Mpox

Mpox was first identified in Aotearoa New Zealand in July 2022. As of 7 May 2025, there have been 76 cases reported, of which 71% 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 2 further smaller outbreaks in December 2023 and September 2024. Most cases have been among GBMSM and their sexual networks and all cases tested for clade have been clade II mpox. 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) Notifiable Disease dashboard (external link) and the Immunisation Handbook mpox chapter for further information on the epidemiology of mpox in Aotearoa New Zealand.

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 predominately 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 August 2022, the World Health Organization (WHO) declared the multi-country clade IIb mpox outbreak a Public Health Emergency of International Concern (PHEIC) [4]. 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 [4]. 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 [5]. 

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 [6]. 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 [7]. Children are the largest demographic group impacted during outbreaks of clade I mpox in DRC [8,9] transmission likely via skin-to-skin exposure to lesions which is more likely to occur among household contacts [10]. 

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 [3,11]. There have also been sporadic travel-related cases of clade Ia mpox detected outside Africa since February 2025 [3].

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 [12].  

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).

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. 

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.

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

• 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'.
• Clade typing if not linked to cases where the clade type is already determined (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 (currently African countries, may later include others as outbreak progresses)
• 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.

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.

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 [50]. 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 [50].

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 [35,51,52])
• 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 [36,46]. 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 [22]
• vertical transmission during pregnancy [26–29]
• 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 [43,44,54]. 

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 [55]
• 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 [56]. 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 [57].

Depending on these factors, MPXV can persist on surfaces from days to weeks. Alcohol-based disinfectants provide effective control [58].

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 for 21 days after diagnosis or until symptoms resolve.

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 high-risk sexual 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.

All suspected cases should be investigated with an interview to determine symptom history including:

• onset date
• any travel history
• identification of any high-risk settings
• any exposure to a confirmed or probable case
• the nature of any contact with a confirmed or probable case
• sexual contact, and intimate partners within 21 days of symptom onset
• smallpox and mpox vaccination status
• other relevant clinical findings to exclude other common causes of rash.

Risk factors for severe disease

The suspected case should be assessed for risk factors that could cause them to experience more serious disease, including:

• age (very young children are at greater risk)
• having or having had a history of severe atopic eczema
• being pregnant or recently post-partum
• having extensive lesions at an anatomic site that could lead to complications
• being immunocompromised.

Where risk factors are present, consider involvement of additional clinicians from a relevant specialty.

Infection prevention control requirements

Contact and droplet precautions should be used in addition to standard precautions for physical examination of cases and when collecting samples from the lesions. Standard Precautions, Contact and Droplet Precautions(external link) (external link). This includes the use of eye protection, Type II fluid resistant medical mask, fluid repellent gown and gloves. Upgrade mask to an P2/N95 when undertaking medical procedures involving the oropharynx (oropharyngeal samples). A medical mask is sufficient for preliminary clinical assessment and handling used contaminated linen, clothing, or towels.

Suspected cases awaiting test results

When testing for mpox, the clinician should ascertain the person’s history and symptoms and liaise with public health if they think mpox is the likely clinical diagnosis.

Risk assessment

Restriction requirements will be decided by public health based on the following factors that increase risk of spread to others.

• Where the clinician has a very high index of suspicion that the person has mpox, such as those who are known sexual or intimate contacts of a case, or those who have attended a high-risk setting, such as a sex-on-site venue or festival, during their incubation period.
• The presence of oral mucous membrane lesions.
• The presence of lesions that are not able to be easily covered—for instance lesions on the face or hands.
• The presence of systemic symptoms, including cold or flu symptoms such as fever, body aches, vomiting or diarrhoea.

Those awaiting test results where there is a high index of clinical suspicion, are recommended to follow these precautions:

• not to have sexual or intimate activities, including kissing and hugging and all skin-to-skin contact with other people
• if they develop systemic symptoms, uncoverable or oral lesions while awaiting their test result, they should advise their clinician or public health representative
• to avoid, where possible, all face-to-face contact with people at high risk of serious disease from mpox. This includes being excluded from work or education if their usual activities are likely to bring them into direct skin-to-skin contact with high-risk people. High-risk groups include pregnant people, young children, people with severe atopic eczema, and immunocompromised people
• that they must inform any healthcare setting they plan on attending that they are awaiting the results of a test from mpox prior to attending.

For confirmed or probable cases

The medical officer of health will advise the case on their management plan. Probable and confirmed cases need to have a risk assessment carried out by public health and take precautions to prevent onward transmission. They must continue taking precautions until they are no longer infectious, which is until their lesions have crusted, the scab has fallen off and a fresh layer of skin has formed underneath (symptoms normally last 14–28 days).

Below are the precautions which may be put in place:

• Avoid physical contact, particularly sexual contact over this period (including kissing, intimate touching).
• Cover skin lesions (where possible) when around others.
• Where possible, sleep in a separate room and limit contact with household members.
• Do not share clothing, bedding, towels and unwashed crockery and cutlery.
• Avoid close direct contact with animals, including domestic animals, (such as cats, dogs, mice, and other rodents), livestock, and other captive animals, as well as wildlife due to the possibility of human-to-animal transmission.
• Dispose of all waste, including medical waste, in a safe manner which is not accessible to rodents and other scavenger animals.
• Where possible, 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.
• Avoid contact with people who are at risk of serious illness, including immunocompromised people, young children, people with a history of severe atopic eczema, and pregnant people. If this is not possible with the case’s living situation, this should be escalated to the medical officer of health.
• Inform healthcare providers of their diagnosis prior to visiting so that appropriate safeguards can be put in place for staff and other patients.

 Public Health follow up

Public Health should follow up cases at regular intervals via phone or email to check that symptoms are resolving and are well controlled. The medical officer of health will continue to assess whether the case should remain under restrictions. Such assessments must consider the cases occupation and workplace environment including presence of and contact with people at high risk of serious illness from mpox, ability to work from home, ability to physically distance at workplace, etc.

The following factors may be taken into account when considering removal of recommended precautions restrictions:

• It is at least 7 days since first rash/lesion onset.
• No new lesions for 48 hours.
• No oral mucous membrane lesions, or all oral mucous membrane lesions completely healed (scab has fallen off and fresh skin has formed underneath).
• No fever or other systemic symptoms due to mpox for 72 hours.
• All lesions on exposed skin (hands, arms, face) have scabbed over, the scab has fallen off and fresh skin has formed underneath or can adequately cover any unhealed lesions with a dressing and/or clothing.
• Not immunocompromised (note that a case with HIV who has an undetectable viral load would not be considered immunocompromised). Immunocompromised cases to be managed on a case-by-case basis with their treating clinician.

This may mean cases can return to work if deemed safe to do so by the medical officer of health.

If new symptoms develop which cause the medical officer of health to believe there is a greater risk to public health posed by the case, restrictions may again be put in place. It is anticipated this will be rare and exceptional.

Cases can be fully released from public health management when all lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath.

The medical officer of health will advise (either in person or via photographic evidence) that all lesions are healed and recommend lifting of restrictions.

Condom use during sexual activity (where a cases semen could come in contact with another person) is recommended for 3 months as the virus may still be present in semen.

Most cases recover within 2–4 weeks and will not require specific treatment other than good supportive management or treatment of complications, for example, pain relief and antibiotics for secondary cellulitis.

Advice on clinical management should be sought from an infectious diseases or sexual health physician. The use of antivirals should be considered by an infectious disease team for all cases with moderate to severe symptoms based on available evidence. Refer to the HealthPathways for further mpox information.

Advise the case of the nature of infection and mode of transmission. Educate cases regarding high-risk people, activities, and settings to avoid while infectious.

For more sexual health support and information please access the following websites:

• OutLine(external link) (external link)
• Burnett Foundation(external link) (external link)
• Rainbow Youth website(external link) (external link)
• Just the Facts website(external link) (external link)

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.

For mpox there are 2 main categories of contacts — close contacts and casual contacts — and the definitions and key actions differ for each clade.

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 whether the contact is at higher risk of severe disease (e.g. infants and young children, individuals who are unvaccinated, 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.

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.

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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) [DOCX] for a full list of members.