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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: 11,890 (8.15.2022) (full version).
- NY State: As of August 15 2022, a total of 2,548 confirmed orthopoxvirus/monkeypox cases – a designation established by the Centers for Disease Control and Prevention (CDC). (NY Sit Rep and County List)
- U.S. offers more monkeypox vaccine to states and cities (Star Tribune) The U.S. Department of Health and Human Services had previously anticipated allowing 221,000 doses to be ordered starting Monday. But officials said they would release 442,000 doses for order by state, local and territorial health departments.
- In an article titled “The Unfiltered Faces of Monkeypox,” the New York Times discusses how people with monkeypox are taking to social media to share photos and videos of their symptoms to fight stigma and demand more action.
- Why monkeypox is a repeat of the data mistakes made with Covid-19 (Vox) With monkeypox, the US can lean on the systems and infrastructure built during the Covid-19 pandemic, but some programs, like those that reimburse providers for treating uninsured patients or provide free Covid-19 tests, vaccines, and antiviral drugs to community health centers, were already scaled down after funding was decreased. In order to pull together a national response, the US needs straightforward, transparent data reporting that can be compared and combined on a national level.
- U.S. to Provide States With up to 442,000 Jynneos Doses to Combat Monkeypox (U.S. News) The government was initially planning to dispatch the doses in two segments but combined them together after the Food and Drug Administration last week allowed administering the shot intradermally or between the layers of the skin. The emergency use of the shot through an alternate method of use would result in splitting a single vial of Jynneos into five doses and help the government stretch the vaccine stockpile.
- The US monkeypox response is failing queer men (Vox) The federal government has been criticized because it didn’t act with urgency against monkeypox after a July New York Times report surfaced that, despite a vaccine supply and information coming in from Europe in June, the US took a wait-and-see approach. Protests have erupted. New York City, California, Illinois, and other cities and states have declared states of emergency to receive and deploy resources to battle the epidemic. Appointments are few and far between, many without any second doses planned, though Jynneos is a two-dose vaccine, and overall, the handful of cases in May and June have, as of August 11, increased to 10,392 reported cases in the US, and 2,132 in the state of New York.
- Smallpox vaccines may not protect against monkeypox for life (The Guardian) Vaccination with a jab initially developed to protect against smallpox, a related but more serious disease, is among the measures being taken to control infections. However, while experts stress that it is important for those at risk of monkeypox to take up the offer of vaccination, as it reduces the chance of symptomatic infection and severe illness, the protection offered by a smallpox jab may decline over time. A study into monkeypox cases in Spain revealed that 32 of the 181 patients had previously received a childhood vaccination against smallpox.
- QIAGEN Launches Syndromic Test for QIAstat-Dx Device to Combat Global Monkeypox Health Emergency (Business Wire) “Monkeypox cases are soaring across the globe with many demographic groups infected. Surveillance is an essential tool in the fight against infectious diseases. QIAstat-Dx Viral Vesicular Panel in combination with the QIAstat-Dx platform will allow medical researchers to detect monkeypox with gold-standard PCR testing-technology in about one hour,” said Jean-Pascal Viola, Senior Vice President, Head of the Molecular Diagnostics Business Area at QIAGEN. “Currently the world’s only syndromic test for the pathogen, the panel will prove to be crucial for detecting and then combatting the spread of monkeypox around the globe.”
- Britain says monkeypox outbreak “shows signs of slowing” (Lawton Constitution) In a statement on Monday, the Health Security Agency said authorities are reporting about 29 new monkeypox infections every day, compared to about 52 cases a day during the last week in June. In July, officials estimated the outbreak was doubling in size about every two weeks. To date, the U.K. has recorded more than 3,000 cases of monkeypox, with more than 70% of cases in London.
Official Guidance Sources
Articles by Category
The Terrence Higgins Trust, which co-wrote the letter, says the rollout needs to be speeded up across the UK to help combat “fear and anxiety” within the LGBT community. Its head of policy Ceri Smith told BBC News: “We need to see far better co-ordination, increased vaccine procurement, improved delivery and a cash injection to sexual health services to treat monkeypox.” The letter was also signed by representatives from LGBT groups for the Conservatives, Labour, Liberal Democrats, the SNP and the Green Party. It reads: “Without urgent action, we risk monkeypox becoming endemic in the UK. This poses a serious risk to health and will exacerbate the health inequalities already experienced by gay and bisexual men and other men who have sex with men.
Assigning names to viruses normally falls under WHO jurisdiction, but the organization is allowing people to submit ideas through an online portal, according to the statement. The announcement comes nearly two months after the WHO said it was planning to rename the virus, following demands from international scientists and public health officials who said the current name encourages harmful stigma.
What does it mean to declare monkeypox a PHEIC? (Talha Burki, The Lancet)
On Aug 5, the USA declared a public health emergency for monkeypox. At the time, the country had registered over 6600 cases of the disease. In the days preceding the declaration, New York state, Illinois, and California, which together accounted for roughly half the American cases of monkeypox, had all declared emergencies. New York City and San Francisco have taken similar measures. The mayor of New York City and the health commissioner issued a joint statement asserting that the “outbreak must be met with urgency, action, and resources, both nationally and globally, and this declaration of a public health emergency reflects the seriousness of the moment”. They went on to suggest that 150 000 city residents could be at risk of contracting monkeypox. A national public health emergency declaration in the USA releases funding and opens a path for the Secretary of Health and Human Services to take action to address the crisis. Gostin recommends strengthening the International Health Regulations so that declaring a PHEIC is associated with comparable powers.“We have to find an appropriate approach to communicate with the affected communities without increasing stigma”, said Evans. “We should be working closely with community leaders and arranging vaccination campaigns at sites where MSM congregate”. He has not been impressed by the response so far. “This is a relatively poorly spread orthopoxvirus in a narrowly defined community, for which we have stockpiles of vaccine and drugs; yet we have struggled to get enough vaccines into people’s arms and break transmission”, said Evans. “It makes you wonder how we would fare in the event of an accidental or deliberate release of smallpox.
Monkeypox caused less worry than COVID-19 among the general population during the first month of the WHO Monkeypox alert: Experience from Saudi Arabia (Mohamad-Hani Temsah et al., Travel Medicine and Infectious Disease)
Monkeypox re-emerged in May 2022 as another global health threat. This study assessed the public’s perception, worries, and vaccine acceptance for Monkeypox and COVID-19 during the first month of WHO announcement. A large-scale, cross-sectional survey was conducted between May 27 and June 5, 2022, in Saudi Arabia. Data were collected on sociodemographic characteristics, previous infection with COVID-19, worry levels regarding Monkeypox compared to COVID-19, awareness, and perceptions of Monkeypox, and vaccine acceptance. Among the 1546 participants, most respondents (62%) were more worried about COVID-19 than Monkeypox. Respondents aged 45 years and above and those with a university degree or higher had lower odds of agreement with Monkeypox vaccination (OR .871, p-value .006, OR .719, p-value <0.001), respectively. Respondents with moderate to a high level of self and family commitment to infection control precautionary measures and those who expressed self and family worry of Monkeypox infection had significantly higher odds of vaccination agreement (OR 1.089 p-value = 0.047, OR1.395 p-value = 0.003) respectively. On the other hand, respondents who previously developed COVID-19 were significantly more worried about the Monkeypox disease (1.30 times more, p-value = 0.020). Worry levels amongst the public are higher from COVID-19 than Monkeypox. Perception of Monkeypox as a dangerous and virulent disease, worry from contracting the disease, and high commitment to infection precautionary measures were predictors of agreement with Monkeypox vaccination. While advanced age and high education level are predictors of low agreement with vaccination
In interviews with NBC News, epidemiologists and infectious disease experts dispelled some of the most common misconceptions, including whether the virus spreads easily through the air, that cases among women and children are being undercounted, and that health care workers are at high risk.
Evidence of human-to-dog transmission of monkeypox virus (Sophie Seang et al., The Lancet)
In endemic countries, only wild animals (rodents and primates) have been found to carry monkeypox virus. However, transmission of monkeypox virus in prairie dogs has been described in the USA and in captive primates in Europe that were in contact with imported infected animals. Infection among domesticated animals, such as dogs and cats, has never been reported. To the best of our knowledge, the kinetics of symptom onset in both patients and, subsequently, in their dog suggest human-to-dog transmission of monkeypox virus. Given the dog’s skin and mucosal lesions as well as the positive monkeypox virus PCR results from anal and oral swabs, we hypothesise a real canine disease, not a simple carriage of the virus by close contact with humans or airborne transmission (or both). Our findings should prompt debate on the need to isolate pets from monkeypox virus-positive individuals. We call for further investigation on secondary transmissions via pets.
Monkeypox virus: a re-emergent threat to humans (Qizan Gong et al., Virologica Sinica)
Human monkeypox (MPX) is a rare zoonotic infection characterized by smallpox-like signs and symptoms. It is caused by monkeypox virus (MPXV), a double stranded DNA virus belonging to the genus Orthopoxvirus. MPX was first identified in 1970 and mostly prevailed in the rural rainforests of Central and West Africa in the past. Outside Africa, MPX was reported in the United Kingdom, the USA, Israel, and Singapore. In 2022, the resurgence of MPX in Europe and elsewhere posed a potential threat to humans. MPXV was transmitted by the animals-human or human-human pathway, and the symptoms of MPXV infection are similar to that of smallpox, but in a milder form and with lower mortality (1%–10%). Although the smallpox vaccination has been shown to provide 85% protection against MPXV infection, and two anti-smallpox virus drugs have been approved to treat MPXV, there are still no specific vaccines and drugs against MPXV infection. Therefore it is urgent to take active measures including the adoption of novel anti-MPXV strategies to control the spread of MPXV and prevent MPX epidemic. In this review, we summarize the biological features, epidemiology, pathogenicity, laboratory diagnosis, and prevention and treatment strategies on MPXV. This review provides the basic knowledge for prevention and control of future outbreaks of this emerging infection.
Brief report: Determinants of potential sexual activity reduction in the face of the Monkeypox epidemic (Haoyi Wang et al., Department of Work and Social Psychology, Maastricht University, the Netherlands)
The current monkeypox epidemic is most prevalent among men-who-have-sex-with-men (MSM). Vaccination programs are being rolled-out to curb the epidemic. Behavioural measures have been called for as well, e.g., by the WHO to reduce the number of sexual partners and sexual activity. We investigated intentions and determinants among Dutch MSM to follow such measures. Early July 2022, 394 MSM answered an online questionnaire. The overall intentions to reduce number of partners and sexual activity was high, but only a minority had developed definite intentions. Determinant analysis revealed that dating/open relationship status was a positive predictor, vaccination intentions did not predict sexual behaviour change; those not on PrEP were more likely to change their sexual behaviour. Monkeypox infection concern was negatively related to weaker intentions and only predicted definite intentions. Our results show that additional public health measures are necessary to reach and convince MSM to engage in sexual behaviour change.
Therapeutic strategies to address monkeypox (Matthew W. McCarthy, Expert Review of Anti-infective Therapy)
Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks, but severe cases do occur, with some studies revealing a case fatality rate of 3–10%. There are no treatments specifically approved for monkeypox virus infections. However, due to the genetic similarity between monkeypox and smallpox, antiviral drugs developed to treat smallpox, including tecovirimat and brincidofovir, may have clinical applications in the treatment of monkeypox, although clinical experience with these agents is limited. This manuscript reviews what is known about these treatments based on a literature search of PubMed through August 9, 2022. Tecovirimat (previously ST-246) is a small-molecule inhibitor of viral egress that has shown efficacy in vitro and in vivo against orthopoxviruses, including vaccinia, camelpox, cowpox, ectromelia (mousepox), variola viruses, and monkeypox. Tecovirimat was identified after screening a chemically diverse library of more than 350,000 unique compounds, and was subsequently discovered to target a gene that produces p37, a major envelope protein required for the production of extracellular virus. Brincidofovir (formerly CMX001) is an orally bioavailable lipid acyclic nucleoside phosphonate that is absorbed in the small intestine and transported throughout the body as a phospholipid. Brincidofovir is a lipid conjugate of cidofovir, an antiviral approved for the treatment of cytomegalovirus retinitis in AIDS patients and also has activity against poxviruses, but cidofovir must be administered intravenously and is associated with nephrotoxicity. Brincidofovir, by contrast, has good oral bioavailability, no associated nephrotoxicity, and achieves higher intracellular levels of the active drug compared to cidofovir, making it an appealing agent for the treatment of a variety of infectious diseases. Brincidofovir has shown activity against double-stranded DNA viruses, including poxviruses such as monkeypox.
A Rapid Systematic Review and Meta-Analysis of Monkeypox Case Hospitalization Rates Since 2003 (Michael DeWitt et al., The Lancet, preprint)
Estimates of the case hospitalization rate and case fatality rate when hospital care is available for monkeypox (MPX) infections have not been well defined. This systematic review and meta-analysis aimed to estimate the case hospitalization rate and case fatality rate where hospital care is available as well as describe differences in demographics, treatments, the epidemiology of documented cases, and outcomes. We systematically search PubMed for studies published between 1995 and 2022. We included documents which contained both the number of cases and associated hospitalizations of MPX infections. We excluded studies that were duplicates, were multiple characterizations of the same outbreak, single case reports, or characterization of only hospitalized individuals. From eligible studies we extracted the country, the year of the study, the study design type, the clade of MPX, the participant characteristics, transmission type, any treatments used, number of cases, number of hospitalizations, hospitalized patient outcomes, and case definition. Case hospitalization rate (CHR) was defined as the proportion of cases that were admitted to hospital care while case fatality rate (CFR) was defined as the proportion of cases that died. CHR and CFR were analyzed in a fully Bayesian meta-analytic framework using both fully pooled and random effects models. Of the 110 unique documents identified, fifteen studies were eligible for inclusion. Included studies represented 7131 reported cases among which there were 542 hospitalizations. Of the 7118 cases for whom outcomes were available there were seven recorded deaths. Overall pooled CHR was estimated to be 7·6% (95% credible interval, CrI, 7·0 – 8·2) while the random effects CHR was estimated to be 19·2% (8·2-35·6), with some difference reported for the West African genetic clade. CFR was estimated to be 0.1% (95% CrI 0·0-0·2) and 0·1% (95% CrI 0·0-0·8) in the fully pooled and random effects models. MPX infections have a relatively high rate of hospitalization. Public health organizations should prepare for the potential increase in healthcare utilization. Rapid identification of infection and use of appropriate therapies such as antivirals play a role reducing the CHR and associated CFR.
Clinical characteristics and comparison of longitudinal qPCR results from different specimen types in a cohort of ambulatory and hospitalized patients infected with monkeypox virus (Dominik Norz et al., Journal of Clinical Virology)
This study represents one of the first clinical case series from the ongoing monkeypox virus outbreak including serial viral DNA-load measurements in different specimen types throughout the course of disease. Different from previous monkeypox clusters outside endemic regions in Africa, most patients presented with rather mild absent systemic symptoms, which is consistent with recent reports from the 2022 outbreak. Longitudinal observation of viral DNA-load kinetics demonstrated the reliability of cutaneous lesion swab samples for monkeypox virus detection, which are considered the gold standard for diagnostics. In this study, lesion swabs never returned negative in infected patients, even at later stages of disease; however, very high concentrations of viral DNA and the ability to infect cell culture, especially during the first two weeks after symptom onset, may have implications for risk of contamination and personnel safety. It should be noted that viral DNA-copies are not indicative of the amount of infectious viral particles. Other clinical material such as blood and oropharyngeal swabs were recently reported to contain detectable monkeypox virus-DNA; however, throat swab samples are known to be unreliable and difficult to standardize, e.g. in SARS-CoV-2 diagnostic. Blood and oropharyngeal swabs were consistently PCR-negative in 1/5 and 2/5 patients of our cohort respectively, thus making them unreliable standalone specimen types for primary diagnosis. However, their potential value for pre-/asymptomatic cases remains to be established. Interestingly, the highest levels of viral-DNA in blood were detected in two HIV-positive patients (under ART) and coincided with substantially increased numbers of pustulae. Therefore, viremia as a parameter for monitoring and risk assessment, as well as potentially increased risk of severe disease in HIV patients despite adequate therapy, warrants further investigation.