This document provides guidance for transplant practitioners on monkeypox (MPX) and organ transplants. We acknowledge that our current understanding of the disease is incomplete. This guidance will require revision as new evidence emerges.
In these guidelines, we adopt a conservative approach to organ donation with regards to MPX transmission. We err on the side of safety.
We recognize that many institutions already have experience with MPX. This document makes suggestions, but its aim is not to be dogmatic. Individual programs and patients should make their own decisions based on the clinical circumstances of the potential donor and the needs of the potential recipient, as well as their own experience with MPX disease.
The impact of MPX and the potential risk of viral transmission through organ donation are still unknown and the guidelines will be updated as new evidence emerges. Therefore, the current position is one of caution.We suggest that any person in the following categories be excluded from organ donation:
In monkeys, viremia is a “constant feature of infection”, likely responsible for dissemination of the virus to the secondary and tertiary target organs.  Viremia is said to occur from the 3rd and 14th days.  The data on DNAemia and viremia in humans is sparse. Norz et al found that DNAemia could be demonstrated but that it fell during the week during which blood was obtained and tested for DNAemia.  Norz et al, however, did not test for DNAemia beyond the first 10 days.  Adler et al documented MPX DNA and blood and urine up to about the 70th day of illness in a one patient (the others were not tested beyond 20 – 25 days).  There is no information on whether or not this represented viable virus.
There are also infection control considerations. WHO advises that MPX patients be managed with a combination of contact and droplet precautions.  MPX DNA has been found on a variety of patient samples apart from skin lesions – these include nasopharyngeal swabs, saliva, urine, feces, and semen. 
There are also reports indicating that MPX DNA can be found in the inanimate environment of rooms occupied by MPX patients. 
In light of the subtle clinical presentation in a small percentage of MPX cases, we suggest that the medical team managing potential donors conduct a full physical examination that includes inspecting the genitalia for ulcers.
Until we have a clear understanding of the clinical virology of this emerging virus, such as the duration of viral viability in the viscera, we recommend against accepting organs from a person currently suffering from MPX.
Several distinguished organizations have commented on this. How soon after recovery can organs from an infected a person be used for transplantation – there is no consensus. The American Society of Transplantation (AST) considered that donors with confirmed MPX infection should postpone donation until all skin lesions have healed and skin re-epithelialization has occurred. 
The NHS-Blood and Transplant United Kingdom, on the other hand, recommended that donation may be considered from 8 weeks after complete recovery from illness in proven cases.  This recommendation seems to have been based on the Adler et al publication mentioned above. (We know that one patient in the series of Adler et al had “ongoing lymphadenopathy”. After sexual intercourse about 6 weeks after recovery, he appears to have had a clinical relapse, with skin lesions that were MPX PCR-positive. We are unable to determine if this represented re-infection, or recrudescence of the original infection. We also do not know the immune status of the patient. )
The Spanish recommendations for transfusion recommend that persons confirmed positive for MPX be excluded from donation for 120 days.  It is not clear if the countdown starts from the first day of symptoms or the first day of recovery from the illness (generally taken as the time when all skin lesions and scabbed and are dry).
The Global Vigilance and Surveillance Database for Products of Human Origin makes the following statement: "A person diagnosed with MPX is not eligible to donate MPHO during the clinical course of the disease and two weeks (14 days) after the end of symptoms and the disappearance of crusted vesicular lesions. If the illness required hospitalization, the grace period is longer (up to three months).” 
At the same time, there are UK recommendations suggesting that confirmed or highly probable cases use condoms for 12 weeks after complete recovery from MPX infection. 
By general virological principles, the newly-transplanted patient, who will be under intense immunosuppression, is at high risk of severe disease from a primary infection – more so than a routine sexual partner. We also note that several European organizations have veered towards a longer interval after recovery from MPX. It would seem appropriate to adopt a more conservative window for excluding donors in the absence of clear data.
We recommend deferring all organs from donors with confirmed and active MPX. In recovered cases, we suggest practitioners follow at least the guidelines of their national organizations, though adhering to a stricter rule (3, or even 6 months) is clearly an option in the interest of patient safety. We have provided a wide window because individual circumstances will necessarily dictate bedside actions. Ultimately, the decision to accept a donor with a history of MPX should be a balance between the medical urgency faced by the potential recipient and the risk of passing MPX to him/her.