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Monkeypox

Monkeypox FAQs for clinicians

Monkeypox is an emerging public health issue around the world, including in Victoria where an increasing number of cases are being diagnosed. The Western Public Health Unit is responsible for case, contact and outbreak management in the west-metro region as well as activities and campaigns to promote health and prevent infections. This document has been created to ensure that clinicians across the west feel well-equipped to identify cases and manage monkeypox should they encounter it.

When do providers need to notify public health? 

Monkeypox is an urgent notifiable condition, in accordance with Victorian statutory requirements. Medical practitioners and pathology services must notify cases to the Department of Health by telephone upon initial diagnosis or clinical suspicion (which includes suspicion to test for monkeypox) as soon as practicable and within 24 hours. 

Notify any suspected or confirmed case to the Department of Health by calling 1300 651 160 (available 24/7). 

Who is at highest risk of monkeypox

Monkeypox can affect anybody, although the current multinational outbreak has disproportionately affected gay, bisexual and other men who have sex with men. Whilst the majority of cases diagnosed in Victoria so far have been acquired overseas, there has been local transmission. Monkeypox should be considered in anybody who has a consistent clinical syndrome (see below). 

How is monkeypox transmitted?

Monkeypox can be transmitted through direct contact (such as with lesions or scabs, bodily fluids or contaminated objects) or through respiratory droplets. People with monkeypox are considered infectious from the time that they develop their first symptoms until their rash lesions crust, dry and fall off. 

What are the clinical features of monkeypox infection? 

Most – but not all – people who experience monkeypox experience an initial prodrome of symptoms that can include: a rash, fever, sore throat, aches and pains, fatigue, and/or swollen lymph nodes. 

The characteristic skin rash usually begins within 1-4 days of fever onset and progresses for a period of 2-3 weeks. The rash follows a similar progression to chickenpox; it can begin as macules that evolve to papules, vesicles and then pustules. The lesions eventually crust over; these crusts dry up and fall off.  

Some cases in the current global outbreak of monkeypox have had atypical presentations e.g. lack of prodrome, a single skin lesion only, or with proctitis or urethritis. A high index of suspicion should be applied to anybody presenting with skin lesions that are otherwise unexplained, or proctitis.

How should samples be collected for testing? 

Sampling procedures vary depending on the phase of the rash. Specific packaging and transport of samples are required. 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, and eye protection – face shields or goggles. 

Suitable sample types for monkeypox PCR include fluid or tissue from a suspected monkeypox lesion, the crust of a suspected monkeypox lesion, or skin biopsy of affected tissue. Swabs should be taken from the base of an affected lesion, which may need to be deroofed if a crust is present. 

In addition, nasopharyngeal or throat swab should be performed in all suspected cases, and rectal swab can be performed if proctitis is present.  

At the current time, given there is a significant overlap between monkeypox and other sexually transmissible infections (STIs), consider testing for concurrent STIs. Similarly, consider testing for monkeypox when testing for other STIs with similar signs and symptoms. A dedicated swab is needed for monkeypox testing so additional samples will be required for testing other STIs. 

See Monkeypox – Laboratory case definition for further advice on specimen collection, handling and transport.

How can a clinician arrange testing? 

Medical practitioners no longer need approval from the Department of Health to test for monkeypox. Work with your usual laboratory, who will forward specimens on to the Victorian Infectious Diseases Reference Laboratory (VIDRL) . Remember to also notify the Department of Health when monkeypox is suspected at 1300 651 160 (available 24/7). 

All suspected monkeypox cases should be notified to the Department of Health on 1300 651 160. Testing is discussed and arranged at that point. 

What personal protective equipment (PPE) should be worn when treating individuals with suspected and confirmed monkeypox? 

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, or 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 (PFR) – P2/N95 or equivalent, when providing certain care that might be higher risk, such as showering patients; handling contaminated linen, clothing, or towels; conducting procedures involving the oropharynx. 

See ICEG Interim Guidance on Monkeypox for Health Workers for more information.

Should suspected and confirmed cases isolate? 

Suspected cases should be advised to isolate until they receive their test results. 

Confirmed cases should be advised to isolate in their home, away from others as much as possible. They should stay in a separate room and use a separate bathroom if possible. Due to the risk of onward transmission, they should not share any household items such as towels, bed linen or clothes with others, and ensure any shared surfaces are disinfected after contact. 

If a confirmed case must leave home (e.g. for medical care), they should wear a surgical mask and cover any lesions or rash. 

Confirmed cases will be contacted by the local public health unit to ensure they are aware of the recommended precautions to take. 

Do cases need clearance to leave isolation? 

Cases are advised to isolate to prevent onward transmission. 

The decision to “clear” a person with monkeypox (that is, decide that they can safely leave isolation), can be made by the person’s treating clinician. A clinical review should be arranged once the patient reports their symptoms are improved. The clinician should inform the Department of Health or the local public health unit monitoring the case of the outcome of the assessment. WPHU can be contacted by calling 1800 497 111 or emailing wphu@wh.org.au.   

A person with monkeypox can be advised isolation is no longer recommended when the following criteria are met:  

  • They are clinically well: any symptoms (such as fevers, malaise, swollen lymph nodes) must have resolved, AND 
  • There have been no new lesions for at least 48 hours, there are no mucous membrane lesions and all lesions in exposed areas have crusted, the scabs have fallen off, and an intact fresh layer of skin has formed underneath. Lesions on unexposed skin must also have crusted over, but if not fully healed (e.g., where a scab is still present) must continue to be covered at all times when in contact with other people.  

Intimate or sexual contact should be avoided until the scabs have fallen off. Although it is not clear if transmission via sexual fluids is possible – it is recommended to use a condom during sex for 8 weeks after leaving isolation. In addition, patients should continue to avoid close contact with immunosuppressed people, pregnant women, and children aged under 12 years until all lesions are fully healed. 

Clearance letters can be provided to people with monkeypox if required (for example, to support their return to the workplace). 

What is the clinical management of monkeypox infection? 

The management of a confirmed case of monkeypox is the responsibility of the treating doctor. This includes notifying the patient of the diagnosis, clinical management, and assessment for case clearance. If a case is diagnosed by an emergency department and subsequently discharged home, follow up should be handed over to the case’s usual GP, or an appropriate sexual health centre or infectious diseases unit. 

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). 

Monkeypox skin and mucosal lesions can be painful, and adequate pain relief is a requirement of clinical care. Inadequate pain relief is the most common indication for emergency department presentation. It is also important to provide advice to minimise the risk of secondary infection of monkeypox lesions. 

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

Additional resources are available for managing symptoms at home, such as those produced by CDC and by BMJ

What is the role of antivirals? 

Antivirals are generally not required.  If further information is required, please contact an infectious diseases physician or refer to the Australian Human Monkeypox Treatment Guidelines.  

What is the role of vaccination? 

Postexposure Prophylaxis 

Vaccination may be warranted for susceptible high-risk contacts following a risk benefit assessment within 4 days of exposure if there are no contraindications. 

See Victorian Department of Health Monkeypox for more information on vaccination eligibility criteria. 

High risk individuals 

Vaccine supply is limited. Certain high-risk individuals are eligible for vaccination prior to exposure. See Victorian Department of Health Monkeypox for information on current vaccination eligibility criteria and availability. 

Healthcare workers 

Certain laboratory and healthcare workers may be eligible for vaccination. See Victorian Department of Health Monkeypox for more information on current vaccination eligibility criteria. 

How can Monkeypox be discussed with patients without applying stigma? 

While monkeypox can affect anybody, a significant majority of cases in the current global outbreak are amongst gay, bisexual and other men who have sex with men (MSM). The MSM community has a longstanding history of experiencing stigmatisation, including in healthcare environments, and it is important to avoid applying further stigma. 

It is important to remember that monkeypox is not known to be a sexually transmitted infection, although we are still learning about this disease. Most cases in the current outbreak have been acquired through close physical contact, which includes activity with sexual partners. In addition, anybody can be affected, regardless of sexual preferences.