Mpox

September

• Full chapter update to include guidance for clade I mpox and align with new format. Includes changes to the following sections:
  • Epidemiology – new subsection for global epidemiology and updated information on epidemics and high priority groups in Aotearoa
  • At risk and priority populations – new section. Includes clade-specific risk and priority groups
  • The disease – new section
  • Spread of infection - reservoir, and infection prevention and control – new subsections
  • Routine prevention – new section. Includes information on immunisation and other preventative measures to minimise the risk of transmission in communities
  • Case definition – updates to definitions, clinical and epidemiological criteria
  • Notification and reporting – national escalation, and international reporting – new subsections
  • Case management – addition of clade I - specific guidance and clade I risk assessment tool to determine priority for public health action, considerations around manaaki and how care is provided
  • Exposure event management – new section. Includes clade-specific risk assessments and guidance for managing high-priority settings
  • Outbreaks – new section. Includes clade-specific outbreak definitions and specific response objectives.

For an overview of all updates made to the Communicable Disease Control Manual, refer to Updates to the Communicable Disease Control Manual – Health New Zealand | Te Whatu Ora.

November

• Updates to Contact management 
• Updates to Laboratory testing guidelines

August

• Updates to Management of Case

For an overview of all updates made to the Communicable Disease Control Manual, refer to Updates to the Communicable Disease Control Manual – Health New Zealand | Te Whatu Ora.

Mpox is a disease caused by the zoonotic (transmissible from animals to humans) monkeypox virus (MPXV) which belongs to the Orthopoxvirus genus in the Poxviridae family. Historically mpox has been endemic to parts of Central and West Africa, with predominantly zoonotic transmission and limited onward human-to-human transmission. There are 2 distinct clades of the MPXV [1,2]:

• clade I (with subclades Ia and Ib), endemic to Central Africa (previously known as the Congo Basin clade)
• clade II (with subclades IIa and IIb), endemic to West Africa (previously known as the West African clade).

In May 2022, multiple countries outside Africa reported cases of clade IIb mpox transmitted primarily via sexual contact and primarily occurred among men who have sex with men (MSM) [3], marking the beginning of a multi-country mpox outbreak. In July 2022 [4,5], the World Health Organization (WHO) declared the multi-country clade IIb mpox outbreak a public health emergency of international concern (PHEIC) [6]. While cases have declined since the peak in 2022, clade IIb mpox transmission persists globally, and continues to disproportionately affect MSM and their sexual networks [3].

In late 2023, the novel clade Ib variant emerged in the Democratic Republic of the Congo (DRC) with sustained human-to-human transmission primarily via sexual contact in young adults. This outbreak was strongly associated with sexual and intimate contact and has been amplified in heterosexual networks associated with commercial sex and sex workers [6]. Initial reports indicate that the highest incidence of transmission through sexual contact is in adolescents and young adults not involved in sex work, followed by sex workers [7]. 

In response to an upsurge in clade Ia and Ib mpox cases in the DRC, and expansion of these clades to previously unaffected neighbouring African countries, the WHO declared mpox a PHEIC for the second time in August 2024 [8]. Outbreaks of clade Ia and Ib mpox have continued in Central and Eastern Africa, with increased household and community transmission of clade Ib. Sustained human-to-human transmission of a strain of clade Ia mpox in an area of the DRC has also been reported by WHO in 2025, with no early indications of increased transmissibility or severity [9]. Children are the largest demographic group impacted during outbreaks of clade I mpox in DRC [10,11] with transmission likely via skin-to-skin exposure to lesions which is more likely to occur among household contacts [12]. 

There have been sporadic detections of clade Ib mpox cases outside Africa, predominantly among people with a history of travel to affected African countries. Some countries have reported limited secondary transmission from these cases, but no sustained transmission of clade Ib mpox has been reported outside Africa at the time of writing in May 2025 [3,13,14]. There have also been sporadic travel-related cases of clade Ia mpox detected outside Africa since February 2025 [3,14]. The status of mpox as a PHEIC was lifted in September 2025 [15].

The case fatality rate of clade IIb mpox for the multi-country outbreak between 2022 and 2023 was estimated to be 0.2% [3]. The estimated case fatality rate in 2024 in countries with clade I mpox only (Ia and/or Ib) ranged from 0.3% to 3.3%, with higher case fatalities observed in rural and remote areas and where a higher proportion of children were affected.

Clade IIa mpox is the least studied subclade. In early 2025 WHO reported evidence of increasing numbers of human cases of clade IIa mpox across multiple regions in Côte d’Ivoire, Ghana, Guinea, and Liberia, mostly affecting adults, related to zoonotic spillover events and some human-to-human transmission [16].  

The epidemiology of mpox continues to evolve rapidly. For the latest updates on global mpox trends, refer to WHO emergency situation reports (external link) and the WHO Global Mpox Trends dashboard (external link).

Mpox was first identified in Aotearoa New Zealand in July 2022. As of 1 August 2025, there have been 98 cases reported, of which 76% were locally acquired (data from EpiSurv (external link)). After an initial outbreak between September and December 2022, there have been sporadic imported and locally acquired cases, and 3 further smaller outbreaks in December 2023, September 2024 and July 2025. Most cases have been among gay, bisexual, takatāpui and other men who have sex with men (GBMSM), and their sexual networks, and all cases tested for clade have been confirmed as clade II mpox. As of 1 August 2025, no cases of clade I mpox have been reported in Aotearoa New Zealand.

Refer to the New Zealand Institute for Public Health and Forensic Science Limited (PHF Science) monthly notifiable disease reports (external link) or the notifiable disease dashboard (external link) and the Immunisation Handbook mpox chapter for further information on the epidemiology of mpox in Aotearoa New Zealand.

The following definitions should be applied wherever GBMSM and increased transmission-risk activities is referenced throughout the chapter.

GBMSM is defined as gay, bisexual, takatāpui and other men who have sex with men. This definition incorporates both elements of sexual identity (gay, bisexual, takatāpui), gender identity (cis or transgender men, or non-binary people) and behaviour (engaging in sexual behaviour with another man). 

Increased transmission-risk activities describes sexual behaviours or activities that increase the risk of mpox transmission. These may include having multiple sexual partners, participating in sex at sex-on-site premises or events, unprotected sex, using stimulant drugs to enhance sexual experience (i.e. chemsex) and/or the sharing of sex toys.

It is important to note that behaviour, rather than identity, is most relevant to the risk of acquiring and transmitting mpox.

In Aotearoa New Zealand, the groups at higher risk of infection with clade II mpox are:

• people who travelled to countries with clade II mpox cases or outbreaks and had:
  • close contact (including sexual and intimate contact) with others, or with infected materials (e.g. bed linens, towels, clothing)
  • close contact with an infected animal or prepared/consumed bushmeat
• GBMSM who engage in increased transmission-risk activities
• those with GBMSM who engage in increased transmission-risk activities in their sexual networks. This may include people of any gender or sexual identity, whether they are transgender or cisgender, and non-binary people.

Intimate and sexual contact plays a key role in transmission of both clade I and clade II mpox therefore individuals that engage in sexual activity, particularly increased transmission-risk activities, are at risk of mpox if exposed to a case [3,7,17].

Social determinants of health significantly impact the prevalence and outcomes of sexually transmitted infections in Aotearoa New Zealand and are a particularly significant contributor to health inequity among priority populations [18]. GBMSM, Māori and Pacific peoples have disproportionately higher rates of sexually transmitted infections [19] due to the compounding effect of intersecting social factors (socioeconomic deprivation, homelessness, increased barriers to accessing care, stigma, discrimination and health literacy). For any individual with mpox, particularly those in priority groups already experiencing health inequity (i.e. Māori, Pacific peoples, tāngata whaikaha | disabled people, rainbow communities^a), awareness of the multiple compounding and interwoven social factors that may further contribute to increased risk is critical for appropriate and effective mpox management.

For further information on providing culturally safe and equitable care for a range of population groups, refer to the Equity chapter (external link).

For further information on advancing hauora in the management of communicable diseases, refer to the Tū Kōkiritia chapter (external link).

^a_{Rainbow communities: a broad umbrella term encompassing individuals who identify with diverse sexual orientations, gender identities, and expressions, and variations of sex characteristics.}

As of 2025, there have been no confirmed cases of mpox clade I in Aotearoa New Zealand and spread of clade I mpox outside of Africa has been limited to household and sexual contacts with no evidence of sustained transmission [9]. However, based on epidemiological evidence of transmission dynamics in Africa, the following groups may be considered at higher risk of infection in the Aotearoa New Zealand context.

• People who travelled to countries with clade I mpox cases or outbreaks and had:
  • • close contact (including sexual and intimate contact) with others, or with infected materials (e.g. bed linens, towels, clothing)
    • close contact with an infected animal or prepared/consumed bushmeat.
• Sexual contacts, and household members of clade I mpox cases (including infants and young children) and those caring for them.
• Individuals engaging in increased transmission-risk activities if clade I mpox is detected in Aotearoa New Zealand.

Sexual contact is an important route of transmission and therefore individuals that engage in sexual activity, particularly increased transmission-risk activities, are at risk of mpox if exposed to a case [3,7,17].

Household transmission, particularly to children, has been observed during the clade I outbreaks in Africa [3], indicating transmission through close physical contact — that is not sexual contact — is more common for clade I mpox. While the role of household transmission in other countries is not clear, it may have a particular impact on individuals in shared accommodation settings and in larger communal/multigenerational households, if exposed to a clade I mpox case. This may include Māori, Pacific peoples, tāngata whaikaha | disabled people and those experiencing socioeconomic deprivation or homelessness who also experience compounding issues of health inequities and increased rates of communicable diseases [20–24]. Individuals experiencing homelessness, are also at higher risk of both exposure to mpox and severe disease due to factors such as reduced access to hygiene facilities and reduced access and engagement with healthcare services.

For further information on providing culturally safe and equitable care for a range of population groups, refer to the Equity chapter (external link).

For further information on advancing hauora in the management of communicable diseases, refer to the Tū Kōkiritia chapter (external link).

The following groups may be at increased risk of severe disease if infected with mpox (all clades). Individuals who are:

• unvaccinated
• immunocompromised, particularly people living with poorly controlled human immunodeficiency virus (HIV) infection (CD4 count <350 cells/μL) or undergoing immunosuppressive therapy [25,26]. People who are HIV-positive but have a normal CD4 count are not considered immunocompromised
• pregnant
• infants and young children.

Those with chronic skin conditions (e.g. atopic dermatitis) and acute skin conditions (e.g. burns) may be at higher risk for mpox complications, such as bacterial infection (based on limited data) [26].

Mpox is usually a mild self-limiting disease, but for some individuals it can cause severe illness requiring hospitalisation and fatalities have been reported internationally. Vaccination offers some protection against infection and hospitalisation [27,28], however, people who have been vaccinated can still acquire and transmit mpox. Unvaccinated people are more likely to experience more dispersed lesions and severe disease.

Although mpox has not been reported in this group in Aotearoa New Zealand, variable evidence from global mpox outbreaks indicates pregnancy may increase the risk of severe disease. In addition, vertical transmission of mpox (either across the placenta in utero or contact during the birthing process) does occur and may carry a high risk of pregnancy loss or severe congenital infection in some cases [29–33].

Children are at higher risk for severe illness and death due to complications from mpox, although the risk of infection remains low in Aotearoa New Zealand. Historically, they are the largest demographic group impacted by mpox in Africa and emerging data suggest that clade I is more prevalent among childhood cases than clade II [34,35]. Severe illness in children is likely associated with their lack of immunity from prior infection or smallpox immunisation and other contributing factors (e.g. poorer access to healthcare services, poorer sanitation, malnutrition and prevalence of other infectious diseases [29,36–38). Children in Aotearoa New Zealand would also have a lack of immunity from prior infection or smallpox immunisation, however, it is unclear whether they would be similarly affected; initial modelling by the CDC does not suggest a similar age-related risk is expected if clade I mpox is introduced in the United States [35]. 

As for other infections transmissible by direct contact, children may pose an increased risk of transmission of clade I mpox to others. Facilitating access to post-exposure vaccination will be a key priority.

The following occupational groups whose work involves close contact with groups of people more likely to be exposed and infected with mpox are at higher risk of infection.

For both clade I and clade II mpox:

• sex workers (at high risk of both infection and of transmitting mpox to others if infected)
• healthcare workers (including laboratory staff handling specimens and cleaning staff) not wearing appropriate personal protective equipment (PPE) or who experience PPE failure, are more likely to be exposed to contaminated environments and materials. Healthcare and laboratory staff may perform procedures such as those that generate aerosols, increasing the risk of exposure.

In addition, for clade I mpox:

• teachers and other staff at early childhood education centres/schools who have close contact with children may be at higher risk of infection if exposed to a child with mpox. They may also be at risk of transmitting mpox to others in these settings.

The goal of public health action for mpox is to eliminate transmission through effective and appropriate public health action.

The following groups should be prioritised for clinical and public health follow up for clade II mpox.

• GBMSM who engage in increased transmission-risk activities and those with GBMSM who engage in increased transmission-risk activities in their sexual networks.
• Sex workers.
• Individuals at higher risk of severe disease (e.g. infants and young children, individuals who are immunocompromised, or pregnant). 
• Individuals who routinely interact with individuals at higher risk of severe disease (e.g. healthcare workers, carers).

In addition to the groups described above, the following groups should also be prioritised for clinical and public health follow up for clade I mpox.

• Individuals in shared accommodation settings (e.g. prisons, homeless people or those in shelters, halls of residence, disability care, aged care and other residential facilities) or larger communal/multigenerational households (e.g. Māori and Pacific communities), particularly those within other priority groups and/or those who have compounding risk factors.  
• Individuals who routinely have skin-to-skin contact with children (e.g. healthcare workers, carers, early childhood education teachers/kaiako and/or staff). 

Mpox is usually a self-limiting disease with symptoms lasting for 2 to 4 weeks.

The illness may present with a prodromal period lasting 1 to 5 days, characterised by fever (≥38°C) or history of fever, lymphadenopathy (swollen lymph nodes), headache, myalgia (muscle pain), arthralgia (joint pain), back pain, and sore throat. However, not all people with mpox experience prodromal symptoms [39].

Prodromal symptoms may be followed by a maculopapular rash which may develop 1 to 5 days after the onset of fever. The rash can affect any part of the body including on the face, arms, legs and genitals, or inside the mouth (ulcers) and anus. The rash may progress through stages starting first as macules (lesions with a flat base), which progress to papules (slightly raised firm lesions), before evolving to vesicles (lesions filled with clear fluid) and pustules (lesions filled with yellowish fluid), or pseudo pustules (resembling pustules but without pus). Crusted scabbing usually begins 14 to 21 days after rash onset. Scabs then fall off, leaving dyspigmented scars [40].

Common presentations for clade II mpox

Clinicians should be aware that clade II mpox can present as follows [41]:

• lesions may be localised to ano-genital skin, or oropharynx
• cases may present with the following in the absence of any visible lesions:
  • proctitis (e.g. rectal pain and bleeding) [42]
  • urethritis, (e.g. urethral pain, discharge and dysuria) [43]
  • oropharyngeal symptoms (e.g. sore throat, pharyngitis and tonsillitis) [44]
• fever, malaise and other prodromal symptoms may be absent, or may develop after the onset of lesions
• there may be very few lesions, or a single lesion
• the lesions may not necessarily progress through multiple stages.

Useful mpox images can also be found at World Health Organization: Atlas of mpox lesions (external link) and DermNet: Mpox images (external link).

Differential diagnosis and co-infections

Clinical presentation of mpox may be similar to other sexually transmitted infections (STIs), such as herpes simplex and syphilis [45,46], and co-infection with STIs is common. If testing for mpox in sexually active people, ensure that this is done as part of a complete STI screen that includes testing for chlamydia, gonorrhoea, human immunodeficiency virus and syphilis.

Mpox may also have a similar presentation to other illnesses which cause acute skin lesions, particularly in children, such as hand foot and mouth disease, varicella zoster (chickenpox), and molluscum contagiosum [45,46] and these infections should be considered, and excluded where appropriate.

Complications

Mpox can cause severe pain and affect vulnerable anatomical sites including the genitals and oropharynx; painful proctitis or oral lesions may be the primary presentation. Gastrointestinal symptoms may occur [45]. More severe complications of mpox include secondary infections including cellulitis, bronchopneumonia, sepsis, encephalitis, and ocular involvement including conjunctivitis, blepharitis, keratitis, and vision loss [47,48].

Vertical transmission during pregnancy can cause clinical manifestations in babies such as hydrops fetalis, maculopapular skin lesions on the body, hepatomegaly, and premature birth [16,49–53].

Reinfections

Mpox reinfections after the initial infection and infections in partially or fully vaccinated people can occur, although evidence regarding these cases is currently limited. One study has demonstrated that cases who are infected after vaccination may report mild symptoms [54]. Other evidence states that people infected with mpox, during or after the 2022 clade IIb outbreaks, report milder symptoms than those infected in previous outbreaks of clade IIb, though this has not been explicitly linked to vaccination [55].

The natural reservoir of the monkeypox virus (MPXV) remains unknown. However, the virus has been isolated from several African rodents and primates.

The median incubation period for mpox is estimated to be 5 to 9 days, with a range of 1 to 21 days [56]. There is no evidence to suggest that the incubation period varies by clade-type but it can be shorter with invasive exposure, such as through broken skin or mucosal surfaces, and for people living with human immunodeficiency virus with low CD4 counts [56].

Mpox may be transmitted through close contact with an infected person, including:

• direct skin-to-skin contact with rash, skin lesions or scabs
• contact with bodily fluids (i.e. saliva, nasal mucus, semen or vaginal fluids, blood [41,57, 58])
• contact with materials, objects or surfaces that have been used (e.g. bed linens, towels, clothing, healthcare equipment) by an mpox case.

Transmission occurs through broken skin, or via mucous membranes (i.e. respiratory tract, conjunctiva, nose, mouth, or genitalia). Intimate and sexual contact plays a key role in transmission of both clade I and clade II mpox.

Mpox may also be transmitted through: 

• respiratory transmission during prolonged face-to-face contact or aerosol-generating procedures [49,50,59,60]. While respiratory transmission has been demonstrated in controlled animal-to-human studies, there has been no evidence to date of respiratory transmission in human outbreaks [26]
• vertical transmission during pregnancy [30–33]
• animal-to-human transmission. This can occur via bites or scratches and indirectly from contact with blood, bodily fluids, cutaneous lesions or mucosal lesions. There is also limited evidence to suggest that humans can transmit the virus to household pets [49,50,61]. 

The spread of mpox through contact with contaminated materials requires the persistence of viable MPXV on surfaces which depends on 3 main factors:

• temperature — persistence increased with decreasing temperatures [62]
• surface type/material — MPXV lasts for a shorter period on porous surfaces such as wood and cardboard compared with non-porous surfaces such as glass and stainless steel [63]. MPXV was more stable on smooth surfaces
• type of body fluid — increased persistence in more proteinaceous substances (e.g. blood, semen, serum) compared to saliva, urine and faeces [64].

Depending on these factors, MPXV can persist on surfaces from days to weeks. Alcohol-based disinfectants provide effective control [65].

Mpox cases are infectious from the onset of symptoms until all symptoms have resolved, and all lesions have formed scabs which have fallen off, leaving fresh skin underneath. This usually takes 2 to 4 weeks. Scabs may still contain infectious virus.

International reports of asymptomatic mpox infection in cases associated with the ongoing clade IIb 2022 outbreak are rare and generally only detected and described in research studies. There is limited evidence available to determine whether asymptomatic cases are infectious. Cases who develop no visible lesions (i.e. with proctitis only) should be considered infectious until symptoms resolve or for 21 days after diagnosis (whichever is sooner).

Community cases

For cases managed in the community, attending healthcare workers and other occupational care workers should follow infection prevention and control precautions as described for hospitalised cases below (refer to Table 2).

Whānau, friends or other individuals who may be involved in providing care to cases in the community (this also includes cleaning, managing linen or waste) should use a mask, disposable or personal washing up gloves, and clothes that cover the skin as much as possible (e.g. long-sleeved top and full-length trousers). These should be washed (separately) as soon as possible after contact with the case and/or cleaning has finished. For tasks where infected particles may be dispersed into the air (e.g. vacuuming, changing linen) eye protection should be considered, if available.

Recommended restrictions for community cases to prevent transmission can be found in the isolation and restriction — clade II and isolation and restriction — clade I sections. Recommended restrictions for contacts to prevent transmission can be found in the quarantine and restriction — clade II and quarantine and restriction — clade I sections.

In addition, Table 1 provides advice on strengthening cleaning practices that should be shared with households where a case resides and/or other relevant exposure event settings to prevent onward spread of mpox.

Vaccines to prevent or reduce infection and disease severity are available. Both primary preventative vaccination and post-exposure vaccination may have some impact on reducing transmission. Refer to the Immunisation Handbook mpox chapter for advice specific to available vaccines and their use for primary preventative and post-exposure vaccination.

The mpox vaccine is a smallpox vaccine with cross-protection against mpox and is recommended and funded for individuals aged 18 years and over who are at higher risk of infection (as listed in section 14.5.1 of the Immunisation Handbook).

Children and adolescents exposed to mpox, or who are at higher risk of infection can be given the mpox vaccine under prescription and consent. Refer to section 14.5.5 of the Immunisation Handbook.

To access mpox vaccine outside of a sexual health clinic or GP (not all practices stock and administer mpox vaccine) for the purpose of post-exposure vaccination (i.e. for children who may be close contacts of mpox cases), a medical officer of health can directly request off cycle delivery of 2 vials to any cold chain accredited fridge of their choosing by contacting Healthcare Logistics (external link) through the inventory portal who will distribute by next business day. Healthcare Logistics are the sponsor and distributor of mpox vaccine in Aotearoa. Post-exposure vaccination is co-ordinated by the public health service and administered by anyone credentialled (external link) to do so (such as in primary care or specialist services).

Data on the efficacy of the mpox vaccine against smallpox or mpox in humans is limited, for more information refer to the Immunisation Handbook mpox chapter. Vaccination offers some protection against infection and hospitalisation [26,27]. There is also evidence that vaccination reduces disease severity, extragenital lesions and systemic symptoms [27,28,66,67]. Once vaccinated, immunity levels can wane, and the immune response could be reduced in those who are severely immunosuppressed. Antibody levels produced by the mpox vaccine can fall to very low levels within one month to a year but it is not clear yet what the implication of this is for continuing vaccine efficacy. As people who have been vaccinated can still acquire and transmit the virus, vaccinated people should not engage in intimate or sexual activity with people who are confirmed or suspected to have mpox and should seek medical care if they develop symptoms that are clinically compatible with mpox.

Public health services may consider taking the following measures to prevent sustained transmission.

• Work with sexual health clinics and general practices to facilitate testing, promote and facilitate vaccination and connect cases and contacts with support organisations.
• Engage with local community organisations for the rainbow community, people living with HIV, and sex workers, to deliver information on preventative measures they can take and the importance of vaccination.
• Promote community awareness by distributing mpox educational material to key priority groups (in an accessible, cultural and language appropriate format) and making guidance publicly available for people at higher risk of transmission, including advice to:
  • exchange contact information with any new sexual partner(s) during periods of local mpox transmission to facilitate contact tracing should it be required
  • use a condom (note: condoms will not prevent transmission of mpox but may stop people from developing penile and anal lesions and can prevent other sexually transmitted infections)
  • perform hand hygiene after condom use especially if:
    • having sex while travelling 
    • attending sex-on-site venues or events where intimate or sexual contact with multiple people occurs (noting that condoms are not sufficient to stop transmission of mpox and mpox may also transmit in these settings via fomites, such as clothes/linen)
  • refrain from sexual contact for 3 weeks if you have been in a setting where mpox transmission may have occurred
  • self-monitor for mpox symptoms and seek healthcare advice if symptoms develop
  • if travelling to countries where mpox is endemic (particularly Central and West Africa):
    • check the SafeTravel (external link) advice prior to departure
    • avoid contact with animals that may be infected with monkeypox virus, including rodents, other mammals, and primates, and avoid handling or eating wild game and bushmeat.

Proactive engagement with specific settings

To minimise the risk of an outbreak occurring at sex-on-site venues, public health services should encourage venues to implement the following preventative measures.

• Display informative posters and provide clear information about:
  • the potential for transmission through sexual and close contact and how this can be prevented
  • vaccination
  • how to identify symptoms
  • encouragement to seek medical assessment and testing if symptoms develop.
• Ensure appropriate infection prevention and control measures are taken to prevent the spread of mpox including routine cleaning, disinfection, and waste disposal.

To minimise the risk of an outbreak occurring at a festival or other large event, public health services should work with event organisers to implement the following preventative measures.

• Support proactive communications and social media about the risk of mpox and engage with appropriate stakeholders to facilitate this.
• Coordinate information and/or pop-up vaccination stalls at the event.
• Encourage the use of information resources (e.g. posters, pamphlets) in the setting to inform of the risk of mpox, how it is spread, symptoms to be aware of.
• Ensure appropriate infection prevention and control measures are in place to prevent the spread of mpox.

Confirmed: a person with laboratory definitive evidence.

Probable: a person who meets the clinical and epidemiological criteria and mpox is the most likely diagnosis, and laboratory testing for mpox is not possible (e.g. because lesions have healed, or the person has left the country).

Under investigation: a person who has been reported to a medical officer of health, but information is not yet available to classify them as confirmed, probable or not a case. 

Not a case: a person who has been investigated and subsequently found not to meet the case definition. This includes people who meet the clinical and epidemiological criteria and have a negative monkeypox virus (MPXV) polymerase chain reaction (PCR) test result from a swab from skin or mucosal lesion.

A clinically compatible illness characterised by the presence of one or more acute unexplained^b skin and/or mucosal lesion(s) or proctitis (anorectal pain, bleeding, discharge).

^b_{More common causes of acute rashes with similar appearances should be considered and excluded where possible; varicella zoster, herpes simplex, syphilis, molluscum contagiosum.} 

At least one of the following in the 21 days before symptom onset:

• close contact^c with a confirmed or probable case
• travel to an area where mpox is endemic or there is sustained human-to-human transmission of mpox^d
• history of intimate or sexual contact with:
  • gay, bisexual, takatāpui or other men who have sex with men (GBMSM) or
  • individual(s) at an event associated with mpox cases who have engaged in activities that could lead to transmission.  

^c _{Close contact: Direct contact with skin lesions or mucous membranes of a case (i.e. skin to skin, skin to mucous membranes, mucous membrane to mucous membrane) through close physical, intimate or sexual contact OR Direct contact with potentially contaminated materials (bed linens, towels, clothing, healthcare equipment) from a case which may contain crusts from lesions or bodily fluids from a case.}

^d _{Per WHO (external link) and Mpox: affected countries - GOV.UK (external link)}

Laboratory definitive evidence: laboratory confirmation requires MPXV detection by PCR from a swab from a skin or mucosal lesion.

Refer to Appendix 4 for the direct laboratory notification process for mpox.

Testing may be carried out for the following reasons.

• To confirm or exclude a diagnosis of mpox in suspected cases.
• To confirm the mpox clade type.
• To guide in the management, control and prevention of mpox cases.

Approval from the medical officer of health or the clinical microbiologist is not required for mpox testing. There may be regional variation, and some clinical microbiologists do triage mpox testing.

The medical officer of health should discuss the following with the on-call clinical microbiologist.

• Urgent mpox testing for immunocompromised patients or cases requiring immediate public health action (e.g. a high priority exposure event). If agreed, the on-call clinical microbiologist will arrange prompt processing with the laboratory. Samples that require urgent processing should be marked 'Urgent Public Health'.
• If clade typing is indicated (refer to clade I and clade II typing below).
• Testing options for close contacts with prodromal symptoms.

Laboratory definitive evidence for a confirmed case requires monkeypox virus (MPXV) detection by polymerase chain reaction (PCR) testing from an appropriate sample (swabs from skin or deroofed mucosal lesions). A positive MPXV laboratory result indicates the patient is actively infected at the time of testing.

Monkeypox virus polymerase chain reaction (MPXV PCR)

Polymerase chain reaction tests (and other nucleic acid amplification tests) have good sensitivity, especially if more than one lesion has been sampled. The test is carried out using material collected from skin/mucosal lesions, dry crusts from scabbed lesions or fluid collected from pustules using a swab in universal transport medium. Multiple (up to 3) samples of lesions are recommended for each person.

In cases where the clinical diagnosis is consistent with mpox and the MPXV PCR is negative, discussion with a clinical microbiologist is recommended. Repeat MPXV testing may be recommended along with additional testing to exclude other causes of the symptoms.

Samples are processed throughout the country. Turnaround times may vary depending on swab transport times to the processing laboratory, routine testing or increased testing demand.

Clade I and clade II typing

Samples can be referred to the New Zealand Institute for Public Health and Forensic Science (PHF Science) for clade identification if this cannot be undertaken by the local laboratory.

Situations when clade identification is indicated include:

• an epidemiological link to an area with known clade I infections (refer to WHO (external link) and Mpox: affected countries - GOV.UK) (external link)
• where the case is a child aged under 16 years, or someone without known gay, bisexual, takatāpui or other men who have sex with men (GBMSM) in their sexual network
• severe presentation requiring hospitalisation (if not linked to a clade II case).

Clade identification should be considered depending on evolving epidemiology when there is any sporadic case with unknown source and without other indications for clade identification. Clade identification is not indicated when there is an epidemiological link to known clade II case.

Whole genome sequencing

Subclade testing for clade I or clade II mpox will not be routinely undertaken as it does not change the management of cases. However, if subclade identification is considered necessary, a discussion with the National Protection Clinical team is required. Samples can be referred to PHF Science for whole genome sequencing (WGS) to determine the clade subtype after discussion with the clinical microbiologist.

Current indications for WGS are:

• clade I isolate identified on clade specific PCR
• clade II isolate identified on clade specific PCR where there is an epidemiological link to clade IIa cases.

There may be other indications for WGS to support public health responses as the international epidemiology changes.

Mpox became a notifiable infectious disease in Schedule 1 of the Health Act 1956 in 2022. This means clinicians must notify the local medical officer of health of all confirmed, probable and suspected cases of mpox, and laboratories must notify all positive mpox PCR results.

The local public health service should commence case investigation and ensure complete information is entered into the appropriate surveillance database for notifiable diseases (i.e. EpiSurv) ideally within one working day of notification.

Clade II

Clinicians must notify the local medical officer of health as soon as possible in any of the following situations:

• a positive mpox PCR result
• where there is a high index of suspicion of a clade II case (i.e. the clinician considers the clinical and epidemiological criteria to be met)
• the suspected case attended, and was involved in increased transmission-risk activities at, a large event where (if mpox is confirmed) an outbreak could occur.

For all other suspected clade II mpox cases, clinicians should follow local processes to notify the local medical officer of health. Where testing of suspected cases is being undertaken by a sexual health or infectious disease clinician with expertise in mpox, as part of broad sexually transmitted infection testing and there is not a high index of suspicion or public health implications (such as links to events/potential outbreaks), notification to the local medical officer of health need only occur if/when mpox is confirmed.

Clade I

Clinicians must notify the local medical officer of health (by phone) as soon as possible of all suspected clade I cases (i.e. the attending clinician considers the clinical and epidemiological criteria to be met and clade I is considered more likely). Refer to clade I risk assessment for detailed guidance.

Suspected clade I cases should be notified as 'under investigation' pending test results.

When escalating nationally, any identifiable information about the case should not be included. If providing clinical information, this should only be shared with the National Protection Clinical team. A template email is available for use: click here (external link) and select 'download'.

Refer to Appendix 5: Escalation pathways for more information.  

Clade II

National escalation is not required for suspected clade II cases. For probable and confirmed clade II cases national escalation is not routinely required but is recommended in the following situations.

• An outbreak is suspected or confirmed (noting that notification to national team is for awareness purposes only, unless additional support is required).
• The case is in a demographic group not usually associated with clade II mpox (e.g. children/adolescents (aged under 16 years) or someone who does not have known GBMSM in their sexual network.  
• Media interest is likely. 
• There is a public health concern.
• A national focal point (NFP) notification is being considered (refer to international reporting below).

Clade I

National escalation is required as soon as possible for all suspected, probable and confirmed clade I mpox cases.

The World Health Organization (WHO) has declared mpox a public health emergency of international concern (PHEIC) twice, the first time in July 2022 and the second time in August 2024. The status of mpox as a PHEIC was lifted in September 2025.

National focal point (NFP) notifications of individual cases or contacts

Clade II

An NFP to inform other countries of clade II mpox cases or contacts who have travelled or returned to their country is only required if the medical officer of health considers the individual poses a significant risk to public health in that country. A risk assessment to determine if an NFP notification is warranted will not be done by the medical officer of health alone but in consultation with the National Protection Clinical team and Office of the Director of Public Health.

Careful consideration should be given to the potential negative impacts of an NFP notification for the individuals involved and the wider community, particularly in countries where some sexual behaviours including homosexuality are illegal. 

Clade I

National focal point notifications to inform other countries of clade I mpox cases or contacts who have travelled or returned to their country is required if the medical officer of health considers the individual poses a significant risk to public health in that country.

Mpox is a high-priority disease requiring urgent public health risk assessment.

Clade II requires a public health response to limit the risk of transmission within communities.

Clade I is an emerging high-priority disease that requires urgent public health response due to the limited evidence on transmissibility and severity in settings outside Africa, and potential to affect different population groups.

A manaaki-centred approach to case follow up is crucial for establishing relationships and trust between public health services, cases and their contacts. For more information on this approach refer to the Equity and Tū Kōkiritia chapters.

As mpox may infrequently require a period of isolation due to the long infectious period, restrictions and exclusions (including from employment or school), there needs to be considerations around manaaki and how care is provided. For any cases required to isolate, a care management plan should be developed in consultation with the case (and their whānau/caregivers as appropriate). The following approaches should be taken when engaging with cases, contacts and their whānau/caregivers.

• The stigma of mpox may be a cause of distress for cases. Remember that mpox can potentially affect anyone, not only GBMSM and those with GBMSM in their sexual networks.
  • GBMSM represent a broad spectrum of sexual behaviours and identities — from openly out as gay and/or bisexual to discreetly private.
  • Mpox cases that are likely sexually acquired require discreet and sensitive approaches with strong reassurances of their privacy being protected. Public health services will need to build trust with cases and work in partnership to navigate contact tracing and any necessary notifications to others.
  • Where appropriate, consider engaging with local sexual health services to ensure alignment of care.
  • Mpox cases in women and people who do not have sex with GBMSM may require support to understand that mpox may be transmitted through heterosexual sexual contact, and/or close non-sexual contact.
  • Where there is an mpox case in a child, the whānau/caregivers may require support to understand that the virus may be transmitted through close non-sexual contact (such as hugging, sharing a bed). This will most likely occur in the context of clade I mpox.
• Consistently communicate in a caring, sensitive and non-judgemental manner. Building a genuine and trusted relationship with cases in an authentically culturally responsive manner is consistent with approaches applied across all culturally diverse communities. Where possible, it is recommended that public health services assign one individual to manage all cases for continuity and consistency of care when there is a cluster/outbreak. Consider tone, non-stigmatising language and where appropriate, reducing use of gendered language to avoid creating stigma and shame.
• Work with all the appropriate clinical and support services while maintaining confidentiality and privacy. Key regional partners may include primary care, sexual health services, cultural health services/providers and infectious disease clinicians depending on who is providing clinical care for the case to ensure they receive appropriate care and support.

For more information on accessing manaaki (support) and welfare assistance, refer to Appendix 7: Manaaki and Welfare. 

Response procedure

On receiving the notification, the local public health service should check with the testing clinician if the case has been advised they will be contacted by the public health service and ensure that the:

• diagnosis is confirmed and, where possible, the testing clinician is aware of the result (if notified by a laboratory)
• appropriate samples are taken (if not done already) to:
  • confirm the diagnosis of mpox (if notified by a clinician)
  • test for other sexually transmitted infections (if appropriate), including syphilis and HIV, to ensure prompt initiation of treatment by their clinician
• clinical staff caring for the case are following infection prevention and control guidelines, if case is hospitalised
• case is:
  • informed of possible/confirmed diagnosis (recognising differentials and co-infections)
  • provided with the appropriate isolation/restriction advice to prevent transmission and knows how to seek medical care as needed.

As soon as possible, within 24 hours from notification, the local public health service should begin a clade I mpox risk assessment for all suspected, probable, and confirmed cases to determine if clade I mpox should be suspected and if there are any other risk factors for early escalation. If clade I mpox is suspected, a full case investigation should be prioritised and the National Protection Clinical team should be informed using the usual escalation pathway. 

This section provides guidance on restriction measures for clade II mpox cases. For clade I guidance, refer to isolation and restriction ­— clade I section.

Restrictions for clade II cases

Clade II cases (including suspected cases) are not routinely required to isolate. However, restrictions to prevent transmission are required until the case is no longer considered infectious (refer to key restrictions for community clade II cases to prevent transmission section for details).

Community clade II cases

A risk assessment should be undertaken to determine which restrictions or exclusions are required. The risk assessment should consider the number and location of lesions (including the presence of oral lesions), whether lesions can be appropriately covered, and the type of work or activities the case does.

Key restrictions for community clade II cases to prevent transmission

• Do not have intimate or sexual contact (including intimate touching and the use of sex toys) with others until no longer infectious (refer to release from restrictions for clade II cases).
• Cover skin lesions (where possible) when around others (e.g. using dressings, adhesive bandages/plasters or clothing).

The following additional restrictions are recommended for all clade II cases.

• Wash hands frequently.
• Limit close contact with household members where possible by:
  • sleeping in a separate bed and ideally a separate room. Where this is not possible, ensure lesions are covered using dressings and pyjamas and separate bedding is used by the case
  • not sharing clothing, bedding or towels and washing these items separately from other household laundry
  • not sharing cutlery or crockery
  • cleaning shared spaces after use.
• Avoid direct contact with other people, particularly those who are at higher risk of severe disease (e.g. infants and young children, individuals who are immunocompromised or pregnant). Where this is not possible the medical officer of health should risk assess on a case-by-case basis to allow for appropriate precautions to be put in place for the situation.
• Avoid direct contact with animals, especially domestic animals (such as cats, dogs) by:
  • covering skin lesions to avoid contact through licking, biting or sniffing etc.
  • keeping pets away from beds and bedding used by the case.
• To prevent secondary infection and spread of lesions:
  • avoid scratching lesions or touching eyes after touching lesions, which may result in auto-inoculation and more severe illness
  • avoid use of contact lenses to prevent infection of the eyes. Where this is not possible, ensure hands are thoroughly washed prior to touching lenses or eyes, and that there are no open lesions on hands (cover these where present).
• Do not donate blood, cells, tissue, breast milk, semen, organs or faeces.
• Dispose of all waste in a safe manner which is not accessible to animals.

Accessing healthcare: if the case requires in-person access to healthcare, the public health service should ensure that the healthcare provider is aware the person has mpox (or is suspected of having clade II mpox) so that appropriate infection prevention and control (IPC) measures can be put in place for staff and others. The case should be advised to cover lesions and wear a mask.

Breastfeeding: public health services should liaise with the lead maternity carer to advise on a plan to support breastfeeding. The World Health Organization advises that cases who are breastfeeding can continue to breastfeed provided there are no lesions in direct contact with the infant [26].

To reduce the risk of transmission, they should wash their hands before and after feeding, wear a medical mask and cover any lesions on areas which have direct contact with the infant.

If there are lesions on the areola, the case should be advised to express and discard milk from that breast and feed with the other until lesions are fully resolved (i.e. all lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath). If lesions are present on both breasts, cases should consider non-breast milk alternatives until lesions are healed and breastfeeding can resume. 

Work exclusions

The medical officer of health should determine if exclusion from attending work or school is required. This may be appropriate if lesions cannot be covered and the case works in occupations where close physical contact is required or cannot be avoided (e.g. with young children, disability support services or carers), particularly if the setting includes individuals at higher risk of severe disease.

Decisions about work exclusion for clade II cases who work in healthcare settings should be made in consultation with the relevant occupational health and/or IPC team if available, only sharing information relevant for lowering the risk of transmission.

Hospitalised clade II cases

Hospitalised clade II cases should be placed in a single room with their own bathroom. Refer to infection prevention and control section for details of the IPC requirements for staff caring for mpox cases in healthcare settings.

To ensure the privacy of the case is maintained, public health services should engage and liaise with clinicians, IPC and occupational health teams as soon as possible after notification.

If the case is still infectious at the time of discharge from hospital, public health services should take over the care of the case. They should be managed as community cases and provided guidance for preventing onwards transmission at home (included in the case information letter and mpox information sheet (external link)).

Release from restrictions for clade II cases

Cases can be released from restrictions when the medical officer of health has determined they are no longer infectious.

Cases are no longer infectious once:

• all lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath
• or for cases with no visible lesions, either proctitis symptoms have resolved or it has been 21 days since diagnosis (whichever is sooner).

This can be determined through:

• review by a sexual health or other clinician familiar with clinical mpox who can advise the public health service when all lesions have healed
• review of lesions via a video call with the case, or review of photographic evidence provided by the case
• the case’s assertion of resolved symptoms, where there is a trusted relationship between the public health service and a case.

Cases should be sent the release from public health management letter (refer to advice to case section for detailed guidance).

This section provides guidance on isolation and restriction measures for clade I mpox cases. For clade II guidance, refer to isolation and restriction — clade II section.

Isolation for clade I community cases

Confirmed and probable cases are required to isolate for the duration of their infectious period. They should only leave their house in an emergency or to access urgent healthcare.

Suspected clade I cases must isolate until clade typing results are known; or for symptomatic clade I close contacts being managed as suspected clade I cases, until PCR results are known (refer to symptomatic clade I close contacts section for management of those with prodromal symptoms only).

In addition to isolation, the following restrictions to prevent transmission are required until the case is no longer considered infectious.

Key restrictions to prevent transmission to household members

• Do not have sexual contact (including kissing, intimate touching) and avoid physical contact with others.
• Cover skin lesions (where possible) when around others (e.g. using dressings, adhesive bandages/plasters or clothing).

The following additional restrictions are recommended for all clade I cases.

• Wear a surgical mask when in the same room as others (even if no oral lesions or pharyngitis are present).
• Wash hands frequently.
• While isolating, avoid direct contact with household members, particularly those who are at higher risk of severe disease (e.g. infants and young children, individuals who are immunocompromised or pregnant). Where this is not possible the medical officer of health should risk assess on a case-by-case basis to allow for appropriate restrictions to be put in place for the situation.
• Limit close contact with household members by:
  • sleeping in a separate bed and ideally a separate room. Where this is not possible, ensure lesions are covered using dressings and pyjamas and separate bedding is used by the case
  • not sharing clothing, bedding or towels and washing these items separately from other household laundry
  • not sharing cutlery or crockery
  • cleaning shared spaces after use.
• Avoid direct contact with animals, especially domestic animals (such as cats, dogs) by:
  • covering skin lesions to avoid contact through licking, biting or sniffing etc.
  • keeping pets away from beds and bedding used by the case.
• To prevent secondary infection and spread of lesions:
  • avoid scratching lesions or touching eyes after touching lesions, which may result in auto-inoculation and more severe illness
  • avoid use of contact lenses to prevent infection of the eyes. Where this is not possible, ensure hands are thoroughly washed prior to touching lenses or eyes, and that there are no open lesions on hands (cover these where present).
• Do not donate blood, cells, tissue, breast milk, semen, organs or faeces.
• Dispose of all waste in a safe manner which is not accessible to animals.

Accessing healthcare: if the case requires in-person access to healthcare, the public health service should ensure that the healthcare provider is aware the person has clade I mpox (or is suspected of having clade I mpox) so that appropriate IPC measures can be put in place for staff and others. The case should be advised to cover lesions and wear a mask. 

Breastfeeding: public health services should liaise with the lead maternity carer to advise on a plan to support breastfeeding. The World Health Organization advises that cases who are breastfeeding can continue to breastfeed provided there are no lesions in direct contact with the infant [26].

To reduce the risk of transmission, they should wash their hands before and after feeding, wear a medical mask and cover any lesions on areas which have direct contact with the infant.

If there are lesions on the areola, the case should be advised to express and discard milk from that breast and feed with the other until lesions are fully resolved (i.e. all lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath). If lesions are present on both breasts, cases should consider non-breast milk alternatives until lesions are healed and breastfeeding can resume.

Hospitalised clade I cases

To ensure the privacy of the case is maintained, public health services should engage and liaise with clinicians, IPC and occupational health teams as soon as possible after notification.

Suspected, confirmed and probable clade I cases should be isolated in an airborne infection isolation room. Refer to the infection prevention and control section for details of the IPC requirements for staff caring for clade I cases in a healthcare setting.

After cases are discharged from hospital they should be managed as community cases and provided guidance for preventing onwards transmission at home (included in the case information letter and mpox information sheet (external link)). 

Release from isolation and restrictions for clade I cases

Cases can be released from isolation and restrictions when the medical officer of health has determined they are no longer infectious.

Cases are no longer infectious once:

• all lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath
• or for cases with no visible lesions (e.g. proctitis), either all symptoms have resolved or it has been 21 days since diagnosis (whichever is sooner).

Which may be determined through:

• review by a sexual health or other clinician familiar with clinical mpox who will advise the public health service when all lesions are healed
• review of lesions via a video call with the case, or review photographic evidence provided by the case.

Cases should be sent the release from public health management letter (refer to advice to case section for detailed guidance).

Public health services should monitor cases in a manner appropriate to the individual (via phone, text message, email or NZ Relay (external link)) until the end of their infectious period.

• For clade II cases, the frequency and method of monitoring is at the discretion of the medical officer of health.
• For clade I cases, daily active monitoring should occur.

If the case is hospitalised, regular check ins with the clinical team on disease progression is recommended with public health monitoring to commence once the case is discharged (if still infectious). 

When monitoring, public health services should:

• check if the case is having difficulty following the recommended isolation and/or restrictions and discuss any mitigations for this
• ensure welfare and support needs are being met
• evaluate symptom deterioration providing a plan for seeking healthcare
• review resolution of symptoms and release from public health management
• ensure the case is able to contact their local public health service to seek advice or support where required.

Public health services should liaise with the relevant clinician(s) as required for symptom management advice. 

Treatment for all mpox cases focuses on relieving symptoms. Most cases recover within 2 to 4 weeks and will not require specific treatment other than good supportive management or treatment of complications (e.g. pain relief and antibiotics for secondary cellulitis). Antihistamines and other topical solutions/sitz baths can be used for pain and itch relief.

When required, advice on clinical management can be sought from an infectious disease clinician, a sexual health clinician or another clinician with experience managing mpox.

The use of antivirals (tecovirimat) could be considered by an infectious disease or sexual health clinician for cases with severe symptoms or those at higher risk of severe disease (e.g. infants and young children, individuals who are immunocompromised^g or pregnant, or who have significant skin integrity issues, or extensive lesions at an anatomic site that could lead to complications). For cases aged under 15 years, discuss with a paediatric infectious disease clinician/consultant.

People who are post-partum should also be considered for treatment due to their close contact with their newborn after birth (as infants are at increased risk of severe disease). More information on mpox for clinicians is available on HealthPathways.

Cases with proctitis should have a clinical review by a sexual health clinician (or similar) to ensure that management is appropriate and includes testing for other sexually transmitted infections that may be present and require treatment (e.g. herpes simplex virus).

^g _{People with HIV are recognised to be at higher risk but those with HIV on antiviral treatment are not considered immunocompromised.}

Provide all mpox cases (or their relevant caregiver) with the appropriate case information letter and mpox information sheet (external link) for the mpox clade they are suspected (or confirmed) to have. These provide information about mpox, the nature of the infection and the mode of transmission, explain the isolation and/or restrictions that are required to prevent transmission to others and where to get further advice and support.

Public health services should ensure communication is provided in an accessible format and is culturally and language appropriate. The letters provide the case with contact details for their local public health service so that they can seek advice or non-clinical support if needed.

In particular, it is important that the case understands:

• what isolation means (i.e. staying home except to access urgent healthcare, avoiding close contact with others in their household and particularly those at higher risk of severe disease) — isolation applies to clade I cases only
• the restriction measures or activities and settings to avoid while infectious
• which individuals are at higher risk of severe disease and how to limit the risk of transmission
• what to do if symptoms require clinical support
• that public health services will engage regularly with them during their infectious period to provide support, advice and check on their (and their whānau’s) wellbeing.

Refer to Appendix 7: Manaaki and Welfare for a list of the welfare support (including weblinks) to consider for all cases.

Once the case has received clearance and been released from isolation/restrictions, they should be sent the release from public health management letter (external link) which includes information advising them that:

• as the virus may still be present in semen, they should:
  • use a condom during sexual activity (receptive and insertive oral/anal/vaginal sex) for the next 12 weeks
  • seek guidance from their relevant clinician if they (or their partner) are planning to get pregnant 
• protection from infection is not lifelong and how they can reduce the risk of future re-infection.

The primary goal of contact tracing for mpox is to enable early identification of any secondary cases and prevent onward transmission. Contact tracing should be initiated as soon as possible. Where prioritisation is required, public health services should prioritise follow-up of contacts with the highest risk of exposure and contacts at risk of severe disease. Refer to at risk and priority populations for more information.

Manaaki (wellbeing) considerations are the same for cases and contacts. Refer to the manaakitanga/manaaki in practice section in the case management section for guidance.

This section provides the definitions for the 2 categories of clade II mpox contacts — close contacts and casual contacts. For clade I definitions, refer to definitions ­— clade I section.

This section provides the definitions for the 2 categories of clade I mpox contacts — close contacts and casual contacts. For clade II definitions, refer to definitions ­— clade II section.

Contact investigation for both clades should focus on:

• identifying individuals who had close contact with an infectious case from the start of their prodrome symptoms (or 24 hours before lesion or rash onset for cases without prodrome) until all lesions are healed
• determining the extent of the contact’s exposure to the case (refer to contact definitions)
• determining the immune/vaccination status of the contact
• determining the restriction and active monitoring period for close contacts
• assessing (if possible) whether the contact is at higher risk of severe disease (e.g. infants and young children, individuals who are immunocompromised or pregnant) and liaise with clinical team as appropriate
• determining the appropriateness of post-exposure vaccination if not already fully vaccinated (including children)
• referring contacts who develop symptoms/skin lesions to a health provider for urgent clinical assessment and testing
• providing clear advice around activities that should be restricted and actions to take to prevent transmission
• conducting a case-by-case assessment of risk to release contacts from restrictions.

Where public health services are not able to identify or follow up contacts directly (e.g. where sexual contact has been anonymous, or cases are unwilling or unable to provide details of contact) other communication options for identifying and communicating with close contacts should be explored. This could include:

• asking cases to inform their contacts of their exposure and the actions they should take. Public health services should provide cases with the contact information letter and mpox information sheet to facilitate this (refer to advice to contact section) 
• providing the case with messaging that can be shared with people they think may be at risk, through social media or ‘hookup’ apps.

This section provides guidance on restriction measures for clade II mpox contacts. For clade I guidance, refer to quarantine and restriction ­— clade I section.

Clade II

This section provides guidance on quarantine and restriction measures for clade I mpox contacts. For clade II guidance, refer to quarantine and restriction ­— clade II section.

General information for clade I close contacts

Clade I close contacts are not required to quarantine.  

For 21 days after their last exposure to a case, the following restrictions are recommended to reduce the risk of transmitting mpox to others should the contact become a case. 

• Not engage in intimate and sexual contact with others.
• Avoid any close physical contact with others, particularly those at higher risk of severe disease (e.g. infants and young children, individuals who are immunocompromised or pregnant).
• Not attend high-priority settings (including education and healthcare settings) and any other settings at the discretion of the medical officer of health (refer to exclusions for clade I close contacts). If needing to access in-person healthcare, they should phone ahead and alert the service that they are a close contact of an mpox case so actions can be taken to limit the risk of transmission and wear a surgical mask when attending.
• Not donate blood, cells, tissue, breast milk, semen, organs or faeces.
• Not travel internationally. Domestic travel should be risk assessed by the medical officer of health and discussed with the National Protection Clinical team.

Close contacts should be advised to practice good hand hygiene. They should also self-monitor for symptoms and seek advice from their healthcare provider or public health team if these develop (refer to symptomatic clade I close contacts section for further guidance).

Close contacts should not engage in intimate and sexual contact because lesions can be difficult to detect, which means the contact could spread mpox to others before they are aware they are infected. This is more likely if there are small numbers of lesions or the lesions are small, which may be more likely in vaccinated cases, or the lesions are in positions that make them difficult to see.

Exclusions for clade I close contacts

Clade I close contacts should generally be excluded from working in high-priority settings and attending or working in schools and early childhood education centres until they are no longer at risk of infection. However, an earlier return to work or school may be appropriate in some circumstances based on an individual risk assessment which includes an assessment of the ability of the contact to follow all public health advice to prevent transmission. 

For other work settings, exclusion may be appropriate if the contact works in occupations where close physical contact is required or cannot be avoided (e.g. with young children), or if the setting includes individuals at risk of severe symptoms. This will be at the discretion of the medical officer of health.

Where the contact is a healthcare worker in a setting where there is an occupational health team, the public health service should inform occupational health (and/or IPC team, if available) and seek their advice regarding return to work.

Where return to work/education is agreed, restrictions may include:

• practicing good hand hygiene
• wearing a surgical mask
• avoiding non-essential outings, especially to crowded settings
• avoiding contact with animals.

Symptomatic clade I close contacts

Clade I close contacts who develop symptoms/skin lesions should be isolated and managed as suspected clade I cases until PCR results are known (refer to isolation for clade I community cases section). A precautionary approach is recommended for those with prodromal symptoms only which includes advising the contact to stay at home and continue to follow the restrictions under general information for clade I close contacts until further symptoms develop and testing can be performed, or all symptoms resolve. Discussion with the National Protection Clinical team is recommended for all symptomatic clade I close contacts.

Where testing is possible and appropriate given the contact’s symptoms (i.e. presence of one or more lesions), liaison with local infectious disease team and/or if appropriate sexual or primary health providers, should be undertaken to arrange priority testing. Testing of contacts with prodromal symptoms is not generally recommended. However, PCR testing of mucosal sites (throat or anus) may be considered if it will support public health management. Discussion with the clinical microbiologist is required. Refer to laboratory testing guidelines section for more information.

Release of clade I close contacts from public health follow up

The public health service will conduct a case-by-case assessment of risk regarding return to work/education.

Close contacts can be released from public health follow up (unless symptomatic) 21 days after their last exposure to a case at the discretion of the medical officer of health.  

General information for clade I casual contacts

As for clade II casual contacts, no precautions are required.  

Monitoring of close contacts (both clades)

Public health services should actively monitor close contacts in a manner appropriate to the individual (via phone, text message, email or NZ Relay (external link)) for 21 days after their last close contact with the mpox case. Alternatively, clade II close contacts may self-monitor if considered appropriate by the medical officer of health.

Daily monitoring is not required, and the frequency of monitoring can be determined by the public health service after discussion with the contact.

Monitoring of casual contacts (both clades)

No monitoring by public health services is required for casual contacts.

Close contacts (including children) who have not had 2 mpox vaccine (MPV) doses should be offered a single dose of MPV to help prevent or attenuate (lessen the severity of) mpox if they become a case. This should be arranged by the public health service. Post-exposure vaccination is most effective if given within 4 days of exposure and can be given up to 14 days after exposure.

Close contacts who receive their first MPV as post-exposure vaccination should be advised to have a second dose of MPV 4 weeks later if they remain mpox symptom free and are eligible for vaccination due to having an ongoing risk of exposure to mpox.

Contacts outside of the 14-day window for post-exposure vaccination should be offered vaccination if there is an ongoing risk of exposure or if they meet other eligibility criteria.

Children and adolescents

Mpox vaccination is strongly recommended for close contacts aged under 18 years as they are at higher risk of severe disease. As MPV is not approved for use in this age group, a prescription is required from an authorised prescriber. Refer to the routine prevention section for more information.

Refer to the Immunisation Handbook mpox chapter for more detailed information on the mpox vaccine.

For both clade I and clade II mpox contacts, provide them (or their relevant caregiver) with the appropriate contact information letter and mpox information sheet (external link) for the mpox clade they were exposed to. These provide information about mpox, the nature of the infection and the mode of transmission, explain the restrictions that are required to prevent transmission to others and where to get further advice and support. 

These resources can also be used by the case to send to any potential contacts. Ensure communication is provided in an accessible format and is culturally and language appropriate.

In particular, it is important that the contact understands:

• which activities and settings to avoid
• which symptoms to look out for and what to do if they develop (i.e. isolate/restrict contact and get tested)
• the importance of immunisation for post-exposure prophylaxis or prevention for those with ongoing exposure risk but that protection from immunisation or infection is not lifelong.

Refer to Appendix 7: Manaaki and Welfare (external link) for a list of the welfare support (including weblinks) to consider for all contacts.

The primary goal of exposure event management is to prevent and control transmission of mpox within a setting and prevent spread to the community.

Exposure event management involves:

• promptly identifying exposure settings
• undertaking a risk assessment to determine the risk of ongoing transmission in the setting and/or onward transmission to the wider community
• working with setting management to:
  • identify close contacts (or ensure information can be provided to them)
  • support communication
  • implement infection prevention and control (IPC) practices.

During case investigation, public health services should identify all places or settings a case attended during their infectious period, where an exposure may have occurred, and log these as exposure events. Public health services should identify all exposure events for probable and confirmed mpox cases, and for suspected cases where there is a high index of suspicion for clade I mpox and/or if the setting or event is associated with a higher risk of transmission.

The local public health service is responsible for identifying and investigating exposure events to:

• determine the risk of transmission in the setting and the risk of wider community transmission
• classify contacts as close and/or casual (refer to contact management)
• identify (if possible) contacts who are at higher risk of severe disease and/or those who may benefit from post-exposure prophylaxis so they can be prioritised for follow up.

Outcomes of the risk assessment will determine the extent and urgency of public health action.

Information to inform the risk assessment may come from interviews with the case, contacts or setting management personnel.

The risk assessment should consider (but is not limited to) the factors outlined in Table 4. 

Setting management

The following principles should be applied by public health services during assessment and management of an exposure event.

• Ensuring (and re-assuring) that the privacy and confidentiality of the case and their contacts will be maintained.
• Empowering cases to enable sharing of contact tracing information to those at risk (i.e. their contacts).
• Providing appropriate infection prevention and control (IPC) information to decrease the risk of transmission.
• Working collaboratively with venues or event organisers to develop a good relationship to ensure public health action is successful.

If the local public health service has not had experience managing mpox exposure events it is recommended that they seek guidance from the National Protection Clinical team or another medical officer of health with relevant experience for support.

The public health service should work with exposure event setting managers, organisers or leaders, alongside relevant stakeholders and cultural advisors (e.g. Rainbow advocates/leaders/organisations) as required. When interacting with hāpori (community) Māori settings such as marae and/or kōhanga, public health services should work alongside Māori leadership from within the setting for joint decision-making and guidance. When interacting with Pacific settings such as Pacific churches or Aoga Amata, public health services should work alongside Pacific leadership.

Public health service actions should include the following as required.

• Informing the setting manager or other appropriate person that an mpox case has attended their setting during their infectious period. This should be undertaken maintaining duty of confidentiality to the case.
• Providing information and advice about the disease.
• Requesting information to inform risk assessment and contact tracing including:
  • information about the setting, including details about IPC, cleaning and waste disposal processes
  • names and contact details of staff and any attendees who meet the close contact definition.
• Identifying and managing close contacts (refer to contact management section).
• Supporting communication from the setting manager to those connected with the setting (e.g. staff and attendees); this may include providing letters and information sheets.
• Communication to the public (particularly for clade I mpox cases and/or outbreaks), where necessary.

A high-priority setting (or event) is a setting where the nature of interaction may pose a higher risk of transmission and is determined by a risk assessment which considers the following factors.

For clade II mpox exposure events, where there is:

• a higher risk of community transmission (e.g. there are already multiple cases linked to the same event, or the event involved increased transmission-risk activities, or had a high proportion of contacts that are likely or known to be more socially/sexually active) 
• a high proportion of contacts who are at higher risk of severe disease
• potential for contacts to be widely dispersed (i.e. events attended by people from outside the local community, from multiple cities/regions such as Pride festivals and associated events).

For clade I mpox exposure events, additional considerations to those listed for clade II should include settings where there may be an increased risk of spread through other viable transmission routes, such as where there is:

• sustained contact with a case and/or large numbers of attendees or residents (e.g. households, shared accommodation settings or larger communal/multigenerational households, or shared transport)
• a higher risk of community transmission (e.g. a high proportion of contacts who are children).

For detailed operational guidance for the following high-priority settings refer to Guidance for management of specific high-priority settings for mpox exposure events (external link).

High-priority settings for both clade I and II mpox include:

• sex work related settings
• sex-on-site premises/venues or other organised events where anonymous sexual activity takes place
• large scale events (e.g. raves, festivals, community events, and other mass gatherings where there is likely to be prolonged close contact)
• healthcare settings — hospitals
• healthcare settings — primary care and other specialist services (e.g. sexual health clinics).

Additional high-priority settings for clade I mpox are:

• household settings
• shared accommodation settings (e.g. prisons, shelters, halls of residence, disability care, aged care and other residential facilities)
• early childhood education centres and school settings.

Healthcare settings

Where an exposure event is identified in a healthcare setting the local public health service should engage with IPC and occupational health teams. The local public health service should provide public health input into the risk assessment and contact tracing of staff and in-patients.

Settings without IPC or occupational health teams will be supported by public health services to identify and manage contacts.

Refer to healthcare settings guidance (external link) for more information about managing exposure events in healthcare settings.

Exposure events on flights and other shared transport

Flights and other shared transport may be considered exposure events in limited circumstances.  Management should be guided by a risk assessment carried out by the medical officer of health. This assessment should consider the mpox clade, the number and location of uncovered lesions, the likelihood that the case had direct physical contact with others on the flight or other shared transport, and the duration of time the case was present. All flight contact tracing should be discussed with the on-call medical officer of health from the National Protection Clinical team.

Clade II

Contact tracing for clade II mpox cases is generally not required but could be considered if the case was on a flight/shared transport during their infectious period with lesions not covered by dressings or clothing.

Passengers seated either side of the clade II case may be considered close contacts at the discretion of the medical officer of health.

Clade I (confirmed, probable or suspected)

Contact tracing for confirmed, probable or suspected clade I mpox cases is recommended in either of the following circumstances.

• The case was on a flight/shared transport during their infectious period with lesions not covered by dressings or clothing.
• The case was on a flight/shared transport during their infectious period for a duration of 3 hours or more, if the case had oral lesions or respiratory symptoms and was not wearing a mask.

For flights/shared transport of 3 hours or more where the case had oral lesions or respiratory symptoms and was not wearing a mask, passengers seated in the same row as the case as well as 2 rows in front of and behind the clade I case (i.e. 5 rows in total) should be considered close contacts.

For flights/shared transport of any duration, where the case had uncovered lesions, passengers seated on either side of the case should be considered close contacts.

Drivers and passengers (who were not wearing a mask) in the same vehicle as the case, if the case had oral lesions or respiratory symptoms and was not wearing a mask, are recommended to be considered close contacts at the discretion of the medical officer of health.

An outbreak of suspected or confirmed clade II mpox is defined as 2 or more cases associated in time, place or person. At least one case must have been laboratory confirmed. Where the index case acquired their infection overseas and a secondary case occurred in a household member or known sexual contact, this would not be considered an outbreak.

An outbreak of suspected or confirmed clade I mpox is defined as 2 or more cases associated in time, place or person. At least one case must have been laboratory confirmed.

If clade testing indicates cases connected by time, place and person are infected with different mpox clades, this would no longer meet the definition of an outbreak.

A single case of mpox does not meet the definition of an outbreak. However, a single case of confirmed or suspected clade I mpox warrants an urgent public health response with immediate national escalation (refer to national escalation section).

The overarching goal of Aotearoa New Zealand’s response activities is to eliminate mpox through early detection and management of imported cases and prevention and containment of outbreaks.

The specific response objectives for mpox are as follows.

• Provide effective and culturally appropriate public health management of cases, contacts and exposure events.
• Promote awareness about mpox, mpox vaccination and preventive measures among groups at risk.
• Increase awareness of mpox among clinicians to promote appropriate clinical care, testing, vaccination and notification to public health services.
• Ensure access to diagnostic consultations and testing for suspected cases.
• Maintain sufficient surveillance capability to rapidly detect cases and outbreaks. This includes the ability to detect any clade I cases.
• Monitor epidemiology and any changes to risk factors or at-risk groups.
• Communication and engagement with key stakeholders and the community.

Management of outbreaks

Individual cases and outbreaks will be managed by the local medical officer of health with support from regional and/or national teams as required.

The occurrence of an outbreak does not always indicate a significant increase in risk to the wider community. An assessment of risk will be made by the medical officer of health in consultation with regional and/or national teams as appropriate.

All outbreaks, including within a household, should be entered into the appropriate surveillance database for notifiable diseases (i.e. EpiSurv) and given an outbreak number. Refer to the notification and reporting section for notification and national escalation requirements.

Activities to support response objectives

During periods of sustained local transmission, public health services should encourage active case finding by:

• reminding local clinicians, sexual health clinics, emergency departments and laboratories to notify suspected cases of mpox to the local public health service immediately (this may be done by clinician alert or other means)
• considering the need for broader communications to assist in case finding. Refer to the exposure event management section for guidance on how to manage this alongside ensuring (and re-assuring) that the privacy and confidentiality of the case and their contacts will be maintained.

If considering vaccination for large scale events, this should be done in consultation with National Prevention Immunisation and Protection Clinical teams.

During an outbreak of mpox, public health services should inform and update key stakeholders such as primary care and urgent care providers, sexual health services, pharmacy providers, infection prevention and control and occupational health teams, laboratory providers and key communication agencies such as HealthPathways, Healthline etc.

National support and coordination

Support from national teams is always available.

A single case or outbreak of clade I mpox must be escalated nationally as soon as possible (refer to the notification and reporting section and Appendix 5: Escalation Pathways). National coordination will be activated following a discussion (usually an Initial Assessment Team meeting) between local and national teams (refer to Nationally Coordinated Response Plan for Outbreaks of Communicable Disease (external link)).

Determining when an outbreak is over

An outbreak can be declared over once there have been 2 full incubation periods (42 days) since the last day of the infectious period of the most recent case, or from the date of implementation of precautions to prevent onwards transmission by that case. However, this should be considered in the context of outbreak epidemiology and features of the response.

For more information

Refer to the following documents for more information.

• The Nationally Coordinated Response Plan for Outbreaks of Communicable Disease (external link) for guidance on a nationally coordinated response.
• The Guidelines for the investigation and control of disease outbreaks (external link) for a comprehensive guide on outbreak investigation and management.

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• Health NZ: Infection prevention and control — Specific guidance for Mpox (external link)
• Health NZ: Immunisation Handbook — Mpox chapter (external link)
• Case and contact management resources (external link) (including letters, information sheets, case and contact management chart and clade I risk assessment tool)
• Guidance for management of specific high-priority settings for mpox exposure events (external link)

We would like to acknowledge the effort, contribution and commitment of all members of the Mpox Clinical and Technical Advisory Group who have supported this work. Refer to Mpox CTAG membership (external link) for a full list of members.