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PRI’s MPV (Monkeypox) Situation Update – August 18

Aug 18, 2022 | News

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Summary

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 8/7/2022 / Dashboard )
  • US: Total confirmed monkeypox/orthopoxvirus cases: 13,527 (8.17.2022) (full version). 
  • NY State: As of August 17 2022, a total of 2,675 confirmed orthopoxvirus/monkeypox cases – a designation established by the Centers for Disease Control and Prevention (CDC). (NY Sit Rep and County List)

US Updates/News

  • DC Health Expands Eligibility Criteria for Monkeypox Vaccinations (DCHealth.gov) DC Health announced expanded eligibility for the monkeypox vaccine to align with the Centers for Disease Control and Prevention’s (CDC) current vaccination criteria and in response to a continued rise in monkeypox cases. DC Health reports that there are currently 321 cases of monkeypox in the District, representing the highest number of cases per capita in the United States.  
  • ‘Frustration and Stress’: State Officials Fault Rollout of Monkeypox Vaccine (NY Times) The federal government’s distribution of monkeypox vaccine has been blemished by missteps and confusion, burdening local officials and slowing the pace of immunizations even as the virus spreads, according to interviews with state health officials and documents obtained by The New York Times.
  • 9th child in US tests positive for monkeypox (ABC News) “We have a known connection to a previously diagnosed case,” Dr. Dean Sidelinger, health officer and state epidemiologist at the Oregon Health Authority, said in a press release. “This child did not get the virus at school, child care or another community setting.” The case has been linked to an adult monkeypox infection that was confirmed last month, officials said, adding that public health authorities received the positive test result on Aug. 15.

Global Updates/News

  • Monkeypox cases jumped 20% in the last week to 35,000 across 92 countries, WHO says (CNBC) The overwhelming majority of patients continue to be men who have sex with men, WHO Director-General Tedros Adhanom Ghebreyesus said. The global supply of the monkeypox vaccine, called Jynneos in the U.S., remains limited and data on its effectiveness in the current outbreak is sparse, Tedros said. Jynneos is manufactured by Danish biotech company Bavarian Nordic.
  • Monkeypox Vaccine Maker Seeks Partners in Race to Meet Demand (Bloomberg) Bavarian Nordic A/S, the only company with an approved vaccine for monkeypox, said it’s no longer certain it can meet demand and is talking to multiple production partners as cases rise across the world. The Danish company is exploring the possibility of outsourcing some of its production, including a technology transfer to a US contract manufacturer, to meet accelerating demand. Bavarian Nordic “is in conversations with multiple companies to further expand manufacturing capacity globally,” a company spokesperson said in an email. 
  • Dog infected with monkeypox prompts isolation warning (BBC) Dr Mike Ryan, director of the health emergencies programme, said it was “not unexpected”. “But what we don’t want to see happen is disease moving from one species to the next, and then remaining in that species (and) moving around within a new species because that’s when the virus can adapt, and then adapting to that new species (the virus) is incentivised to evolve as such.”
  • 34-year-old woman is Iran’s first monkeypox case (ABC News) The report said health authorities quarantined a 34-year-old woman living in the southwestern city of Ahvaz. Pedram Pakaeen, health ministry spokesperson, said the patient and her family members informed doctors after she developed symptoms on the skin of her hands.

Official Guidance Sources

Articles by Category

Communications/Stigma

World Health Organization renames 2 known clades of monkeypox virus (ABC News) 

The World Health Organization renamed the two known clades, or lineages, of the monkeypox virus Monday. Director-General Tedros Adhanom Ghebreyesus said the lineages will be referred to going forward using Roman numerals. “The clade formerly known as the Congo Basin or Central African clade will now be referred to as clade I, while the West African clade will be called clade II,” he said during a news conference.Subsequent lineages will be named using Roman numerals for the clade and lowercase letters will be used for the subclade.The WHO has been in talks to rename the virus itself due to concerns about stigmatization.

Assessment of Knowledge of Monkeypox Viral Infection among the General Population in Saudi Arabia (Alshahrani et al., Pathogens) 

Monkeypox is re-emerging and spreading over the world, posing a serious threat to human life, especially in non-endemic countries, including Saudi Arabia. Due to the paucity of research on knowledge about monkeypox in Saudi Arabia, this study aimed to evaluate the general population’s knowledge of monkeypox in a sample of the country. A web-based cross-sectional survey was conducted from 25 May 2022 to 15 July 2022. Participants’ knowledge about monkeypox on a 23-item scale and socio-demographic characteristics were gathered in the survey. Pearson’s Chi-square test was used to compare knowledge level (categorized into high and low) and explanatory variables. Out of 480, only 48% of the respondents had high knowledge (mean score > 14). Participants’ age, marital status, residential region, living in the urban area, education level, employment status, being a healthcare worker, income, and smoking status were significantly associated with the level of knowledge about monkeypox (p < 0.01). Overall, social media (75.0%) was the most frequently reported source from where participants obtained monkeypox-related information followed by TV and radio (45.6%), family or friend (15.6%), and healthcare provider (13.8%). We found that overall knowledge of monkeypox infection was slightly poor among the Saudi population. These findings highlight the urgent need for public education on monkeypox to promote awareness and engage the public ahead of the outbreak.

Epi/Transmission/Mitigation 

Human Monkeypox without Viral Prodrome or Sexual Exposure, California, USA, 2022 (Karan et al., Emerging Infcetious Diseases) 

The 2022 multicountry monkeypox outbreak has been linked primarily to intimate contact among men who have sex with men. We describe a case of monkeypox in a traveler who returned from the United Kingdom to the United States who did not report recent sexual contact. This case highlighted the distinctiveness of clinical manifestations as they indicated potential routes of transmission during the 2022 multicountry outbreak of monkeypox. This patient did not report recent sexual contact, did not have evidence of genital lesions or inguinal lymphadenopathy, and did not report a viral prodrome. His primary risk factor was close, nonsexual contact with numerous unknown persons at a crowded outdoor event. His case highlights the potential for spread at such gatherings, which may have implications for epidemic control. The lack of both sexual exposure and anogenital involvement indicates that mode of transmission may be associated with clinical symptoms; fomites (hotel bedding and sheets, high-touch areas in public settings) may be alternative modes of transmission. Overall, the viral inoculum required for all possible modes of transmission remains an area of active investigation.This case also demonstrates the importance of local monkeypox virus testing, rather than centralized testing in public health or commercial reference laboratories. Local testing enabled diagnosis in <12 hours and immediate notification to local and state public health authorities for isolation and contact tracing. 

How to Protect Against Monkeypox as School Starts (NY Times) 

Though monkeypox is unlikely to spread widely in schools and day cares, parents should expect to hear of more cases spilling over to these and other settings if the disease continues to proliferate. “There will absolutely be cases that will occur in women, in children and in people who are pregnant,” said Dr. Jay Varma, a physician and epidemiologist who specializes in infectious diseases at Weill Cornell Medical School in New York City.

Sexual history of human monkeypox patients seen at a tertiary hospital in Bayelsa, Nigeria (Ogoina et al., International Aids Journal of STD & AIDS)

Between September 2017 and December 2018, and for the first time after 38 years, Nigeria reported 122 confirmed and probable cases of HMPX, representing the largest outbreak of the WA clade in Africa to date. Epidemiological data from this outbreak revealed that males, urban dwellers, and young adults between the ages of 20–40 years were the most affected. Although, the sources of infection could not be identified in majority of cases, there was epidemiological and genomic evidence of human-to-human transmissions among household clusters and in a prison setting. In this study, we report prior sexual activity, MSP, CCS, transactional sex, and sex with someone with skin rash among a subset of HMPX patients from a single centre in Nigeria. The patients who reported HRB were all male heterosexuals, and all had genital ulcers. Our results seem to support some role of sexual contact in MPX transmission among cases indigenous to Nigeria. Our study findings highlight the potential of HMPX to spread among persons with high-risk behaviours irrespective of sexual orientation and geographical location. Future controlled observational studies with larger sample sizes are required to confirm if specific sexual behaviour, sexual orientation, and sexual route are associated with transmissions of HMPX in Nigeria, as well as in other MPX endemic African countries.

Monkeypox reported in India – South East Asia Region: Health and economic challenges (Sah et al., The Lancet, Regional Health)

South-East Asia (SEA) consists of multiple countries that differ in their economic, social, and health status. There is an urgent need for modernization of the existing infrastructure and diagnostic facilities. With the constant increase in the population of these countries, there is a huge pressure on the already exhausted healthcare system in the form of reduced healthcare workers’ (HCWs) efficiency, lack of funding directed towards healthcare advancement, and the re-emergence of communicable diseases. India witnessed a similar situation during the COVID-19 outbreak when the whole health system was severely affected with a substantial negative impact on HCWs’ mental health. The country was on lockdown and health facilities were overfilled with COVID-19 patients. Simultaneously, non-COVID patients could not access regular healthcare services. As the COVID-19 pandemic unraveled the exhausted healthcare system, an urgent need for improvement became evident. Additionally, we are currently witnessing multi-country outbreaks of Monkeypox (MPXV) and Marburg viruses. 

On July 14, 2022, India reported the first case of MPX from the SEA region.5 Four days later, the second case was reported from the same state (Kerala).6 Lately, on July 22nd, the third case was also reported from the Mallapuram district, Kerala.7 All three cases were males who travelled from United Arab Emirates (UAE) and were immediately isolated and hospitalized. Subsequently, their family members, other primary contacts and co-passengers were isolated and advised to observe any symptoms. Afterward, the State Health Minister employed a multidisciplinary team to mitigate further spread. Now, contact tracing is being carried out along with strict implementation of appropriate prevention and control measures to limit further spread of MPX. Fourth case of MPX has been reported from the capital city, New Delhi without any international travel history.

Treatment

Tecovirimat for the Treatment of Human Monkeypox: An Initial Series From Massachusetts, United States  (Matias et al., Open Forum Infectious Diseases) 

Tecovirimat was identified by a high-throughput screen conducted for compounds with inhibitory in vitro activity against Vaccinia virus and Cowpox virus. It appears to act by inhibiting the product of the F13L gene, which is conserved throughout orthopoxviruses. Pivotal studies subsequently demonstrated protection from mortality in a Rabbitpox virus model of smallpox in rabbits, as well as a Monkeypox virus model of smallpox in nonhuman primates. Pharmacokinetic and safety studies of 361 healthy controls randomized to 600 mg tecovirimat orally twice daily achieved levels 4 times that associated with efficacy in nonhuman primates. No safety signals were identified, and adverse effects were similar to placebo. Tecovirimat is currently available from the United States Strategic National Stockpile and can be administered under the careful monitoring specified under the CDC Institutional Review Board protocol. The CDC currently advises consideration of tecovirimat in patients with severe disease, those at risk for severe disease, and those with disease involvement in anatomic areas that might constitute a special hazard (such as the genitals). Data on efficacy of tecovirimat against MPXV in humans are limited. A secondary case (from a returning traveler from Nigeria in 2021) was observed to have an increase in viral DNA PCR cycle threshold from the oropharynx and blood coincident with tecovirimat initiation. No new lesions developed after 24 hours of tecovirimat. No adverse effects were reported and no hematological or biochemical abnormalities were noted. Detailed clinical information is not reported for 2 other treated patients (1 in 2021 returning from Nigeria and 1 involved in the current outbreak). 

Virology/Lab/Immunology 

Severe monkeypox-virus infection in undiagnosed advances HIV infection (Boesecke et al., Infection) 

A 40-year old male presented to his GP with a red spot on the tip of his nose which was initially classified as a sunburn. Within three days, the nasal area progressed to necrosis (Fig. 1). In parallel, typical MPXV lesions (confirmed by PCR) appeared on the whole body with serious infection of the penis and oral mucosa. The patient was transferred to a tertiary care hospital for tecovirimat treatment. Diagnostic work-up revealed a concomitant syphilis of longer duration (TPPA 1:2560, VDRL 1:8) and an advanced HIV infection with a CD4 T cell count of 127/uL. The patient had never been tested for sexually transmitted diseases (STD) before. The patient was treated with oral tecovirimat 600 mg bid for 7 days in addition to antiretroviral therapy (bictegravir/emtricitabine/tenofoviralafenamide single tablet p.o. qd) for the HIV infection and ceftriaxone 2 g i.v. for 10 days for the syphilis. The monkeypox lesions on the skin dried out and the nose partially improved with less swelling. Most cases of MPXV infection so far have been reported as mild and controlled HIV infection does not appear to be a risk factor for severe courses. However, this case illustrates the potential severity of MPXV infection in the setting of severe immunosuppression and untreated HIV infection. 

Detection of Monkeypox Virus in Anorectal Swabs From Asymptomatic Men Who Have Sex With Men in a Sexually Transmitted Infection Screening Program in Paris, France (Marie Ferre et al., Annals of Internal Medicine) 

The objective of this research letter was to assess the presence of MPXV in anorectal samples among asymptomatic MSM routinely tested for bacterial sexually transmitted infections. Researchers retrospectively performed testing for MPXV on all anorectal swabs that were collected in their center as part of a screening program for Neisseria gonorrhoeae and Chlamydia trachomatis. Per French guidelines, this screening is performed every 3 months among MSM with multiple sexual partners who are either taking HIV preexposure prophylaxis (PrEP) or living with HIV and receiving antiretroviral treatment. They report on asymptomatic MSM who tested negative for N gonorrhoeae and C trachomatis on MPXV anal swabs collected from 5 June to 11 July 2022. During the study period, 706 MSM visited their clinic, 383 had symptoms suggestive of MPXV infection (40% had anal lesions), and MPXV infection was confirmed in 271 of those with symptoms. Of the 706 MSM, 323 had no MPXV symptoms, and 213 had anal swabs collected and were negative for C trachomatis and N gonorrhoeae. Among these 213 MSM, the median age was 38 years (IQR, 29 to 48 years), and 110 (52%) were living with HIV and receiving antiretroviral therapy, with a median of 9 years (IQR, 4 to 18 years) since diagnosis. MPXV PCR was successfully performed on 200 of 213 anal swabs and was positive in 13 (6.5%). Of those testing positive, 8 were living with HIV; all had undetectable HIV-1 viral load, and all had a CD4 T-cell count above 0.500 × 109 cells/L, except 1 who had a CD4 T-cell count of 0.123 × 109 cells/L. They contacted all 13 MPXV-positive participants who were initially asymptomatic, and none reported symptoms suggestive of MPXV infection, but 2 subsequently presented with symptoms. Of the 187 asymptomatic participants who tested negative for MPXV, 3 presented to their clinic more than 3 weeks after the initial MPXV-negative anal swab with symptoms suggestive of MPXV infection and tested positive. This report documents positive MPXV PCR results from anal samples in asymptomatic MSM.

Retrospective detection of asymptomatic monkeypox virus infections among male sexual health clinic attendees in Belgium (De Baetselier et al., Nature Medicine)

The magnitude of the 2022 multi-country monkeypox virus outbreak has surpassed any preceding outbreak. It is unclear whether asymptomatic or otherwise undiagnosed infections are fuelling this epidemic. We aimed to assess whether undiagnosed infections occurred among men attending a Belgian sexual health clinic in May 2022. We retrospectively screened 224 samples collected for gonorrhoea and chlamydia testing using a monkeypox virus (MPXV) PCR assay, and identified MPXV DNA-positive samples from four men. At the time of sampling, one man had a painful rash, and three men had reported no symptoms. Upon clinical examination 21 to 37 days later, these three men were free of clinical signs and they reported not having experienced any symptoms. Serology confirmed MPXV exposure in all three men, and MPXV was cultured from two cases. These findings show that certain cases of monkeypox remain undiagnosed, and suggest that testing and quarantining of individuals reporting symptoms may not suffice to contain the outbreak.

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