epidemiological link (face-to-face exposure, including health care workers without appropriate PPE; direct physical contact with skin or skin lesions, including sexual contact; or contact with contaminated materials such as clothing, bedding or utensils is suggestive of a strong epidemiological link). 3.3 Confirmed case: A case which is laboratory confirmed for monkeypox virus (by detection of unique sequences of viral DNA either by polymerase chain reaction (PCR) and/or sequencing). 4. Surveillance Strategies The aims of the proposed surveillance strategy are to rapidly identify cases and clusters of infections and the sources of infections as soon as possible in order to: a) isolate cases to prevent further transmission b) provide optimal clinical care c) identify and manage contacts d) protect frontline health workers e) effective control and preventive measures based on the identified routes of transmission. 4.1 Surveillance outline a) Use Standard Case Definitions by all District Surveillance Units (DSUs) under Integrated Disease Surveillance Programme (IDSP) and at Points of Entry (PoEs). b) Even one case of monkeypox is to be considered as an outbreak. A detailed investigation by the Rapid Response Teams need to be initiated through IDSP. c) Report any suspected case immediately to the DSU/State Surveillance Units (SSUs) and CSU (Central Surveillance Unit), which shall report the same to Dte. GHS MoHFW. d) Send the samples as per the guidelines to the designated laboratories. 4.2 The salient features include: a) Targeted surveillance for probable case or clusters. 5 b) Initiate contact tracing and testing of the symptomatic after the detection of the probable/confirmed case. 4.3Core Surveillance Strategy a) Hospital based Surveillance: - Health facility-based surveillance & testing – in Dermatology clinics, STD clinics, medicine, paediatrics OPDs etc. b) Targeted Surveillance: This can be achieved by: i) Measles surveillance by Immunization division ii) Targeted intervention sites identified by NACO for MSM, FSW population 4.4 Reporting Reporting of cases to be done in the format as placed in Annexure 1. 5. Clinical Features Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. Severe cases occur more commonly among children and are related to the extent of virus exposure, patient health status and nature of complications. The extent to which asymptomatic infection occurs is unknown. The case fatality ratio of monkeypox has historically ranged from 0 to 11% in the general population and has been higher among young children. In recent times, the case fatality ratio has been around 3-6%. 5.1 Common symptoms and signs · Prodrome (0-5 days) a. Fever b. Lymphadenopathy Ø Typically occurs with fever onset Ø Periauricular, axillary, cervical or inguinal Ø Unilateral or bilateral c. Headache, muscle aches, exhaustion d. Chills and/or sweats e. Sore throat and cough · Skin involvement (rash) a. Usually begins within 1-3 days of fever onset, lasting for around 2-4 weeks b. Deep-seated, well-circumscribed and often develop umbilication 6 c. Lesions are often described as painful until the healing phase when they become itchy (in the crust stage) d. Stages of rash (slow evolution) Ø Enanthem- first lesions on tongue and mouth Ø Macules starting from face spreading to arms, legs, palms, and soles (centrifugal distribution), within 24 hours Ø The rash goes through a macular, papular, vesicular and pustular phase. Classic lesion is vesicopustular Ø Involvement by area: face (98%), palms and soles (95%), oral mucous membranes (70%), genitalia (28%), conjunctiva (20%).Generally skin rashes are more apparent on the limbs and face than on the trunk. Notably the genitalia can be involved and can be a diagnostic dilemma in STD population Ø By 3rd day lesions progress to papules Ø By 4th to 5th day lesions become vesicles (raised and fluid filled). Ø By 6th to 7th day lesions become pustular, sharpy raised, filled with opaque fluid, firm and deep seated. Ø May umbilicate or become confluent Ø By the end of 2nd week, they dry up and crust Ø Scabs remain for a week before falling off Ø The lesion heals with hyperpigmented atrophic scars, hypopigmented atrophic scars, patchy alopecia, hypertrophic skin scarring and contracture/deformity of facial muscles following healing of ulcerated facial lesions Ø A notable predilection for palm and soles is characteristic of monkey pox e. The skin manifestation depends on vaccination status, age, nutritional status, associated HIV status. Monkeypox chiefly occurs in communities where there is often a high background prevalence of malnutrition, parasitic infections, and other significant heath-compromising conditions, any of which could impact the prognosis of a patient with MPX. f. The total lesion burden at the apex of rash can be quite high (>500 lesions) or relatively slight (uman zoonotic epidemic Multi-Jurisdictional Monkeypox Outbreak 2022 – What We Know So Far Published: June 2022 Introduction Public Health Ontario (PHO) is actively monitoring, reviewing and assessing relevant information related to the worldwide monkeypox