Appendix 2: Instructions for Episurv

Monkeypox CRF instructions version 1 26/5/2022

Monkeypox case report form instructions for Public Health Units

While a specific questionnaire for monkeypox is being designed, please use the generic case report form. https://surv.esr.cri.nz/episurv/CaseReportForms/Generic-Dec2013.pdf

Please complete the mandatory fields on page one of the case report form.

See additional instructions for the basis of diagnosis, clinical course and outcome and protective factors field, and provide additional detail requested below in the comments section of the form.

Basis of Diagnosis

In this section for clinical and laboratory criteria please refer to case definition

For epidemiological criteria, please indicate yes here if there was exposure to a confirmed OR probable case in the 21 days before symptom onset (see case definition)

Clinical course and outcome

In this section date of onset refers to date of prodrome symptoms, or rash if prodrome absent

Protective factors

History of smallpox vaccination unlikely but please indicate in this section if there is a history of smallpox vaccination

Comments section

Please indicate if the following epidemiological risk factors were present

• Is the case a health care worker? Y/N

Monkeypox can be sexually transmitted, and the following questions are about types of sexual exposure which have been associated with the spread of this disease overseas.

• In the past 21 days have they had sexual contact with more than one person or someone for whom they have no contact details? Y/N • If the case identifies as male were any of these sexual contacts with a male? Y/N

Please indicate if the following risk factors for severe disease were present

• Pregnancy Y/N if yes indicate how many weeks pregnant are they: • Immunodeficiency Y/N if yes indicate cause:

Case management

• Has the case been instructed to isolate at home during infectious period? Y/N/Unsure • Has the case been instructed to avoid close personal contact including sexual contact? Y/N/Unsure • If the case has been admitted to hospital, have appropriate isolation and PPE arrangements been made? Y/N/Unsure or yet to be confirmed • Are there any difficulties with home isolation which need to be addressed? Y/N If Yes, please specify: (eg unable to isolate from family/housemates or welfare concerns please specify)