Mpox (monkeypox) update and FAQs for clinicians
WPHU would like to draw your attention to an alert issued by the Chief Health Officer on 3 August 2023 about the recent local transmission of mpox (previously called monkeypox) in Victoria.
The key messages for clinicians are:
- Two new locally acquired cases of mpox have been reported in Victoria, indicating local transmission is now occurring.
- Be alert for unrecognised mpox acquired both locally and from overseas.
- Request mpox PCR in all patients presenting with compatible symptoms, in particular those presenting with a genital rash, lesions, or proctitis.
- Please collect a specimen using a dedicated dry swab, mark as “urgent” and send to the Victorian Infectious Diseases Reference Laboratory (VIDRL) via your normal pathology provider.
- Offer vaccination to eligible people at risk of infection. A second dose of vaccine is required for optimal protection, at least 28 days after the first dose.
- Any suspected or confirmed cases of mpox must be immediately notified to WPHU by calling 1800 497 111 or the Department of Health on 1300 651 160.
- For further information about mpox and vaccination see www.wphu.org.au/mpox
The below FAQs have been created to ensure that clinicians across the west feel well-equipped to identify cases and manage mpox should they encounter it.
When do providers need to notify public health?
Mpox 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 mpox) 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 mpox?
Mpox 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. Mpox should be considered in anybody who has a consistent clinical syndrome (see below).
How is mpox transmitted?
Mpox can be transmitted through direct contact (such as with lesions or scabs, bodily fluids or contaminated objects) or through respiratory droplets. People with mpox 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 mpox infection?
Most – but not all – people who experience mpox 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 mpox 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 mpox virus infection. This includes fluid repellent surgical mask, gloves, disposable fluid resistant gown, and eye protection – face shields or goggles.
Suitable sample types for mpox PCR include fluid or tissue from a suspected mpox lesion, the crust of a suspected mpox 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 mpox and other sexually transmissible infections (STIs), consider testing for concurrent STIs. Similarly, consider testing for mpox when testing for other STIs with similar signs and symptoms. A dedicated swab is needed for mpox testing so additional samples will be required for testing other STIs.
See Mpox – 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 mpox. 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 mpox is suspected at 1300 651 160 (available 24/7).
All suspected mpox 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 mpox?
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 mpox. This includes:
- Fluid repellent surgical mask
- 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 Mpox 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 mpox (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 email@example.com.
A person with mpox 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 mpox if required (for example, to support their return to the workplace).
What is the clinical management of mpox infection?
The management of a confirmed case of mpox 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.
Mpox 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).
Mpox 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 mpox lesions.
For further advice, refer to the Australian Human Mpox Treatment Guidelines.
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 Mpox Treatment Guidelines.
What is the role of vaccination?
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 Mpox for more information on vaccination eligibility criteria.
High risk individuals
Certain high-risk individuals are eligible for vaccination prior to exposure. See Victorian Department of Health Mpox for information on current vaccination eligibility criteria and availability.
Certain laboratory and healthcare workers may be eligible for vaccination. See Victorian Department of Health Mpox for more information on current vaccination eligibility criteria.
How can mpox be discussed with patients without applying stigma?
While mpox 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 mpox 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.