On this page

1. Suspected cases
2. Confirmed and probable cases
3. Clinical management of cases
4. Follow up of contacts using Whispir survey
5. Low risk contacts
6. Contact fact sheets
7. Infection prevention and control
8. Adverse events following immunisation

Suspected cases

Case notification and actions

Public Health Unit (PHU) should begin follow-up investigation (Figure 1) following notification of a suspected case of mpox. PHU should ensure that action has been taken to:

• Notify the Communicable Disease Branch (CDB) through CD on-call and enter case details in NCIMS.
• Interview the case (or caregiver) if deemed necessary at this time using the NSW mpox case questionnaire to ascertain:
• onset date and symptoms of the illness
• travel history including flight details (dates, flight number, seat number, etc)
• exposures to a confirmed or probable case and nature of contact with a confirmed or probable case
• history of sexual contact and intimate partners within the 21 days prior to first symptom onset (prodrome symptoms, or rash in the absence of prodrome symptoms), including from overseas
• childhood smallpox vaccination status and date of vaccination (if vaccinated)
• adulthood smallpox vaccination status and date of vaccination (if vaccinated)
• other relevant clinical findings to exclude other common causes of rash
• people that have had contact with since symptom onset
• Advise suspected case to follow case exclusions and restrictions until a negative result is received as per CDNA guidelines
• If mpox is suspected, collect samples per the PHLN guidelines and send these to the NSW Health Pathology-ICPMR laboratory at Westmead Hospital or SEALS laboratory (Randwick) for mpox virus testing
• Discuss with notifier if relevant pathology specimens have been collected and transportation to reference laboratories arranged
• Provide collectors and laboratory staff with information about infection control requirements (refer to Monkeypox Laboratory Case Definition - Specimen collection and handling).

If required and on a case-by-case basis, the Communicable Diseases Branch (CDB) can convene an urgent Expert Panel meeting to discuss the clinical, epidemiological and laboratory information for the management of the suspected case. The Expert Panel may comprise of:

• Health Protection NSW
• Westmead Hospital Infectious Diseases/Clinical Microbiologist physicians
• Public Health Unit / treating clinician or ID physician / Sexual Health Clinic.

If the initial test result is negative for orthopoxvirus or mpox virus, the PHU should work with the treating clinician to contact the suspected case to inform them of the result and, if they are a contact of a confirmed case, advise them to continue to monitor for any clinically compatible symptoms for 21 days after their last exposure. If they develop any symptoms, they should be advised to call ahead before presenting to their GP for assessment and testing.

Confirmed and probable cases

1. Case notification and actions

• Following notification of an orthopoxvirus or mpox virus PCR positive result, CDB can convene an urgent Expert Panel meeting to discuss the case, for example, if the case has a complex past medical history, multiple high-risk contacts, or high-risk exposures.
• Interview the case (or caregiver) if not previously done using the NSW mpox case questionnaire to ascertain:
  • onset date and symptoms of the illness
  • travel history including flight details (dates, flight number, seat number, etc)
  • exposures to a confirmed or probable case and nature of contact with a confirmed or probable case
  • history of sexual contact and intimate partners within the 21 days prior to first symptom onset (prodrome symptoms, or rash in the absence of prodrome symptoms), including from overseas
  • childhood smallpox vaccination status and date of vaccination (if vaccinated)
  • adulthood smallpox vaccination status and date of vaccination (if vaccinated)
  • other relevant clinical findings to exclude other common causes of rash
  • people that they have had contact with since symptom onset.
• The Expert Panel can advise on the appropriate actions to be taken for the clinical management of the case and assessment of contacts.
• The PHU should ensure the case has been informed of their result, provided with the case fact sheet and advised on infection control measures using the Clinical Excellence Commission: Household cleaning and disinfection information - Monkeypox fact sheet for household cleaning and disinfection.
• If the case is unable to remain separated from others in the home, other appropriate accommodation options for either other household members or the case should be explored, that is, friends, family, LHD facilities (to be arranged by LHD).
• Household cleaning and disinfection advice has been published by the CEC and contains information about isolation in shared residences: Clinical Excellence Commission: Household cleaning and disinfection information - Monkeypox fact sheet.
• If clinically indicated by Westmead Hospital Infectious Diseases/Clinical Microbiologist physicians, cases may be isolated and managed at the NSW Biocontainment Centre (NBC) at Westmead Hospital, especially in the event of a person being high-risk of severe illness due to pregnancy, immunocompromise or children.
• Vaccination with Smallpox vaccine [JYNNEOS^®] should be discussed with high-risk and in some instances medium-risk contacts. In the case of a contact aged under 18 years requiring PEP vaccination, PHUs may refer to the SESLHD process for arranging PEP for child. Vaccination is likely most appropriate via the emergency department of a children's hospital, in discussion with the infectious diseases consultant on call. Refer to the Mpox PEP Protocol.
  
• Case clearance decisions will be undertaken by the treating clinician or local infectious diseases service and the local PHU.
• Cases once cleared must be informed by the PHU of the necessity of household cleaning and disinfection and given the Clinical Excellence Commission: Household cleaning and disinfection information - Monkeypox fact sheet to provide advice on cleaning and disinfection.

2. Clinical management of cases in the community

The PHU should arrange for the cases to be medically monitored from home by clinicians in the local health district, either:

i. an engaged sexual health physician in the relevant LHD, with co-share arrangement with local ID service to take calls after hours or weekends or where advice sought, or

ii. a GP to whom the patient may already be known, with co-share arrangement with local ID service to take calls after hours or weekends or where advice sought, or

iii. the local ID service (with delegation to a service such as HiTH).

If a patient in the community requires a medical review (for example, surgical, ophthalmological, medical) with concerns that they have complications, this should be escalated to the Westmead Hospital Infectious Diseases/Clinical Microbiologist physician on call so that they can arrange telehealth consult or facilitate transfer and assessment.

The decision to arrange transport of a patient who requires admission to NSW Biocontainment Centre by NSW Ambulance/Patient Transport Services should be dictated by severity of illness. This should be a shared decision between the treating physician and PHU. For patients with mild illness, patients can be transported by a family member or carer, or by public transport, provided lesions are covered and the patient is instructed to wear a mask and be diligent with hand hygiene.

Figure 1. Mpox case notification procedure

PHUs are advised to follow the below procedure for any confirmed, probable or suspected mpox cases:

NSW specific contact management

Contacts of probable and confirmed cases of mpox virus infection should be instructed to monitor their temperature and watch for signs and symptoms daily for 21 days after their last exposure.

Follow up of contacts using Whispir survey

• PHUs should enter medium- and high-risk contacts in NCIMS and link to the probable or confirmed case to facilitate regular monitoring for symptoms for 21 days after the last exposure. If the case's NCIMS number is unknown, contact CD On-Call.
• PHU is responsible for making initial contact with all high and medium risk contacts of their cases, entering them into NCIMS, providing them with the high and medium risk contact fact sheets, and informing them of follow-up process via Whispir.
• Where a contact resides in a different jurisdiction to the case, the PHU should still enter that contact into NCIMS, set the owning jurisdiction to the PHU of contact's residence, and advise the PHU by email (or telephone on weekends) that there are new contacts in their PHU for follow-up.
• CDB will manage the follow-up of contacts using Whispir and record responses in NCIMS.

Low risk contacts

• Low-risk contacts can be followed up at PHU discretion and supplied with the low-risk contact fact sheet.

Contact fact sheets

• There are three contact fact sheets available:
• Monkeypox (mpox): Information for high-risk contacts
• Monkeypox (mpox): Information for medium-risk contacts
• Monkeypox (mpox): Information for low-risk contacts

Infection prevention and control

Infection prevention and control in healthcare facilities

• Guidance on infection prevention and control in community, hospital, and institutional settings including sexual health clinics, primary care, and laboratories is available from Clinical Excelence Commission: Infection Prevention and Control Information for clinicians - Monkeypox.

Infection prevention and control in a private residence

• Guidance on how to clean and disinfect a private residence for mpox cases who are isolating at home is available from The Clinical Excellence Commission: Household Cleaning and Disinfection Information – Monkeypox.

Infection prevention and control in hotels and other community accommodation

• Guidance on recommendations from an infection prevention and control perspective for infectious cleans as may be requested by NSW Health Protection: Clinical Excellence Commission cleaning and disinfection information - Hotels.

Adverse events following immunisation

• The PHU should routinely check NCIMS workflows for contacts who have reported compatible symptoms and action according to the SoNG. An adverse event following immunisation (AEFI) is an unwanted or unexpected event occurring after the administration of vaccine(s). AEFIs are notifiable conditions under the Public Health Act 2010. Public Health Units are required to manage all AEFI reported following vaccination with a mpox vaccine in accordance with the Adverse event following immunisation (AEFI) control guideline.
• In addition, vaccine recipients who have enrolled in the AusVaxSafety program and have reported medical attendance or a suspected serious AEFI (Refer to Table 1) are required to be followed up and contacted by the PHU using the password protected Vaxtracker portal. All suspected AEFI must be entered into NCIMS and reported to the Therapeutic Goods Administration (TGA) as per the AEFI Control Guidelines.

Table 1: Criteria for follow up of AusVaxSafety participants reporting medical attendance or a suspected serious AEFI

List of abbreviations