Monkeypox (MPX)

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Last Updated: 16 September 2022

Monkeypox (MPX) is a rare viral disease caused by the monkeypox virus (MPXV). 

MPX causes a rash that can appear as flat red spots, little pimple-like spots, or large blisters or ulcers. These may form crusts or scabs and fall off. Other symptoms may include fever, headache, muscle aches, backache, swollen lymph nodes, chills, and exhaustion. 

Although MPX is not an STI, it is primarily transmitted through bodily fluids and close skin-to-skin contact with someone with symptoms, including sexual activity.

MPX usually resolves itself without treatment, with symptoms lasting from 2 to 4 weeks. However, severe infection may require hospitalisation. Symptoms include severely painful lesions.

In Australia and internationally, as of September 2022, people at highest risk from MPXV are gay, bisexual or other men who have sex with men (GBMSM) who have close and intimate contact with multiple partners. However, MPX can be transmitted to any person who has close contact with an infected person and is not restricted to any particular demographics.

To date, most people with MPX in Australia have been infected while overseas. Still, some people have been infected in Australia following contact with people who have recently travelled overseas.

Information about MPX is rapidly changing as the outbreak unfolds and case numbers increase, so it is important to monitor health information.

Scarlet Alliance will continue to provide updates as they become available.

Signs and Symptoms

MPX can present no or minimal symptoms. If symptoms do appear, they usually begin 7-14 days after exposure but can be as short as 5 days or as long as 21 days. A person with MPX may be infectious from the onset of symptoms until all scabs have fallen off, leaving intact skin underneath. Skin lesions may take up to four weeks to disappear after the appearance of the first symptoms.

MPX rash

The MPX rash can look like flat red spots, little pimple-like spots or large blisters or ulcers, which form crusts or scabs and fall off. The number of lesions can vary from a few to several thousand.

The MPX rash usually begins within 1 to 3 days of a fever, headaches and body pain. The rash typically appears on the face and then spreads to the limbs and other body parts. 

Some people will only have a rash on the genitals, anus and surrounding areas, but MPX can appear anywhere on the

  • face
  • palms of the hands and soles of the feet
  • inside of the mouth
  • genitals and surrounding areas
  • anus and surrounding areas
  • eyes

Other symptoms may include

The MPX rash may be the first sign of infection, but in most cases, the rash usually follows other signs or symptoms, including

  • swollen lymph nodes
  • fever
  • headache
  • muscle aches
  • joint pain
  • back pain
  • inflammation of the rectum and severe pain (proctitis)

Many cases in the 2022 outbreak are presenting with different symptoms than previously-recorded MPX outbreaks. This means it’s important to remain aware and watch for symptoms.

These different (atypical) symptoms include

  • Presentation of only a few sores (lesions) or even a single lesion.
  • Sores/rash begins in the genital or around the ‘taint’ or anal area and does not spread further.
  • Appearance of lesions at different stages of infection.
  • Appearance of lesions before the start of lymph node swelling, fever, malaise or other symptoms.

Anyone with symptoms should seek medical attention right away. Self-isolation is recommended if you are concerned you may have MPX.

Though MPX is not an STI, it is transmitted through close physical contact with someone with symptoms, including sexual activity. 

MPX is far less contagious than COVID-19, but it poses a potential risk to sex workers who may have intimate skin-to-skin contact with clients with the virus.

A person with MPX can spread it to others from the time that symptoms start until the rash has fully healed and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks.

MPX can be transmitted via 

  • Direct skin-to-skin contact (most common transmission route)
  • Respiratory droplets (less common)
  • Objects and surfaces (less common) 

Sex work activities that may be a risk for MPX transmission include:

  • Oral, anal, and vaginal sex or touching the genitals (penis, testicles, labia, and vagina) or anus of a person with MPX (higher risk).
  • Hugging, massage, and kissing involving skin-to-skin contact (higher risk).
  • Prolonged face-to-face contact (lower risk).
  • Touching fabrics and objects used by a person with MPX that have not been disinfected, such as bedding, towels, fetish gear, and sex toys (lower risk).

As of September 2022, more research is needed to determine

  • Whether the virus can be spread when someone has no symptoms.
  • How commonly is MPX spread through respiratory droplets, or when a person with MPX symptoms might be more likely to spread the virus through respiratory droplets.
  • Whether MPX can be spread through semen, vaginal fluids, urine, or faeces.

Prevention

Vaccination and avoiding close contact with people who have MPX is the most effective way to prevent infection. 

Find MPX vaccination information for your state and territory here.

Some things sex workers can do to reduce the risk of MPX transmission

  • Extend health checks to check areas like the mouth, face, palms of hands, and soles of feet for lesions or blisters. 
  • Wash your hands after the check if you don’t use gloves.
  • If in doubt after a health check, you can refuse service or offer an alternative service such as hand relief or mutual masturbation using gloves 
  • Use condoms, gloves and/or dental dams as barriers. Remember that they will only protect the skin directly covered by the barrier.
  • Cover toys with condoms, and wash and re-cover before using on yourself.
  • You may want to include questions about overseas travel in your screening practices and check if your client has a fever or is feeling unwell. 
  • Inform your clients of potential symptoms to look out for and tell them to let you know if they are exposed to MPX. 
  • If signs or symptoms develop, self-isolate immediately and seek care by calling ahead to make an appointment with your local GP or sexual health clinic.
  • Inform your clients and colleagues if you are exposed to MPX. 
  • Wear gloves when handling soiled bedding in a communal work environment.
  • Talk to a sex worker-friendly GP or sexual health clinic about getting vaccinated. You can view a sex worker-friendly sexual health clinic list on our Where To Test page.
  • If you cannot access a vaccine, getting vaccinated within 4 days of first exposure still protects against serious infection (known as post-exposure prophylaxis). 
  • You may also choose to refuse service if you are in doubt.

Vaccination

Find MPX vaccination information for your state and territory here.

There is a limited supply of the two-dose JYNNEOS vaccine around the world. Australia has secured an initial supply and is working with the manufacturer to secure more.

JYNNEOS is the preferred vaccine for use in Australia based on its safety profile and because it is easier to administer.

Where JYNNEOS is not suitable or unavailable, ACAM2000 (one dose), a smallpox vaccine, may be considered for healthy, non-pregnant adults who are not living with HIV.

Given vaccine supply is limited, access to vaccines will initially be prioritised for higher-risk populations. 

The current national vaccination guidelines identify high-risk groups as 

  • Anyone categorised by public health authorities as a high-risk MPX contact in the past 14 days. 
  • Gay, bisexual and other men who have sex with men (GBMSM) who are at higher risk of MPX infection due to having a high number of sexual contacts. 
    • Risk criteria for infection may include:
      • Those living with HIV.
      • A recent history of multiple sexual partners, participating in group sex, or attending sex on premises venues. 
      • Other contributing risk factors, such as recent sexually transmitted infection or those being advised to take PrEP due to number of sexual partners. Whilst many people prescribed PrEP are monogamous with an HIV-positive partner, this category can also capture those with multiple partners at high risk.
      • Recommendation from other service providers, such as sexual health clinics.
  • Sex workers, particularly those whose clients are in high-risk categories. 
  • Anyone in the above risk categories planning to travel to a country experiencing a significant outbreak, with vaccination recommended 4-6 weeks before departure. 
  • MPX immunisation providers.

If you are not eligible for vaccination and are exposed to MPX, you will be eligible for a dose as post-exposure prophylaxis within 4 days of the exposure event.

There is still a risk of infection following vaccination, and it is still important to take steps to reduce the chance of catching or spreading MPX.

Find MPX vaccination information for your state and territory here.

Testing 

Here’s some information about testing for MPX. You can view a sex worker-friendly sexual health clinic list at our Where To Test page.

Testing Method

  • Swab or scraping from a blister or sore

When to Test

  • Test if you think you may have MPX symptoms, especially if you have recently returned from overseas or been in contact with a case in Australia. 
  • Test if you think you may have been exposed to MPX, especially if you have recently returned from overseas or have been in contact with a case in Australia. 

Other Info

  • Call your GP or sexual health clinic before attending in person if you think you need an MPX test.
  • Self-isolation is recommended if you are concerned you may have MPX.
  • Until you can see your healthcare provider, you should try to stay at least 2 metres from other people and wear protective clothing that covers your rash and open sores. 
  • MPX testing is not included in routine STI testing, so you need to request it.
  • Sexual health clinic testing is often bulk billed, even if you don’t have Medicare, so the test will most likely be free. 
  • If you see a GP, you may pay a fee or be bulk billed. 

Treatment

MPX usually resolves itself without treatment, with the symptoms lasting from 2 to 4 weeks. Anyone with symptoms should seek medical attention right away. Treatment of symptoms may include over-the-counter pain relief. Patients with more severe cases may need antiviral treatment.

If you are exposed to MPX, getting vaccinated within 4 days of first exposure will provide the highest chance of avoiding the disease. 

How might this impact my work? 

Practical Considerations

  • MPX can spread from when symptoms start until all sores (including scabs) are fully healed.
  • If you have MPX (or if you feel sick or have a rash or open wounds), you are recommended not to have sex until the infection has fully healed (or you have been able to test for MPX).
  • If you can’t avoid having sex, these options may reduce your risk of transmitting MPX, but there is no guarantee: 
    • Offer alternative services such as mutual masturbation without touching each other and without touching any rash or sores.
    • Wear condoms, gloves and/or dental dams when engaging in sexual activity. Remember that barriers only protect the skin that they cover. 
    • Have sex with your clothes on or cover areas where a rash or sores are present. Remember that clothing offers limited protection and only protects the covered skin. 
    • Avoid kissing.
    • Wash your hands, sex toys and furniture, and any fabrics (bedding, towels, clothing) after having sex.
    • Limit the number of clients you see to avoid opportunities for further infection.
  • You should inform any recent or current doubles partners if you test positive for MPX or are experiencing symptoms.
  • You should inform your colleagues if you test positive for MPX or are experiencing symptoms.

Where can I get more information?

Here are some additional sources of information:

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