World Health Organization · May 2025 edition (living guideline) · 96 pages
Evidence-based recommendations for screening, IPC measures, and clinical care of mpox patients in community and health facility settings.
- Issuer
- World Health Organization
- Edition
- May 2025 edition (living guideline)
- Audience
- Public health specialists, health emergency responders, clinicians, health facility managers, health and care workers, IPC practitioners in primary care, sexual health clinics, emergency departments, infectious diseases, maternity services, paediatrics
- Evidence
- GRADE methodology; systematic reviews through September 2024 covering 130 studies and 89,722 patients for risk factors and prognosis; transmission review of 222 studies covering 32,317 cases; expert consensus from Guideline Development Group and technical working groups
- Reviewed
- 15 Oct 2026 · GMJ
What this guideline says
GMJ summary
This living guideline from WHO provides updated recommendations for managing mpox (monkeypox) infection across all settings, incorporating evidence through January 2025 covering clades Ia, Ib, IIa, and IIb. As of March 2025, 129,172 confirmed cases including 283 deaths have been reported globally from 130 Member States.
Key updates include conditional recommendations that persons with mild mpox at home are not required to isolate if lesions are covered and they wear a medical mask when near others, rather than strict isolation. In health facilities, health workers should use contact and droplet precautions rather than airborne precautions. Strong recommendations include rapid ART initiation (within 7 days) for people with HIV and mpox, and conditional recommendations support continued breastfeeding with IPC measures to limit direct contact.
The guideline uses GRADE methodology and addresses the full care pathway from screening and triage through treatment of complications. Transmission data show 95.4% of cases result from close contact (primarily sexual), 2.9% from non-sexual close contact, with environmental and other routes accounting for <2%. The document provides detailed practical implementation guidance for resource-limited settings.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Persons with mild mpox at home need not isolate if lesions are covered and they wear a medical mask when near others until all lesions are fully healed (crusted, scabs fallen off, fresh skin underneath)
- Health workers caring for mpox patients should use contact and droplet precautions (gloves, gown, medical mask, eye protection based on risk assessment); consider respirator when ventilation is poor or for aerosol-generating procedures
- Rapid ART initiation (≤7 days of HIV diagnosis, including same-day offer) is strongly recommended for people with mpox and HIV who are ART-naïve or have had prolonged interruption
- Mothers with mpox should continue breastfeeding whilst limiting direct contact with non-infected infants until lesions are fully healed; do not breastfeed from breast with areolar lesions
- IPC measures at home include hand hygiene, dedicated personal items, laundering linens separately with hot water (>70°C) or 0.05% chlorine, cleaning surfaces with 0.05% sodium hypochlorite or 70% ethanol (1-minute contact time)
- Admit patients at high risk (young children, pregnant persons, immunosuppressed especially CD4 <350 cells/mm³, HIV positive) or with severe/complicated disease for closer monitoring
- Environmental surfaces in health facilities should be cleaned and disinfected at least twice daily, with immediate cleaning of visibly soiled surfaces; use 0.05–0.5% sodium hypochlorite or 70% ethanol with 1-minute contact
- Pain management with antipyretics and analgesia; for oral lesions rinse with salt water ≥4 times daily; for genital/anorectal lesions warm sitz baths; monitor for secondary bacterial infection but do not use prophylactic antibiotics
Risk factors associated with severe disease or hospitalization
Table extracted from the guideline
| Risk factor | Odds ratio (95% CI) | Certainty of evidence | Summary |
|---|---|---|---|
| HIV positive | 1.79 (1.07–3.00) | Moderate | Probably associated with increased odds of severe disease |
| HIV with CD4 <350 cells/mm³ | 2.45 (1.19–5.02) | High | Associated with increased odds of severe disease vs HIV negative |
| HIV with CD4 ≥350 cells/mm³ | 0.82 (0.55–1.22) | Low | May be associated with little or no increase vs HIV negative |
| Age (per 10 years) | 0.88 (0.63–1.23) | Low | May be associated with little or no increase in severe disease |
| Male sex | 0.78 (0.34–1.78) | Low | Males may have little or no increase vs females |
| Mpox or smallpox vaccination | 0.88 (0.57–1.36) | Low | May be associated with little or no decrease in severe disease |
Source: World Health Organization, Clinical management and infection prevention and control for mpox: living guideline, May 2025. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Updated IPC recommendation: persons with mild mpox at home are not required to isolate if lesions are covered and they wear medical mask, replacing previous guidance requiring isolation
- New IPC recommendation: health workers should use contact and droplet precautions (not airborne) for mpox patients, with respirator use based on risk assessment
- New clinical recommendation: strong recommendation for rapid ART initiation (≤7 days) in people with HIV and mpox
- New clinical recommendation: conditional recommendation for mothers with mpox to continue breastfeeding whilst limiting direct contact with non-infected infant
- Incorporated evidence on transmission routes through September 2024 showing close contact (sexual/non-sexual) accounts for 98.3% of 32,317 reviewed cases
- Added risk factor analysis showing HIV positive (OR 1.79) and CD4 <350 cells/mm³ (OR 2.45) as significant predictors of severe disease
From the guideline
Verbatim
“WHO suggests that persons with mild, uncomplicated mpox infection cared for at home are not required to isolate provided their lesions are covered and they wear a well-fitting medical mask when in close proximity with others until all lesions are healed.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia and a WHO consultant, I recognise this guideline's importance for our region given increasing travel-associated mpox risk and the evolving evidence on clade Ib transmission. The most critical recommendation for Georgian clinicians is the strong guidance on rapid ART initiation within 7 days for HIV-positive mpox patients—our national HIV programme has the infrastructure to implement this immediately, building on lessons from our hepatitis C elimination efforts since 2015. The shift away from mandatory home isolation toward pragmatic IPC measures (covered lesions, masks, hand hygiene) is realistic for our context where many families lack separate rooms, though we must invest in clear public communication to prevent stigma-driven underreporting. One implementation challenge specific to Georgia and neighbouring countries is ensuring adequate ventilation assessment in older health facilities; where Soviet-era buildings have poor airflow, the conditional recommendation for respirators becomes more salient, requiring us to expand our respiratory protection stockpiles beyond current COVID-19 reserves and tuberculosis programme supplies.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 15 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and Eastern European countries face specific considerations for mpox preparedness given travel connectivity with affected regions and variable HIV programme maturity. Georgia’s established HIV treatment infrastructure (with ART coverage expanding under the UHC programme since 2013) supports the rapid ART initiation recommendation, though CD4 monitoring capacity in rural areas may need strengthening. The shift away from mandatory home isolation aligns with resource constraints in community settings but requires clear risk communication strategies adapted to local stigma concerns around both mpox and HIV. Health facilities in the region should assess ventilation adequacy given Soviet-era infrastructure limitations; where natural ventilation is poor, the conditional recommendation for respirators becomes more relevant. National programmes should integrate mpox screening into existing sexual health and HIV services, leverage wastewater surveillance capacity where available (as Georgia has developed for polio and COVID-19), and ensure infection prevention supplies (medical masks, gloves, 0.05% chlorine solutions) reach primary care level. The breastfeeding recommendation requires contextual adaptation given varied access to safe water and breastmilk substitutes across rural areas.
Questions this guideline answers
Quick answers
When can a person with mpox at home stop isolating and wearing a mask?
All lesions must be fully healed: crusted, scabs have fallen off, and a fresh layer of intact skin has formed underneath. Until then, lesions should be covered and a well-fitting medical mask worn when in close proximity to others. This typically takes 2–4 weeks but can be longer in some patients.
What PPE do health workers need when caring for mpox patients?
Contact and droplet precautions: gloves, gown, medical mask, and eye protection (based on risk assessment). Consider using a respirator instead of medical mask when ventilation is poor or unknown, during aerosol-generating procedures, if the patient is immunocompromised with mucosal lesions, or if varicella/measles are suspected. Always follow standard precautions including hand hygiene.
Should we delay starting HIV treatment in a patient with mpox?
No. WHO strongly recommends rapid ART initiation within 7 days of HIV diagnosis, including same-day offer, for people with mpox. The mortality benefits of rapid ART outweigh theoretical risks of immune reconstitution inflammatory syndrome (IRIS). Delaying ART may worsen mpox outcomes, especially in those with CD4 <350 cells/mm³.
Can mothers with mpox breastfeed their babies?
Yes, WHO suggests continuing breastfeeding whilst limiting direct contact with the non-infected infant. Cover all active lesions during feeding, wear a medical mask, perform hand hygiene before and after feeding. If there are lesions on the areola, do not use that breast; if unilateral, feed from the unaffected breast only. The benefits of breastfeeding (reduced mortality, infection, sepsis, diarrhoea) must be weighed against transmission risk in each context, considering availability of safe alternatives.
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Other guidelines on this topic
- Strategic actions for infection prevention and control and water, sanitation and hygiene during mpox outbreak response
- Guidelines for clinical management of arboviral diseases: dengue, chikungunya, Zika and yellow fever
- Guidelines on lenacapavir for HIV prevention and testing strategies for long-acting injectable pre-exposure prophylaxis
- Recommendations on the delivery of health services for the prevention and care of sexually transmitted infections
- Strategic actions for infection prevention and control and water, sanitation and hygiene during mpox outbreak response
- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- May 2025 edition (living guideline)
- Replaces
- Interim guidance: Clinical management and infection prevention and control for monkeypox, June 2022
- Status
- Current
- Published
- 2025-06-04
- Languages
- English
- Scope
- Screening, triage, testing, infection prevention and control (community and health facility), clinical management (home-based and hospital care), symptomatic treatment, optimized supportive care, timing of ART initiation, breastfeeding, care during pregnancy, follow-up
- Audience
- Public health specialists, health emergency responders, clinicians, health facility managers, health and care workers, IPC practitioners in primary care, sexual health clinics, emergency departments, infectious diseases, maternity services, paediatrics
- Pages
- 96
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE methodology; systematic reviews through September 2024 covering 130 studies and 89,722 patients for risk factors and prognosis; transmission review of 222 studies covering 32,317 cases; expert consensus from Guideline Development Group and technical working groups
- Next review
- Living guideline: continuous monitoring and updates as new evidence emerges
- Record history
- Created 15 Oct 2026 · updated 15 Oct 2026 · next check Apr 2027
World Health Organization. Clinical management and infection prevention and control for mpox: living guideline, May 2025. Geneva: World Health Organization; 2025. 96 p. Licence: CC BY-NC-SA 3.0 IGO. https://doi.org/10.2471/B09434GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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