News & Events

PRI’s MPV (Monkeypox) Situation Update – September 1

Sep 1, 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)

  • From 1 January through 22 August 2022, 41 664 laboratory-confirmed cases of monkeypox and 12 deaths have been reported to WHO from 96 countries/territories/areas[i] in all six WHO Regions (Table 1). Since the last edition of this report published on 10 August 2022, 13 859 new cases (50% increase) and 1 new death were reported; and 7 new countries reported cases. In the past seven days, 23 countries reported an increase in the weekly number of cases, with the highest increase reported in the United States of America. There are 16 countries that have not reported new cases for over 21 days, the maximum incubation period of the disease. No new WHO report. (WHO from 8/24 Situation update)
  • US: Total confirmed MPV cases: 18,989. Trends indicate outbreak may be slowing.(8.31.2022). (full version). 
  • NY State: As of August 31 2022, a total of 3,234 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

  • U.S. Will Set Aside Monkeypox Vaccines in New Equity Program (NY Times) The program, called an “equity intervention pilot,” will offer 10,000 vials of vaccine, or as many as 50,000 doses, that can be distributed by local officials to five different venues. Officials said the doses were meant for people who might struggle to find appointments or worry about the stigma of attending public vaccination events.
  • Texas reports death tied to monkeypox, a first in the U.S. (STAT) Monkeypox deaths have been rare, with 15 fatalities reported globally prior to the Texas case out of some 47,000 documented cases this year. Deaths have been reported from countries including Spain and Brazil, where the virus has not historically spread, as well as countries in West and Central Africa where the virus is endemic.
  • Monkeypox infections are slowing in the US. It’s not clear if that will last (CNN) On Friday, US Centers for Disease Control and Prevention Director Dr. Rochelle Walensky said that she is “cautiously optimistic” about the downward trend, but warned that the overall case count is still growing. “The rate of rise is lower, but we are still seeing increases and we are of course a very diverse country and things are not even across the country. So, we’re watching this with cautious optimism,” she said.

Global Updates/News

  • Monkeypox outbreak can be eliminated in Europe, WHO says (Reuters) There are encouraging signs of a sustained week-on-week decline in the onset of cases in many European countries, including France, Germany, Portugal, Spain and Britain, as well as a slowdown in some parts of the United States, despite scarce vaccine supplies.
  • World monkeypox outbreak tops 50,000 cases (The News) The World Health Organisation’s dashboard listed 50,496 cases and 16 deaths as reported this year to the UN agency, which declared the outbreak a global public health emergency in July. WHO chief Tedros Adhanom Ghebreyesus said the declines in new infections proved the outbreak could be brought to a halt.

Official Guidance Sources

Articles by Category

Epi/Transmission/Mitigation

Ten-Week Follow-Up of Monkeypox Case-Patient, Sweden, 2022 (Pettke et al., Emerging Infectious Diseases)

The patient, a previously healthy man with no history of smallpox vaccination, first noticed an inguinal swelling (day 0). The next day, he observed a small skin change on his foreskin, progressing over the next days to a deeper, well-circumscribed lesion with local lymphadenopathy. Fever developed on day 5 and 6, peaking at 39°C. One week after symptom onset, the patient sought care at an outpatient clinic. By then, the fever had subsided. No new lesions appeared. He reported a history of receiving oral sex from several male partners within the 3 weeks before symptom onset. At a follow-up visit on day 11, the lesion had increased in size to 2 cm in diameter. Microbiologic analyses for herpes simplex virus, syphilis, and Haemophilus ducreyi returned negative results; they performed real-time PCRs for orthopoxvirus DNA and MPXV DNA on the genital lesion swab; results were positive and confirmed. The genital lesion slowly healed but with increasing local lymphadenopathy; on day 25, the patient had a ruptured local lymph node with discharge. At a follow-up visit on day 53, the patient was feeling well but still had enlarged lymph nodes. The original genital lesion had diminished to 5 mm in diameter and bled slightly when touched. The wound from the ruptured lymph node had healed. The researchers took repeated samples from the patient during the 10-week follow-up period from the genital lesion, the ruptured local lymph node, urine, semen, blood and the respiratory tract. They detected MPXV DNA in most samples. Although tests of all genital samples were initially positive, all showed a rapid decline in viral DNA content. Of note, MPXV DNA was detected in swabs from the ruptured lymph node 40 days after symptom onset, in semen and saliva after 54 days, and in saliva after 76 days. This report highlights an alternative clinical manifestation of the strain of MPXV associated with the 2022 multinational outbreak, causing localized lesions rather than the classic generalized rash or vesicles spread over the bod and lymph node rupture is an unusual manifestation. Second, they presented viral kinetics in different sample materials over time and show that, despite the localized lesion in this patient, viral DNA could also be found in urine, blood, and the respiratory tract. So far, this type of data has been published for few cases within the current multinational outbreak, connected to sexual transmission of MPXV. The persistent detection of MPXV DNA in samples from semen and the respiratory tract in this case could have implications for transmissibility.

The first imported case of monkeypox in Singapore during the 2022 outbreak – Reflections and lessons (Tan et al., Travel Medicine and Infectious Disease)

The authors present the clinical details, management and public health measures for the second imported case of human MPX in Singapore and the first linked to the recent global outbreak. The case was identified via enhanced surveillance instituted in response to the 2022 MPX global outbreak. The patient is a 42-year-old male who had travelled to Singapore and had symptoms suggestive of MPX. He was conveyed to the National Centre for Infectious Diseases (NCID), the national treatment Center for emerging infectious diseases, where swabs of perianal lesions and nasopharynx tested positive by both MPXV generic and West African specific PCR on June 20,20 June 2022. He presented with a headache on 14 June 2022 and fever two days later. These symptoms later resolved before skin rashes developed on 19 June 2022, prompting a tele-consult that led to the admission to the isolation ward in NCID where he was managed under full airborne and contact precautions. On admission, the patient reported no significant symptoms apart from perianal discomfort. He was afebrile and hemodynamically stable. Physical examination revealed non-tender cervical, axillary, inguinal lymphadenopathy with 11 vesicular lesions involving the back and neck and numerous vesiculo-pustular lesions and erosions in the perianal region. There were no lesions observed in oral cavity and external genitalia. In all, 13 close contacts (of which 10 were airline crew members and three were local close contacts) and six other local low-risk contacts were identified. All close contacts were given quarantine orders for 21 days since their last contact with the patient. Close follow up for contacts did not reveal secondary transmission.

Monkeypox diagnostic and treatment capacity at epidemic onset: A VACCELERATE online survey(Grothe et al., Journal of Infection and Public Health)

Since May 2022 multiple cases of monkeypox have been reported outside of the endemic regions in West and Central Africa [1]. As the number of confirmed cases in Europe continues to rise, efforts are made to localise and contain the outbreak [2], [3]. However, the healthcare system preparedness for this transmissible infection remains unclear. Hospitals and other medical facilities are not only important in treating affected patients, but also responsible for detecting and monitoring cases in close cooperation with Public Health institutions [4]. Aside from that, high standards of infection prevention and control must be in place to avoid health-care associated outbreaks [5]. The state of knowledge regarding this disease is extremely dynamic and a high level of alertness is required. Hence, we aimed to collect data about the preparedness of European tertiary care institutions for the current outbreak of monkeypox and the distribution of diagnostic and treatment capacities. In this online survey we summarise the diagnostic and treatment capacity for monkeypox in European institutions at the time of initial outbreaks. With the collected variables we could observe how they have an acceptably good diagnostic capacity, although there is some room for improvement treatment-wise in several institutions. 

Estimating the undetected infections in the Monkeypox outbreak (Maruotti et al., Journal of Medical Virology) 

The  proposed  method answers  to  a  fundamental open  question:  “How many  undetected cases are going around?”. We remark that lower bound of the number of total  infections  is  provided, but  this  information  may  be  treated  as  a  starting  point  whenever  interventions  and  tools  to dampen  the  spread  of  the  epidemic  are rolled out.  This  is  a  relevant  result  as  it  provides  reasonable  information to  the  policy  makers about the undetected cases and the magnitude this phenomenon may have at least, so that national health systems may be aware of the minimum number of cases that may demand health care services.The  sudden  appearance  of  Monkeypox  in  multiple  countries  across  the  world  indicates the virus  has  been  spreading undetected  for  some  time  outside  the  West  andCentral   African   nations where  it  is  usually  found.  Having  an  estimate  of  this  phenomenon  is  fundamental  to  apply  non-pharmaceutical-interventions  to  contain the  spread  of  the  virus.  And  when a  virus  spreads cryptically  like  this,  it  can  be  really hard to stop, and there’s a chance it could become a long- term  problem.Further attention should be in place as cases may be undetected because the disease looks different than what’s described in medical textbooks. The concern on how the virus  might  change,  especially  in  terms  of  how  it  spreads,  is  real:  there’s  a  possibility it has beco me more contagious. We  believe  it  is  not  too  late  to  contain  Monkeypox.  However,  to  prevent  onward  spread,  as  a  general  guide,  high  quality  data  are  required.  Indeed,  when  the  poor  quality of the data, as often happens at the beginning of an outbreak, does not allow to  correctly  apply  sophisticated models,  a  robust  data-driven  approach,  like  the  capture-recapture  approach  here  proposed,  could be  used  as  a  starting  point  of  any analyses.Contact tracing and isolating patients who have Monkeypox are crucial to stopping the  spread,  and  are  still  the  only  tools  we  have  at  the  moment  to  manage  the  epidemic,  along  with  strengthening  national  surveillance  (Nuzzo  et  al.,  2022).  Vaccination  should  be  recommended  for  all contacts  of  positives  and  for  at  risk subjects (Guarner et al., 2022). 

Co-infection of COVID-19 and Monkeypox: A Case Report from Florida, USA, 2022 (Knopp et al., Current Research in Emergency Medicine)

Monkeypox is a re-emerging zoonotic disease of the orthopoxvirus genus presenting with myocutaneous symptoms similar to those caused by smallpox. Patients infected with monkeypox may experience a prodromal period with flulike symptoms lasting between 1-4 days, an asymptomatic incubation period lasting 7-17 days and a symptomatic rash period lasting 14-28 days between the appearance of widespread vesiculopapular lesions and desquamation. Specific risk factors for the current monkeypox outbreak include HIV infection, prior STI infection, male sex, young-adult age (specifically being in the 20’s-30’s age group), engaging in risky behaviors (such as unprotected sex) and men having sex with other men. We report the case of a 38-year old HIV+ patient testing positive for monkeypox, COVID-19 and herpes who presented to the emergency department with widespread vesiculopapular lesions. One week prior to ED presentation, the patient experienced flu-like symptoms including fever and, two days later, developed a vesiculopapular rash beginning on his face and spreading downwards to his extremities, trunk and genitalia. The flu-like symptoms developed twelve days after attending an event where the patient reported having sex with multiple other men. The patient was treated with intravenous fluids and supportive care alongside his HIV medications. Nine days after initial ED presentation, all skin lesions were desquamated and the patient was discharged from the hospital. To our knowledge, this is one of the first reported cases of co-infection with COVID-19 and monkeypox in Florida and the United States more broadly. Despite our patient’s several risk factors for monkeypox infection, and immunosuppressed status, he experienced an uncomplicated clinical course. As vaccination and antiviral treatments become more available for monkeypox patients, our case suggests supportive care with airborne and contact precautions may be adequate in the treatment of future monkeypox patients where these treatments are unavailable. 

The first imported case of monkeypox in Singapore during the 2022 outbreak – Reflections and lessons (Tan et al., Travel Medicine and Infectious Disease)

We describe the first imported human MPX infection in Singapore arising from the 2022 globally-linked outbreak. Singapore has had a prior importation of MPX from Nigeria in 2019 [5] which although was also related to the West African clade, was on a divergent phylogenetic branch in relation to viral isolates from the current 2022 MPX outbreak, indicating continued evolution and adaptation of this virus [6]. The risk factors of disease acquisition differed for both cases. The 2019 case from Nigeria was thought to be linked with consumption of bushmeat or from the environment where Nigeria was experiencing human MPX outbreak, while this case was likely from close skin-skin contact. Both patients had lesions in differing stages of development on admission. The duration from symptom onset to de-isolation and discharge was 24 days for the case in 2019 and 23 days for the current case. Both cases did not develop complications and were not given antivirus treatment. As of 25 July, eight more MPX cases were identified through the surveillance programme instituted in view of the 2022 MPX global outbreak. Robust surveillance mechanisms, continued partnership between public health and frontline practitioners, out-reach to at-risk communities through existing networks, availability of testing and diminishing barriers in seeking medical attention are crucial in the control of this outbreak.

Vaccine

Repositioning potentials of smallpox vaccines and antiviral agents in monkeypox outbreak: A rapid review on comparative benefits and risks (Islam et al., Health Science Reports)

In this rapid review, researchers aimed to review and discuss the repurposing potentials of smallpox vaccines and drugs in monkeypox outbreaks based on their comparative benefits and risks. Google Scholar and PubMed were searched for relevant information and data. Many articles were identified that have suggested the use of smallpox vaccines and antiviral drugs in monkeypox outbreaks according to the study findings. The relevant articles were read to extract information. According to the available documents, researchers found two replication-competent and one replication-deficient vaccinia vaccines were effective against Orthopoxvirus. However, healthcare authorities have authorized second-generation live vaccina virus vaccines against Orthopoxvirus in many countries. Smallpox vaccine is almost 85% effective in preventing monkeypox infection as monkeypox virus, variola virus, and vaccinia virus are similar. The United States and Canada have approved a replication-deficient third-generation smallpox vaccine for the prevention of monkeypox infection. However, the widely used second-generation smallpox vaccines contain a live virus and replicate it into the human cell. Therefore, there is a chance to cause virus-induced complications among the vaccinated subjects. In those circumstances, the available Orthopoxvirus inhibitors might be a good choice for treating monkeypox infections as they showed similar efficacy in monkeypox infection in different animal model clinical trials. Also, the combined use of antiviral drugs (e.g., cidofovir, brincidofovir [CMX001], and tecovirimat [ST-246]) and vaccinia immune globulin can enhance significant effectiveness in immunocompromised subjects. In summary, repurposing of these smallpox vaccines and antiviral agents might be weapons to fight monkeypox infection. Furthermore, authors recommend further investigations of smallpox vaccines and Orthopoxvirus inhibitors in a human model study to explore their exact role in human monkeypox infections.

Virology

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%). They 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.

Monkeypox: an international epidemic (Focosi et al., Reviews in Medical Virology)

Human monkeypox (MPX) is a viral zoonosis caused by the Monkeypox virus. For decades outbreaks exclusively occurred in the tropical rainforests of Africa, with a few imported cases and very limited human-to-human transmission outside Africa. Nevertheless, in the last years sustained outbreaks have emerged, peaking at 4600 cases in 2020 in the Democratic Republic of Congo. Since May 2022, an international epidemic originated at 2 events in Spain and Belgium led to sustained human-to-human transmission across multiple continents, mostly in males having sex with males subjects. We review here clinical presentation, epidemiology, viral evolution, vaccines, and therapeutics against human MPX.

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