PRI provides situational updates on the monkeypox (orthopoxvirus) outbreak. Visit our website every Tuesday and Thursday for the latest editions.
Case Counts/Trends and Large Guidance/Response Changes (Limited by latest reporting)
- GLOBAL: From 1 January through 7 August 2022, 27 814 laboratory confirmed cases of monkeypox, and 11 deaths have been reported to WHO from 89 countries/territories/areas in all six WHO Regions (Table 1). Since the last edition of this report published on 25 July 2022, 11 798 new cases (74% increase), and six new deaths have been reported; 14 new countries have reported cases. In the past seven days, 42 countries reported an increase in the weekly number of cases, with the highest increase reported in Brazil. There are 14 countries that have not reported new cases for over 21 days, the maximum incubation period of the disease. (WHO Sit Rep – Latest 8/10/2022 / Dashboard )
- US: Total confirmed monkeypox/orthopoxvirus cases: 9,492 (8.9.2022). Table at right is cases reported to CDC, full version here.
- NY State: As of August 10 2022, a total of 2,132 confirmed orthopoxvirus/monkeypox cases – a designation established by the Centers for Disease Control and Prevention (CDC). (NY Sit Rep and County List)
- U.S. Moves to Stretch Out Monkeypox Vaccine Supply (NY Times) The move (given as one-fifth of the current dose intradermally) would help alleviate a shortage of vaccine that has turned into a growing political and public health problem for the administration.
- Monkeypox vaccine maker voices concerns on U.S. dose-splitting plan (WaPo) “We do have some reservations … due to the very limited safety data available,” Bavarian Nordic CEO Paul Chaplin wrote to Health and Human Services Secretary Xavier Becerra. Becerra said. “We wouldn’t have moved forward unless we thought it was safe and effective.
- Multiple articles appears about cleaning clothes and surfaces to prevent the virus; see an example in “Infection Control” below.
- Maps & Stats: CDC / Tableau Dashboard (based on global.health) / New York Times
- As monkeypox spreads, university campuses prepare for another outbreak (STAT) Many schools have begun preparing for cases. A spokesperson for Georgetown said the university’s Student Health Center and university hospital will work together “to identify, test, and manage suspected and confirmed cases.” Students and staff will be able to get tested at the campus health center.
- 2 men attacked in suspected hate crime that referenced monkeypox: Police (ABC News) Most cases so far in the U.S. have been reported among men who have sex with men, a group that includes people who identify as gay, bisexual, transgender and nonbinary. However, health officials have repeatedly stressed that anyone can contract the virus.
- Monkeypox in children: Everything to know about symptoms, vaccines and treatments (USA Today) The World Health Organization said children are more likely than adults to develop severe disease. As of Aug. 3, there have been only two pediatric infections out of the more than 9,400 monkeypox cases reported in the country
- UK will ‘run out of monkeypox vaccine in 10 to 20 days’ (The Guardian) The BASHH estimates that 250,000 doses of vaccine must be procured in order to vaccinate approximately 125,000 eligible people, yet the government has only procured over 100,000 to date.
- Anger and anxiety stalk EU’s monkeypox vaccine lottery (Politico) The infection can spread through the kind of close contact that happens during sex, at crowded parties or even kissing on a date. The outbreak has resulted in disagreement over how to provide accurate but non-stigmatizing messaging, while limited vaccine supplies and strict eligibility criteria have left many who are desperate to get their hands on the vaccine without access, leading to “vaccine tourism”.
- Monkeypox cases driven ‘underground’ by anti-gay stigma in India (Deccan Herald) In countries where homophobia and life-threatening discrimination is rife, many people may not seek help, World Health Organization Director-General Tedros Adhanom Ghebreyesus has warned, “making the outbreak much harder to track, and to stop.”
- WHO stresses monkeypox surge not linked to monkeys amid attack reports (Guardian) World Health Organization issues statement after reports of animals being poisoned in Brazil
Official Guidance Sources
Articles by Category
Key quote “The prevailing perception in the international media and scientific literature is that [monkeypox virus] is endemic in people in some African countries. However, it is well established that nearly all [monkeypox virus] outbreaks in Africa prior to the 2022 outbreak, have been the result of spillover from animals to humans and only rarely have there been reports of sustained human-to-human transmissions”
Monkeypox virus: A tale of disparity between the wealthy and low-to-middle income nations (National Library of Medicine)
With the current economic instability and the toll COVID-19 took on healthcare systems, many national health systems cannot afford pharmaceutical tools like vaccinations, diagnostic kits, and antivirals. Therefore, it is imperative to consider the beneficial outcomes of various interventions such as raising awareness, surveillance including self-reporting, and quarantining measures. Although the possibility of occurrence in low-to-middle income (LMI) countries is uncertain, given their current economic crisis secondary to the COVID-19 pandemic, safety measures are essential to prevent the viral spread and greater havoc. Travelers from endemic regions should be screened routinely, while suspected or confirmed cases should also be quarantined for a prodromal period. Hospitals should have well-equipped isolation units on standby to place patients in quarantine. Moreover, as the most vulnerable group, healthcare personnel should be fully equipped with the required Personal Protective Equipment (PPEs), especially in light of the global shortage witnessed during the COVID-19 epidemic. The course of outbreaks is significantly shaped by laboratories, however, several LMI countries such as Pakistan currently lack viral diagnosis facilities. Currently, mass immunization against monkeypox is neither necessary nor advised by WHO. However, vaccine supplies should be stocked for pre and post-exposure prophylaxis in high-risk groups. The vaccine, MVA-BN (modified vaccinia Ankara-Bavarian Nordic) has been licensed for viral prevention in the USA. Lastly, international funding must be made readily available to assist LMI countries cope with the developing situation and establish a globally extensive surveillance system to understand the continually changing epidemiology of this emerging illness.
Does washing clothes eliminate monkeypox? What to know about disinfecting for the virus (Fort Worth Star Telegram) *Several Similar Articles Appeared Focused on This Issue* The virus can survive on linens, clothing and other surfaces, according to the CDC. In one study, health officials found live virus 15 days after a patient’s home was left unoccupied. The CDC recommends using a disinfectant registered with the U.S. Environmental Protection Agency.
Why the monkeypox outbreak constitutes a public health emergency of international concern (BMJ) Under the International Health Regulations (IHR), the decision to declare a PHEIC rests with the WHO Director-General, taking into consideration the information provided by countries; the risk to human health, international spread, and the potential for interference with international traffic; scientific principles, evidence, and other relevant information; and the advice of the Emergency Committee, a panel of external experts convened by the Director-General to advise her or him on whether the public health event in question constitutes a PHEIC. On this occasion, the Emergency Committee was, for the first time since the IHR entered into force in 2007, unable to reach consensus.
Prevention in the form of targeted vaccination to break transmission chains offers hope for the control of the UK’s current outbreak if challenges in supply and distribution of smallpox vaccines can be overcome. Smallpox vaccines provide cross protection against monkeypox. The new study corroborates other evidence that infections are occurring predominantly among higher risk men who have sex with men.9 This pattern enables vaccine prioritisation, which may need flexibility if and when new at risk groups emerge.10 Vaccination must be delivered sensitively to avoid the kind of stigmatising public health messaging used early in the HIV epidemic. Creative approaches will be needed to ensure equitable distribution to people at risk who have poorer access to services or health literacy, both in the UK and globally.11
Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study (Tarin-Vicente et al., The Lancet)
In the early stages of the monkeypox outbreak in 2022, diagnosis and disease control have been difficult because many cases have not followed the patterns of illness described in the medical literature. In concert with recent studies, we found that most participants presented with a low number of lesions located in one or more of the genital, oral, and anal regions and that systemic symptoms were very common. Almost half of the participants had systemic illness before the rash appeared (prodromal stage) and just over half had systemic illness shortly afterwards (early clinical stage). These symptoms are attributable to the invasive phase of illness, which might sometimes occur after lesions have formed at the site of inoculation. During the invasive phase, the virus might spread to distant areas such as the face, limbs, and trunk and cause lesions at a different stage of progression than the initial local rash. In contrast to previous reports of monkeypox virus infections, no generalised swelling of the lymph nodes was observed, but regional lymphadenopathies were often present in the lymph catchment area of lesions. Nearly all participants had previous sexual exposure to an individual known to have monkeypox or had risk factors for sexually transmitted diseases, such as multiple sexual partners in the 12 weeks before their monkeypox diagnosis or use of recreational drugs during sex. The fact that 32 individuals acquired monkeypox despite smallpox vaccination in their childhood is of note and warrants further investigation to better understand the protection provided by vaccination in the context of the current outbreak. Additionally, 40% of individuals were HIV-positive, including eight participants with a CD4 cell count of less than 500 cells per μL. Neither the severity nor the progression of the disease differed between people who were HIV-positive and the rest of the participants. Given the high CD4 counts of participants in this study, we cannot comment on whether more immunosuppressed individuals might develop more severe disease. Due to the sampling strategy, we could not assess whether people who were HIV-positive were more susceptible to monkeypox infection because half of the participants were recruited from a hospital that provides health services to many individuals with HIV.
Monkeypox: An emerging global threat during the COVID-19 pandemic (Journal of Immunology, and Infection)
The emergence of the monkeypox outbreak in early 2022 has posed a new global health threat. As of July 8, 2022, 9,069 laboratory-confirmed cases have been reported, and most of them are from non-endemic countries. The monkeypox virus is an enveloped double-stranded DNA virus, and preliminary genetic data suggest that the 2022 monkeypox virus belongs to the West African clade. In the current outbreak, human-to-human transmission has been the primary transmission mode. Although direct skin-to-skin contact with lesions during sexual activities can spread the virus, it remains unclear whether monkeypox can spread through sexual contact, specifically through contaminated body fluids. The typical presentation of monkeypox includes prodromal symptoms, followed by a rash that usually begins within 1–3 days of symptom onset, and the skin lesions can last for 2–4 weeks and then gradually resolve. However, the monkeypox outbreak in 2022 may exhibit atypical features. A definite diagnosis of monkeypox virus infection requires nucleic acid amplification testing via the polymerase chain reaction method. Supportive care is essential, and antiviral therapy is not considered for all affected patients, but recommended for those at highrisk for severe diseases. The mitigation of monkeypox outbreaks include enhanced case detection, case isolation, contact tracing, and post-exposure vaccination. In conclusion, the current monkeypox outbreak is a new threat during the COVID-19 pandemic. Clinicians should be aware of this new situation, which presents a different scenario from those of prior outbreaks. Global health systems should develop effective strategies to mitigate the spread of monkeypox.
We must recognize that the least stigmatizing and least homophobic approach to this infectious disease is to provide individuals with information on how it spreads and what steps can mitigate their risk of disease. Our patients have the autonomy to figure out what’s best for them. As a healthcare community, it’s our job to help individuals make informed decisions about what they want to do with their bodies, and provide empathetic care regardless of what that decision is. As doctors, we must show the basic compassion that is missing in all of our policies for monkeypox.
Breakthrough infections after post-exposure vaccination against Monkeypox (Thy et al., medRxiv)
There is no specific vaccine to prevent Monkeypox but a third-generation vaccine against smallpox has been validated and is available for the indication of active immunization against smallpox. Stocks exist in numerous countries for the potential bioterrorism threat of smallpox. This vaccine is a non-replicating live vaccine containing a live modified form of the vaccinia Ankara virus (MVA), produced by Bavarian Nordik and authorized since 2013 in Europe under the trade name IMVANEX. Vaccination after a Monkeypox exposure may help to prevent the onset of the disease or make it less severe. In the context of the current outbreak, early post-exposure ring vaccination (EPRV) with smallpox vaccine (off-label use) has been recommended by WHO, USA Centers for Disease Control & Prevention (CDC) and France to reduce symptoms of Monkeypox disease and to limit transmission. In France, the French high authority of health (HAS) has recommended the implementation of a reactive vaccination strategy in early post-exposure with the third-generation vaccine administered in 2 doses spaced 28 days apart, the first dose being ideally administered within 4 days after the high-risk exposure with a PCR-confirmed Monkeypox patient and no longer than 14 days after the high-risk exposure. The aim of this study was to describe the outcomes of high-risk contacts receiving third-generation smallpox vaccine and in particular tolerance of the vaccine and potential breakthrough infections within the 28 days after the first dose of vaccine.
Key Quote: “The FDA is also now allowing children to receive the vaccine if they are at high risk of monkeypox infection. Dr. Peter Marks, head of the FDA’s vaccine division, said there has been an increase in possible exposures among children over the past week”
The unexpected increase in human monkeypox cases in non-endemic countries that began in May, 2022, is raising concerns of a novel global infectious threat. Since the first human case in 1970 in the Democratic Republic of the Congo, the virus has become endemic in several countries in central and western Africa. Imported cases have been sporadically reported outside Africa (in England, the USA, Singapore, and Israel), with the majority of cases associated with travellers returning from endemic countries, or due to nosocomial contact or contact with infected imported rodents. As of July 22, 2022, 16 016 laboratory-confirmed monkeypox cases have been reported from 75 countries worldwide, and the WHO Director-General has declared the escalating global monkeypox outbreak to be a public health emergency of international concern. The vast majority of cases have been reported in Europe and other non-endemic countries, mostly diagnosed in young men, self-identifying as men who have sex with men (MSM). Monkeypox virus transmission might occur through close contact of mucosa or non-intact skin with infectious material, or large respiratory droplets during prolonged face-to-face contact. Whether monkeypox virus can be sexually transmitted via genital fluids remains under investigation. Monkeypox virus transmission during sexual intercourse has been documented in the UK in two men with no travel history to endemic countries and evidenced by the temporal association of symptoms with sexual contact and the location of primary lesion sites matching those of sexual contact. Viral DNA detection in semen samples has been reported in three cases in Italy and subsequently in two patients with monkeypox in Germany. Furthermore, monkeypox DNA was detected in the seminal fluid of 29 (91%) of 32 people affected by monkeypox in a large case series on the 2022 global outbreak. However, to date, no evidence is available on the infectiousness of monkeypox virus in semen. Therefore, we investigated viral shedding in longitudinal semen samples collected 5–19 days after symptom onset from one confirmed monkeypox virus case diagnosed at the National Institute for Infectious Diseases ‘Lazzaro Spallanzani’.