PRI’s MPV (Monkeypox) Situation Update – October 13

Oct 13, 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: 27,022 (10.12.2022). (full version). 
  • NY State: As of October 9 2022, a total of 3,656 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 response looks to long term (Roll Call) The nation’s monkeypox response is shifting from crisis mode to a more long-term approach as the Biden administration acknowledges that it will be impossible to eradicate the virus from the country anytime soon.
  • What does the future look like for monkeypox? (Nature) Specialists don’t expect that this year’s outbreak will cause the kind of worldwide disruption seen with COVID-19. The monkeypox virus doesn’t seem to be airborne like COVID-19, highly transmissible like smallpox or long-lasting in the body like HIV.
  • Neonatal monkeypox viral infection (New England Journal of Medicine) The ongoing monkeypox outbreak was recently declared to be a Public Health Emergency of International Concern by the World Health Organization.1 Young children are at risk for severe disease; therefore, early recognition and prompt treatment are important.

Global Updates/News

Articles by Category

Epi/Transmission/Mitigation

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

In this cross-sectional study, researchers aimed to describe the epidemiological and clinical characteristics among individuals with confirmed cases of monkeypox infection. They descriptively analyzed 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. In totally, 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. In summary, clinical manifestations of monkeypox infection differed by HIV status. Authors suggest that 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.

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

In this observational study, researchers aimed to measure the extent of environmental contamination in the isolation rooms of patients with symptomatic monkeypox. They 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 analyzed using quantitative PCR to assess monkeypox virus contamination levels. They 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. Overall, 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. Authors conclude that contamination of hard surfaces in doffing areas supports the importance of cleaning protocols, PPE use, and doffing procedures.

Monkeypox as an emerging infectious disease: the ophthalmic implications (Milligan et al., British Journal of Ophthalmology)

The 2022 outbreak of monkeypox is of worldwide significance. There has been a rapid escalation in case numbers despite efforts to contain it and the WHO has declared it a Public Health Emergency of International Concern. To date, over 51 257 laboratory-confirmed cases have been reported, the majority in non-endemic countries, with 3279 in the UK. It is vital for ophthalmologists to understand this disease and the risk it poses. Human monkeypox is a zoonotic disease caused by the monkeypox virus, a double-stranded DNA virus in the Orthopoxvirus genus of the Poxviridae family. Other orthopoxviruses include variola (smallpox), cowpox and vaccinia; all of which have significant ocular sequelae. Transmission occurs from an animal reservoir (unknown, likely rodents) to a human host, leading to secondary human-to-human spread. During the recent outbreak, a higher incidence has been found in gay, bisexual or other men who have sex with men. Clinical diagnosis may be challenging as presentation can mimic common ophthalmic diseases. A thorough history is key to identifying potential cases. Ophthalmic manifestations may include preseptal cellulitis, conjunctivitis and keratitis. The oral antiviral agent tecovirimat, which was developed to treat smallpox, is the mainstay of treatment. Trifluorothymidine (trifluridine) eye-drops can be used for ophthalmic involvement. In addition, smallpox vaccines have provided some cross-immunity. Ocular monkeypox should be managed by infectious diseases specialists, in consultation with ophthalmologists to provide the expertise needed to treat potentially vision-threatening complications. This outbreak highlights the need for healthcare providers to implement appropriate infection control measures and be familiar with the identification and treatment of both cutaneous and ocular disease.

Human Monkeypox Classification from Skin Lesion Images with Deep Pre-trained Network using Mobile Application (Sahin et al., Journal of Medical Systems)

Recently, human monkeypox outbreaks have been reported in many countries. According to the reports and studies, quick determination and isolation of infected people are essential to reduce the spread rate. 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.

A Forecasting Prognosis of the Monkeypox Outbreak Based on a Comprehensive Statistical and Regression Analysis (Yasmin et al., Computation)

The uncommon illness known as monkeypox is brought on by the monkeypox virus. The Orthopoxvirus genus belongs to the family Poxviridae, which also contains the monkeypox virus. The variola virus, which causes smallpox; the vaccinia virus, which is used in the smallpox vaccine; and the cowpox virus are all members of the Orthopoxvirus genus. There is no relationship between chickenpox and monkeypox. After two outbreaks of a disorder resembling pox, monkeypox was first discovered in colonies of monkeys kept for research in 1958. The illness, also known as “monkeypox”, still has no known cause. However, non-human primates and African rodents can spread the disease to humans (such as monkeys). In 1970, a human was exposed to monkeypox for the first time. Several additional nations in central and western Africa currently have documented cases of monkeypox. Before the 2022 outbreak, almost all instances of monkeypox in people outside of Africa were connected to either imported animals or foreign travel to nations where the illness frequently occurs. In this work, the most recent monkeypox dataset was evaluated and the significant instances were visualized. Additionally, nine different forecasting models were also used, and the prophet model emerged as the most reliable one when compared with all nine models with an MSE value of 41,922.55, an R2 score of 0.49, a MAPE value of 16.82, an MAE value of 146.29, and an RMSE value of 204.75, which could be considerable assistance to clinicians treating monkeypox patients and government agencies monitoring the origination and current state of the disease.

Monkeypox in pregnancy: virology, clinical presentation, and obstetric management (Dashraath et al., National Library of Medicine)

The 2022 monkeypox outbreak, caused by the zoonotic monkeypox virus, has spread across 6 World Health Organization regions (the Americas, Africa, Europe, Eastern Mediterranean, Western Pacific, and South-East Asia) and was declared a public health emergency of international concern on July 23, 2022. The global situation is especially concerning given the atypically high rate of person-to-person transmission, which suggests viral evolution to an established human pathogen. Pregnant women are at heightened risk of vertical transmission of the monkeypox virus because of immune vulnerability and natural depletion of population immunity to smallpox among reproductive-age women, and because orthopoxviral cell entry mechanisms can overcome the typically viral-resistant syncytiotrophoblast barrier within the placenta. Data on pregnancy outcomes following monkeypox infection are scarce but include reports of miscarriage, intrauterine demise, preterm birth, and congenital infection. This article forecasts the issues that maternity units might face and proposes guidelines to protect the health of pregnant women and fetuses exposed to the monkeypox virus. We review the pathophysiology and clinical features of monkeypox infection and discuss the obstetrical implications of the unusually high prevalence of anogenital lesions. We describe the use of real-time polymerase chain reaction tests from mucocutaneous and oropharyngeal sites to confirm infection, and share an algorithm for the antenatal management of pregnant women with monkeypox virus exposure. On the basis of the best available knowledge from prenatal orthopoxvirus infections, we discuss the sonographic features of congenital monkeypox and the role of invasive testing in establishing fetal infection. We suggest a protocol for cesarean delivery to avoid the horizontal transmission of the monkeypox virus at birth and address the controversy of mother–infant separation in the postpartum period. Obstetrical concerns related to antiviral therapy with tecovirimat and vaccinia immune globulin are highlighted, including the risks of heart rate–corrected QT-interval prolongation, inaccuracies in blood glucose monitoring, and the predisposition to iatrogenic venous thromboembolism. The possibility of monkeypox vaccine hesitancy during pregnancy is discussed, and strategies are offered to mitigate these risks. Finally, we conclude with a research proposal to address knowledge gaps related to the impact of monkeypox infection on maternal, fetal, and neonatal health.

Monkeypox in a Patient with Controlled HIV Infection Initially Presenting with Fever, Painful Pharyngitis, and Tonsillitis (Fischer et al., Medicina)

With more and more cases emerging outside central and west African countries, where the disease is endemic, the World Health Organization (WHO) has recently declared human monkeypox a Public Health Emergency of International Concern. Typical symptoms of the disease include fever, myalgia, and lymphadenopathy followed by a rash, but other symptoms may occur. Immunocompromised patients, including patients with uncontrolled Human Immunodeficiency Virus (HIV) infection, may be at risk for more severe courses. Case presentation: We present the case of a 30-year-old male patient of Brazilian descent with monkeypox. Initial symptoms were fever and general discomfort, with painful pharyngitis and tonsillitis and finally a papular rash of the anogenital area as the disease progressed. The presumed date of infection was a sexual contact with an unknown male eight days before the first symptoms occurred. The patient had a known and controlled HIV infection. The main reason for the initial presentation at the hospital was painful pharyngitis and tonsillitis, limiting food intake. Monkeypox infection was confirmed via PCR testing from a swab sample of cutaneous lesions. Adequate systemic and local analgesia enabled oral food uptake again. Antiviral therapy with Tecovirimat was not administered due to the stable immune status of the patient and the mild clinical symptoms. To cover a possible bacterial superinfection or Syphilis infection of the tonsil, antibiotic therapy with Ceftriaxone was added. Several days after presentation, the inflammation of the pharynx resolved and was followed by non-painful mucosal peeling. The patient was followed up with telephone calls and reported a complete recovery. The skin lesions were completely dried out 18 days after the first symptoms. Painful pharyngitis and tonsillitis can be rare early symptoms of monkeypox, which is highly relevant in everyday clinical practice. Particularly in patients with risk factors for monkeypox infection, further clinical and microbiologic testing for monkeypox should be performed if there is a clinical presentation with pharyngitis and tonsillitis.

Virology

Evaluation of Five Buffers for Inactivation of Monkeypox Virus and Feasibility of Virus Detection Using the Panther Fusion® Open Access System (Fischer et al., Viruses)

Rapid diagnosis is key to containing viral outbreaks. However, for the current monkeypox outbreak the major deterrent to rapid testing is the requirement for higher biocontainment of potentially infectious monkeypox virus specimens. The current CDC guidelines require the DNA extraction process before PCR amplification to be performed under biosafety level 3 unless vaccinated personnel are performing assays. This increases the turn-around time and makes certain laboratories insufficiently equipped to handle specimens from patients with suspected monkeypox infection. We investigated the ability of five commercially available lysis buffers and heat for inactivation of monkeypox virus. We also optimized the use of monkeypox virus in Hologic® Panther Specimen Lysis Buffer for detection of virus in the Panther Fusion® Open Access System using published generic and clade specific monkeypox virus primers and probes.

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