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1. Case definitions
   
2. Laboratory testing
3. Case management
4. Contact management

1. Case definitions

Reporting

Both confirmed cases and probable cases should be notified. A suspected case definition has been developed in response to the current multi-country outbreak of monkeypox virus infection in non-endemic countries and may be discontinued as the outbreak evolves. Suspected cases should not be notified to the National Notifiable Disease Surveillance System (NNDSS) but should be reported to state and territory public health units.

Confirmed case

A confirmed case requires laboratory definitive evidence only.

Laboratory definitive evidence

• Detection of monkeypox virus by nucleic acid amplification testing in clinical specimens
  or
• detection of monkeypox virus-specific sequences using next generation sequencing for clinical specimens
  or
• isolation of monkeypox virus by culture from clinical specimens.

Probable case

A probable case requires laboratory suggestive evidence and clinical evidence.

Laboratory suggestive evidence

• Detection of Orthopoxvirus by nucleic acid amplification testing in clinical specimens or
  
• detection of Orthopoxvirus by electron microscopy from clinical specimens in the absence of exposure to another orthopoxvirus.

Clinical evidence

A clinically compatible illness with rash¹,²,³ on any part of the body with or without one or more classical symptom(s) of monkeypox virus infection:

• lymphadenopathy
• fever (>38°C) or history of fever
• headache
• myalgia
• arthralgia
• back pain.
  

Suspected case³

A suspected case requires clinical evidence⁴and epidemiological evidence.

Epidemiological evidence

• An epidemiological link to a confirmed or probable case of monkeypox virus infection in the 21 days before symptom onset, or
• overseas travel in the 21 days before symptom onset, or
• sexual contact and/or other physical intimate contact with a gay, bisexual or other man who has sex with men in the 21 days before symptom onset.

Notes

1. Lesions typically begin to develop simultaneously and evolve together on any given part of the body, and may be generalised or localised, discrete or confluent. The evolution of lesions progress through four stages – macular, papular, vesicular, to pustular – before scabbing over.
2. For which the following causes of acute rash do not explain the clinical symptoms: chickenpox, shingles, measles, herpes simplex, or bacterial skin infections.
3. Public health units should seek advice from the responsible authorising pathologist and the clinician regarding testing for monkeypox virus and other alternative causes.
4. A high or medium risk contact of a confirmed or probable case only requires one or more symptoms of a clinically compatible illness (i.e. does not require rash, if another symptom present) to be a suspected case.

2. Laboratory testing

Testing guidelines

Testing is performed at jurisdictional public health laboratories. Prior to testing, suspected cases must be notified through the relevant state or territory public health unit (PHU).

The testing laboratory should be contacted to arrange receipt of specimens. Specific advice from the medical microbiologist at the testing laboratory may be sought to obtain advice on specimen collection, safe packaging, and transport.

Specimen collection and handling

Appropriate personal protective equipment (PPE) should be worn while collecting samples from patients suspected of monkeypox virus infection. This includes:

• fluid repellent surgical mask
• gloves
• disposable fluid resistant gown
• eye protection – face shields and goggles.

Lesion material should be collected from persons with suspected monkeypox virus infection with an active lesion or rash. Acceptable sample types include lesion fluid, lesion tissue, lesion crust or skin biopsy.

It is advisable to collect a sample from more than one lesion where able, however excessive sample collection should be discouraged to minimise risk to healthcare workers or laboratory personnel.

Material should be collected using a sterile dry swab. Do not use transport medium, which both dilutes the sample and risks leakage. For further advice, including on safe handling and transport of specimens refer to Monkeypox (Monkeypox Virus) - Laboratory case definition.

3. Case management

Response times

Urgent: suspected, probable or confirmed cases should be notified immediately to the relevant PHU or communicable diseases unit.

Response procedure

PHUs should begin follow-up investigation for all probable and confirmed cases on the day of notification to identify the source of exposure (e.g. another case or an environmental source) and contacts.

PHUs should ensure suspected cases are rapidly and safely tested for Orthopoxvirus infection and that they isolate until a result is received.

PHUs should ensure that action has been taken to:

• ascertain the onset date and symptoms of the illness
• conduct relevant pathology tests and confirm results
• remind collectors and laboratory staff of infection control requirements
• interview the case (or caregiver)
  
  • Ensure the diagnosis has been discussed with the case (or caregiver) before an interview.
  • The interview should include symptom history including onset date; travel history, exposure to a confirmed or probable case, nature of contact with a confirmed or probable case, history of sexual contact and intimate partners within the 21 days prior to symptom onset; smallpox vaccination status; and other relevant clinical findings to exclude other common causes of rash.
• identify the likely source of infection
• alert doctors and laboratories in the area where a monkeypox case has been infectious
• implement public health management of confirmed cases and their contacts
• ensure infection control guidelines are followed in caring for the case
• report cases to the state or territory communicable diseases unit.

Treatment

Monkeypox is generally a self-limiting infection. Most cases will not require specific treatment other than supportive management or treatment of complications (e.g. antibiotics for secondary cellulitis).

Advice on clinical management should be sought from an infectious disease physician. If antiviral treatment is indicated, it should be initiated in consultation with an infectious disease physician.

Standard and transmission based precautions, including contact and droplet precautions, are considered the minimum level of PPE when caring for a person with suspected, probable, and confirmed monkeypox. This includes:

• fluid repellent surgical mask
  
• gloves
• disposable fluid resistant gown
• eye protection – face shields and goggles.

Health workers may consider applying a fit-checked particulate filtrate respirator (PFR) - P2/N95 or equivalent, when providing certain care for a patient with probable or confirmed monkeypox, including but not limited to:

• showering patients
• handling contaminated linen, clothing, or towels
• conducting procedures involving the oropharynx.

For further advice, refer to the Australian Human Monkeypox Treatment Guidelines.

Isolation and restriction

Isolation is an effective measure to reduce the spread of disease. Isolation of monkeypox cases should occur during the presumed and known infectious periods, including the prodomal and rash stages of the illness.

• Confirmed and probable cases should immediately isolate until all lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath. The PHU or managing clinician will advise on release from isolation.
• Suspected cases should immediately isolate until a negative Orthopoxvirus laboratory test result is returned.

Isolation should be in a separate room. Cases should use designated household items (clothes, bed linen, towels, crockery and cutlery). Cases should not leave the home except as required for follow-up medical care, or for solo outdoor exercise. If a case leaves the home, they should wear a surgical mask and cover their rash.

Cases should avoid close contact with wildlife and in particular rodents (mice, rats, hamsters, gerbils, guinea pigs, squirrels etc), due to the possibility of human-to-animal transmission.

Household members should avoid physical contact with the case.

If isolation from the rest of the household is not possible, this should be discussed with the PHU; moving the case from the household should be considered, particularly if there are children or pregnant women in the household.

Careful hand and respiratory hygiene are recommended for the case and everyone in the household; a surgical face mask should be used when in the same room as other people if this is unavoidable.

Cases isolating in the community setting should be provided with their PHU or communicable diseases unit contact number to seek advice or support where required.

Active case finding

Alert local doctors, sexual health clinics, emergency departments and laboratories in the areas where the monkeypox case may have acquired infection or was infectious and not all contacts were able to be identified.

• Ask them to report suspected cases to the local PHU immediately.
• Provide advice on appropriate management including PPE and other infection control measures and specimen collection.
• Consider the need for communications to assist in case finding.

4. Contact management

Contacts of people confirmed to have monkeypox virus infection should monitor for symptoms for 21 days after their last exposure. All contacts should be encouraged to practise good hand hygiene and respiratory etiquette.

Transmission of monkeypox virus occurs when a person comes into close contact with the virus from an animal, human, or materials contaminated with the virus. Human-to-human transmission occurs through mucous membrane or non-intact skin contact with infectious material from skin lesions of an infected person; through respiratory droplets in prolonged face-to-face contact; and through fomites.

Medium and high-risk contacts

All medium and high-risk contacts should be instructed to monitor their temperature and watch for signs and symptoms. Additional measure, including consideration of post-exposure prophylaxis, may be considered (as per Table 1).

If any clinically compatible symptoms develop, medium and high-risk contacts should isolate and:

• if symptoms include rash, Orthopoxvirus testing should be conducted as soon as practicable
• if symptoms do not include rash, the PHU shold consult the responsible authorising pathologist and the clinician regarding the appropriateness of testing.

Low-risk contacts

People involved in brief indirect contact with a case, or indirect contact wearing appropriate personal protective equipment (PPE) are at low risk of transmission and do not routinely require follow up. However, on a case-by-case basis public health units may advise low-risk contacts to monitor for signs and symptoms.

See Table 1 for detailed guidance for management of contacts.

Table 1: Classification of contacts and public health management

Part A: Definition and examples

Part B: Testing and surveillance

Part C: Additional measures

1. Direct contact is defined as physical contact with a monkeypox case during their infectious period, and/or contact with materials such as linens, clothing, healthcare equipment, soiled surface), with crusts from lesions, or with bodily fluids of the case.
2. Active monitoring for symptoms is when public health officials are responsible for contacting cases (i.e. by phone, email, text) to see if a person under monitoring has signs/symptoms. The individual under monitoring must take their temperature twice daily, watch for signs/symptoms compatible with monkeypox virus infection, and immediately isolate and report to public health officials if they have signs/symptoms.
3. Appropriate PPE is the minimum standard as defined in section 3.
4. Indirect contact is defined as being within 1.5 metres of a monkeypox case (including sitting 2 rows either side on a plane) for more than 3 hours during their infectious period.
5. Self-monitoring is when the person being monitored is responsible for watching for signs/symptoms compatible with monkeypox. Self-monitoring for symptoms may be advised for low risk contacts. The individual should immediately isolate and report to public health officials if they have such signs/symptoms within 21 days of last exposure.

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