PRI’s MPV (Monkeypox) Situation Update – October 11

Oct 11, 2022 | News

Created by PRI for the NYC Health Department. Latest editions Tuesday and Thursdays. While we use the language “MPV”, most sources do not, and readers will see the language fluctuate within the report. For questions and feedback, please email info@pri.nyc

Summary

Case Counts/Trends and Large Guidance/Response Changes (Limited by latest reporting)

  • GLOBAL: From 1 January through 2 October 2022, 68 900 laboratory-confirmed cases of monkeypox and 25 deaths have been reported to WHO from 106 countries/territories/areas(hereafter ‘countries’[i]) in all six WHO Regions(Table 1). Since the last edition published on 21 September 2022, 7147 new cases (11.6% increase in total cases), and three new deaths have been reported. In the past seven days, 26 countries reported an increase in the weekly number of cases, with the highest increase (44.4%) reported in Nigeria. One new country, Egypt, reported its first case in the past seven days(27 September). Overall, 39 countries have not reported new cases for over 21 days, the maximum incubation period of the disease. (WHO Sit Rep – Latest 10/5/2022 / Dashboard)
  • US: Total confirmed MPV cases: 26,577 (10.07.2022). (full version). 
  • NY State: As of October 7 2022, a total of 3,626 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

  • CDC: Monkeypox in the US ‘unlikely to be eliminated in the near future’ (Medical News Today) While monkeypox is not usually fatal — the few reported cases of deaths have involved people with severely compromised immune systems — it is still an unwelcome experience. It is characterized by swollen lymph glands, fever, muscle aches, and a painful, blister-like rash appearing on the face or at the infection site. The rash typically dries up in a week or two.
  • First Commercial Monkeypox Authorized by the U.S. FDA (Precision Vaccinations) The U.S. Food and Drug Administration (FDA) recently issued an Emergency Use Authorization (EUA) to Abbott Molecular, Inc., for the Alinity m MPXV, a real-time polymerase chain reaction (PCR) test intended to detect monkeypox DNA using lesion swab specimens.

Global Updates/News

  • Monkeypox cases waning, but global threat remains (Gavi) While numbers of cases are dropping off overall, clusters of infections remain and the virus continues to circulate in parts of Africa. While rich countries are using vaccines licensed against monkeypox, lower income regions have yet to use them. Scientists are warning that it’s critical to watch how the virus mutates and understand how well vaccines and treatments are working.
  • Monkeypox: A dangerous variant circulating in the DRC could go global (NewScientist) This year’s global outbreak of monkeypox has seen cases in more than 100 countries, and deaths have occurred outside of the virus’ endemic countries in West and Central Africa for the first time. The World Health Organization’s official death toll for the outbreak as of 7 October stands at 26, but this excludes large numbers of suspected deaths in countries where there is little laboratory testing.

Articles by Category

Epi/Transmission/Mitigation

Human Monkeypox Classification from Skin Lesion Images with Deep Pre-trained Network using Mobile Application (Sahin et al., J Med Syst.)

This study presents an Android mobile application that uses deep learning to assist this situation. The application has been developed with Android Studio using Java programming language and Android SDK 12. Video images gathered through the mobile device’s camera are dispatched to a deep convolutional neural network that runs on the same device. Camera2 API of the Android platform has been used for camera access and operations. The network then classifies images as positive or negative for monkeypox detection. The network’s training has been carried out using skin lesion images of monkeypox-infected people and other skin lesion images. For this purpose, a publicly available dataset and a deep transfer learning approach have been used. All training and testing steps have been applied on Matlab using different pre-trained networks. Then, the network that has the best accuracy has been recreated and trained using TensorFlow. The TensorFlow model has been adapted to mobile devices by converting to the TensorFlow Lite model. The TensorFlow Lite model has been then embedded into the mobile application together with the TensorFlow Lite library for monkeypox detection. The application has been run on three devices successfully. During the run-time, the inference times have been gathered. 197 ms, 91 ms, and 138 ms average inference times have been observed. The presented system allows people with body lesions to quickly make a preliminary diagnosis. Thus, monkeypox-infected people can be encouraged to act rapidly to see an expert for a definitive diagnosis. According to the test results, the system can classify the images with 91.11% accuracy. In addition, the proposed mobile application can be trained for the preliminary diagnosis of other skin diseases.

Monkeypox virus: The changing facets of a zoonotic pathogen (Forni et al., Infection, Genetics and Evolution)

In the last five years, the prevalence of monkeypox has been increasing both in the regions considered endemic for the disease (West and Central Africa) and worldwide. Indeed, in July 2022, the World Health Organization declared the ongoing global outbreak of monkeypox a public health emergency of international concern. The disease is caused by monkeypox virus (MPXV), a member of the Orthopoxvirus genus, which also includes variola virus (the causative agent of smallpox) and vaccinia virus (used in the smallpox eradication campaign). Here, we review aspects of MPXV genetic diversity and epidemiology, with an emphasis on its genome structure, host range, and relationship with other orthopoxviruses. We also summarize the most recent findings deriving from the sequencing of outbreak MPXV genomes, and we discuss the apparent changing of MPXV evolutionary trajectory, which is characterized by the accumulation of point mutations rather than by gene gains/losses. Whereas the availability of a vaccine, the relatively mild presentation of the disease, and its relatively low transmissibility speak in favor of an efficient control of the global outbreak, the wide host range of MPXV raises concerns about the possible establishment of novel reservoirs. We also call for the deployment of field surveys and genomic surveillance programs to identify and control the MPXV reservoirs in West and Central Africa.

Clinical Conundrums: Differentiating Monkeypox From Similarly Presenting Infections (Hussain et al., Cureus)

Post the coronavirus disease 2019 (COVID-19) pandemic, there arises the concern of a new epidemic as cases of monkeypox are being confirmed, globally. With the initial clinical manifestation of monkeypox resembling that of the common cold or seasonal flu, recognizing alternative differential diagnoses is imperative as a medical health practitioner. The characteristic monkeypox maculopapular rash with the progression to vesicles and pustules before scabbing can be described in several other infections. Understanding the disease progression and distinct clinical presentation of monkeypox in its various stages may allow for a more expedient diagnosis among healthcare providers. Though eradicated, the clinical presentation of smallpox is the most similar to that of monkeypox; however, smallpox is no longer a concern for the general population. Other conditions such as molluscum contagiosum, syphilis, varicella zoster, measles, rickettsialpox, and scabies can present with rashes that may resemble singular or multiple states of the monkeypox rash progression. The ability to correctly diagnose an individual’s condition promptly may allow healthcare providers to provide correct supportive therapies or treatments.

Epidemiology-based analysis of the risks and elimination strategies of the monkeypox outbreak in 2022 (Chen et al)

Monkeypox, caused by monkeypox virus, has spread unprecedentedly to more than 100 countries since May 2022. Here we summarized the epidemiology of monkeypox through a literature review and elucidated the risks and the elimination strategies of this outbreak mainly based on the summarized epidemiology. We demonstrated that monkeypox virus became more contagious and less virulent in 2022, which could result from the fact that the virus entered a special transmission network favoring close contacts (i.e., sexual behaviors of men who have sex with men) and/or the possibility that the virus accumulated a few adaptive mutations. We gave the reasons to investigate whether cattle, goats, sheep, and pigs are susceptible to monkeypox virus and whether infection of monkeypox virus could be latent in some primates. We listed six potential scenarios about the future of the outbreak (e.g., the outbreak could lead to endemicity outside Africa with increased transmissibility or virulence). We also listed multiple factors aiding or impeding the elimination of the outbreak. We showed that the control measures strengthened worldwide after the World Health Organization declared the outbreak a public health emergency of international concern (PHEIC) could well control but could not eliminate the outbreak in 2022. We clarified eight strategies, i.e., publicity and education, case isolation, vaccine stockpiling, risk-based vaccination or ring vaccination, importation quarantine, international collaboration, and laboratory management, for the elimination of the outbreak.

Monkeypox and co infections presenting as a painful genital rash (Kiselinova et al., Journal of Clinical Images and Medical Case Reports)

Since May 2022, there is an ongoing Monkeypox (MPX) outbreak that has been declared as a public health emergency of international concern by WHO. Most of the cases are men who have sex with men, frequently presenting to the clinic with one or more Sexually Transmitted Diseases (STDs). We present one of the first cases admitted to our hospital ward with a clinical image of multiple painful peri anal lesions. To our experience, even most extensive cases can be treated with symptomatic and directed therapy. Screening and treatment for concomitant STDs is mandatory. The MPX outbreak has become a public health concern for which the best preventive options are actively discussed. Currently, pre-exposure and post-exposure vaccination are available in Belgium, but vaccines are scarce. Pre-exposure vaccination may be effective in the transmission of MPX virus, but probably insufficiently in the current ongoing epidemic. Therefore, there is urgent need for structured prevention programs, improved diagnostic strategies and systematic clinical management. 

The Evolving Epidemiology of Monkeypox Virus (Li et al., Cytokine & Growth Factor Reviews)

Monkeypox, caused by the monkeypox virus (MPXV), is a zoonotic disease endemic mainly in West and Central Africa. As of 27 September 2022, human monkeypox has occurred in more than 100 countries (mostly in non-endemic regions) and caused over 66,000 confirmed cases, which differs from previous epidemics that mainly affected African countries. Due to the increasing number of confirmed cases worldwide, the World Health Organization (WHO) has declared the monkeypox outbreak as a Public Health Emergency of International Concern on July 23, 2022. The international outbreak of human monkeypox represents a novel route of transmission for MPXV, with genital lesions as the primary infection, and the emergence of monkeypox in the current outbreak is also new, as novel variants emerge. Clinical physicians and scientists should be aware of this emerging situation, which presents a different scenario from previous outbreaks. In this review, we will discuss the molecular virology, evasion of antiviral immunity, epidemiology, evolution, and detection of MPXV, as well as prophylaxis and treatment strategies for monkeypox. This review also emphasizes the integration of relevant epidemiological data with genomic surveillance data to obtain real-time data, which could formulate prevention and control measures to curb this outbreak.

Epidemiological and clinical characteristics of patients with monkeypox in the GeoSentinel Network: a cross-sectional study (Angelo et al., The Lancet)

The early epidemiology of the 2022 monkeypox epidemic in non-endemic countries differs substantially from the epidemiology previously reported from endemic countries. We aimed to describe the epidemiological and clinical characteristics among individuals with confirmed cases of monkeypox infection. We descriptively analysed data for patients with confirmed monkeypox who were included in the GeoSentinel global clinical-care-based surveillance system between May 1 and July 1 2022, across 71 clinical sites in 29 countries. Data collected included demographics, travel history including mass gathering attendance, smallpox vaccination history, social history, sexual history, monkeypox exposure history, medical history, clinical presentation, physical examination, testing results, treatment, and outcomes. We did descriptive analyses of epidemiology and subanalyses of patients with and without HIV, patients with CD4 counts of less than 500 cells per mm3 or 500 cells per mm3 and higher, patients with one sexual partner or ten or more sexual partners, and patients with or without a previous smallpox vaccination. 226 cases were reported at 18 sites in 15 countries. Of 211 men for whom data were available, 208 (99%) were gay, bisexual, or men who have sex with men (MSM) with a median age of 37 years (range 18–68; IQR 32–43). Of 209 patients for whom HIV status was known, 92 (44%) men had HIV infection with a median CD4 count of 713 cells per mm3 (range 36–1659; IQR 500–885). Of 219 patients for whom data were available, 216 (99%) reported sexual or close intimate contact in the 21 days before symptom onset; MSM reported a median of three partners (IQR 1–8). Of 195 patients for whom data were available, 78 (40%) reported close contact with someone who had confirmed monkeypox. Overall, 30 (13%) of 226 patients were admitted to hospital; 16 (53%) of whom had severe illness, defined as hospital admission for clinical care rather than infection control. No deaths were reported. Compared with patients without HIV, patients with HIV were more likely to have diarrhoea (p=0·002), perianal rash or lesions (p=0·03), and a higher rash burden (median rash burden score 9 [IQR 6–21] for patients with HIV vs median rash burden score 6 [IQR 3–14] for patients without HIV; p<0·0001), but no differences were identified in the proportion of men who had severe illness by HIV status. Clinical manifestations of monkeypox infection differed by HIV status. Recommendations should be expanded to include pre-exposure monkeypox vaccination of groups at high risk of infection who plan to engage in sexual or close intimate contact.

Vaccine

Residual humoral immunity sustained over decades in a cohort of vaccinia-vaccinated individuals (Chan et al., Journal of Infectious Diseases)

In 2019, Singapore experienced a case of imported Monkeypox. As with smallpox, disease can be prevented through vaccination, which was mandatory for Singaporean infants until 1981. However, the degree of residual immunity in older vaccinated Singaporeans remains unknown. To address this question, sera from individuals born from 1946-1984 who were vaccinated with ACAM2000 were obtained through the Tan Tock Seng Hospital Normal Control Programme and tested. Serum samples were grouped into 12-year cohorts (1946-1957, 1958-1969, 1970-1981) and tested for anti-vaccinia IgG. 3 individuals born post 1981, the year in which smallpox vaccination was halted in Singapore, were grouped as a separate unvaccinated cohort. As expected, the unvaccinated cohort had no detectable vaccinia IgG. However, there were also individuals in the vaccinated cohorts with no detectable IgG. Those born prior to 1981 were found to have higher anti-vaccinia IgG and neutralizing activity titres.  Interestingly, there was a marked increase in geometric mean titre with age, with a statistically significant difference between the 1970-1981 and 1946-1957 cohort. This suggests that protective humoral immunity remains which could reduce disease severity in an orthopoxvirus outbreak. The authors conclude that correlation between IgG and neutralizing titres was observed indicating that serology could be used as a surrogate marker for immunity.

Virology

Air and surface sampling for monkeypox virus in a UK hospital: an observational study (Gould et al., The Lancet Microbe)

An outbreak of monkeypox virus infections in non-endemic countries was recognised on May 12, 2022. As of September 29, more than 67 000 infections have been reported globally, with more than 3400 confirmed cases in the UK by September 26. Monkeypox virus is believed to be predominantly transmitted through direct contact with lesions or infected body fluids, with possible involvement of fomites and large respiratory droplets. A case of monkeypox in a health-care worker in the UK in 2018 was suspected to be due to virus exposure while changing bedding. We aimed to measure the extent of environmental contamination in the isolation rooms of patients with symptomatic monkeypox. We investigated environmental contamination with monkeypox virus from infected patients admitted to isolation rooms at the Royal Free Hospital (London, UK) between May 24 and June 17, 2022. Surface swabs of high-touch areas in five isolation rooms, of the personal protective equipment (PPE) of health-care workers in doffing areas in three rooms, and from air samples collected before and during bedding changes in five rooms were analysed using quantitative PCR to assess monkeypox virus contamination levels. Virus isolation was performed to confirm presence of infectious virus in selected positive samples. We identified widespread surface contamination (56 [93%] of 60 samples were positive) in occupied patient rooms (monkeypox DNA cycle threshold [Ct] values 24·7–37·4), on health-care worker PPE after use (Ct 26·1–35·6), and in PPE doffing areas (Ct 26·3–36·8). Of 20 air samples taken, five (25%) were positive. Three (75%) of four air samples collected before and during a bedding change in one patient’s room were positive (Ct 32·7–36·2). Replication-competent virus was identified in two (50%) of four samples selected for viral isolation, including from air samples collected during bedding change. These data show contamination in isolation facilities and potential for suspension of monkeypox virus into the air during specific activities. PPE contamination was observed after clinical contact and changing of bedding. Contamination of hard surfaces in doffing areas supports the importance of cleaning protocols, PPE use, and doffing procedures.

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