PRI’s MPV (Monkeypox) Situation Update – August 23

Aug 23, 2022 | News

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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 8/7/2022 / Dashboard )
  • US: Total confirmed monkeypox/orthopoxvirus cases:15,433 (8.22.2022). (full version). 
  • NY State: As of August 22 2022, a total of 3,180 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

  • Monkeypox in children: What experts want parents to know (Medical News Today) “First of all, it’s not a large likelihood for [children] to get [monkeypox] at day care or school […] Because of increased hygiene practices that they’re doing there, it should decrease the chance of all infections, including the transmission of monkeypox,” said Dr. Ganjian. As with COVID-19, practicing good hygiene is a great place to start. The CDC also recommends vaccination for individuals who have been or may be more likely to be exposed to monkeypox. Currently, public health leaders favor the two-dose JYNNEOS vaccine for monkeypox.
  • Who Should Get a Monkeypox Vaccine? (AARP) People who are most likely to get monkeypox should get the vaccine, the Centers for Disease Control and Prevention (CDC) says, though this advice could change as supplies increase. And even though anyone can get monkeypox, the vast majority of individuals who are getting infected right now are men who are having sex with men and with multiple partners in areas where the virus is spreading, health experts say. Risks are much lower for people in monogamous relationships.
  • CDC reports evidence of monkeypox virus on household surfaces: 5 updates (Becker’s Hospital Review) Monkeypox virus genetic material was detected on 70 percent of 30 specimens, the CDC said. Virus DNA was detected on all samples from porous items (cloth furniture and blankets), 68 percent of nonporous surfaces (handles and switches) and on one chair. The findings indicate “some level of contamination occurred in the household environment,” however, no live virus was detected.

Global Updates/News

  • EU regulator OKs plan to increase monkeypox vaccine supplies (ABC News) A smaller dose of the monkeypox vaccine appears to still be effective and can be used to stretch the current supply by five times, the European Medicines Agency said Friday, echoing a recommendation made earlier this month by the U.S. Food and Drug Administration. The EU drug regulator said in a statement that injecting people with just one fifth the regular dose of the smallpox vaccine made by Bavarian Nordic appeared to produce similar levels of antibodies against monkeypox as a full dose.
  • U.S. Monkeypox Cases Surpass 15,000, Most of Any Country (U.S. News) It’s the highest total of any country. States that report the most cases include California, Texas, Florida, Georgia, New York and Illinois. Over the last week, the U.S. also saw the largest increase in monkeypox infections of any country, according to data from the World Health Organization. Globally, however, the number of reported new cases decreased last week compared to the week before, according to WHO. The 10 most affected countries are the U.S., Spain, Brazil, Germany, the U.K., France, Canada, the Netherlands, Peru and Portugal.
  • Monkeypox Outbreak Declining In The U.K. (Forbes) New monkeypox cases have started to decline in the U.K.: a country that’s seen more than 3,000 since May. That’s more than 10% of the world’s lab-confirmed infections. Cases are currently appearing at a rate of around 20 per day, official statistics show, with London experiencing the biggest fall in new cases.

Official Guidance Sources

Articles by Category


A Repeat of COVID: Data Show Racial Disparities in Monkeypox Response (Yahoo News)

New York City released new data Thursday showing stark disparities in monkeypox vaccine access, with Black men receiving the vaccine at a much lower rate than members of other racial groups. White New Yorkers represent about 45% of people at heightened risk of monkeypox infection and received 46% of vaccine doses. Black New Yorkers, who make up 31% of the at-risk population, received only 12% of doses administered so far, according to data from the city’s Health Department. Hispanic residents were overrepresented among vaccine recipients. They made up 16% of the at-risk population but received 23% of shots. Hispanic men so far represent the largest share of monkeypox patients. 

Why we shouldn’t tiptoe around who is at highest risk for monkeypox infection (CNN) 

`The Biden administration this month declared the outbreak of monkeypox, a virus spreading disproportionately among men who have sex with men and their sexual networks, a public health emergency. The Biden administration this month declared the outbreak of monkeypox, a virus spreading disproportionately among men who have sex with men and their sexual networks, a public health emergency. Yet experts say that the insistence on generalizing warnings both hurts outreach to the most vulnerable people, including Black and Latino men, and oversimplifies the lessons of the AIDS crisis, which illuminated the importance of battling stigma and pushing for care for those who needed it. “We don’t want to add stigma to a delicate situation, but then our messaging becomes so broad that nobody knows which people we’re speaking to – and that becomes a real problem,” Robert Fullilove, a professor of clinical sociomedical sciences at the Columbia University Medical Center, told CNN.

Medical Students’ Perception Regarding the Re-emerging Monkeypox Virus: An Institution-Based Cross-Sectional Study From Saudi Arabia (Alshahrani et al., Cureus)

Introduction: The recent multi-nation outbreaks of human monkeypox in non-endemic areas have created an emerging public health issue. Medical students who will become future healthcare providers are directly associated with community people and can easily sensitize the general population, so it is crucial to assess their degree of knowledge and attitudes regarding recently emerging infections or pathogens. However, studies on medical students’ perception of the monkeypox virus are scarce in Saudi Arabia. Therefore, the objective of this study was to assess the monkeypox virus-related knowledge and attitudes among medical students in the country. In general, this study showed that medical students had inadequate knowledge and awareness about the monkeypox virus. Students’ age, GPA, fathers’ education level, and training received about the monkeypox virus were significantly associated with the level of knowledge about the monkeypox virus. Although they were optimistic about the system’s ability to manage future outbreaks of the monkeypox virus in Saudi Arabia, they were unaware of the disease transmission and possessed a limited understanding of the virus. These findings emphasize the urgent need to increase their knowledge because controlling outbreaks requires significant cooperation from knowledgeable and skilled healthcare providers. Our research suggests that, in order to make it easier for students to learn about new epidemic outbreaks, such subjects be covered in educational courses, and public health training and awareness programs.

Insights into the monkeypox virus: Making of another pandemic within the pandemic? (Chadha et al., Environmental Microbiology) 

The world has already struggled to cope with the COVID-19 pandemic and the unprecedented devastations it caused. Now that mankind presently faces the challenge of a widespread MPX outbreak, it is a pressing need that we take timely measures to prevent its spread by promoting stringent surveillance, disease management (social distancing, isolation, and contact tracing), awareness initiatives, and vaccination drives. With the extensive research and progression of the outbreak, the scientific community will gain better insights into the biological implications and magnitude of the current MPX outbreak. However, this demands stronger inter-organization engagement and synchronization between the relevant stakeholders. Mankind cannot afford another pandemic and hence it is the need of the hour for the research community to realize the significance of such outbreaks and address them accordingly, without playing double standards or underestimating the implications of pathogens that have the potential to cause widespread epidemics. This outbreak can be viewed as an eye-opener for us to adopt a holistic approach toward the management of infectious diseases, not just in developed economies, but also in the middle- and low-income countries that have been experiencing the tyranny of such pathogens for decades. 


Asymptomatic Infection? Another Reason to Consider Monkeypox a Disease of Public Health Concern (Isaacs., Annals of Internal Medicine)

The current worldwide outbreak of disease caused by the monkeypox virus is unprecedented. Monkeypox virus was first found to cause disease in humans about 50 years ago, during the time of the intensified smallpox eradication program sponsored by the World Health Organization (WHO). At that time, it was described as “a rare zoonotic infection, of little public health significance compared with other infectious diseases in central and western Africa …”. People were infected by contact with infected animals. Occasional human-to-human transmission occurred, typically within a household. Long chains of human-to-human transmission were rare. When human-to-human transmission occurred, the disease in the contact was usually milder, and previous smallpox vaccination further reduced disease manifestations. Routine smallpox vaccination, which also protected against monkeypox disease, ended when smallpox was declared eradicated in 1980. At the time, it was deemed that the risk of continued use of the historical smallpox vaccine in Africa to prevent monkeypox was greater than the benefit. However, it was clear to scientists and epidemiologists that monkeypox needed to be monitored. Indeed, 30 years after cessation of smallpox vaccination, incidence of human monkeypox cases in central Africa was 20 times higher than during WHO surveillance of central Africa in the 1980s. In recent years, monkeypox cases outside endemic countries in Africa were related to travelers from an endemic country, and human-to-human transmission was rare. Before the current worldwide outbreak, the largest outbreak of monkeypox outside Africa occurred in the United States in 2003. That outbreak of 72 confirmed or probable cases was related to contact with prairie dogs that had been accidentally infected at an animal distribution center that was also housing exotic rodents from Ghana. Of note, there was no evidence of human-to-human transmission, and the outbreak lasted about 2 months.

Monkeypox virus from neurological complications to neuroinvasive properties: current status and future perspectives (Sepehrinezhad et al., Journal of Neurology) 

Cases of monkeypox (MPV) are sharply rising around the world. While most efforts are being focused on the management of the first symptoms of monkeypox, such as cutaneous lesions and flu-like symptoms, the effect of the monkeypox virus (MPXV) on multiple organs still remains unclear. Recently, several neurological manifestations, such as headache, myalgia, malaise, fatigue, altered consciousness, agitation, anorexia, nausea, and vomiting, have been reported in patients with MPV. In addition, data from experimental studies have indicated that MPXV can gain access to the central nervous system (CNS) through the olfactory epithelium and infected circulatory monocytes/macrophages as two probable neuroinvasive mechanisms. Therefore, there are growing concerns about the long-term effect of MPXV on the CNS and subsequent neurological complications. This paper highlights the importance of the neuroinvasive potential of MPXV, coupled with neurological manifestations.

High-Contact Object and Surface Contamination in a Household of Persons with Monkeypox Virus infection – Utah, June 2022 (Pfeiffer et al., Morbidity and Mortality Weekly Report) 

Monkeypox virus DNA was detected from many objects and surfaces sampled indicating that some level of contamination occurred in the household environment. However, the inability to detect viable virus suggests that virus viability might have decayed over time or through chemical or environmental inactivation. Although both patients were symptomatic and isolated in their home for >3 weeks, their cleaning and disinfection practices during this period might have limited the level of contamination within the household. These data are limited, and additional studies are needed to assess the presence and degree of surface contamination and investigate the potential for indirect transmission of Monkeypox virus in household environments. Monkeypox virus primarily spreads through close, personal, often skin-to-skin contact with the rash, scabs, lesions, body fluids, or respiratory secretions of a person with monkeypox; transmission via contaminated objects or surfaces (i.e., fomites) is also possible. Persons living in or visiting the home of someone with monkeypox should follow appropriate precautions against indirect exposure and transmission by wearing a well-fitting mask, avoiding touching possibly contaminated surfaces, maintaining appropriate hand hygiene, avoiding sharing eating utensils, clothing, bedding, or towels, and following home disinfection recommendations.

Introduction and Differential Diagnosis of Monkeypox in Argentina, 2022 (Lewis et al., Emergency Infectious Diseases) 

We report detection of cases of monkeypox virus infection in Argentina in the context of a marked increase in confounding cases of atypical hand-foot-and-mouth syndrome caused by enterovirus coxsackie A6. We recommend performing an accurate differential virological diagnosis for exanthematous disease in suspected monkeypox cases. In summary, we report 3 cases of monkeypox in patients in Argentina. Six additional patients in Argentina and Bolivia had monkeypox ruled out by differential diagnosis; 4 of those cases were atypical hand-foot-mouth syndrome caused by CV-A6. We recommend considering virological diagnosis of this disease in suspected cases of monkeypox. Clinicians should be aware of the possibility for misdiagnosis related to these viral infections. In summary, we report 3 cases of monkeypox in patients in Argentina. Six additional patients in Argentina and Bolivia had monkeypox ruled out by differential diagnosis; 4 of those cases were atypical hand-foot-mouth syndrome caused by CV-A6. We recommend considering virological diagnosis of this disease in suspected cases of monkeypox. Clinicians should be aware of the possibility for misdiagnosis related to these viral infections.

Monkeypox self-diagnosis abilities, determinants of vaccination and self-isolation intention after diagnosis among MSM, the Netherlands, July 2022 (Wang et al., Euro Survillance) 

This article reports the findings of an online survey among men who have sex with men (MSM) using a cohort established in 2017 (n = 257), along with recruitment of MSM on a gay online dating app (n = 137) in the first half of July 2022, before the start of targeted monkeypox vaccination in the Netherlands. Of the included 394 MSM, 43% (n=171) were below the age of 45-years, 6% (n=22) were living with HIV and 66% (n=241) were currently using HIV pre-exposure prophylaxis (PrEP). Participants were provided with 4 images and were asked to indicate what condition they could be. All of the images were showing lesions in parts of the face, one depicted a monkeypox lesion, the other three a vesicle due to a staphylococcal skin infection, a syphilis stage-2, and eczema. Only the image of eczema was diagnosed predominantly correct (67%), monkeypox lesion and staphylococcal infection images triggered some correct hits, but also considerable amounts of false self-diagnoses (up to 48% and 58%, respectively, for all alternative diagnoses combined), syphilis stage-2 was most frequently misdiagnosed as monkeypox (52%). Overall, 70% of participants showed high vaccination intention and 44% showed high intention for self-isolation after diagnosis i.e. until all lesions are gone, usually for up to 21 days. Given that currently monkeypox vaccinations are administered to PrEP-using MSM in the Netherlands, researchers adjusted for PrEP use status (current users (n = 241) vs PrEP-naïve MSM or PrEP-discontinued MSM (n = 122)) to compare the standardized prevalence ratio (SPR). They found that despite of the higher prevalence among PrEP users in both vaccination intention and self-isolation intention, the adjusted SPRs showed no significant differences, indicating similar vaccination and self-isolation intentions among PrEP users and non-PrEP-users. Lastly, for vaccination intention as endpoint, among socio-demographic determinants, MSM who were single but dating (adjusted OR (aOR) = 2.42), who had an open/polyamorous relationship (aOR = 3.96) and who were retired (aOR = 11.04) were more likely to have high vaccination intentions.


Current status of monkeypox vaccines (Gruber., Vaccines 7) 

In an effort to extend the limited vaccine supply, in the US, public health officials are considering dose-sparing approaches, e.g., using one dose of Jynneos administered subcutaneously (s.c.) instead of the licensed two doses and/or using two doses administered at a fraction of the standard dose by the intradermal route (i.d.) of administration of the attenuated MVA vaccine. In these situations, the safety and immunogenicity of the vaccine when administered at doses and routes of administration (RoA) different than licensed will need to be evaluated in the context of appropriately designed clinical studies. This could be achieved by way of conducting immunogenicity studies comparing vaccinia-specific neutralizing antibody titers induced by the vaccine administered at fractional doses and/or administered by different RoA to those induced using currently licensed doses and RoA as well as comparing the local and systemic reactogenicity in subjects enrolled. In the US, FDA can authorize the emergency use of an unapproved medical product or an unapproved use of an approved medical product for certain emergency circumstances under Emergency Use Authorization (EUA). The latter would require a determination by the Secretary of HHS of a public health emergency as occurred on August 4, 2022. On August 9, 2022, FDA authorized emergency use of JYNNEOS to increase the vaccine supply. This allows health care providers use of a) two doses (0.1 ml each rather than 0.5 ml each) of JYNNEOS 4 weeks apart via the i.d. RoA to individuals 18 years of age and older determined to be at high risk for monkeypox and b) two doses (0. 5 ml each) of Jynneos 4 weeks apart via the s.c. RoA to individuals younger than 18 years determined to be at high risk of monkeypox infection. Alternatively, and different from EUA, individuals could be enrolled into a clinical study under Expanded Access (EA) to administer fractional doses and alternate RoA of the vaccine. EA is a regulatory mechanism with the primary purpose to prevent or treat the patients’ disease, not to obtain safety or effectiveness data of the product provided certain criteria are met. This mechanism was used during the shortage of Yellow fever vaccine.


First case of monkeypox virus, SARS-CoV-2 and HIV co-infection (Nolasco et al., Journal of Infection)  

This case highlights how monkeypox and COVID-19 symptoms may overlap, and corroborates how in case of co-infection, anamnestic collection and sexual habits are crucial to perform the correct diagnosis. SARS-CoV-2 BA.4 and BA.5 subvariants are currently responsible for more than 1 million COVID-19 cases per day worldwide. Hence, clinicians should be aware of the possibility of SARS-CoV-2 and monkeypox virus co-infection, particularly in subjects with a recent history of travel to monkeypox-outbreak areas. If monkeypox is suspected, an oropharyngeal swab should be performed even in the absence of cutaneous manifestations as the skin may be spared, but the oral or rectal mucosa may be involved. Our case emphasises that sexual intercourse could be the predominant way of transmission. Therefore, complete STI screening is recommended after a diagnosis of monkeypox. In fact, our patient tested positive for HIV-1 and, given his preserved CD4 count, we could assume that the infection was relatively recent. To note, the monkeypox oropharyngeal swab was still positive after 20 days, suggesting that these individuals may still be contagious for several days after clinical remission. Consequently, physicians should encourage appropriate precautions. As this is the only reported case of monkeypox virus, SARS-CoV-2 and HIV co-infection, there is still not enough evidence supporting that this combination may aggravate patient’s condition. Given the current SARS-CoV-2 pandemic and the daily increase of monkeypox cases, healthcare systems must be aware of this eventuality, promoting appropriate diagnostic tests in high-risk subjects, which are essential to containment as there is no widely available treatment or prophylaxis.