On this page

1. Summary
2. The disease
3. Routine prevention activities
4. Surveillance objectives
5. Data management
6. Case definition
7. Testing
8. Case management
9. Contact definitions
10. Contact management
11. Infection control
12. Special situations
13. NSW SoNG Appendix
14. References

1. Summary

These interim guidelines describe recommended public health responses to cases and contacts of monkeypox virus infection. CDNA will continue to review these guidelines as more information becomes available.

Public health priority

Monkeypox virus infection (monkeypox) is a nationally notifiable disease.

Urgent: Respond to suspected, probable and confirmed cases immediately (within 24 hours).

Data entry timeline: Within 1 working day for all probable and confirmed cases.

Actions in the event of a suspected case

Suspected cases should be notified to the relevant state or territory Public Health Unit (PHU).

When a suspected case has been identified, immediately (within 24 hours):

• arrange for appropriate testing to be undertaken in collaboration with the diagnosing clinician and relevant laboratory
• advise the suspected case to follow case exclusions & restrictions until a negative result is received
• consider identifying contacts and assessing their risk while waiting for test results.

Actions in the event of a probable or confirmed case

All probable and confirmed cases should be notified immediately to the relevant state or territory PHU.

When a probable or confirmed case has been identified, immediately (within 24 hours):

• advise the case to follow case exclusions & restrictions to prevent further disease spread
• identify contacts during the case's infectious period and follow the contact management guidance
• attempt to identify the source of infection and/or risk factors.

Refer to case management for further details on response times and procedures, treatment and exclusion and restriction guidance.

Management of contacts

For contacts of probable and confirmed monkeypox cases:

• monitor for monkeypox symptoms for 21 days after the date of last exposure, including for the development of a rash or pimple-like lesions, or a fever
• if symptoms compatible with monkeypox develop, advise the contact to follow case exclusions and restrictions, and contact the local PHU for further guidance.

Refer to contact management for information about physical distancing and other public health measures recommended for medium and high-risk contacts.

2. The disease

Infectious agent

Monkeypox is caused by infection with monkeypox virus. Monkeypox virus is an enveloped double-stranded deoxyribonucleic acid (dsDNA) virus of the genus Orthopoxvirus, which also includes variola virus (which causes smallpox), vaccinia virus (which is used to produce the smallpox vaccine) and cowpox virus.

Monkeypox virus has two distinct genetic clades, the Central African (Congo Basin) clade and the West African clade. The Congo Basin clade has historically caused more severe disease (1). On 12 August 2022, the World Health Organisation announced new nomenclature for the monkeypox virus. The former Congo Basin (Central African) clade is now referred to as Clade one (I) and the former West African clade as Clade two (II), of which there are two subclades; Clade IIb refers primarily to the group of variants largely circulating in the 2022 global outbreak (2).

Reservoir

The natural reservoir of monkeypox virus remains unknown. However, it has been isolated from several African rodents and primates, including the Gambian pouched rat, tree squirrel, rope squirrel and sooty mangabey monkey (3).

Disease occurrence and public health significance

Following the eradication of smallpox in 1980 and subsequent cessation of smallpox vaccination programs, monkeypox virus has emerged as the most significant Orthopoxvirus for public health. Historically, monkeypox has primarily occurred in central and west Africa, often in proximity to tropical rainforests (4).

Before 2018, the only cases with transmission outside Africa occurred in the United States of America, in a 2003 outbreak associated with imported rodents from Ghana that infected prairie dogs sold as pets (5). Since early May 2022, monkeypox transmission has been reported in multiple countries outside Africa, including Australia. Cases notified since 20 May 2022 represent the first time the virus has been detected in Australia.

It has been suggested that the increasing case numbers and geographic spread of monkeypox in recent years may be related to decreasing population immunity due to cessation of smallpox vaccination programs and increasing urbanisation (6) Smallpox vaccination is protective against other Orthopoxviruses, including monkeypox.

Mode of transmission

Transmission of monkeypox virus can occur when a person comes into contact with the virus from an infectious animal or human, or with materials contaminated with the virus (fomites). Transmission occurs through broken skin (even if not visible), or mucous membranes (respiratory tract, conjunctiva, nose, mouth, or genitalia), and may occur though contact with infectious material from skin lesions of an infected person, through respiratory droplets in prolonged face-to-face contact, or through fomites. It remains unclear whether the virus can be transmitted through semen or vaginal fluids. Aerosol-generating procedures are also a transmission risk (7).

Human to animal transmission of monkeypox has been described following a case study of likely transmission to a dog due to close contact (8).

Incubation period

The incubation period is typically 7 to 14 days, with a range of 5 to 21 days (1, 9, 10). The incubation period may be influenced by the route of transmission, with invasive exposure (e.g. contact with broken skin or mucous membrane) having a shorter incubation period than non-invasive exposure (11).

Infectious period

The infectious period begins with the onset of symptoms, either prodromal or rash. Cases remain infectious until the rash has resolved, and all lesions have formed scabs and fallen off, leaving fresh skin underneath. Cases are not considered infectious prior to the onset of symptoms, however some cases may not be aware of their exact symptom onset date as initial symptoms may be both very subtle and/or not visible (12-16).

Clinical presentation and outcomes

Monkeypox is usually a self-limiting disease with symptoms lasting for 2 to 4 weeks.

The illness may have a prodromal period lasting 1 to 5 days that is characterised by lymphadenopathy, fever (≥38°C) or history of fever, headache, myalgia, arthralgia and back pain (17). Not all cases report prodromal symptoms (17).

A maculopapular rash is typical of monkeypox and may develop 1 to 5 days after the onset of fever. The rash may be generalised or localised, discrete or confluent. It is classically described as centrifugal, more concentrated on the face and extremities than the trunk. Skin lesions often present at first as macules (lesions with a flat base), which progress to papules (slightly raised firm lesions), vesicles (lesions filled with clear fluid) and pustules (lesions filled with yellowish fluid). Crusted scabbing usually begins 14 to 21 days after rash onset. Scabs then fall off, leaving dyspigmented scars (18).

Lymphadenopathy is characteristic of monkeypox (although may not be present). It is usually not observed in smallpox or varicella.

However, atypical presentations have been reported in the current global outbreak with many cases not presenting with the classically described clinical picture for monkeypox.

• Cases have usually been mild, sometimes with very few lesions, or a single lesion.
• Lesions have appeared in the genital or perianal area and have not spread further. Visible skin lesions have been absent in some cases, with rectal pain and bleeding reported as a presenting symptom.
• Rash has been reported with no prodrome or before onset of fever (17). Of 5,266 cases reported in the European region, 96% presented with a rash, and 69% with systemic symptoms such as fever, fatigue, muscle pain, vomiting, diarrhea, chills, sore throat or headache (19).

More severe complications of monkeypox infection include secondary infections such as skin infections including cellulitis, bronchopneumonia, sepsis, encephalitis and infection of the cornea with subsequent scarring and loss of vision. Severe dehydration may occur, secondary to vomiting, diarrhoea and oral lesions preventing adequate hydration.

Mortality

Internationally, the monkeypox case fatality rate globally ranges from 0% to 11%, but there are challenges in accurately estimating this rate (20).

The multi-country outbreak in non-endemic countries which began in May 2022 is associated with the milder West African clade which has a reported historical case fatality rate of 0-3.6%.

As of 05 September 2022, more than 52,000 cases of monkeypox have been reported according to the WHO. There have been 18 deaths - ten in endemic countries and eight in non-endemic countries (26).

Groups at increased risk of severe disease

Immunocompromised patients, including those with HIV infection that is not well-controlled (CD4 count <200 cells/μL), are believed to be at higher risk of severe disease.

Although not in the current outbreak, more severe outcomes have historically been recorded in children, especially young children (younger than 10). This could be related to the cessation of smallpox vaccination (22-24).

Vertical transmission from mother to fetus has been recorded (25).

Severe disease occurs more commonly among people who are unvaccinated (13).

High-risk settings and communities

Anyone who is in very close contact with someone with monkeypox, particularly where skin-to-skin contact occurs, is at risk. While the mode of transmission means that anyone can acquire or transmit monkeypox, cases in the current outbreak have occurred primarily, but not exclusively, in gay, bisexual and other men who have sex with men (16, 19).

As of 05 September 2022, of the 52,996 cases reported to the WHO, 98.2% (26,953/27,449) were males, and the median age of reported cases was 36 years (26).

Cases have sometimes been associated with large events or parties, including festivals in Europe (27).

High-risk settings and activities for transmission in the context of the current outbreak include:

• sexual activity (28)
• households (29)
• sex-on-premises venues
• events or venues where skin-to-skin contact and other intimate contact occurs (30)
• healthcare settings.

3. Routine prevention activities

Infections with monkeypox virus can be prevented by the following measures:

• People with monkeypox should follow restriction advice to stay away from other people (and animals) until all sores have healed and new skin has grown.
• As it is unclear whether viable virus may be present in semen after recovery, people who have had monkeypox should use condoms when having sex for a further 8 weeks after clearance.
• If caring for, or having contact with, someone who has monkeypox, wear personal protective equipment (PPE) including gloves and a surgical mask.
• Avoid exposure to body fluids, lesion material or contaminated material from an infected person. Avoid contact with any materials, such as bedding, that have been in contact with an infected person.
• If having sex while travelling or attending venues or events where intimate contact with a large number of people occurs, be aware of the risk of monkeypox. Although condom use is recommended, condoms are not protective, as any skin-on-skin contact with an infected person poses a transmission risk.
• In healthcare settings, the risk of transmission can be significantly reduced through appropriate infection control precautions and environmental cleaning (see Section 11 Infection control for further details).
• Practise good hand hygiene after contact with an infected person. After removing gloves, wash hands for 20 seconds with soap and water or use an alcohol-based hand sanitiser.
• If travelling to countries in Central and West Africa where monkeypox is known to be present, avoid contact with sick animals that could harbour monkeypox virus, including rodents, marsupials and primates, and avoid handling or eating wild game and bush meat.

4. Surveillance objectives

Key surveillance objectives are to:

• rapidly identify cases, clusters of infection and sources of infection to provide clinical care and prevent further transmission through case exclusions and restrictions and contact management
• enable effective prevention and control measures and effective communication strategies based on identified routes of transmission and high-risk settings.

5. Data management

Confirmed and probable cases should be entered on to the National Notifiable Diseases Surveillance System (NNDSS) by jurisdictional PHUs, ideally within one working day of notification.

The date of onset is the date of symptom onset, which may be prodromal/systemic symptoms, or may be a rash.

Cases subsequently shown not to have monkeypox should be excluded within one working day.

Multi-jurisdictional outbreaks requiring national coordination may require support from the National Incident Centre (NIC).

6. Case definition

For case definitions please see CDNA surveillance case definitions | Australian Government Department of Health and Aged Care.

7. Testing

Before testing, suspected cases should be notified to the relevant state or territory PHU or Communicable Disease Unit (CDU).

Subject to advice from the jurisdictional PHU, patients with symptoms who present with a history suggestive of exposure to monkeypox should have a specimen collected and be referred for laboratory testing.

Testing is performed at jurisdictional public health laboratories. 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 PPE should be worn while collecting samples from patients suspected of monkeypox virus infection.

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

It is advisable to collect samples from more than one lesion where possible, 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. Avoid using transport medium, as this may dilute the sample and increase risk of leakage. For further advice, including on appropriate PPE and safe handling and transport of specimens, refer to the Monkeypox Laboratory Case Definition.

8. Case management

Response times

Urgent: immediately (within 24 hours).

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 and contacts.

PHUs should ensure that action has been taken to:

• Conduct relevant pathology tests and confirm results.
• Provide collectors and laboratory staff with information about infection control requirements (see Monkeypox Laboratory Case Definition- Specimen collection and handling).
• Interview the case (or caregiver)
• Ensure the diagnosis has been discussed with the case (or caregiver) before an interview.
• Ascertain the onset date of illness and symptoms.
• The interview should include symptom history including travel history, identification of any high-risk settings or activities, any exposure to a confirmed or probable case, the nature of any contact with a confirmed or probable case, sexual contact and intimate partners within 21 days of symptom onset, smallpox and monkeypox vaccination status, other relevant clinical findings to exclude other common causes of rash.
• Prioritise identification of high and medium-risk contacts.
• Active case finding
• Alert local doctors, sexual health clinics, emergency departments and laboratories in the areas where a 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.
• Identify the likely source of infection.
• Implement public health management of confirmed and probable cases and their contacts.
• Ensure infection control guidelines are followed in caring for the case.

Exclusion and restriction

Exclusion and restriction of monkeypox cases should occur during the presumed and known infectious periods, including the prodromal and rash stages of the illness. Cases should be advised to do the following during their infectious period and until advice has been provided by PHUs regarding clearance of infection.

Until they meet the clearance criteria:

Cases should not:

• Attend high-risk settings such as early childhood education and care services, aged care, healthcare settings, and schools, especially settings with young children and those at higher risk of severe disease, including for routine appointments, unless seeking medical attention.
• Donate blood, cells, tissue, breast milk, semen, or organs

Cases should avoid:

• Physical or intimate contact with others including sexual activity.
• Contact with people who are at higher risk of severe disease, including immunosuppressed people, pregnant women, and young children.
• Close contact with animals, particularly dogs and rodents (mice, rats, hamsters, gerbils, guinea pigs, squirrels etc), due to the possibility of human-to-animal transmission.
• Public transport if lesions cannot be completely covered; cases should wear a mask.

Cases should:

• Stay at home, except for undertaking essential activities and following a risk assessment:
• Sleep in a separate room and limit contact with household members; avoid any interaction with people at higher risk of severe disease.
• Wear a mask when in the same room as others and cover skin lesions (where possible).
• Do not share clothing, bedding, towels and unwashed crockery and cutlery. If others must touch these items, they should wear gloves and a surgical mask.
• Visitors to the home should be discouraged.
• Work from home where possible.
• Practise careful hand and respiratory hygiene.

If a case is required to leave the home for essential activities, undertake a risk assessment considering the severity of symptoms, location of lesions and potential exposure to others.

• Cases may leave the home for essential activities in non-crowded settings including to buy groceries, medicines or for solo outdoor exercise.
• Cases should avoid appointments that can be safely postponed, particularly those in high-risk settings such as healthcare, educational or aged care settings, unless seeking medical attention.
• If leaving the home, cases should wear a surgical mask, ensure any rash or lesions are covered, and avoid close contact with others.
• If cases cannot work from home, PHUs may conduct a risk assessment on a case-by-case basis, to advise whether the case can attend the workplace. Factors to consider include: the type and nature of their work, number and location of their lesions, and mode of transport to and from work.
• For example, a person who works primarily in an outdoor setting where physical distancing can be maintained, may be considered as being able to attend work. Those working in a high-risk setting, particularly in a care-giving role, should not attend work.

PHUs should ensure people with monkeypox have access to a PHU or CDU contact number to seek advice or support where required.

Case clearance

Cases can resume normal activity when 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 clearance of a case.

For 8 weeks following clearance, cases should be advised to wear a condom during sexual activity.

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 diseases physician. If antiviral treatment is indicated, it should be initiated in consultation with an infectious disease physician and/or sexual health physician. Tecovirimat is the preferred treatment for severe monkeypox virus infection.

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

9. Contact definitions

Table 1: Contact definitions and examples

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 a case.
2. Appropriate PPE as determined by the PHU based on a risk assessment including the nature of contact, likely transmission pathway/s and setting type, noting the minimum standard defined in section 11 Infection control.
3. Indirect contact is defined as being within 1.5 metres of a case for more than 3 hours during their infectious period.

• A higher risk social setting or situation constitutes those settings where the nature of interaction may pose some risk of transmission e.g. sex-on-premises venues, raves, festivals and other mass gatherings where there is likely to be prolonged close contact. A risk assessment should consider the case's symptoms and location of lesions. This should be limited to identifiable social contacts unless broader communications for the venue is considered necessary by the PHU.
• **At present, there is no evidence of transmission in these settings as part of the global outbreak in 2022, however some countries have identified that the exact route of acquisition is not always possible to ascertain. Should there be transmission demonstrated in these settings, the evidence and advice will be reviewed.

10. Contact management

Contacts of probable and confirmed monkeypox cases should monitor for signs and symptoms of monkeypox for 21 days after the date of their last exposure. All contacts should be encouraged to practise good hand hygiene and respiratory etiquette.

See Table 2 for detailed guidance on management of high- and medium-risk contacts.

Table 2: Management of high- and medium-risk monkeypox contacts

Note:

¹ Active monitoring is:

• recording temperature twice a day
• watching for signs or symptoms compatible with monkeypox infection; if they appear, follow case exclusion and restriction criteria and immediately report to public health officials
• monitoring from public health officials (i.e. by phone, email, text) to check the emergence of any signs or symptoms.

11. Infection control

Management in healthcare settings

Monkeypox is spread by contact with lesions, body fluids and respiratory secretions, and contaminated materials. The extent to which transmission occurs via the respiratory route remains unclear. The Infection Prevention and Control Expert Group (ICEG) continues to review evidence and update its guidance on appropriate measures for infection control in relation to monkeypox. Refer to the latest guidance here: Interim Guidance on Monkeypox for Health Workers.

This guidance is for health workers, including but not limited to those who work in sexual health clinics, primary care, acute care, and laboratories.

Key recommendations:

• Patients with suspected, probable, or confirmed monkeypox should ideally be placed in a single room with separate bathroom facilities; or if separate room is not available, in a separate cubicle.
• Patients should wear a surgical mask, if possible, and exposed skin lesions should be covered with non-stick dressings, a sheet or gown.
• Avoid having immunocompromised staff allocated to a patient with suspected, probable, or confirmed monkeypox. Staff who have received smallpox vaccination in the past are preferred.
• When handling clothing and linen of suspected, probable, or confirmed cases, avoid shaking items or handling them in a manner that may disperse infectious particles into the environment.
• Thoroughly clean and disinfect consultation and inpatient rooms used by a person who has suspected, probable, or confirmed monkeypox. Don a new set of PPE before cleaning and disinfecting rooms. Do not reuse cloths, avoid dry dusting, sweeping, vacuuming, to prevent dispersal of infectious particles.

Personal protective equipment

Standard and transmission-based precautions, including contact and droplet precautions, are considered the minimum level of personal protective equipment (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 filter respirator – P2/N95 or equivalent – when providing certain care, including but not limited to:

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

12. Special situations

Vaccination

Monkeypox is vaccine-preventable. However, the global supply of vaccines is limited and potential side-effects need to be weighed carefully against the risk of infection and the risk of severe disease. Vaccine administration requires specialised training and careful consideration of potential benefits and risks.

Refer to ATAGI clinical guidance on vaccination against Monkeypox | Australian Government Department of Health and Aged Careand the Australian Human Monkeypox Treatment Guidelines for advice.

13. NSW SoNG appendix

Please refer to the NSW specific SoNG appendix for additional advice on management of monkeypox cases and contacts.

14. References

1. World Health Organization. Monkeypox 2022
2. World Health Organization. Monkeypox: experts give virus variants new names
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5. Centers for Disease Control and Prevention. Update: Multistate Outbreak of Monkeypox --- Illinois, Indiana, Kansas, Missouri, Ohoi, and Wisconsin, 2003 Centers for Disease Control and Prevention2003
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11. Miura F, van Ewijk CE, Backer JA, Xiridou M, Franz E, Op de Coul E, et al. Estimated incubation period for monkeypox cases confirmed in the Netherlands, May 2022. Eurosurveillance. 2022;27(24):2200448.
12. Centers for Disease Control and Prevention. How it Spreads: Centers for Disease Control and Prevention; 2022
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19. European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Monkeypox, Joint Epidemiological overview. 2022.
20. Public Health Laboratory Network. Monkeypox (Monkeypox Virus) Laboratory Case Definition (LCD). 2022.
21. Centers for Disease Control and Prevention. 2022 Global Map and Case Count
22. Bunge EM, Hoet B, Chen L, Lienert F, Weidenthaler H, Baer LR, et al. The changing epidemiology of human monkeypox—A potential threat? A systematic review. PLOS Neglected Tropical Diseases. 2022;16(2):e0010141.
23. Centers for Disease Control and Prevention. Clinician FAQs. 2022.
24. Centers for Disease Control and Prevention. Monkeypox in the United States: What Clinicians Need to Know. 2022.
25. 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. The Journal of Infectious Diseases. 2017;216(7):824-8.
26. World Health Organization. Disease Outbreak News; Multi-country outbreak of monkeypox, External situation report #5: World Health Organization; 2022
27. World Health Organization. Monkeypox in the European Region: what we know so far and how we need to respond. 2022.
28. Egan C, Kelly CD, Rush-Wilson K, Davis SW, Samsonoff WA, Pfeiffer H, et al. Laboratory-confirmed transmission of vaccinia virus infection through sexual contact with a military vaccinee. J Clin Microbiol. 2004;42(11):5409-11.
29. Nolen LD, Osadebe L, Katomba J, Likofata J, Mukadi D, Monroe B, et al. Introduction of Monkeypox into a Community and Household: Risk Factors and Zoonotic Reservoirs in the Democratic Republic of the Congo. Am J Trop Med Hyg. 2015;93(2):410-5.
30. Centers for Disease Control and Prevention. Social Gatherings, Safer Sex, and Monkeypox. 2022.

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