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About Monkeypox
Monkeypox (MPX)
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MPX is a viral zoonotic disease (transmitted to humans from animals) caused by the monkeypox virus with symptoms like those seen in the past in smallpox patients (1,2). The disease was first identified in colonies of monkeys kept for research in 1958 (hence the name) and only later detected in humans in 1970 (2). However, MPX is typically spread by rodents and is endemic in central and west Africa (2) See https://www.who.int/news room/fact sheets/detail/monkeypox for more information (3)
MPX has emerged as the most important orthopoxvirus for public health since the eradication of smallpox in 1980 (1,4)
Signs and Symptoms
• From exposure, incubation is usually six to 13 days but can range from five to 21 days (5)
• First symptoms (prodrome) of MPX include fever, intense fatigue, headache, muscle ache, backache and lymphadenopathy. A person may sometimes be contagious during this period (5)
• Following the prodrome, which usually has a duration of one to three days, a rash develops. Lesions first begin in the mouth and spread to the face, arms and legs. Lesions start as a macular rash that develops into papules, vesicles, then pustules, which crust and fall off see images below (5). A person is no longer considered infectious once all the scabs have fallen off (5)
In the 2022 outbreak, presentations of monkeypox have been atypical(6):
The rash/lesions may be localised to ano genital skin, or oropharynx or rectal mucosa (proctitis)
There may be a solitary lesion
The rash/lesions may not necessarily progress through four stages as described above Systemic symptoms may be absent or have developed after the onset of rash.
Complications of MPX can include secondary infections, bronchopneumonia, sepsis, encephalitis, and infection of the cornea with ensuing loss of vision (1). The extent to which asymptomatic infection may occur is unknown (1)
The clinical presentation is similar to diseases that are more commonly encountered in clinical practice, such as hand foot and mouth disease, varicella zoster, herpes simplex, syphilis and molluscum contagiosum (6) As a result, more common causes of acute rashes with similar appearances should be considered and excluded where possible (6) However, co infections have occurred sporadically, and given the evolving epidemiology of monkeypox, patients with a rash suggestive of monkeypox should be considered for testing, even if other conditions are likely (6).
Prognosis
In most cases, the symptoms of MPX are mild and go away on their own within a few weeks, but in some individuals, they can lead to medical complications and even death (2,5). New borns, children, pregnant people, the elderly, and those with underlying immune deficiencies may be at risk of more serious symptoms and death from MPX (2,7)
The case fatality ratio (CFR) of MPX has historically ranged from 0 to 11 % in the general population and has been higher among young children (1). There are two clades of MPX virus, human infections with the West African clade (Clade 2) appear to cause less severe disease (CFR = 3.6%) compared to the Congo Basin clade (Clade 1, CFR = 10.6%) (8). All sequenced PCR samples identified during the current outbreak are the less severe West African Clade MPX virus (6). It is important to note that the CFR may be an overestimate because surveillance in endemic countries is limited (2).
Treatment
Secondary bacterial infections should be treated as indicated. An antiviral agent known as tecovirimat that was developed for smallpox was licensed by the European Medical Association (EMA) for MPX in 2022 based on data in animal and human studies. It is not yet widely available and the Ministry of Health and PHARMAC are exploring options to secure access to antivirals(1,9).
Vaccination
People who have been vaccinated against smallpox in the past will also have some protection against MPX (2). However, people below the age of 40 50 years are unlikely to have been vaccinated against smallpox as vaccination ended in 1980 after smallpox was eradicated (2).
The UK Health Security Agency has recently advised there is only one smallpox vaccine (not a live attenuated vaccine) appropriate for MPX pre and post exposure prophylaxis (PEP) (10). It is produced in Norway in low volumes (10) This vaccine is currently not available in New Zealand and the Ministry of Health is currently inquiring about vaccine availability (10)
Case definition (6)
Clinical criteria
A clinically compatible illness characterised by the presence of acute unexplained1 skin and/or mucosal lesions or proctitis (for example anorectal pain, bleeding) and
• an acute unexplained and compatible rash (evolving typically in four stages macular, papular, vesicular, to pustular followed by scabbing, with lesions progressing simultaneously on any part of the body). The rash may be generalised or localised.
Epidemiological criteria
At least one of the following:
• exposure2 to a confirmed or probable case in the 21 days before symptom onset
• history of travel to an area where MPX is endemic or where there is a current outbreak in the 21 days before symptom onset3
• is a priority group for testing.
At this time priority groups for testing include the following:
• persons who had multiple (two or more) or anonymous sexual partners in the 21 days before symptom onset
• gay, bisexual or other men who have sex with men (MSM).
Laboratory test for diagnosis
Laboratory definitive evidence for a confirmed case requires MPX virus detection by NAAT. Testing should be limited only to patients who meet the clinical AND epidemiological criteria
Laboratory confirmation requires the detection of MPX virus nucleic acid by PCR from an appropriate clinical sample. Laboratories are to test for Varicella (chickenpox, VZV), Herpes simplex (HSV), enterovirus, +/ syphilis, prior to referral to a reference laboratory for MPX testing.
In addition to Standard Precautions, Contact and Airborne Precautions should be adhered to for clinical assessment and collecting samples (6). This includes the use of eye protection, P2/N95 mask, fluid repellent gown and gloves (6).
Cases are most likely to present to sexual health, primary care or emergency Departments. The treating physician should collect diagnostic samples. Note that patients should not present to a community collection centre for sampling. The on call Microbiologist should be called if there is suspicion of MPX for guidance on appropriate sampling. Clinicians are advised to (9):
• Collect 3x viral swabs using Dacron or polyester flocked swabs from vesicle/pustule fluid in universal transport medium (UTM, red top) or viral transport medium (VTM, green top) ideally at least 3 separate vesicles/pustules. Lesions may need to be de roofed to collect the vesicle/pustule fluid and the base of the lesion swabbed vigorously.
• Scab lesions or crust material should be sent to the laboratory in a sterile pottle.
• For patients with proctitis rectal swab along sidewall of rectum.
• Bacterial swab and a further viral swab, for bacterial culture and HSV/VZV PCR respectively if required.
1 More common causes of acute rashes with similar appearances should be considered and excluded where possible; varicella zoster, herpes simplex, syphilis, molluscum contagiosum.
2 Exposure: direct physical contact with skin or skin lesions, including sexual contact; or contact with contaminated materials such as clothing, bedding or utensils; or prolonged face to face contact, including health care workers without appropriate PPE
3 Refer to: https://www.who.int/emergencies/emergency events/item/2022 e000121
• Where possible, it is recommended to also include nasopharyngeal swab in UTM to exclude other respiratory viruses and for MPX PCR as patients may have detectable MPX virus in the nasopharynx for a prolonged period.
• A dedicated 4ml Ethylenediaminetetraacetic acid (EDTA, purple top) blood is also recommended if the patient presents with signs of systemic illness such as fever.
Samples must be clearly labelled and indicated on the request form as possible MPX, including that the Medical Officer of Health and clinical Microbiologist have been consulted (5) Include on request form details of suspected contact, travel history, date of onset. Use separate bags and request forms for routine tests and those specifically for monkeypox testing. Double bagging not required.
While waiting for test results, probable cases are to isolate and avoid close contact (including kissing or sexual contact) with others.
Updated testing advice can be found on the New Zealand Microbiology Network website https://www.nzmn.org.nz/
Case classification (6):
• Under investigation: A person that has been reported to a Medical Officer of Health but information is not yet available to classify it as confirmed, probable or not a case.
• Confirmed: A person with laboratory definitive evidence.
• Probable: A person who meets the clinical and epidemiological criteria and laboratory confirmation is not possible
• Not a case: A person that has been investigated and subsequently found not to meet the case definition.
Spread of Infection
Incubation period
5 21 days; commonly 6 13 days (11)
Mode of transmission
The MPX virus is typically transmitted from animal to human by rodents but can be transmitted from person to person (10). Transmission occurs by close contact with skin lesions, body fluids, respiratory droplets, and contaminated materials such as bedding (10) People should be particularly vigilant around animals known to be susceptible, such as rodents and non human primates.
Care must be taken when handling used linen, clothing and towels. Avoid shaking used/soiled linen to avoid dispersal of infectious particles.
The virus can also spread from someone who is pregnant to the foetus from the placenta, or from an infected parent to child during or after birth through skin to skin contact (2) There has been evidence that it is in semen, but uncertainty around whether it can be transmitted this way (6)
Examples where MPX can or cannot spread (see Contact definition below for further details) (12):
• No: Casual conversations. Walking by someone with MPX in a grocery store. Touching items like doorknobs.
• Yes: Direct skin skin contact with rash lesions. Sexual/intimate contact. Kissing while a person is infected.
• Yes: Living in a house and sharing a bed with someone. Sharing towels or unwashed clothing.
• Yes: Respiratory secretions through face to face interactions (the type that mainly happen when living with someone or caring for someone who has MPX).
• Maybe/Still learning: Contact with semen or vaginal fluids.
• Unknown/Still learning: Contact with people who are infected with MPX but have no symptoms (we think people with symptoms are most likely associated with spread, but some people may have very mild illness and not know they are infected).
Infectious period
People with MPX are considered infectious from the time that they develop their first symptoms (either prodrome or rash, whichever is first) until all the scabs have fallen off and there is intact skin underneath (normally for between two and four weeks) (2,11)
PPE for healthcare workers
Standard, Contact and Airborne Precautions which include eye protection, P2/N95 mask, fluid repellent gown and gloves are recommended for healthcare workers interacting with Probable and Confirmed cases of MPX, and when taking MPX samples for laboratory testing (5)
Infection prevention and control advice
Infection prevention and control advice for people who need to isolate, accommodation and healthcare providers can be found on the Ministry of Health webpage linked here: Monkeypox (MPX) | Ministry of Health NZ.
Contact definition
Contacts can be separated into three groups: high, medium, and low/uncertain risk, based on their exposure to the case (9). See Appendix 1 for contact management.
High risk contact
A high risk contact is defined as a person with one or more of the following exposures to a probable or confirmed MPX case without appropriate PPE:
• prolonged face to face respiratory exposure in close proximity4
• direct physical skin to skin contact, including sexual contact
• contact with crusts, bodily fluids or contaminated materials such as clothing or bedding
• any health worker or household member who has cared for a person with probable or confirmed MPX, including management of potentially contaminated materials even without direct patient contact, without appropriate PPE.
Medium risk contact
A medium risk contact is defined as a person with one or more of the following exposures to a probable or confirmed MPX case:
• prolonged indirect contact4 with an unmasked MPX case without wearing, at a minimum, a surgical mask
• passengers seated either side of a MPX case during a flight of 8 hours or more
• participated in activities resulting in contact between sleeves and other parts of an individual’s clothing and the patient’s skin lesions or bodily fluids, or their soiled linens or dressings (for example, turning, bathing, or assisting with transfer) while wearing gloves but not wearing a gown)
• exposure that, at the discretion of public health authorities, is recategorized to this risk level because of unique circumstances (for example, if the potential for aerosol exposure is low when Airborne Precautions are meant to be applied, public health authorities may choose to decrease risk level from high to intermediate)
4 Currently defined as being within 2 metres of a monkeypox case in the same poorly ventilated indoor physical space for 3 hours or more.
Low/uncertain risk contact
A low/uncertain risk contact is defined as a person with one or more of the following exposures to a probable or confirmed MPX case:
• people involved in brief in direct contact with a case (for example, passengers on a plane seated outside of either side of the case, flight crew who provided service to a case, people sharing the same lift as the case, drivers and passengers in the same vehicle as the case for less than 3 hours, colleagues in the same area of an office as the case, brief face to face, and unmasked conversations with a case)
• people who have had direct contact with a case or its environment while wearing personal protective equipment (PPE) in accordance with transmission based precautions are considered to be at low risk of transmission and do not require follow up (for example, cleaners of a case’s hotel room, health worker or household member caring for a MPX case, laboratory workers working with case material).
• all interactions between a health worker or household member caring for a person with probable or confirmed MPX conducted using appropriate PPE in accordance with transmission based precautions are low risk.
• exposure that, at the discretion of public health authorities, was recategorized to this risk level based on unique circumstances (for example, uncertainty about whether MPX was present on a surface and/or whether a person touched that surface)
Public Health Unit Response
In the absence of a vaccine currently being available in New Zealand, Public Health Unit disease investigation activities should focus on contact tracing, and isolation of suspected or confirmed cases, and supporting contacts (10). See Appendix 1 below for the most recent Ministry of Health advice regarding case definitions and contact tracing.
Notification procedure
MPX is now a notifiable disease and on the list of infectious diseases in New Zealand. All health care workers are required to notify the Medical Officer of Health of any suspected, probable or confirmed cases of MPX.
The Medical Officer of Health is to confirm whether the notification meets the probable or confirmed case definition and notify the Ministry of Health through Communicable Diseases (notifycommdiseases@health.govt.nz) or call 0800 GET MOH for any out of hours enquiries. If out of hours and sufficient information is available to ascertain that the risk to public health is low, then the Medical Officer of Health can use their discretion and wait until usual business house to report, but if initial indications suggest risk of potential onward transmission or high risk factors then the case should be reported by phoning 0800 GET MOH (9). In addition to informing the Ministry of Health, the Medical Officer of Health should also consider informing the following (based on level of suspicion/confirmation and/or other circumstances as applicable):
• Toi Te Ora business manager
• Toi Te Ora communications team
• Infectious disease physician and/or sexual health physician
• Hospital Infection Prevention and Control team
• Hospital Occupational Health team
• Laboratory
• District Director or Chief Operating Officer
• District communications team
• Emergency department
• Primary Health Care
Management of case and contacts
Medical Officer of Health in conjunction with the case investigation HPO or CD nurse will:
1. Review the clinical features of the case to see if they meet the clinical criteria
2. Review if the case meets epidemiological criteria
3. Liaise with laboratory staff and notifying clinician to arrange microbiological testing if not done
4. Liaise with the infectious disease physician and/or sexual health physician and clinical microbiologist
5. Identify the date of symptom onset to guide source finding and contact tracing
6. Conduct source finding by completing history for the 21 days prior to symptom onset
7. Conduct contact tracing to identify contacts during the infectious period (from symptom onset until all the scabs have fallen off and there is intact skin underneath)
8. Actively monitor high risk contacts for 21 days post exposure
9. Provide at least twice weekly welfare and isolation checks for cases while they are isolating
See Appendix 1 below for the management of suspected, probable and confirmed cases and contacts.
Toi Te Ora Staff Responsibilities
The management team is responsible for ensuring that staff have the opportunity to obtain the necessary training to fulfil the requirements of this SOP.
Communicable disease administration is responsible for ensuring all forms of notification are forwarded to the duty Medical Officer of Health as soon as possible to confirm that a public health follow up is required. If the Duty Medical Officer of Health is unavailable then one of the other Medical Officers of Health should be consulted.
Laboratory notifications confirming the diagnosis must be forwarded to the Medical Officer of Health and the investigating HPO/CD nurse as soon as possible.
Medical Officer of Health is responsible for:
Action Quality measure
Confirming whether a notification meets the suspected, probable or confirmed case definition
In discussion with the notifying clinician, make an initial assessment on how issues of patient confidentiality and anonymity will be managed, and whether contact tracing will follow a model aligned with notifiable STI’s or a more standard CD approach.
Deciding whether to initiate a public health follow up investigation of contacts and informing the investigating HPO/CD Nurse.
Notifying the Ministry of Health of any probable or confirmed cases.
On the day of the notification being received
As soon as practicable, but within a few hours and immediately if it is the first case in TTO district notifycommdiseases@health.govt.nz or call 0800 GET MOH for any out of hours enquiries.
If this is the first case in the region:
• Consider setting up an Incident Management Team (IMT).
• Notify both the National Director of Public Health and the Regional Director of Public Health. Consider informing the following (based on level of suspicion/ confirmation and/or other circumstances as applicable):
• Toi Te Ora business manager
• Toi Te Ora communications team
5
• Infectious disease physician and/or sexual health physician
• Hospital Infection Prevention and Control team
• Hospital Occupational Health team
• Laboratory
• District Director or Chief Operating Officer
• District communications team
• Emergency department
• Primary Health Care
Confirming the status of contacts
Providing advice on the management of suspected, probable or confirmed cases and contacts
Responding to, or initiating any contact with, the media.
Responding to, or initiating any contact with other parties such as Iwi leaders, local council or mayor, etc.
As contacts are identified by the HPO/CD Nurse or other investigating team member.
As required by the HPO/CD Nurse or other investigating team member.
In consultation Te Whatu Ora and in line with Toi Te Ora policies.
In line with Toi Te Ora policies
The Health Protection Officer or Communicable Disease Nurse is responsible for:
Action Quality Measure
Ensuring case/caregiver/family is aware of the diagnosis
Interviewing case/caregiver/family to obtain contact details of all contacts of the case, including up to 21 days before symptoms onset for source finding.
Conduct contact tracing for contacts by risk level. Priority should be given to recent sexual partners, household contacts and any healthcare workers not wearing appropriate PPE. Note: Low risk contacts do not need to be contacted.
Individual Case Investigation Questionnaire5 form completed for all local cases on the day of notification, up to 8pm.
Individual Contact Investigation Questionnaire6 form completed for all medium and high risk local contacts on the day of notification, up to 8pm.
Ensuring that the index case and /or caregiver, and all contacts understand the disease, are aware of the risk factors and understand how they can minimise the risk of the disease.
Ensuring that all medium and high risk contacts are aware of the daily temperature and symptom monitoring requirements and advice around mask wearing and avoidance of high risk settings and behaviours as per their risk level.
At the time of interview.
Provide hard copies or email the MPX case and
Found here: G:\Toi Te Ora\Z_E_FINALS\CD Notifiable\Monkeypox (MPX)\MPX Case Investigation Questionnaire
6 Found here: G:\Toi Te Ora\Z_E_FINALS\CD Notifiable\Monkeypox (MPX)\MPX Contact Investigation Questionnaire
Provide infection prevention and control advice for people who need to isolate, and for accommodation and healthcare providers (if needed). Advice documents can be found on the Ministry of Health webpage linked here: Monkeypox (MPX) | Ministry of Health NZ
Informing Sexual Health Services of a positive case as soon as possible (during business hours Monday to Friday, 8am to 4:30pm):
Western Bay of Plenty (WBOP):
Monday to Thursday: Dr Massimo Giola and/or Ross Mackay via hospital switchboard or Massimo.Giola@bopdhb.govt.nz, Ross.Mackay@bopdhb.govt.nz
Friday: Dr Anne Edwards via hospital switchboard or Anne.Edwards@bopdhb.govt,nz.
Eastern Bay of Plenty (EBOP):
Cover is mostly Monday and Wednesday but call the Tauranga clinic (WBOP contact details above) and they will triage and contact their EBOP clinic.
contact information sheets7 .
Lakes:
Monday and Thursday: Dr Massimo Giola via hospital switchboard or Massimo.Giola@bopdhb.govt.nz
Tuesday, Wednesday, and Friday morning (until 12 noon): Dr Noreen Mir via hospital switchboard or Noreen.mir@lakesdhb.govt.nz.
For cases isolating in the community:
Check that either their GP (or in some cases, Sexual Health Physician) is aware that they are a suspected, probable or confirmed case of MPX and can provide clinical oversight. If they do not have a GP, this may require support enrolling them into a GP clinic.
If a clinical review is required out of hours this should be discussed with the on call Medical Officer of Health to liaise with the on call Acute General Medical Physician at either BOP or Lakes hospital.
Provide regular welfare and isolation checks (at least twice weekly via phone or email), to identify and address any welfare concerns and check compliance with isolation advice.
Monitor high risk contacts daily for symptoms for 21 days from last exposure with daily temperature checks.
Monitoring high risk contacts may include: Providing thermometers as needed for daily temperature checks (asking the contact to record temperature readings). Daily phone call from the HPO or CD nurse to review recorded temperatures and symptom check (see Clinical criteria).
Record of twice weekly contact with case using the Appendix 4: Welfare/isolation check form.
Record of daily phone call to high risk contacts noting temperature and symptom checks using the Monitoring high risk contacts form in Appendix 3.
7 Found here: G:\Toi Te Ora\Z_E_FINALS\CD Notifiable\Monkeypox (MPX)\, look for MPX Case Information Sheet for cases, Actively Monitored Contact Information Sheet for high risk contacts, or MPX Self Monitoring Contact Information Sheet for medium risk contacts.
If any contact develops initial symptoms (other than a rash) they should self isolate and be watched closely over the next seven days. If no rash develops, they can stop self isolating and continue temperature monitoring for the remaining days (11)
If the case has presented to a hospital for care and treatment:
Notify the Occupational Health Service of the relevant hospital and providing the case’s NHI, along with contact details for the on call HPO/CD nurse.
Lakes: Call 07 348 1199 and during office hours ask for the Health and Safety Consultant, after hours ask for the Duty Manager.
Bay of Plenty: email OccupationalHealth@bopdhb.govt.nz
If the case has presented to other health services:
Advise the health services about managing contacts when a case has presented to their services e.g. medical centres, ambulance.
Contact medical centres directly.
Contact relevant St John Territory Manager through control 0800 244 111.
Notifying other PHUs of contacts currently in their region; follow up to confirm success.
Details of contacts in other districts to be recorded and forwarded to relevant PHU within 24 hours of identification.
Follow up within 7 days of notification.
Obtaining accurate data about the index case to ensure epidemiological monitoring of disease in New Zealand is accurate and complete.
All case identification fields completed in EpiSurv within one working day. See Appendix 2
Reporting the investigation outcome to the National Disease Statistics Collection Centre (via Episurv).
Following up contacts of cases in other health districts, as requested by other Public Health Units.
Responsibilities of Other Services
Sexual Health Service
Within seven days of notification
Ross Mackay (Clinical Nurse Coordinator for the Sexual Health Service in the Bay of Plenty) would like to know of any MPX cases within the BOP region during work hours and is happy to liaise with TTO to arrange clinical review of cases during business hours if required. Ross works Monday Thursday.
Hospitals
When a case is admitted to hospital, Infection Control Services will be responsible for ensuring that the case is managed appropriately to prevent disease transmission. Occupational Health Services are responsible for protecting staff and ensuring their safety when involved in the care of the index case.
The HPO/CD Nurse will contact the relevant occupational health service to let them know the details of the case. The Occupational Health Service will arrange their own staff contact tracing and counselling. Toi Te Ora’s priority is managing the public health risk, not the infection control risk or occupational health risk.
Other healthcare organisations
Toi Te Ora will provide information to services that provided care to the case before their admission to hospital e.g. medical centres, ambulance. These organisations should be able to manage their own contacts, but Toi Te Ora may be called upon to give advice.
References
1. World Health Organization. Monkeypox: Key facts [Internet]. World Health Organisation. 2022 [cited 2022 May 23]. Available from: https://www.who.int/news room/fact sheets/detail/monkeypox
2. World Health Organization. Monkeypox [Internet]. World Health Organization. 2022 [cited 2022 May 23]. Available from: https://www.who.int/philippines/news/q a detail/monkeypox
3. World Health Organization. Monkeypox [Internet]. 2022 [cited 2022 Jun 3]. Available from: https://www.who.int/news room/fact sheets/detail/monkeypox
4. Centers for Disease Control and Prevention. Monkeypox [Internet]. National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). 2022 [cited 2022 May 23]. Available from: https://www.cdc.gov/poxvirus/monkeypox/index.html
5. Ministry of Health. Monkeypox (MPX) clinical update 7 June 2022 Update two. 2022 Jun.
6. Ministry of Health. Monkeypox: Part of the Communicable Disease Control Manual [Internet]. New Zealand Government. 2022 [cited 2022 Aug 9]. Available from: https://www.health.govt.nz/our work/diseases and conditions/communicable disease control manual/monkeypox#5
7. World Health Organization. Monkeypox Q&A : What you need to know about monkeypox [Internet]. 2022 [cited 2022 Jul 14]. Available from: https://www.who.int/europe/news/item/10 06 2022 monkeypox q a what you need to know about monkeypox
8. World Health Organization. Multi country monkeypox outbreak in non endemic countries [Internet]. 2022 [cited 2022 Jul 12]. Available from: https://www.who.int/emergencies/disease outbreak news/item/2022 DON385
9. Ministry of Health. Monkeypox (MPX) Interim Communicable Disease Manual Chapter. 2022 Jul.
10. Ministry of Health. Monkeypox update to medical officers of health: Update one. 2022 May.
11. Ministry of Health. Monkeypox clinical update. 2022 May.
12. Centers for Disease Control and Prevention. CDC Monkeypox Response: Transmission Media statement [Internet]. 2022 [cited 2022 Jun 13]. Available from: https://www.cdc.gov/media/releases/2022/0509 monkeypox transmission.html
Appendix 1: MPX Case and Contact Management Chart adapted from the Monkeypox (MPX) Communicable Disease Manual Chapter
Note:
• MPX is now a notifiable disease on the list of infectious diseases in New Zealand.
• The Monkeypox Communicable Disease Manual chapter can be found here: https://www.health.govt.nz/our work/diseases and conditions/communicable disease control manual/monkeypox
Category Description Actions for the Case or Contact
Under investigati on/ Suspected case
A clinically compatible illness characterised by the presence of acute unexplained8 skin and/or mucosal lesions or proctitis (for example anorectal pain, bleeding) and
• an acute unexplained and compatible rash (evolving typically in four stages macular, papular, vesicular, to pustular followed by scabbing, with lesions progressing simultaneously on any part of the body). The rash may be generalised or localised.
• Advise the case to self isolate while under investigation until it is determined whether or not they meet the case definition.
Actions/Advice for Public Health/DHB
Health workers to practice Standard, Airborne and Contact infection control precautions to prevent transmission via droplets. This includes eye protection, P2/N95 mask, fluid repellent gown and gloves.
Collect standard information to enable contact tracing including recent travel and sexual history and smallpox vaccination status.
Notify Communicable Diseases (notifycommdiseases@heal
8 More common causes of acute rashes
zoster, herpes simplex, syphilis, molluscum contagiosum.
Probable or confirmed case
A person meeting the case definition for a suspected case.
AND at least one of the following:
• exposure9 to a confirmed or probable case in the 21 days before symptom onset
• history of travel to an area where MPX is endemic or where there is a current outbreak in the 21 days before symptom onset10
• is a priority group for testing.
• Ensure the case self isolates until their lesions have crusted, the scab has fallen off and a fresh layer of skin has formed underneath (symptoms normally last 14 28 days).
•
•
At this time priority groups for testing include the following:
• persons who had multiple (two or more) or anonymous sexual partners in the 21 days before symptom onset
• gay, bisexual or other men who have sex with men (MSM).
Confirmed case:
A case meeting the definition of either a suspected or probable case and is laboratory confirmed for MPX virus by detection of unique sequences of viral DNA either by real time polymerase chain reaction (PCR) and/or sequencing.
Self isolate means that cases should not go out to public places or venues, or attend places of worship. Cases must avoid physical contact, particularly sexual contact over this period (including kissing, intimate touching). Cases are able to walk by themselves while keeping a 2 metre distance from other and must wear a mask when leaving the house. Due to some evidence MPX virus in semen and uncertainty around whether transmitted this way condom use for 8 weeks after infection; this information can be provided to cases as they may be motivated to use condoms for a period of time.
• Probable or confirmed cases should avoid close direct contact with animals, including domestic animals (such as cats and dogs), livestock, and other captive animals, as well as wildlife. People should be particularly vigilant around animals known to be susceptible, such as rodents and non human primates.
• Ensure that all waste, including medical waste, is disposed of in a safe manner and that it is not accessible to rodents and other scavenger animals.
th.govt.nz) or call 0800 GET MOH for any out of hours enquiries.
• Complete Case Investigation Questionnaire form11
• Arrange laboratory testing if required
• Inform the local Sexual Health Service
• Provide Case Information Sheet (found in G:drive).
• Twice weekly welfare checks via phone or email, to identify and address any welfare concerns while the case is isolating and check on compliance with isolation advice. See Appendix 4: Welfare/isolation form.
prolonged face to face contact,
health care
High risk contacts
A high risk contact is defined as a person with one or more of the following exposures to a probable or confirmed MPX case without appropriate PPE:
• prolonged face to face respiratory exposure in close proximity12
• direct physical skin to skin contact, including sexual contact
• contact with crusts, bodily fluids or contaminated materials such as clothing or bedding
• any health worker or household member who has cared for a person with probable or confirmed MPX, including management of potentially contaminated materials even without direct patient contact, without appropriate PPE.
All high risk contacts are advised:
• to undergo active monitoring13 for symptoms for 21 days following last exposure.
• if any MPX symptom appears, contacts are to immediately isolate and contact PHU
• post exposure (PEP) vaccination may be considered when available
• to always wear masks when around others
• hand hygiene and respiratory etiquette
• for 21 days after last exposure to a case: o do not need to be excluded from work duty if asymptomatic as long as symptoms are not present however are encouraged to work from home if possible.
o If working in a high risk setting, should be managed on a case-by-case basis in consultation with local National Public Health Service. As a minimum, ensure symptom free and wear a mask. o to wear a mask in high risk settings including healthcare settings14, childcare settings and aged care facilities, as well as places of indoor gatherings where infection may spread via droplets such as bars, restaurants or places of worship
• Complete Contact Investigation Questionnaire15
• Provide Active Monitoring Contact Information Sheet (found in G:drive)
• HPO or CD nurse to provide thermometers as needed for daily temperature checks (asking the contact to record temperature readings).
• Daily phone call from the HPO or CD nurse to review recorded temperatures and symptom check (see Clinical criteria and Appendix 3).
12 Currently defined as being within 2 metres of a monkeypox case in the same poorly ventilated indoor physical space for 3 hours or more.
13 Active monitoring for symptoms is when public health officials are responsible for contacting (i.e. by phone, email, text) periodically to see if a person under monitoring has signs/symptoms. The individual under monitoring must take their temperature daily, watch for signs/symptoms compatible with MPX, and immediately isolate and report to public health officials if they have signs/symptoms. If initial symptoms (other than a rash) they should be quarantined and watched closely over the following seven days. If no rash develops, they can return to temperature monitoring for the remaining days. Completion of monitoring will be based on a high trust model. If a contact reports no presentation of rash for 21 days since last close contact exposure to the case (while infectious), they will be released from follow up.
14 unless seeking medical attention, in which case the contact should call the facility in advance and explain their status.
15 Found here: G:\Toi Te Ora\Z_E_FINALS\CD Notifiable\Monkeypox (MPX)\MPX Contact Investigation Questionnaire
Medium risk contacts
A medium risk contact is defined as a person with one or more of the following exposures to a probable or confirmed MPX case:
• prolonged indirect contact16 with an unmasked MPX case without wearing, at a minimum, a surgical mask
• passengers seated either side of a MPX case during a flight of 8 hours or more • participated in activities resulting in contact between sleeves and other parts of an individual’s clothing and the patient’s skin lesions or bodily fluids, or their soiled linens or dressings (for example, turning, bathing, or assisting with transfer) while wearing gloves but not wearing a gown)
• exposure that, at the discretion of public health authorities, is recategorized to this risk level because
o to avoid high risk activities including sexual activities and other activities that involve close physical contact such as kissing
o to wear a mask when in close contact with people potentially at higher risk of infection including infants, older people and immunocompromised people
o not to donate blood, cells, tissue, breast milk, semen, or organs while they are under symptom surveillance.
All medium risk contacts are advised to:
• Self monitoring17 for symptoms for 21 days following last exposure
• if any MPX symptom appears, contacts are to immediately isolate and contact local National Public Health Service.
• PEP (if available) to be considered on a case by case basis only for those at high risk of severe illness eg, immunocompromised.
• Intermediate testing priority if compatible prodromal symptoms develop, high if a clinically compatible rash develops.
• For 21 days after last exposure to a case: o If working in a high risk setting or people at higher risk of severe infection (incl.
• Complete Contact Investigation Questionnaire18
• HPO or CD nurse to provide thermometers as needed for daily temperature checks (asking the contact to record temperature readings), and contact information for public health officials if they develop signs/symptoms.
• Provide Self Monitoring Contact Information
16 Currently defined as being within 2 metres of a monkeypox case in the same poorly ventilated indoor physical space for 3 hours or more.
17 Self monitoring for symptoms may be advised for low risk contacts. Self monitoring is when the person being monitored is responsible for taking their temperature once daily and watching for signs/symptoms compatible with MPX. The individual should immediately isolate and report to public health officials if they have such signs/symptoms within 21 days of last exposure. If initial symptoms (other than a rash) they should be quarantined and watched closely over the following seven days. If no rash develops, they can return to temperature monitoring for the remaining days. Completion of monitoring will be based on a high trust model. If a contact reports no presentation of rash for 21 days since last close contact exposure to the case (while infectious), they will be released from follow up.
18 Found here: G:\Toi Te Ora\Z_E_FINALS\CD Notifiable\Monkeypox (MPX)\MPX Case Questionnaire
Low/ uncertain risk contact
of unique circumstances (for example, if the potential for aerosol exposure is low when Airborne Precautions are meant to be applied, public health authorities may choose to decrease risk level from high to intermediate)
A low/uncertain risk contact is defined as a person with one or more of the following exposures to a probable or confirmed MPX case:
• people involved in brief in direct contact with a case (for example, passengers on a plane seated outside of either side of the case, flight crew who provided service to a case, people sharing the same lift as the case, drivers and passengers in the same vehicle as the case for less than 3 hours, colleagues in the same area of an office as the case, brief face to face, and unmasked conversations with a case)
• people who have had direct contact with a case or its environment while wearing personal protective equipment (PPE) in accordance with transmission based precautions are considered to be at low risk of transmission and do not require follow up (for example, cleaners of a case’s hotel room, health worker or household member caring for a MPX case, laboratory workers working with case material).
• all interactions between a health worker or household member caring for a person with probable or confirmed MPX conducted using appropriate PPE in accordance with transmission based precautions are low risk.
• exposure that, at the discretion of public health authorities, was recategorized to this risk level based on unique circumstances (for example, uncertainty about whether MPX was
•
infant, pregnant women, immunocompromised people), ensure symptom free and wear a mask.
o Should not donate blood, cells, tissue, breast milk, semen, or organs.
On a case-by-case basis local National Public Health Service may wish to advise such low risk contacts to self- monitor17
• if any MPX symptom appears, contacts are to immediately isolate and contact PHU
• generally, do not warrant PEP (should it be available) or active follow up by the PHU
Sheet (found in G:drive).
• No action required unless deemed necessary on a case-bycase basis.
present on a surface and/or whether a person touched that surface)
