​Control guideline for public health units

Public health priority: Urgent.

PHU response time: Respond to any report of monkeypox disease on day of notification. Enter suspected, probable and confirmed cases on NCIMS within 1 working day.

PHUs should refer to the CDNA Monkeypox virus infection case and contact management guidelines (also detailed below).

​Version
​Date
​Revised by
​Changes
​Approval
​1.0
​24/06/2022


​CDNA


Last updated: 30 June 2022

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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.
A fit check should be performed each time the PFR is applied.

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

Risk group Definition of exposure during the case's infectious periodExamples (contact during case's infectious period)
High
  • Direct contact1 via broken skin or mucous membranes with a monkeypox case (whilst symptomatic), potentially contaminated materials (including bed linens, healthcare equipment), crusts, or bodily fluids, without wearing appropriate PPE
    or
  • household contacts
    or
  • within an enclosed room or 1.5m of a monkeypox case during any procedure that may create aerosols from oral secretions, skin lesions or resuspension of dried exudates (e.g., shaking of soiled linens, showering patients, conducting procedures involving the oropharynx), without wearing appropriate PPE3.
  • Sexual partners
  • Household contacts who have been in the same residence as the case for at least one night
  • Caregivers of symptomatic monkeypox cases without appropriate PPE3
  • Healthcare worker present with a case during aerosol generating procedure without appropriate PPE3
  • Body fluid from case in contact with eyes, nose, or mouth
  • Changing or laundering the bedding of a monkeypox patient with rash/lesions in a healthcare setting without appropriate PPE3
Medium
  • Direct contact1 via intact skin with an infectious monkeypox case, case materials, crusts, or bodily fluids without wearing appropriate PPE3
    or
  • indirect contact4 with an infectious monkeypox case without wearing a mask
  • Healthcare worker with direct or indirect contact with a monkeypox case not wearing appropriate PPE3 or in the case of a PPE breach
  • Passengers seated within 2 rows of an monkeypox case on a flight for 3 hours or more without a mask
  • Drivers and passengers in the same vehicle as a case for 3 hours or more without a mask
  • People in a workplace or social setting within 1.5 metres of a case for 3 hours or more without a mask
  • Cleaner or laundry staff (e.g. in a hotel) handling case material without appropriate PPE3 of a monkeypox case with rash/lesions
Low risk
  • Brief non-physical contact4 with a case
    or
  • sharing a room or plane outside of 1.5m distance from a case for greater than 3 hours without a mask
    or
  • direct contact wearing appropriate PPE3
  • Brief face-to-face contact or unmasked conversations with a case
  • Flight crew who provided service to a case
  • Drivers and passengers in the same vehicle as the case for less than 3 hours
  • People in a workplace greater than 1.5 metres from a case
  • People in a workplace within 1.5 metres for less than three hours
  • Passengers seated on a plane outside of 2 rows on either side of a case for 3 hours of more
  • Cleaners of a hotel room wearing appropriate PPE3
  • Healthcare worker who examined or cared for a monkeypox case or a laboratory worker handling case materials wearing appropriate PPE3 (with no known breaches)

Part B: Testing and surveillance

Risk groupSurveillance for 21 days after the last exposurePost-exposure vaccinationTesting priority
HighDaily active monitoring2 Vaccination or other post-exposure prophylaxis (including vaccinia immunoglobulin) may be warranted following a risk benefit assessment, if there are no contraindications

High testing priority if compatible symptoms develop.

MediumActive monitoring2 scheduled on a case by case basisNot recommendedIntermediate testing priority if compatible prodromal symptoms develop, high if a clinically compatible rash develops.
Low risk Self monitoring5 may be advised on a case by case basis
Not recommended Do not test unless compatible prodromal symptoms or rash develops

Part C: Additional measures

Risk groupAdditional measures
High

For 21 days from last exposure:

  • work from home if possible
  • workers in high-risk settings (healthcare, children, aged care facilities) who need to attend work should be managed on a case-by-case basis in consultation with public health units
  • do not visit high-risk settings (healthcare, childcare, and aged care facilities), unless seeking urgent medical attention
  • avoid non-essential outings, especially to crowded settings
  • wear a surgical mask when outside the home and when in the same room as other people in the home
  • abstain from sexual activity
  • avoid close physical contacts with others, maintaining a distance of 1.5 meters at all times, including in the home
  • follow careful hand and respiratory hygiene
  • avoid contact with pet rodents
  • avoid contact with those at potential higher risk of severe infection (infants, older people, immunocompromised people, and people who are pregnant)
  • do not donate blood, cells, tissue, breast milk, semen, or organs.
Medium

For 21 days from last exposure:

  • work from home, if possible
  • avoid visiting high-risk settings (healthcare, childcare and aged care facilities) unless seeking urgent medical attention
  • if working in a high-risk setting, ensure symptom free and wear a surgical mask
  • avoid close contact with those at potential higher risk of severe infection (infants, older people, immunocompromised people, and people who are pregnant)
  • do not donate blood, cells, tissue, breast milk, semen, or organs.
  • follow careful hand and respiratory hygiene.

Low risk

For 21 days from last exposure:

  • consider advising self monitoring4 on a case by case basis
  • consider advising careful hand and respiratory hygiene on a case by case basis.
  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.


Current as at: Thursday 30 June 2022
Contact page owner: Communicable Diseases