Public health priority: Urgent (please refer to public health approach for specific situations where the public health priority may be downgraded to high)
PHU response time: Respond to any report of mpox disease on day of notification. Enter probable and confirmed cases on NCIMS within 1 working day.
Full revision to present evidence-based recommendations for public health.
Revised: The disease, Routine prevention activities, Surveillance objectives, Case management, Specific settings.
This guideline is based on the Mpox - CDNA National Guidelines for Public Health Units. NSW specific mpox guidance is included within these call-out boxes throughout the document. The content of the body of the CDNA SoNG has not been modified. The CDNA SoNG appendices have not been included as NSW has created NSW specific factsheets and investigation forms which replace the SoNG appendices.
These guidelines for public health units (PHUs) outline Australia's agreed national approach for the routine public health management of mpox. They consider available evidence at the time of publication to develop pragmatic guidance, including where evidence is still evolving or where jurisdictional approaches differ. Jurisdictions may implement policies that differ from these national standards based on local factors.
Readhers should not rely solely on the information contained within these guidelines. Guideline information is not intended as a substitute for advice from other relevant sources, including, but not limited to, jurisdictional public health guidelines and advice from a public health specialist or other health professional. Clinical judgement and discretion amy be required to interpret and apply these guidelines. PHUs should refer to and follow jurisdictional guidance regarding disease management where appropriate. These guidelines are not intended to provide public health guidance or advice to other (non-PHU) audiences.
Members of the Communicable Diseases Network Australia (CDNA), the Australian Health Protection Committee (AHPC), and the Australian Government, as represented by the interim Australian Centre for Disease Control (CDC), do not warrant, or represent that the information contained in these guidelines is accurate, current, or complete. The CDNA, the AHPC and the interim Australian CDC do not accept any legal liability or responsibility for any loss, damages, costs, or expenses incurred by the use of, reliance on, or interpretation of the information contained in these guidelines.
Endorsed by CDNA Jurisdictional Executive Group: 7 November 2025
Noted by AHPC: 16 December 2025
Published: 17 December 2025
This section outlines the public health response to notifications of mpox of any clade.
Mpox - the disease caused by the monkeypox virus (MPXV) - is a nationally notifiable disease.
Priority classification of high, rather than urgent, may apply if one of the following conditions is met:
All confirmed and probable cases should be entered on to the National Notifiable Diseases Surveillance System (NNDSS) by state and territory public health units (PHUs), ideally within one working day of notification.
To note:
The jurisdictional communicable disease branch should advise the National Incident Centre (NIC), if required (see Response procedure).
PHUs should complete enhanced mpox data fields, where possible. States and territories should transmit enhanced mpox data to the NNDSS in line with jurisdictional standards. Ideally, mpox enhanced data should be transmitted to the NNDSS on a fortnightly or monthly basis. Mpox data are checked quarterly by the Commonwealth.
Following the eradication of smallpox in 1980 and subsequent cessation of smallpox vaccination programs in the same year, MPXV has emerged as the most significant Orthopoxvirus for public health. Historically, MPXV primarily occurred in humans in Central and West Africa, often in proximity to tropical rainforests. Around 75% of cases during the 1980s were attributable to contact with infected animals [1-4]. Before 2018, the only cases with secondary transmission outside Africa occurred in 2003 in the United States of America (USA), associated with contact with infected animals [5,6].
In early May 2022, multiple countries outside of the African continent reported outbreaks of MPXV clade IIb, predominantly associated with direct transmission of MPXV through sexual/intimate contact. On 20 May 2022, Australian health authorities detected cases associated with this global outbreak locally – this was the first time the virus had been detected in Australia [7].
The World Health Organization (WHO) declared the mpox outbreak, due to MXPV clade IIb, a public health emergency of international concern (PHEIC) on 23 July 2022, followed by Australia's declaration of mpox as a Communicable Disease Incident of National Significance on 28 July 2022 (stood down on 25 November 2022). From January 2022 to June 2025, over 100,000 mpox cases (largely MPXV clade IIb) were reported in more than 100 countries outside of Africa [8]. Case numbers peaked in August 2022, followed by a significant decrease into late 2022 and onward, but transmission continues globally. In Australia, sustained locally acquired human-to-human transmission of MPXV clade IIb was observed in 2024 [9].
The WHO declared mpox a PHEIC for a second time on 14 August 2024, following the upsurge of clade Ib from the Democratic Republic of the Congo (DRC) to several neighbouring African countries from late 2023 [10]. From January 2022 to June 2025, more than 43,000 mpox cases (largely MPXV clade Ib, but also clade Ia) were reported in 30 African countries, with the majority of cases from the DRC, Uganda, and Burundi [8].
By July 2025, imported MPXV clade Ib cases were reported in 18 countries outside of Africa, including Australia, and three countries outside of Africa reported imported clade Ia cases [8]. The PHEIC status for mpox was declared over by the WHO on 5 September 2025 [11].
By October 2025, locally acquired clade Ib cases were reported in four European countries and the USA, indicating ongoing transmission in sexual networks in the community [12].
The aim of the public health response to mpox in Australia is to suppress transmission of mpox and prevent future cases. This approach acknowledges the risk of ongoing incursions of mpox cases into Australia, and inability to eliminate all cases of mpox from Australia given the global epidemiology.
While diverse modes of transmission mean that anyone can acquire or transmit mpox, cases in the global clade IIb outbreak have occurred primarily, but not exclusively, in gay, bisexual, and other men who have sex with men (GBMSM+) [8,13], as has been seen in the Australian context. The ongoing clade Ib outbreak in the DRC and other African countries is also strongly associated with sexual contact/direct physical contact and household contact [14].
High-risk settings for transmission include:
Evidence of mpox transmission in schools and childcare settings outside of Africa is limited [21], and these have not been identified as high-risk settings in Australia. If a case is detected in a school or childcare setting, a risk assessment should be undertaken and guidance followed as in Case management and Contact management.
Cases attending school and childcare settings should be escalated to NSW Health CD on call, in business hours via email and outside of business hours by phone call to the CD on call medical officer.
For NSW specific guidance for responding to an mpox case in a child who attends an early childhood education and care setting please refer to Appendix B.
People infected with MPXV who may be at greater risk of more severe disease include:
On 28 November 2022, the World Health Organization (WHO) announced a change in disease name from monkeypox to mpox. Mpox is caused by infection with MPXV.
MPXV is an enveloped double-stranded deoxyribonucleic acid (DNA) virus of the genus Orthopoxvirus (related to the Poxviridae family), which also includes variola virus (which causes smallpox), vaccinia virus (which is used to produce the smallpox vaccine) and cowpox virus [1].
MPXV has two distinct genetic clades.
The natural reservoir of MPXV remains unknown. However, the virus has been isolated from several African rodents and primates, including the Gambian pouched rat, tree squirrel, rope squirrel, and sooty mangabey monkey.
The primary mode of transmission for mpox is via direct contact with lesions (through broken skin or mucous membranes). Less frequently, transmission of mpox may occur via contact with materials contaminated with MPXV [35-37].
Other potential routes of transmission include:
The average incubation period for mpox is estimated to be 8 days, with a range of 3 to 21 days [50-52]. There is no evidence to suggest the incubation period varies by clade, but it may be influenced by transmission route, with infections acquired through direct exposure (e.g., contact with broken skin or mucous membranes) having a shorter incubation period [53].
People with mpox are typically infectious from the onset of symptoms—either prodrome, rash, or proctitis [26]. People remain infectious until all symptoms have resolved, and all lesions have formed scabs and fallen off, leaving fresh skin underneath. Some people may not be aware of their exact symptom onset date, as initial symptoms may be very subtle or not visible [26,36,54-56].
There is limited evidence regarding infectivity pre-symptom onset. However, a small number of studies have demonstrated pre-symptomatic transmission, or presence of virus, up to 4 days prior to symptom onset [26,57-60].
Contact tracing is generally recommended from symptom onset. However, PHUs may consider undertaking contact tracing for up to 4 days pre-symptom onset for:
Symptomatic cases without visible lesions should be considered infectious until complete resolution of all symptoms, or after 21 days post symptom onset, whichever is longer. See Guidance for cases without visible skin lesions.
Asymptomatic cases should be considered infectious for 21 days after a positive test. See Guidance for asymptomatic cases.
Mpox is usually a self-limiting disease with symptoms lasting 2 to 4 weeks.
The illness may have a prodromal period lasting 1 to 5 days, characterised by lymphadenopathy, fever (≥38 °C) or history of fever, headache, myalgia, arthralgia, back pain, and sore throat. Not all cases report prodromal symptoms [18,61].
A maculopapular rash is typical of mpox 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 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 [62].
Many cases associated with the global clade IIb outbreak have not presented with the classically described clinical picture for mpox outlined above [42,63]. This relates to the mode of transmission predominantly being via sexual contact and attenuated illness among those vaccinated against mpox. Differing presentations have included the following:
Clinical data from mpox cases in the DRC indicate distinct presentations for clade Ia and Ib, with higher proportions of respiratory symptoms (around 50%) and higher lesion counts (median counts: 91 for clade Ib cases; 163 for clade Ia cases), compared with clade IIb outbreaks [14]. This difference likely reflects the greater virulence and systemic dissemination of clade I viruses. Additionally, environmental factors such as biomass smoke from wood and charcoal burning for cooking, common in the DRC [67], could plausibly exacerbate respiratory symptoms among mpox patients.
Imported clade Ib cases reported in Sweden [48], the UK [49] and other European countries [68] have shown mild to moderate illness characterised mainly by fever, localised vesiculopustular rash, and lymphadenopathy.
Symptomatic manifestations of mpox can cause severe pain and affect vulnerable anatomic sites; painful proctitis or oral lesions may be the primary presentation. More severe complications of mpox include secondary infections such as 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 [41].
During the global MPXV clade IIb outbreaks, 9% of cases were hospitalised, 0.4% admitted to an intensive care unit (ICU), and the case-fatality rate was 0.3% [8].
Based on mpox data from the DRC, 50% of mpox clade I cases were hospitalised, and the case-fatality rate was 4.4% for clade Ia and 0.6% for clade Ib [14]. The high case-fatality rate for clade Ia is likely influenced by multiple factors, including varying diagnostic methods, co-existing medical conditions such as HIV, malaria and tuberculosis, treatment availability, and potentially higher virulence [69].
Mpox clade I cases identified in countries outside of Africa have presented with milder symptoms and no deaths have been reported [70]. Additionally, of the first 16 cases identified in the UK, a case review identified high hospitalisation rates initially to manage isolation and perceived transmission risk, rather than due to disease severity, with hospitalisation decreasing over time as the transmission route was better understood and clade Ib cases were managed in the community [71].
Mpox reinfection is very uncommon, occurring in less than 0.2% of reported cases [72]. Documented reinfections typically occur in high-risk populations and are generally milder than the initial illness [73]. Natural infection provides stronger and longer-lasting immunity than vaccination; about 85% of previously infected individuals remain seropositive at around two years, compared with approximately 32% for those vaccinated with the two-dose MVA-BN (JYNNEOS) vaccine [74].
Both confirmed cases and probable cases should be notified.
A suspected case definition has been developed in response to current multi-country outbreaks of mpox in non-endemic countries and may be discontinued as the outbreaks evolve. Suspected cases should not be notified to the National Notifiable Disease Surveillance System (NNDSS).
Clinicians and laboratories should notify cases to state and territory health departments in accordance with jurisdictional legislation and local guidance.
Testing is performed in jurisdictional public or private medical laboratories. For further information on recommendations for laboratory testing please refer to the Public Health Laboratory Network Mpox Laboratory Case Definition. Specific advice from the specialist microbiologist at the testing laboratory may be sought to obtain advice on specimen collection, safe packaging, and transport.
General advice on specimen collection and handling is outlined in the Public Health Laboratory Network Guidance on Monkeypox patient referral, specimen collection and test requesting for general practitioners and sexual health physicians.
It is advisable to collect samples from more than one lesion where possible. However, excessive sample collection should be discouraged to minimise the risk to healthcare workers or laboratory personnel.
While lesion specimens are preferred, rectal, throat or nasopharyngeal swabs are also suitable. Such specimens may be collected in people with prodromal symptoms who present with no lesions (e.g., a contact who develops symptoms).
For further advice, including on appropriate personal protective equipment (PPE) and safe handling and transport of specimens, see the Public Health Laboratory Network Mpox Laboratory Case Definition.
NSW Health Pathology recommends that only one skin lesion is sampled, with swabs also being collected from rectal and nasopharyngeal sites if relevant symptoms. Where the differential diagnosis includes HSV, VSV or syphilis, the lesion should be swabbed twice and specimens and requests placed in separate bags.
Whole genome sequencing (WGS) is used to characterise clades, subclades, and lineages of MPXV; however, some public health reference laboratories may develop and use MPXV nucleic acid amplification (NAA) tests to distinguish between MPXV clade I and MPXV clade II infections.
Public health reference laboratories may conduct WGS of positive samples to:
Decisions about WGS are made by individual states and territories after agreement between laboratory and public health professionals. Jurisdictions may choose to sequence strains where:
The jurisdictional communicable diseases unit should notify the National Focal Point within 3 working days via email to health.ops@health.gov.au if:
A risk-based approach is advised to inform case management and should be guided by the characteristics of case presentation and contact with those at risk of severe disease. Factors to inform a risk-based approach may include:
PHUs should respond to a case in collaboration with the treating clinician and/or local health service, and ensure that the following actions are taken:
PHUs may have agreements with the local sexual health clinic (SHC) that the SHC interviews the case. Interview of the case by the PHU or SHC should be done using the NSW case investigation form (see Appendix A).
PHUs should do the following:
Information on case exposures should be obtained utilising the NSW case investigation form for mpox (see Appendix A).
PHUs should advise cases to undertake the following exclusions and restrictions during their infectious period, including the prodromal and rash stages of the illness.
Until they meet the clearance criteria, cases are recommended to do the following:
If the case is unable to cover their lesions due to disseminated disease or there is potential generation of infectious droplets due to oral lesions, pharyngitis, or respiratory symptoms, the case should isolate (at home or in hospital) and wear a surgical mask when around other people or animals. PHUs may undertake a risk assessment to determine whether a person with lesions that can be covered up and respiratory involvement (e.g., oral lesions or sore throat only) does not need to isolate and may be permitted to resume usual activities with general case exclusion guidance, including wearing a mask when around other people.
Cases are recommended to avoid the following while infectious:
Cases may be able to attend secondary/higher educational settings if preventative measures can be followed independently.
The PHU should conduct an assessment of the case's living situation, the ability of the case and their household members to follow the above advice, and whether they live with any people at increased risk of severe disease. Based on this assessment, the PHU may need to consider providing additional advice and support to mitigate risk.
*PHUs may conduct a risk assessment for cases who work in or visit high-risk settings and cannot work from home. The risk assessment should consider: the disease severity, the type and nature of work, number and location of lesions, the presence or absence of respiratory symptoms, and whether the person works with particularly susceptible populations. Cases must cover all lesions and may be advised to wear a surgical mask when in high-risk settings.
**Cases who are advised to isolate at home should stay at home unless they need to leave for essential reasons (such as seeking medical care).
Mpox is a category 4 condition under the NSWH Public Health Act 2010, as such public health orders can be issued under certain circumstances to ensure adherence to public guidance. A public health order is a measure of last resort and guidance and education should be provided to people diagnosed with mpox in the first instance. Concerns regarding the need for a public health order should be raised with the CD on call medical officer.
Cases can resume most normal activities when all lesions have crusted, scabs have fallen off, and a fresh layer of skin has formed underneath.
The PHU or managing clinician (where appropriate), will advise on clearance of a case.
For 12 weeks following clearance, cases should:
Cases should not donate blood until 4 weeks after they have fully recovered. Refer to Lifeblood guidance.
Longer periods may apply for the donation of breast milk, organs, tissues, cells, and other biological products, as advised by the relevant tissue collection authority.
Clearance of mpox cases is usually a clinician responsibility. For cases not being managed by sexual health clinics, PHUs are to ensure that the managing clinician is aware of their responsibility to review and issue case clearance. The PHU may provide clearance, particularly if there are challenges with accessing a clinician for clearance.
PHUs should ensure cases that work or attend high-risk settings such as early childhood education and care services, aged care, healthcare settings, and settings with young children and those at higher risk of severe disease receive clearance before returning to normal activities in a high-risk setting.
International reports of asymptomatic MPXV infection in cases associated with the ongoing clade IIb outbreak are rare and generally only detected and described in research studies. There is limited evidence available to determine whether asymptomatic cases are infectious [75,77]. In the event an asymptomatic case is detected, they should be managed as per other confirmed cases and can be considered cleared 21 days after their positive test.
PHUs should ensure people with mpox have been advised about:
PHUs should provide information about appropriate social services available to support people with mpox at risk of complex social situations.
Please see NSW information factsheet for cases.
The clinical management of mpox is the responsibility of the treating clinician.
Mpox is generally self-limiting. Most cases will not require specific treatment, other than supportive management of symptoms or treatment of complications (e.g., antibiotics for secondary cellulitis).
Advice on clinical management can be sought from an infectious diseases physician and/or sexual health physician, particularly in persons with, or at risk of, severe disease. If antiviral treatment is indicated, it should be initiated in consultation with an infectious diseases physician and/or sexual health physician.
For further advice, refer to the Australian Human Mpox Treatment Guidelines.
Antiviral agents can be accessed through the NSW Specialist Service for High Consequence Infectious Diseases (or contact the infectious diseases physician on-call at Westmead Hospital via the switchboard on 02 8890 5555).
Healthcare workers should use a risk-based approach to select appropriate PPE and infection prevention and control interventions when caring for individuals with suspected or confirmed mpox. The risk assessment should consider:
Note: the mode of transmission for mpox is primarily the same, regardless of clade.
A risk assessment should be undertaken to inform the use of a particulate filtration respirator, considering the level of exposure and nature of activity, when performing AGPs (including airway management), or for providing care to patients admitted to a healthcare facility with disseminated disease or respiratory symptoms/involvement.
Deroofing lesions and throat swabs are not considered to be AGPs in this context, although they may generate droplets [78]. Healthcare workers should wear PPE for combined droplet and contact precautions when performing these procedures.
See the Australian Guidelines for the Prevention and Control of Infection in Healthcare.
In the event of a large exposure event or outbreak, active case finding should be considered. The extent to which this is taken should be proportionate to the risk. The avenues used may depend on the severity of disease, including information about the clade (if available), public sentiment and fatigue relating to public health messaging, and risk groups affected. Targeted public communications may be preferential compared to general communications.
PHUs should consider the following:
PHU staff should directly follow up, or provide information to, all medium and high-risk contacts.
Where direct follow up by PHUs is not possible, or where the case is not willing or able to provide details of contacts to the PHU for follow up, other strategies should be used to help ensure potential contacts receive public health advice. For example, PHUs may provide written information for the case to pass onto potential contacts, which could include the case messaging their sexual partner/s via direct messaging through social media or 'hook up' apps.
See Response procedure.
The local sexual health service outreach program team (if available) or Sexual Health Information Link (SHIL) may be able to assist with contact tracing, if initial efforts are unsuccessful. Peer groups such as SWOP and ACON may also be able to collaborate with NSW Health in some settings to facilitate contact tracing.
Exposure to aerosols from an mpox case undergoing an aerosol-generating procedure in an enclosed room while the contact was not wearing appropriate PPE1.
Notes:
1 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 Case management. Refer to jurisdictional and local guidelines/policies.
2 A higher risk social setting or situation constitutes those settings where the nature of interaction may pose some risk of transmission (e.g. 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.
PHUs should advise contacts to monitor for signs and symptoms of mpox for 21 days after the date of their last exposure to the case. All contacts should be encouraged to practise good hand hygiene and respiratory etiquette.
Post exposure prophylaxis (PEP) administration2: Vaccination should be offered if not fully vaccinated. See the Australian Immunisation Handbook. Antiviral PEP may be considered under specified circumstances. See the Mpox Treatment Guidelines.
Testing priority: Urgent if symptoms develop3.
Additional recommendations:
For 21 days from last exposure:
For 28 days from last exposure:
PEP administration2: Vaccination should be offered if not fully vaccinated. See the Australian Immunisation Handbook. Antiviral PEP may be considered under specified circumstances. See the Mpox Treatment Guidelines.
Testing priority: High if symptoms develop3
For 21 days from last exposure:
For 28 days from last exposure:
1 Active self-monitoring is the contact watching for signs or symptoms compatible with mpox infection; if they appear, follow case exclusion and restriction criteria and seek medical review. If the contact is facing difficulty accessing medical review call the PHU for assistance. During the incubation period the PHU may choose to regularly monitor high and medium risk contacts (by phone, email, text) to check for the emergence of any signs or symptoms at intervals if there are concerns about the contact's health literacy, self-efficacy, or if other supports are needed.
2 For current ATAGI recommendations and the latest evidence for mpox vaccines, please see the Australian Immunisation Handbook.
3 Treating clinicians may choose to test asymptomatic high-risk contacts based on an assessment of individual clinical risk, e.g. if the patient is immunocompromised. This should not delay PEP administration if appropriate.
4 High-risk settings are defined as childcare, aged care and disability facilities, and healthcare environments.
PHUs should, at a minimum, provide the following information to contacts:
If a large number of contacts is identified in a facility or institution, information to residents, workers or attendees may be distributed via the facility or institution manager.
Please see NSW information factsheet for contacts.
PHUs may consider undertaking the following measures to prevent sustained transmission of mpox in the community:
PHUs should take steps to promote community awareness by making guidance publicly available for at risk people (and the wider community where necessary), to minimise their risk of infection, including the following advice:
Vaccines to prevent or reduce mpox infection and severity are available [80]. Both primary vaccination and post exposure prophylaxis (PEP) can reduce the likelihood of widespread community transmission and should be promoted to high-risk groups.
Refer to:
Identification of mpox in an Aboriginal and Torres Strait Islander community should prompt active case and contact management by the PHU, undertaken in partnership with the affected community.
A small number of mpox clade II cases have been reported among Aboriginal and Torres Strait Islander people in Australia. To date, there have been no documented outbreaks in Aboriginal or Torres Strait Islander communities. It is important to note that limitations in surveillance and reporting may under detect the true burden of disease in Aboriginal and or Torres Strait Islander people.
The risk of severe disease in Aboriginal and/or Torres Strait Islander people and communities remains uncertain and warrants close monitoring and early action to reduce the risk of transmission.
Communications with the community regarding targeted action may be undertaken in partnership with the local Aboriginal Community Controlled Health organisation (ACCHO) and other relevant community-led organisations, as appropriate. Community and local stakeholder engagement should be central to any community-based response and should continue throughout implementation to ensure actions are culturally appropriate.
PHUs must remain cognisant and responsive to the intersection of stigma and discrimination that an Aboriginal and Torres Strait Islander community member may face if diagnosed with mpox. The PHU should work with the person to determine their preferred services to access, including cultural sensitivities related to gender.
To minimise the risk of an outbreak occurring at an SOPV, PHUs should encourage venues to do the following:
In the event a case or cases are reported to have attended an SOPV whilst infectious, a PHU may consider the following outbreak management strategies:
Methods of messaging and the ability to contact trace may be limited due to the willingness of patrons to provide contact information. Messaging through mainstream media may not have adequate reach, and avenues to provide messaging through partnerships with non-government organisations should be explored. Best practice may require assessment on a case-by-case basis.
Congregate living settings are facilities or other housing where people who are not related reside in close proximity and share at least one common room (e.g., sleeping room, kitchen, bathroom, living room). This can include correctional and detention facilities, shelters for people experiencing homelessness or family violence, group homes, dormitories at institutes of higher education, boarding schools, seasonal worker housing, residential substance use treatment facilities and other similar settings—but not healthcare settings.
In the event of a case in a congregate living setting, PHUs may consider the following outbreak management strategies: