PRI’s MPV (Monkeypox) Situation Update  – October 6

Oct 6, 2022 | News

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: 26,049 (10.05.2022). (full version). 
  • NY State: As of September 21 2022, a total of 3,759 confirmed orthopoxvirus/monkeypox cases – a designation established by the Centers for Disease Control and Prevention (CDC). (NY Sit Rep and County List) 
  • CDC Says Monkeypox Virus Transmission Unlikely To Be Eliminated (Forbes) That’s because the slow and disorganized monkeypox response may have allowed the monkeypox virus, which was practically non-existent in the U.S. prior to 2022, establish a new foothold in this country, as a new Centers for Disease Control and Prevention (CDC) technical report has indicated.

US Updates/News

  • Study prompts more monkeypox vaccine efficacy questions (CIDRAP) A new study published in JAMA documents 90 monkeypox cases after one or two doses of the Jynneos vaccine—including 2 infections 3 weeks or more after two doses—among more than 7,000 vaccine recipients. Most post-vaccination cases occurred shortly after the recipients had received only the initial dose of Jynneos vaccine, demonstrating full vaccine efficacy was not reached until 14 or more days after the second dose.
  • What physicians should know about using TPOXX to treat monkeypox (AMA) Tecovirimat is not approved by the FDA for treatment of monkeypox infections. It was approved for treatment of smallpox disease under an FDA regulation known as the Animal Rule, which “allows for approval of drugs when human efficacy studies are not ethical and field trials to study the effectiveness of drugs or biological products are not feasible,” said Adam Sherwat, MD, deputy director of the Office of Infectious Diseases in the Center for Drug Evaluation and Research at the FDA.

Global Updates/News

Articles by Category

Epi/Transmission/Mitigation

Monkeypox Case Investigation — Cook County Jail, Chicago, Illinois, July–August 2022 (Hagan et al., MMWR)

In July 2022, the Chicago Department of Public Health (CDPH) confirmed a case of monkeypox in a person detained in Cook County Jail (CCJ) in Chicago, Illinois. This case was the first identified in a correctional setting in the United States and reported to CDC during the 2022 multinational monkeypox outbreak. CDPH collaborated with CCJ, the Illinois Department of Public Health (IDPH), and CDC to evaluate transmission risk within the facility. Fifty-seven residents were classified as having intermediate-risk exposures to the patient with monkeypox during the 7-day interval between the patient’s symptom onset and his isolation. (Intermediate-risk exposure was defined as potentially being within 6 ft of the patient with monkeypox for a total of ≥3 hours cumulatively, without wearing a surgical mask or respirator, or potentially having contact between their own intact skin or clothing and the skin lesions or body fluids from the patient or with materials that were in contact with the patient’s skin lesions or body fluids.) No secondary cases were identified among a subset of 62% of these potentially exposed residents who received symptom monitoring, serologic testing, or both. Thirteen residents accepted postexposure prophylaxis (PEP), with higher acceptance among those who were offered counseling individually or in small groups than among those who were offered PEP together in a large group. Monkeypox virus (MPXV) DNA, but no viable virus, was detected on one surface in a dormitory where the patient had been housed with other residents before he was isolated. Although monkeypox transmission might be limited in similar congregate settings in the absence of higher-risk exposures, congregate facilities should maintain recommended infection control practices in response to monkeypox cases, including placing the person with monkeypox in medical isolation and promptly and thoroughly cleaning and disinfecting spaces where the person has spent time.

Monkeypox outbreak in a piercing and tattoo establishment in Spain (del Rio Garcia et al., The Lancet Infectious Diseases)

Here, the authors describe the clinical and epidemiological investigations of the first reported outbreak of monkeypox in a piercing and tattoo establishment in Europe, from July 19 to August 3. The piercing and tattoo establishment had only one worker who did not present any epidemiological link or clinical picture related to the infection, however she reported being in contact with a possible index case on July 6. The client had inflammation of the area where the piercing was placed and generalised skin lesions, which he thought to be an adverse effect of taking antibiotics. It could not be confirmed whether this client had monkeypox because the owner had no list of clients, but they are considered the index case. 54 exposed individuals were identified and the attack rate was 37%. Among the 20 individuals with confirmed infection, 13 (65%) were women and seven (35%) were men. Median age was 26 years [IQR 16–40; range 13–45 years). Eight (40%) individuals were younger than 18 years. The predominant clinical feature was rash, found in all 20 individuals in the area of piercing or tattoo. The most frequent first clinical manifestation was piercing or tattoo rash (18 [90%] individuals). Lymphadenopathy was present in 11 (55%) individuals, and the cervical location was the most frequent location (five [45%]). Fever was present in eight (40%) individuals. In all individuals, clinical symptoms were mild and no one required hospitalisation.None of the individuals with confirmed infection reported vaccination against smallpox, immunodeficiencies, or concurrent diseases. All 20 individuals were unaware of or reported no contact with a known case of monkeypox. 96 close contacts were identified, with no secondary cases reported. Surface sampling was performed and all three samples were positive for monkeypox virus. A second sampling was performed on July 27, focusing on sharps and work tools. 15 (94%) of 16 samples were found to be positive for the virus. Together, these findings suggest that monkeypox virus can be transmitted through exposure to contaminated piercing or tattoo material and, potentially through contaminated hands, due to poor aseptic measures and handling of materials.

Laboratory Validation and Clinical Performance of a Saliva-Based Test for Monkeypox Virus (Allan-Blitz et al., Journal of Medical Virology)

Improved diagnostic tests and accessibility are essential for controlling the outbreak of monkeypox. We describe a saliva-based polymerase chain reaction (PCR) assay for monkeypox virus, in vitro test performance, and clinical implementation of that assay testing sites in Los Angeles, San Francisco, and Palm Springs, California. Finally, using pre-specified search terms, we conducted a systematic rapid review of PubMed and Web of Science online databases of studies reporting the performance of oral pharyngeal or saliva-based tests for monkeypox virus. The assay showed in silico inclusivity of 100% for 97 strains of monkeypox virus, with an analytic sensitivity of 250 copies/mL, and 100% agreement compared to known positive and negative specimens. Clinical testing identified 22 cases of monkeypox among 132 individuals (16.7%), of which 16 (72.7%) reported symptoms, 4 (18.2%) without a rash at the time of testing. Of an additional 18 patients with positive lesion tests, 16 (88.9%) had positive saliva tests. Our systematic review identified 6 studies; 100% of tests on oropharyngeal specimens from 23 patients agreed with the PCR test result of a lesion. Saliva-based PCR tests are potential tools for case identification, and further evaluation of the performance of such tests is warranted.

Monkeypox outbreak: Wastewater and environmental surveillance perspective (Tiwari et al., Science of The Total Environment)

Monkeypox disease (MPXD), a viral disease caused by monkeypox virus (MPXV), is an emerging zoonotic disease endemic in some countries of Central and Western Africa but seldom reported outside the affected region. Since May 2022, MPXD has been reported at least in 74 countries globally, prompting the World Health Organization to declare the MPXD outbreak a Public Health Emergency of International Concern. As of July 24, 2022; 92 % (68/74) of the countries with reported MPXD cases had no historical MPXD case reports. From the One Health perspective, the spread of MPXV in the environment poses a risk not only to humans but also to small mammals and may, ultimately, spread to potent novel host populations. Wastewater-based surveillance (WBS) has been extensively utilized for monitoring communicable diseases, particularly during the ongoing coronavirus disease, the COVID-19 pandemic. It helped to monitor infectious disease caseloads as well as specific viral variants circulating in communities. The detection of MPXV DNA in lesion materials (e.g. skin, vesicle fluid, crusts), skin rashes, and various body fluids, including respiratory and nasal secretions, saliva, urine, feces, and semen of infected individuals, supports the possibility of using WBS as an early proxy for the detection of MPXV infections. WBS of MPXV DNA can be used to monitor MPXV activity/trends in sewerage network areas even before detecting laboratory-confirmed clinical cases within a community. However, several factors affect the detection of MPXV in wastewater including, but not limited to, routes and duration time of virus shedding by infected individuals, infection rates in the relevant affected population, environmental persistence, the processes and analytical sensitivity of the used methods. Further research is needed to identify the key factors that impact the detection of MPXV biomarkers in wastewater and improve the utility of WBS of MPXV as an early warning and monitoring tool for safeguarding human health. In this review, we shortly summarize aspects of the MPXV outbreak relevant to wastewater monitoring and discuss the challenges associated with WBS.

Human monkeypox: cutaneous lesions in 8 patients in Canada (Sukhdeo et al., Canadian Medical Association Journal)

Most patients with human monkeypox (HMPX) have cutaneous lesions. In the 2022 outbreak of HMPX across non-endemic countries, cutaneous lesions have been different than previously described. In this outbreak, primary lesions often occur at anogenital and oral sites, suggesting direct inoculation, similar to patterns observed with syphilis. Primary lesions may occur before, with or without the onset of systemic symptoms. Although secondary lesions continue to present in a disseminated fashion, developmental pleomorphism (the phenomenon of lesions at different stages of development at the same anatomic site), is seen more commonly than previous outbreaks in which lesions were classically monomorphic. Furthermore, new lesions can continue to emerge for several days.4,5 The lesions may resemble those caused by other infections including syphilis, herpes simplex virus, molluscum contagiosum or folliculitis. We present clinical images to show the breadth of cutaneous and mucocutaneous lesions that presented in 8 patients with HMPX (confirmed by real-time polymerase chain reaction) who were cared for in Toronto, Canada, from May to July 2022. None of these patients were notably immunocompromised by a condition (including uncontrolled HIV) or immunosuppressing medication, which may modify disease severity. Patients with well-controlled HIV are indicated accordingly in the captions. We include images of active primary lesions at common locations (Figure 1, Figure 2, Figure 3 and Figure 4) and of lesions showing developmental pleomorphism (Figure 5 and Figure 6). We also include images of active secondary lesions by stage of development, including macules, papules, pustules, umbilicated pustules and ulcers that then scab over and heal (Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11). We provide images of lesions on the palms and soles (Figure 6 and Figure 9). In several cases, patients initially received diagnoses of, and were treated for, probable syphilis or herpes simplex virUs before a differential diagnosis of HMPX was considered.

Monkeypox: A Comprehensive Review (Harapan et al., Viruses)

The 2022 multi-country monkeypox outbreak in humans has brought new public health adversity on top of the ongoing coronavirus disease 2019 (COVID-19) pandemic. The disease has spread to 104 countries throughout six continents of the world, with the highest burden in North America and Europe. The etiologic agent, monkeypox virus (MPXV), has been known since 1959 after isolation from infected monkeys, and virulence among humans has been reported since the 1970s, mainly in endemic countries in West and Central Africa. However, the disease has reemerged in 2022 at an unprecedented pace, with particular concern on its human-to-human transmissibility and community spread in non-endemic regions. As a mitigation effort, healthcare workers, public health policymakers, and the general public worldwide need to be well-informed on this relatively neglected viral disease. Here, we provide a comprehensive and up-to-date overview of monkeypox, including the following aspects: epidemiology, etiology, pathogenesis, clinical features, diagnosis, and management. In addition, the current review discusses the preventive and control measures, the latest vaccine developments, and the future research areas in this re-emerging viral disease that was declared as a public health emergency of international concern.

Virology

Myocarditis Attributable to Monkeypox Virus Infection in 2 Patients, United States, 2022 (Rodriguez-Nava et al., Emerging Infectious Diseases)

Here the authors report two immunocompetent and otherwise healthy adults in the United States who had monkeypox and required hospitalization for viral myocarditis. Patient 1 was a healthy 32-year-old man who sought care at a hospital for his diagnosis of monkeypox. He reported having a sexual encounter with a new male partner 15 days earlier. Seven days after that encounter, he had onset of a viral illness with cervical lymphadenopathy, followed by a disseminated rash and a painful penile lesion. Two days before his hospital visit, a nonvariola orthopoxvirus DNA PCR test on a skin lesion specimen was positive. In the hospital, the patient reported ongoing chest pain and dyspnea for 1 day. Cardiac biomarkers revealed an elevated high-sensitivity troponin T (165 ng/L [reference <22 ng/L]) and elevated levels of N-terminal prohormone B-type natriuretic peptide (1,258 pg/mL [reference <450 pg/mL]). Electrocardiogram showed normal sinus rhythm, and chest radiograph results were unremarkable. The patient was admitted for suspected myocarditis and started on oral tecovirimat for treatment of monkeypox. He received no specific treatment for myocarditis given the rapid resolution of symptoms and normalization of troponin levels. By hospital day 6, the high-sensitivity troponin decreased to 11 ng/L from the initial peak of 165 ng/L. Patient 2 was a previously healthy 37-year-old man evaluated in the hospital for rash, fever, dyspnea, and decreased exercise tolerance 13 days after a sexual encounter with multiple partners. Five days after that encounter, he had onset of bilateral inguinal lymphadenopathy, followed by multiple skin lesions in both arms and a lesion at the base of the penis 2 days later. The next day, he had fatigue, low-grade fever, and chills. Two days before he sought care at the hospital, he had difficulty breathing and decreased exercise tolerance without chest pain. He reported dyspnea after climbing a single flight of stairs. Physical examination showed multiple skin lesions with central umbilication in the lower pubic and inguinal areas with smaller vesicular lesions on upper extremities. Laboratory results were notable for an elevated serum troponin I (0.35 ng/mL [reference <0.07 ng/mL]); serial measurements at 4 and 8 hours were stable (0.34 and 0.39 ng/mL, respectively). B-type natriuretic peptide level was 49 pg/mL (reference <100 pg/mL). An electrocardiogram demonstrated normal sinus rhythm, with T wave inversions in the inferior and anterolateral leads. Subsequent tracings showed improvement in the repolarization abnormality. Echocardiography showed normal biventricular size and systolic function with normal regional wall motion, and diastolic indices were age-appropriate. The patient remained hospitalized for 4 days. Dyspnea improved on day 3 and resolved by day 4; cardiac enzymes normalized. The authors conclude the clinical course of human monkeypox is milder than that of smallpox in immunocompetent hosts and the patients in their report improved 10–12 days after illness onset.

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