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Rapid scientific advice on public health measures for mpox (2024)

Last updated: 20 September 2024

DISCLAIMER: ECDC rapid scientific advice disclosure statement: ECDC issues rapid scientific advice to meet an emergent or urgent public health need or to quickly reply to external requests. To accommodate the accelerated timeline, the process and methods used for the development of rapid scientific advice may be modified from those of standard assessments and recommendations. Potential limitations are described. 

Information for travellers to areas with ongoing monkeypox virus (MPXV) transmission

No cross-border travel restrictions are required for the control of mpox based on what is currently known about the epidemiological situation and the modes of transmission.

Instead, public health authorities should provide travellers with appropriate information and advice before, during and after travel. This may for example include the following:

Information before travel 

Provide travellers with information on whether MPXV transmission is occurring in the areas they plan to visit. Public health authorities can find this information from international dashboards such as “2022-24 Mpox (Monkeypox) Outbreak: Global Trends” [1].

Based on an analysis of the patterns of MPXV transmission observed at national level, and considering limitations and uncertainties, ECDC has classified countries where MPXV clade I is endemic or has been reported for the first time in 2024. This classification is available in the weekly Communicable Diseases Threats Report.

Advice during travel 

Based on what is currently known about the modes of transmission of MPXV [2], inform travellers on how they can decrease their risk of infection when travelling to areas with ongoing MPXV transmission:

  • avoid skin-to-skin contact, including sexual contact, with people who may have mpox;

  • avoid sexual contact with new sexual partners and practice safe sex; 

  • to reduce animal-to-human transmission in areas with active MPXV circulation among wildlife, it is recommended to avoid contact with (potential) animal reservoirs and any materials that have been in contact with a potentially infected sick or dead animal;

  • always practice good hand hygiene.

Based on the importance of early diagnosis, treatment and isolation to avoid further spread [2], advise travellers:

  • how to access healthcare while travelling, including information on local clinics and emergency contact numbers for medical assistance in the destination area;

  • to contact healthcare services in the country of travel should they develop mpox symptoms

     such as a rash  

  • to avoid travelling if they develop  mpox symptoms , or were in contact with somebody suspected or confirmed as having mpox

Advice upon return

Based on the importance of early diagnosis, treatment and isolation to avoid further spread, and based on the mpox incubation period [2], advise travellers:

  • to closely monitor their health for 21 days after returning and to contact healthcare services should they develop mpox symptoms, within three weeks after return.

Diagnosis and isolation of cases, and infection prevention and control measures

Mpox testing should be easily accessible and clinicians should be aware of symptoms and when to offer testing. Results should also be shared with public health authorities.

Public health authorities should facilitate the isolation of people with mpox. People with mpox should be instructed to isolate until their rash has completely healed, i.e. until all lesions have crusted over, the scabs have fallen off, and a fresh layer of skin has formed, which indicates the end of infectious period [2]. The decision to isolate and monitor someone at home should be made on a case-by-case basis and be based on their clinical severity, care needs, risk factors for severe disease, possibility of having contact with persons with high risk for severe mpox (such as immunocompromised persons, infants and pregnant women) and their access to hospitalisation referral should their clinical condition deteriorate [3-5].

Furthermore, based on the ECDC Rapid Risk Assessment of 16 August [6], the following advice still holds:  

  • People with mpox should be provided with tailored information to understand the clinical and epidemiological aspects of the disease. 
  • When isolation is organised at home, people with mpox should remain in their own room and use designated household items (clothes, bed linen, towels, eating utensils, plates, glasses, etc.), which should not be shared with other household members.   
  • People with mpox should avoid contact with immunocompromised persons and others at risk for severe disease (such as infants and pregnant women) until their rash completely heals.  
  • Public health authorities should regularly monitor the clinical status of the person with mpox and their adherence to recommended precautions (e.g. via telephone calls or other means, according to national guidance). 
  • Given the potentially long isolation period, people with mpox can temporarily leave their home (e.g. for outdoor exercise, such as running or biking), provided they wear a medical face mask, cover their lesions (e.g. by wearing long sleeves and trousers) and avoid indoor settings or places where many people gather.  
  • People with mpox and their household contacts should practice careful hand hygiene at all times.  
  • People with mpox should wash and change their clothes regularly to avoid transmission through fomites. They should also wash their clothes and linen separately from other household laundry. After cleaning and laundry, appropriate hand washing or hand hygiene with alcohol-based sanitiser should follow.
  • Wet cleaning and home disinfection is recommended instead of sweeping, dusting or vacuuming.
  • People with mpox should abstain from sexual activity until their rash completely heals i.e. no new lesions appear, scabs have fallen off, and new skin has formed. Although the protective effect of condoms is unknown as the virus can spread in other ways, they should still be used to protect against the spread through semen for 12 weeks after recovering from an mpox infection.
  • People with mpox and their close contacts should avoid close direct contact with animals including pets, livestock and wild animals (in captivity) for 21 days after the healing of their rash or the last exposure to the virus respectively. To mitigate the risk of wild animals getting in contact with the virus, waste, including medical waste, should be disposed of safely and should not be accessible to rodents and other scavenger animals.  

In healthcare settings, standard and transmission-based precautions should be applied patient care of those suspected and confirmed with mpox [7]. Mpox infection prevention and control guidance for primary and acute care settings have been developed by ECDC [8]. Detailed options are also available in guidance documents developed by WHO [4], the CDC [5] and the United Kingdom Health Security Agency (UKHSA) [9]. 

Contact tracing 

Contact tracing and partner notification are important measures in the response to mpox and previously published ECDC guidance remains relevant [10]. 

Contact tracing is the process of identifying people in close contact with a person confirmed with the disease who may therefore be at higher risk of becoming infected. Through contact tracing, identified contacts can be informed of their risk and closely followed, which enables early detection of symptoms and helps avoid onward transmission.

Close contacts may be sexual partners, household contacts, health professionals, or other people who had prolonged physical contact with a person with mpox. Individuals who had no close physical contact but were near a person with mpox for a prolonged period of time, e.g. sharing an office and sharing the same equipment, or being seated within two seats of a person with mpox during a long flight, may also qualify as a close contact. However, this would require a case-by-case assessment which should consider the duration and exact type of contact and timing of the contact relative to the onset of rash.

Contact persons need to be provided with tailored information to understand the clinical and epidemiological aspects of the disease and the ways to prevent onward transmission. Also, when possible, contacts need to be followed up by public health authorities or their healthcare provider 21 days after the last potential infectious exposure based on the mpox incubation period [2]. Contact tracing of newly-identified mpox cases should be undertaken with discretion. 

Based on the current epidemiological knowledge of transmissibility [2], close contacts of persons with mpox do not need to quarantine or be excluded from work, as long as no symptoms develop. However, during the 21-day monitoring period, asymptomatic contacts are advised to avoid sexual contact with others and physical contact with persons at risk of severe disease. 

The information public health authorities gather from contact tracing is also relevant to better understand the spread of the disease in the population, the transmission characteristics of the virus, and to identify settings or population groups where targeted interventions are likely to be most effective.

Substances of Human Origin

ECDC recommendations for Competent Authorities for Substances of Human Origin (SoHO) and SoHO professionals are as follows:

  • MPXV has been detected in blood, urine, tissue abscesses and bodily fluids and could potentially be transmitted through SoHO. However, to date, there has been no reported transmission of MPXV through SoHO and the likelihood of this is unknown [11-14]. 
  • Prospective donors returning from countries where clade I MPXV has been detected and who are not deferred due to other risks should be carefully interviewed regarding their contact with people suspected or confirmed with mpox or their contact with infected animals. In the event of deceased donors, data on these risk factors from the deceased person’s medical history should be collected. 
  • Based on the incubation period, it is recommended to defer asymptomatic donors who have been in contact with people with mpox clade I or II (confirmed or suspected) from SoHO donation for a minimum of 21 days from the last day of exposure.
  • People with confirmed or suspected MPXV infection should be deferred from donation for at least 14 days after the resolution of all symptoms.

Vaccination

Vaccination campaigns were implemented in the EU/EEA and other countries [15] to control the outbreak of clade IIb MPXV in 2022, with a third-generation non-replicating smallpox vaccine authorised by the European Medicines Agency (EMA) for protection against mpox in individuals aged 18 years and above [16,17]. On 19 September 2024, EMA recommended extending the indication of Imvanex vaccine to adolescents from 12 to 17 years of age [18].  

The current clade I outbreak requires EU/EEA countries to review their mpox vaccination strategies. 

In the present epidemiological situation, mass vaccination and general travel vaccination in the EU/EEA is not required; current vaccination approaches should follow an ‘at risk’ principle: 

Primary preventive (pre-exposure) vaccination (PPV) could be considered for:

  • Individuals at substantially higher risk of exposure to MPXV, such as individuals: 
    • identifying themselves as gay; bisexual, or other men or transgender people who have sex with men according to a risk assessment based on certain epidemiological or behavioural criteria (e.g. recent history of multiple sexual partners or plans to engage with multiple partners, attending sex on premises venues, or group sex or chemsex practices, use of or eligibility for pre-exposure prophylaxis for HIV, recent history of bacterial sexually transmitted infections, etc).
  • Workers in sex-on-premises venues such as:
    • saunas, if they are regularly exposed to items (i.e. linens) or surfaces likely to be contaminated with body fluids or skin cells; 
    • other groups at higher risk in these premises, such as sex workers.
  • Occupational exposure, such as:
    • health workers, especially those at repeated risk of exposure; 
    • laboratory personnel (e.g. laboratory staff working with orthopoxviruses or in clinical laboratories performing diagnostic testing for MPXV);
    • outbreak response staff should also be considered based on risk assessment.

Post-exposure preventive vaccination (PEPV) could be considered for:

  • Close contacts of cases (i.e. sexual partners, household contacts, healthcare workers, and individuals with other prolonged physical or high-risk contact).
  • Contacts with a high risk of developing severe disease if infected, such as children, pregnant women, and immunocompromised individuals, should be prioritised for PEPV based on a case-by-case risk assessment.

Vaccination to certain individuals at high risk: 

Based on an individual risk assessment by their healthcare provider and considering the available epidemiological data from areas with ongoing MPXV transmission, consider making vaccination available, in addition to other preventive measures, for travellers such as:

  • Those who are at higher risk of infection, such as specific categories of healthcare workers, people visiting families or planning to have close contact with people in areas with active circulation of MPXV clade I;
  • Those who are at higher risk of severe outcomes if infected, such as immunocompromised individuals.

Surveillance

Public health authorities should raise awareness among laboratories and clinicians to report cases to the surveillance system. At the national level, public health authorities in the EU/EEA countries are encouraged to ensure that clade and subclade determination are in place and that such information is reported to the EU surveillance system. This approach will allow for more granular insight into the epidemiology of mpox. In this regard, EU/EEA countries are also encouraged to classify mpox as a nationally notifiable disease.

Additionally, public health authorities should immediately report through event-based surveillance when they detect a case of MPXV clade I, when there is an unexpected increase in case numbers, or if cases are detected in new risk groups, populations or settings. 

DISCLAIMER: ECDC rapid scientific advice disclosure statement: ECDC issues rapid scientific advice to meet an emergent or urgent public health need or to quickly reply to external requests. To accommodate the accelerated timeline, the process and methods used for the development of rapid scientific advice may be modified from those of standard assessments and recommendations. Potential limitations are described. 

List of references 

  1. World Health Organization (WHO). 2022-24 Mpox (Monkeypox) Outbreak: Global trends. Available at: https://worldhealthorg.shinyapps.io/mpx_global/
  2. European Centre for Disease Prevention and Control (ECDC). Factsheet for health professionals on mpox. Stockholm: ECDC; 2024. Available at: https://www.ecdc.europa.eu/en/all-topics-z/monkeypox/factsheet-health-professionals
  3. European Centre for Disease Prevention and Control (ECDC). Monkeypox multi-country outbreak. Stockholm: ECDC; 2022. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/Monkeypox-multi-country-outbreak.pdf          
  4. World Health Organization (WHO). Clinical management and infection prevention and control for monkeypox: interim rapid response guidance. Geneva: World Health Organization; 2022. Available at: https://iris.who.int/bitstream/handle/10665/355798/WHO-MPX-Clinical_and_IPC-2022.1-eng.pdf?sequence=1&isAllowed=y
  5. US CDC. Infection Prevention and Control of Mpox in Healthcare Settings. Available at: https://www.cdc.gov/poxvirus/mpox/clinicians/infection-control-healthcare.html
  6. European Centre for Disease Prevention and Control (ECDC). Risk assessment for the EU/EEA of the mpox epidemic caused by monkeypox virus clade I in affected African countries. Stockholm: ECDC; 2024. Available at: https://www.ecdc.europa.eu/en/publications-data/risk-assessment-mpox-epidemic-monkeypox-virus-clade-i-africa
  7. World Health Organization (WHO). Monkeypox. Geneva: WHO; 2022. Available at: https://www.who.int/en/news-room/fact-sheets/detail/monkeypox  
  8. European Centre for Disease Prevention and Control (ECDC). Monkeypox infection prevention and control guidance for primary and acute care settings. Stockholm: ECDC; 2022. Available at: https://www.ecdc.europa.eu/en/publications-data/monkeypox-infection-prevention-and-control-guidance-primary-and-acute-care
  9. UK Health Security Agency (UKHSA). Collection Monkeypox: guidance. Gov.uk; 2022. Available at: https://www.gov.uk/government/collections/monkeypox-guidance(link is external)
  10. European Centre for Disease Prevention and Control (ECDC). Considerations for contact tracing during the monkeypox outbreak in Europe, 2022. Stockholm: ECDC; 2022. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/Considerations-for-Contact-Tracing-MPX_June%202022.pdf
  11. Lapa D, Carletti F, Mazzotta V, Matusali G, Pinnetti C, Meschi S, et al. Monkeypox virus isolation from a semen sample collected in the early phase of infection in a patient with prolonged seminal viral shedding. Lancet Infect Dis. 2022 Sep;22(9):1267-9.
  12. Mbala PK, Huggins JW, Riu-Rovira T, Ahuka SM, Mulembakani P, Rimoin AW, et al. Maternal and Fetal Outcomes Among Pregnant Women With Human Monkeypox Infection in the Democratic Republic of Congo. J Infect Dis. 2017 Oct 17;216(7):824-8. 
  13. Ritter JM, Martines RB, Bhatnagar J, Rao AK, Villalba JA, Silva-Flannery L, et al. Pathology and Monkeypox virus Localization in Tissues From Immunocompromised Patients With Severe or Fatal Mpox. J Infect Dis. 2024 Mar 26;229(Supplement_2):S219-s28.
  14. Suñer C, Ubals M, Tarín-Vicente EJ, Mendoza A, Alemany A, Hernández-Rodríguez Á, et al. Viral dynamics in patients with monkeypox infection: a prospective cohort study in Spain. Lancet Infect Dis. 2023 Apr;23(4):445-53. 
  15. European Centre for Disease Prevention and Control (ECDC). Public health considerations for mpox in EU/EEA countries. Stockholm: ECDC; 2023. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/Public%20health%20considerations%20for%20mpox%20in%20EUEEA%20countries%202023_0.pdf
  16. European Medicines Agency (EMA). Imvanex- smallpox and monkeypox vaccine (Live Modified Vaccinia Virus Ankara). Amsterdam: EMA; 2024. Available at: https://www.ema.europa.eu/en/medicines/human/EPAR/imvanex. (Accessed: 5 September 2024).
  17. European Medicines Agency (EMA). EMA recommends approval of Imvanex for the prevention of monkeypox disease. Amsterdam: EMA; 2022. Available at: https://www.ema.europa.eu/en/news/ema-recommends-approval-imvanex-prevention-monkeypox-disease
  18. European Medicines Agency (EMA). EMA recommends extending indication of mpox vaccine to adolescents. https://www.ema.europa.eu/en/news/ema-recommends-extending-indication-mpox-vaccine-adolescents