Monkeypox in personal service establishments: Low risk, but know the signs
Photo credit: US CDC. This digitally-colorized electron microscopic (EM) image depicted a monkeypox virion, obtained from a clinical sample associated with the 2003 prairie dog outbreak. It was a thin section image from of a human skin sample. On the left were mature, oval-shaped virus particles, and on the right were the crescents, and spherical particles of immature virions.
In May 2022, cases of monkeypox began to be reported outside of endemic regions. At the time of publication, the World Health Organization had recorded 2103 cases in 42 countries and the Public Health Agency of Canada had confirmed 168 cases in Canada. Of these cases, 141 were reported in Quebec, 21 in Ontario, four in Alberta, and two in BC.
While monkeypox outbreaks have occurred in non-endemic regions before, this is the first such outbreak reported in Canada. Human-to-human transmission is occurring, and most cases are not associated with travel to a monkeypox-endemic country. This document provides an overview of the monkeypox outbreak in Canada and outlines key information for public health inspectors to address risk in personal service establishments (PSEs) and other public settings where there may be potential for transmission.
What is monkeypox?
Monkeypox is a zoonotic infectious disease endemic to parts of central and West Africa. The disease is caused by the monkeypox virus (MPVX), a relative of smallpox that rarely causes severe illness.
There are two primary sub-types of MPVX: the West African clade and the Congo Basin (Central African) clade. Human infections with the West African clade are typically associated with less severe disease, lower mortality, and less frequent human-to-human transmission compared with the Congo Basin clade. So far, all confirmed cases in the 2022 outbreak have been the West African clade. Illness with this clade is usually self-limiting in the absence of specific therapy. Symptoms resolve within two to four weeks; however a recent case study indicates it could take up to six weeks. So far, no deaths have been reported for cases outside of endemic regions.
What are the symptoms of monkeypox?
Symptoms of MPVX infection typically fall into two phases. In the first phase, common symptoms include swollen lymph nodes, fatigue, muscle aches and pains, joint stiffness, fever, headache, back pain, and proctitis (inflammation of the lining of the rectum). In the second phase, the characteristic monkeypox rash develops within 1-3 days after the onset of the fever, though not everyone infected with the West African clade develops a rash. The rash usually lasts between two to four weeks, progressing from flat and raised lesions, to small blisters, and finally to scabs, which eventually flake off.
Individual monkeypox lesions at different stages:
Image credit: UK Health Security Agency
In previous outbreaks, the rash typically started on the face or extremities before progressing to other areas of the body. However, in the current outbreak, genital and peri-anal lesions have been common and have often presented first before spreading to other parts of the body, such as the torso, face, mouth, and extremities, if it spreads at all. This is likely related to a pattern of transmission through sexual networks in the current outbreak, rather than a change in the virus itself. There have also been some cases where lesions appeared before first phase symptoms or at different stages of development. Both of these presentations are atypical of how monkeypox has presented in past outbreaks.
How is monkeypox transmitted?
Transmission of MPVX can occur via animal-to-animal, animal-to-human, and human-to-human spread. A person is considered infectious during both the first and second phase of symptoms, until all scabs have fallen off and new skin can be seen underneath. Current evidence suggests that asymptomatic spread of the virus is extremely uncommon.
Transmission of monkeypox is most likely to occur through direct contact with an individual with monkeypox lesions, either via bodily fluids or contact between open rash lesions and broken skin or mucosa of the next host. However, indirect transmission through contaminated objects such as bedding, clothing, and towels is also possible. The virus may transmit via respiratory droplets during direct and prolonged face-to-face contact, though this is not currently well understood and is not thought to be the dominant route of transmission. Although MPXV is not classified as a sexually transmitted infection, intimate contacts enhance the likelihood of transmission. Finally, transmission of MPVX can also occur through the placenta from mother to fetus, leading to congenital monkeypox.
What is the risk of community transmission in personal service establishments?
Currently, PSEs have not been identified as a setting for MPXV transmission and the likelihood of encountering a case is very low. However, PSEs are public settings in which several risk factors for MPXV transmission may be present. These include services that require prolonged face-to-face interactions, skin-to-skin contact, and/or the use of towels, drapes, etc., that may mediate indirect transmission.
In locales or communities with known MPXV cases, basic knowledge of symptoms may help to inform PSE point-of-service risk assessments. Typically, PSE guidance and legislation advises that clients with open wounds, lesions, or broken skin should not be offered service until the site is healed. This serves both to protect the operator from potential pathogens (even beyond MPXV) and to avoid working on skin that may be unable to heal, further compromising the health of the client.
PSE operators who work in close proximity to clients may also be in a unique position to observe and identify the MPXV rash, thus creating an opportunity to limit onward transmission. If the characteristic MPXV rash is identified on visible skin, or if the client reports any of the early symptoms mentioned above, the operator should alert the client and advise them to seek medical assessment. If the operator is concerned that they have been exposed to an infectious disease, they should (as always) contact local public health or their own healthcare provider.
Are other jurisdictions changing their guidance on PSE practice?
Due to the very low incidence of MPXV cases currently, specific measures for PSEs or other public settings are not being recommended at this time. However, if an MPXV case has been identified in connection with a business, operators may require specific information on how to clean and disinfect their premises for MPXV, including furniture and other items the client touched. Infection prevention and control guidance for MPXV centers on:
- Masking and gloves. As the routes of transmission are not well understood in the current outbreak, Public Health Agency of Canada recommends that suspected MPXV cases don a medical mask and that attending healthcare workers should wear a respirator and gloves. However, outside of a healthcare setting, the US CDC recommends that individuals conducting MPXV decontamination should wear at least a medical mask, as well as gloves.
- Surface cleaning. During the COVID-19 pandemic, operators have been advised to wipe down high-touch surfaces on a more frequent basis, and this remains a good general practice. While there is limited data on how long MPVX can last on surfaces, other orthopoxviruses have been known to persist for months to years due to a more durable outer envelope than coronaviruses. This outer envelope makes them more resistant to heat, desiccation, and pH changes, so surface cleaning is likely to play a much more important role for infection control. Surfaces that came into contact with the client should be treated with cleaning and disinfecting agents that bear a drug identification number (DIN). However, the virus is also susceptible to common household cleaners as well as a 0.5% sodium hypochlorite (household bleach) solution (caution should be exercised when diluting bleach; see here for a bleach dilution calculator). Floors should be wet-mopped rather than swept or otherwise disturbed; floors can be vacuumed using a HEPA filter-equipped vacuum.
- Because orthopoxviruses are stable at ambient temperature when dried, laundering sheets and towels (and steam-cleaning upholstered surfaces) is necessary if those surfaces have been in contact with an MPXV case, particularly if in direct contact with lesions. For laundry, wash the contaminated items separately with normal laundry soap and a minimum washing temperature of 60°C, followed by drying with hot air until completely dry. Operators should be aware that some domestic washers do not reach this threshold; additional hot water can be added directly to the drum in top-loading machines. Because transmission to a healthcare worker via contaminated bedding was reported in a previous outbreak, operators should wear a mask and gloves while handling laundry and avoid shaking it out before washing to prevent environmental or self-contamination.
- Waste disposal. Outside of a healthcare setting where biohazardous waste disposal is available, the US CDC recommends sealing MPXV-contaminated waste in a plastic bag and disposing in the trash
- Hand hygiene. Hands should be cleaned after removing gloves used during decontamination.
While these recommended measures might seem disproportional to the level of individual risk, they are aimed to stop transmission in this early stage of community spread, before it can spread to more at risk populations like pregnant women and children.
Other than personal service establishments, what other places may be at elevated risk for community transmission?
During the current outbreak, both in Canada and abroad, MPXV transmission has occurred mostly (but not exclusively) within a defined sub-population of men who have sex with men. Sex-on-premises venues specific to this community have been important sites of transmission and require enhanced frequency of cleaning.
At present, there is very little cause for concern regarding transmission between members of the public via casual or non-sexual contact. However, settings with surfaces or equipment that come into direct contact with skin or settings where linens, towels, or other items are re-processed (e.g., gyms, hotels, hostels, daycares, correctional facilities) could be potential sites of transmission if MPXV begins to spread more widely. Finally, the World Health Organization has also identified mass gatherings as potentially conducive environments for the transmission of monkeypox virus if they involve close, prolonged and frequent interactions among infected individuals that could expose them to contact with lesions, body fluids, respiratory droplets, or contaminated materials.
The current MPXV outbreak has raised concern due to its atypical presentation and its unprecedented spread through several generations in non-endemic countries. Current spread through sexual interactions emphasizes the importance of very close (skin-to-skin and face-to-face) contact in transmitting the virus. Although PSEs are not currently a setting for transmission, PSE operators should be vigilant as they may have direct contact with or be able to observe broken skin amongst their clients and should take appropriate steps if MPXV is suspected.
Please note: This revised version (June 28, 2022) shows the correct concentration for disinfecting surfaces (0.5% bleach solution). An earlier version contained a misprint that referred to the use of 5% bleach solution.
We are grateful for the valuable input offered by Dr. Caroline Huot (INSPQ), Dr. Stéphane Perron (INSPQ), and Dr. Alexandra Kossowski (Public Health Montreal).
Rosenkrantz L, Eykelbosh A. Monkeypox in personal service establishments: Low risk, but know the signs [blog]. Vancouver, BC: National Collaborating Centre for Environmental Health; 2022 June 22. Available from: https://ncceh.ca/content/blog/monkeypox-personal-service-establishments