeks.5 Symptomatic individuals should be advised to self-isolate at home. When being seen for clinical care, patients should be advised to wear a medical mask and cover their skin lesions while test results are pending. Confirmed cases should self-isolate until lesions are resolved.1 Infection prevention and control recommendations for monkeypox in healthcare settings are available from Public Health Ontario.6 Treatment for monkeypox is mainly supportive. Ontario is working with the Public Health Agency of Canada to determine eligibility for vaccines and/or therapies.1 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.1 Healthcare providers should stress that the risk to the general public from monkeypox infection is very low.2 References 1. de Villa E. Alert: Monkeypox investigation in Toronto. Toronto Public Health's Physician e-Newsletter, May 21, 2022. 2. Toronto Public Health Media Relations. Toronto Public Health investigates first suspected case of monkeypox. May 21, 2022. (accessed May 26, 2022). 3. CBC News. Monkeypox in Toronto: 2 suspected cases, 2 probable cases under investigation.(accessed May 26, 2022). 4. Public Health Ontario. Monkeypox virus. (accessed May 26, 2022). 5. World Health Organization. Monkeypox. May 19, 2022. (accessed May 26, 2022). 6. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Infection prevention and control (IPAC) recommendations for monkeypox in health care settings. Toronto, ON: Queen's Printer for Ontario; May 2022. (accessed May 26, 2022)

What healthcare providers should look out for with suspected monkeypox cases appearing in Canada

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