Monkeypox

Important information for health providers

Monkeypox is an urgently notifiable infectious disease in Western Australia.

Health providers should suspect and test for monkeypox in any patient who presents with clinical evidence AND epidemiological evidence.

Clinical evidence

A clinically compatible illness with rash on any part of the body with or without one or more classical symptom(s) of monkeypox virus infection:

  • lymphadenopathy
  • fever (≥38°C) or history of fever
  • headache
  • myalgia
  • arthralgia
  • back pain

Epidemiological evidence

  • An epidemiological link to a confirmed or probable case of monkeypox virus infection in the 21 days before symptom onset, OR
  • Overseas travel in the 21 days before symptom onset, OR
  • Sexual contact and/or other physical intimate contact with a gay, bisexual or other man who has sex with men in the 21 days before symptom onset, OR
  • Sexual contact and/or other physical intimate contact with individuals at social events associated with monkeypox activity, including events previously associated with monkeypox activity internationally such as sex-on-premises venues, raves, festivals and other mass gatherings where there is likely to be prolonged close contact, or meeting new sexual partners through a dating or hook-up “app”.

Confirmed, probable and suspected case definitions can be found in the CDNA Monkeypox virus infection – Australian national notifiable diseases case definition guidance document.

These suspected cases should be discussed with an Infectious Diseases physician or a clinical microbiologist to ensure appropriate testing and infection control measures.

Suspected cases must also be notified by telephone to Public Health Units or the on-call public health physician after hours on 9328 0553. Refer to ‘Notification’ for further information.

Clinicians should use appropriate PPE for the assessment and management of patients with suspected monkeypox. This includes a fluid repellent surgical mask, gloves, disposable fluid resistant gown, and eye protection (face shield or goggles).

Clinicians must advise a person to isolate while awaiting results after being tested for monkeypox.

Epidemiology

Monkeypox is endemic in tropical and rainforest areas of Central and West Africa, however since May 2022 there has been a large outbreak of monkeypox cases in non-endemic countries around the world, with cases also reported in Australia.

The experience internationally and in Australia to date is most cases have been among gay, bisexual and other men who have sex with men.

Transmission

Person-to-person transmission of monkeypox occurs through very close contact with people that have the infection, such as skin-to skin contact during intimate or sexual contact. Monkeypox can also spread through respiratory droplets and contact contaminated materials or surfaces (such as contaminated clothing, towels or bedding).

Transmission occurs through:

  • direct contact with infectious material from skin lesions of an infected person, including through broken skin (even if not visible), or mucous membranes (respiratory tract, conjunctiva, nose, mouth, or genitalia),
  • respiratory droplets in prolonged face-to-face contact, or
  • fomites, via contact with contaminated objects such as bedding or clothes. It remains unclear whether the virus can be transmitted through semen or vaginal fluids.

Aerosol-generating procedures are also a transmission risk.

Infectious period: People with monkeypox are infectious from the onset of symptoms (either prodrome or rash, whichever comes first), until the rash has scabbed over and the scabs have fallen off. This may take 2-4 weeks.

Clinical presentation and outcomes

Monkeypox is a mild viral illness caused by infection with the monkeypox virus. It is usually a self-limiting illness with symptoms lasting for 2-4 weeks.

Incubation period is usually 7 to 14 days with a range of 5 to 21 days.

A person may have prodromal symptoms, which can include:

  • fever or chills
  • headache
  • myalgia
  • arthralgia
  • back pain
  • lymphadenopathy
  • fatigue

A maculopapular rash is typical of monkeypox, and develops 1 to 5 days after initial symptoms, noting some people do not have prodromal symptoms. The rash often starts on the face and spreads to other parts of the body. The rash may be generalised or localised, discrete or confluent.

The rash usually evolves over 2-3 weeks, with progression of lesions classically occurring as follows:

  • macules (lesions with a flat base),
  • papules (slightly raised firm lesions)
  • vesicles (lesions filled with clear fluid)
  • pustules (lesions filled with yellowish fluid)
  • lesions then scab over after 2-3 weeks, after which scabs fall off.

In the current outbreak, atypical presentations have been observed, for example, patients presenting with no or a mild prodrome, or a rash with few lesions or a single lesion only on the genital or peri-anal region. Some cases may present with proctitis (painful inflammation of the rectum) in the absence of an externally visible rash or lesion(s). 

Hospitalisation is uncommon, and usually occurs for pain management, secondary skin infections, or other complications. More severe complications of monkeypox infection can include cellulitis, pneumonia, sepsis, encephalitis and corneal infection.

Testing and diagnosis

For assessment and testing algorithm, refer to the Monkeypox quick guide for clinicians (PDF 251KB).

All suspected cases of monkeypox should be tested for monkeypox virus. Collection of specimens should first be discussed with an infectious diseases physician or clinical microbiologist and notified to Public Health via Public Health Units or the on-call Public Health Physician (08 9328 0553) by telephone.

Appropriate personal protective equipment (PPE) (external site) should be worn while collecting samples from patients suspected to have monkeypox virus infection. This includes fluid repellent surgical mask, gloves, disposable fluid resistant long-sleeved gown, and eye protection (face shields or goggles).

Monkeypox is diagnosed by PCR testing. Specimens should be collected using a sterile dry swab by vigorously rubbing the base of the lesion, or a skin biopsy. Avoid using transport medium, as this may dilute the sample and increase risk of leakage Nasopharyngeal swabs are also suitable and should be collected. Specimens should be placed in two specimen bags (double-bag) to protect against leakage.

Suspected cases should wear a mask, cover lesions where possible, and isolate until a negative result is received.

Clinicians should consider the possibility of alternative diagnoses and test as appropriate, for example, syphilis, varicella zoster, herpes simplex, measles, molluscum contagiosum and bacterial skin infections.

Notification

All suspected and confirmed cases must be reported urgently by telephone to the Public Health Unit (see contact details at public health units). After hours, notify the on-call Public Health Physician by calling 08 9328 0553.

Notifications should be made using the Infectious Diseases notification form for metropolitan residents (PDF 214KB) or regional residents (PDF 213KB).

See Statutory medical notifications in Western Australia (Monkeypox virus infection) for further information.

Infection Prevention Control

Appropriate personalprotective equipment (PPE) (external site) should be worn while collecting samples from patients suspected to have monkeypox virus infection. This includes fluid repellent surgical mask, gloves, disposable fluid resistant long-sleeved gown, and eye protection (face shields or goggles).

Other precautions should be taken to minimise exposure to surrounding persons and areas. In addition to isolation requirements, these include the person with suspected, probable, or confirmed monkeypox:

  • regularly performing hand hygiene
  • wearing a surgical mask outside their home, and
  • covering any exposed skin lesions with non-stick dressings, a sheet or clothing/ gown.

When handling clothing and linen of suspected, probable, or confirmed cases, avoid shaking items or handling them in a manner that may disperse infectious particles into the environment.

Cleaning and disinfection advice:

Monkeypox virus will be inactivated through the use of a detergent followed by a Therapeutic Goods Administration (TGA) approved hospital-grade disinfectant with activity against viruses (according to the label and product information) or a bleach solution.

Post consultation with a person with suspected, probable, or confirmed monkeypox, the room and fixtures and fittings, equipment (or utilised area) should be thoroughly cleaned and disinfected.

  • Remove PPE worn during the patient interaction and apply a new set of PPE before cleaning and disinfecting the room.
  • Cleaning should be undertaken by cleaning with detergent, followed by cleaning with a TGA-list hospital-grade disinfectant with activity against viruses or a bleach solution. Some products combine a detergent and disinfectant in one.
  • Do not reuse cloths, avoid dry dusting, sweeping, vacuuming, to prevent dispersal of infectious particles.
  • Once surfaces are dry, the room can be safely used for the next patient consultation.

Refer to the Infection Prevention and Control Expert Group (ICEG) interim guidance on Monkeypox for health workers for further information.

For guidance in healthcare settings, refer to Guideline: Monkeypox: Infection Prevention and Control Guidelines for Western Australian Healthcare Facilities on Communicable disease control guidelines.

Case management

Most people recover within a few weeks without any specific treatment. Antiviral medications can be prescribed in certain circumstances, on review by an Infectious Diseases Physician. Refer to the national Human Monkeypox treatment guidelines (external site) for more information.

If antivirals are indicated, the Infectious Diseases Physician should discuss accessing antiviral medication with their public health unit, or after hours via the on-call public health physician on 9328 0553.

Cases of monkeypox must isolate until all lesions have crusted over, scabs have fallen off and a fresh layer of skin has formed underneath. Public Health will provide advice for cases on release from isolation.

Vaccination

WA Health has begun vaccinating people at highest risk of monkeypox.

Due to limited vaccine supply, those who are at highest risk of getting the disease and/or severe disease can access the vaccine first, free-of-charge.

Widespread vaccination is not currently recommended due to the very low risk of infection for the general population.

As more vaccine becomes available, the eligibility criteria will expand to allow more people to access the monkeypox vaccine. More vaccine is expected in October 2022.

Eligibility criteria

Monkeypox vaccination is currently available for the following priority groups:

  • Close physical contacts of people infected with monkeypox, such as intimate partners and people who live in the same household.
  • Population groups who might be at higher risk of exposure or further transmission, such as gay, bisexual, or other men who have sex with men who have a high number of sexual contacts or are travelling to countries where monkeypox is present, or those where monkeypox is more likely to result in serious illness.
  • People whose occupations might put them at increased risk, including laboratory staff and healthcare workers.

Vaccine availability and registering interest

Vaccines are available now and people can register their interest in receiving the monkeypox vaccine.

Medicare cards are not needed to receive the monkeypox vaccine and confidentiality is of priority at all services.

Patients should be encouraged to visit HealthyWA for information regarding vaccination, including registration.

Perth metropolitan area

People in the metropolitan area can register their interest for getting vaccinated at a state-run clinic via VaccinateWA. They will be contacted when they are eligible.

People can alternatively contact a clinic to make an appointment for vaccination. Their eligibility will be assessed over the phone.

Regional Western Australia

People in regional Western Australia can register their interest via the EOI form. They will be contacted when they are eligible.  

They can also contact their local regional Public Health Unit (external link). Their eligibility will be assessed over the phone.

Vaccination resources

Contact tracing and management

Public Health will initiate contact tracing for suspected and confirmed cases, as required. Contacts are classified based on risk of infection from their exposure to a monkeypox case. Contacts must monitor for symptoms for 21 days from exposure and follow public health advice provided by Public Health Units (see Monkeypox virus infection - CDNA National Guidelines for Public Health Units).

Vaccination may be offered as post-exposure prophylaxis for those at highest risk of becoming infected. Public Health will provide guidance regarding the use of the smallpox vaccination in monkeypox contacts.

Refer to your Public Health Unit for further advice.

Last reviewed: 21-09-2022