PRI’s MPV (Monkeypox) Situation Update – September 15

Sep 15, 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 4 September 2022, 52 996 laboratory-confirmed cases of monkeypox and 18 deaths have been reported to WHO from 102 countries/territories/areas in all six WHO Regions (Table 1). Since the last edition of this report published on 24 August 2022, 11 332 new cases (27% increase) and six new deaths were reported; and six new countries reported cases. In the past seven days, 25 countries reported an increase in the weekly number of cases, with the highest increase reported in Colombia, and one country, South Sudan, reported its first case (29 August 2022). There are 27 countries that have not reported new cases for over 21 days, the maximum incubation period of the disease. (WHO Sit Rep – Latest 9/7/2022 / Dashboard)
  • US: Total confirmed MPV cases: 22,774 (9.14.2022). (full version). 
  • NY State: As of September 14 2022, a total of 3,647 confirmed orthopoxvirus/monkeypox cases – a designation established by the Centers for Disease Control and Prevention (CDC). (NY Sit Rep and County List)
  • New concerns about monkeypox (CBS News) Federal health leaders say the monkeypox virus is only one mutation away from evading a key anti-viral drug, the drug is used to treat at-risk patients. Health experts are urging doctors to be “judicious” in prescribing the treatment. Some lawmakers call the U.S. response to monkeypox “a catastrophic failure.”

US Updates/News

  • CDC head says monkeypox slowing in US (CIDRAP) “To address these access issues, we had to work with clinicians, we had to do an extraordinary outreach so providers would know how to test and patients would know when to come in to test,” she said. Walensky also said the nation has continued to grow its capacity to test for the virus, and partnered with commercial labs to expedite testing. In her testimony, Walensky said the outbreak is slowing substantially in the country.
  • Biden administration officials take bipartisan flak on monkeypox response (Politico) Senators from both parties slammed the federal government’s response to the monkeypox outbreak during a congressional hearing on Wednesday, criticizing the slow vaccine rollout in the critical early stages of the spread and the enduring vaccination gaps in communities of color.

Global Updates/News

  • New study estimates monkeypox incubation, generation times and R0 (News Medical) The mean incubation period was 9.1 days, while the generation time was 12.5 days. Moreover, the net reproduction number was 2.43 during the first week of June and subsequently decreased after June 12, 2022. The results of the current study provide important information regarding the early stages of the current MPX outbreak in Italy. These observations also elucidate the duration for which symptoms must be monitored, infected people must be isolated, and contact tracing is necessitated. In addition, the net reproduction number is also a valid parameter to monitor the gradual spread of the disease.

Official Guidance Sources

Articles by Category

Epi/Transmission/Mitigation

Protect the vulnerable from monkeypox (Science) Recent declines in monkeypox infections have elicited comments such as “cautiously optimistic” and “we’re turning a corner.” Indeed, this trend in large cities in the United States and Europe, as well as a global decline in new cases of 21% (according to the World Health Organization), is encouraging. However, if we don’t prioritize and protect the most vulnerable populations, the outbreak will not end any time soon.

Monkeypox infection in pregnancy: a systematic review and meta-analysis (D’American Journal of Obstetrics and Gynecology)

The main aim of this systematic review was to ascertain the maternal and perinatal outcomes of pregnancies complicated by monkeypox infection. Medline, Embase and Cochrane databases were searched on 25th June 2022 utilizing combinations of the relevant medical subject heading (MeSH) terms, key words, and word variants for “monkeypox” and “pregnancy”. The outcomes observed were miscarriage, intra-uterine, neonatal and perinatal death, preterm birth, vertical transmission, maternal symptoms. Meta-analysis of proportion was used to analyze the data. Four studies were included. All the included cases in the present systematic review presented with symptoms and signs of monkeypox infection. There was no case of maternal death. Miscarriage occurred in 39% (95% CI 0-89.0) while intra-uterine fetal death in 23.0% (95% CI 0-74.0) of cases. The overall incidence of late fetal and perinatal loss was 77.0% (95% CI 26.0-100), while only 23% (0-74.0) of the included fetuses survived to birth. The incidence of preterm birth prior to 37 weeks of gestation was 8.0% (0-62.0). Vertical transmission occurred in 62.0% (3.0-100) of cases. When stratifying the analysis according to gestational age at infection, fetal loss occurred in 67.0% (95% CI 9.0-99.0) of cases with first trimester and 82.0% (95% CI 17.0-100) of those with second trimester infection. In summary, monkeypox infection in pregnancy is associated with a high risk of perinatal loss and vertical transmission. The preliminary results from this systematic review affected by a very small number of included cases highlights the need for a thorough maternal and fetal surveillance in pregnancies complicated by Monkeypox infection.

Monkeypox outbreak: The need to include prisons in public health response (Adebisi et al., Ann Med. Surg.)

Amid global efforts to combat the ongoing coronavirus disease 2019 (COVID-19) pandemic brought on by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the monkeypox virus has arisen as a unique menace to humanity [1]. In developed countries, monkeypox, a zoonotic orthopoxviral illness that manifests clinically as a smallpox-like infection in people, is becoming more common [2]. Although the Democratic Republic of the Congo saw the first cases of the monkeypox virus in the 1970s, it has since spread to several other nations [3]. As of August 19, 2022, monkeypox has caused 41,358 cases and 12 deaths worldwide, and the threat is growing [4]. The WHO recently declared monkeypox a global health emergency with a number of response initiatives seen across countries, including efforts to increase access to vaccines and increase surveillance [5]. However, efforts to control the monkeypox outbreak in infectious disease-prone environments like prisons have not received much attention. This neglect in prisons is similar to what is seen with the ongoing COVID-19 pandemic.

Findings on the Monkeypox Exposure Mitigation Strategies Employed by Men Who Have Sex with Men and Transgender Women in the United States (Hubach et al., Archives of Sexual Behavior)

This study aimed to examine U.S. mex who have sex with men (MSM) and transgender women’s behavioral changes and employed exposure mitigation strategies due to the ongoing monkeypox outbreak. Between August 6–15, 2022, MSM and transgender women (N = 703) from across the U.S. were recruited online using paid advertisements on Grindr, a popular sexual networking or hookup app for MSM. All participants completed the online cross-sectional questionnaire. Data was collected on sociodemographic characteristics, recent sexual behavior, and monkeypox exposure mitigation. The average age was 38.08 years (SD = 13.38). About three-quarters lived in an urban county (73.3%). Most were cisgender (91.0%) and gay (72.8%). About half of the respondents were non-Hispanic White (56.7%), followed by Hispanic or Latin American (15.3%) and Black or African American (10.2%). Nearly two-thirds had a bachelor’s degree or higher (61.0%), and 49.7% had an annual household income of $60,000 or higher. Of the total sample, 85.5% had oral sex and 66.4% had condomless anal sex with a non-primary partner during the past 6 months. 393 (55.9%) participants reported a change in their sexual behaviors due to the monkeypox outbreak. Of those, 382 endorsed using at least one of the 14 pre-defined strategies provided (M = 3.96, SD = 2.15, range: 1–11). The most common monkeypox mitigation strategies employed were limiting the number of sexual partners one has (40.8%) and avoiding bars, clubs, and other parties (33.4%). Approximately a quarter of participants became abstinent or avoided having any type of sex (24.8%), asked their sexual partners if they had monkeypox symptoms (25.0%), or inspected their sexual partners to see if they had monkeypox symptoms (24.3%). Fewer participants (2-13%) reported engaging in sexual activities that eliminated skin-to-skin contact to mitigate monkeypox exposure or washing bedding and other fabrics after having sex with a partner. Results from this formative study can advise the tailoring of monkeypox prevention messaging campaigns and interventions for MSM and transgender women in the U.S.

Monkeypox is an outbreak of international concern (Whiteworth, Transactions of the Royal Society of Tropical Medicine & Hygiene)

On 6 May 2022, a case of monkeypox was reported in the UK. Within 2 weeks further cases had been reported in numerous European countries and subsequently around the world. An international case series1 reported that >98% of cases were in men who identified as gay, bisexual or other men having sex with men (GBMSM). Many patients reported classic symptoms of fever and lethargy, myalgia and headache, lymphadenopathy and the characteristic vesiculopustular rash. However, some cases reported little or no systemic features and unusual rash presentations, often limited to the oral or genital region, with prominent severe pain. Public health authorities moved swiftly to institute case detection, isolation and treatment and contact tracing, together with extensive community engagement. Most cases can be managed in the community, only 10–15% require outpatient support or admission to hospital2 and most cases recover fully within a few weeks. Vaccination with MVA-BN (Imvanex/Jynneos), a live replication-defective modified vaccinia Ankara vaccine, has been offered to contacts of confirmed cases, ideally within 4 d of exposure, and to high-risk individuals, including those living with HIV.4 However, even with these measures the epidemic has continued to spread and by 29 July there had been >22 000 cases globally in 79 countries.5 The overwhelming predominance of cases in men has persisted, with few confirmed cases in women and children. The mortality rate has been low with 10 deaths reported in 2022 (five of which have been outside Africa).

Monkeypox and the safety of blood supply (Greninger et al., Transfusion)

MPXV is an orthopoxvirus that is causing an expanding worldwide outbreak of monkeypox in 2022, with spread to more than 32,000 individuals and 82 non-endemic countries at time of this writing. Classic monkeypox is characterized by a prodrome of fever, headache, and lymphadenopathy, followed by the development of mucocutaneous lesions from which virus is shed at high levels. Mortality outside of Africa during the current outbreak has been significantly less than previously reported rates for the two major clades of MPXV (Central Africa, Clade I; and West Africa Clade IIa and IIb). The 2022 outbreak strain is predominantly Clade IIb.1 To date, the vast majority of reported infections have been in men who have sex with men (MSM) in Western Europe and the United States, although diagnostic testing has been limited to date and there may be biases in test seeking behaviors.2 Diagnostic testing is generally performed using PCR testing of skin lesion swabs, which often carry >108 copies/swab. Similar to variola virus (smallpox), MPXV is thought to spread from the site of inoculation systemically via monocytic cells through lymphatic as well as hematogenous routes.3 Viral DNAemia is common in both animal models as well as human cases. Recent reports of human monkeypox cases have detected approximately 105 viral DNA copies/ml whole blood, which mirrors that seen in animal models.46 The relationship of DNAemia to infectious viremia is not established. Notably, MPXV has never been cultured from the blood of humans but has been cultured from the blood of prairie dogs in experimental infection.

Survey on Knowledge and on some Cases of Monkeypox: A Zoonotic Disease Endemic to Ubangian Eco-region of Democratic Republic of the Congo (Ngbolua et al., Britain International of Exact Sciences Journal)

The aim of this study was to investigate knowledge on Simian Orthopoxvirosis or Monkeypox in 180 people (129 males and 51 females) using the stratified probability sampling method. The majority of the respondents were (are): 35-50 years old (45.00%), with secondary education (43.33%), farmers (40.56%) and married (80.00%). The disease appears every year, thus demonstrating its endemic nature (98.33% of the respondents); 58.3% of the respondents said that the disease appears very often during the dry season, on the contrary, 40% of the respondents said that the disease appears during the rainy season. However, 1.7% of respondents said that the disease occurs every other season. The majority of respondents (81.1%) said that the cause of the disease is the consumption of bush meat, followed by wild vegetables (3.3%), fish (2.8%), livestock (2.2%) and caterpillars (1.7%) respectively. 65.2% of the respondents use Manihot esculenta to treat the disease locally, and followed by the leaves and wine of Raphia sese (13%), Morinda morindoides (13%) and Myrianthus arboreus (8.7%). Between January 17 and September 10, 2020, 40 cases of monkey pox were admitted to HGR of Businga (Maximum age: 42 years, minimum age: 1 year, average age: 13.3 years). 28 patients were male and 12 female. It is therefore advisable that surveillance be organized in wild animals and bush meat exposed on the market to ensure that they are not contaminated with Monkeypoxvirus. It is thus needed to establish a veterinary laboratory in Nord-Ubangi Province.

Virology

Evaluation of Virulence in Cynomolgus Macaques Using a Virus Preparation Enriched for the Extracellular Form of Monkeypox Virus (Mucker et al., Viruses)

The 2022 global human monkeypox outbreak emphasizes the importance of maintaining poxvirus research, including enriching a basic understanding of animal models for developing and advancing therapeutics and vaccines. Intravenous administration of monkeypox virus in macaques is arguably one of the best animal models for evaluating the efficacy of medical countermeasures. Here we addressed one criticism of the model, a requirement for a high-titer administration of virus, as well as improving our understanding of monkeypox virus pathogenesis. To do so, we infected macaques with a challenge dose containing a characterized inoculum enriched for the extracellular form of monkeypox virus. Although there were some differences between diseases caused by the enriched preparation compared with a relatively similar unpurified preparation, we were unable to reduce the viral input with the enriched preparation and maintain severe disease. We found that inherent factors contained within the serum of nonhuman primate blood affect the stability of the monkeypox extracellular virions. As a first step to study a role of the extracellular form in transmission, we also showed the presence of this form in the oropharyngeal swabs from nonhuman primates exposed to monkeypox virus. 

Human monkeypox virus infection in an immunocompromised man: trial with tecovirimat (Hernandez et al., The Lancet)

A 37-year-old man attended our hospital with a 1-week history of fever, chills, headaches, sore throat, generalised malaise, and a rash on his arms, legs, trunk, and in his groin. The patient also reported significant pain and discomfort in his rectum when defecating. He had a history of HIV and metastatic Kaposi sarcoma; secondary syphilis, which had been treated; and hypertension. He was prescribed the following medications: emtricitabine-tenofovir, doravarine, darunavir-cobicistat, and hydrochlorothiazide. The patient reported no recent travel or contact with human or animal with a similar rash or illnesses. He reported no history of varicella zoster virus infection as a child and said he had received all childhood vaccinations. The patient reported no sexual activity for the past 6 months.

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