PRI’s MPV (Monkeypox) Situation Update – September 22

Sep 22, 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 18 September 2022, 61 753 laboratory-confirmed cases of monkeypox and 23 deaths have been reported to WHO from 105 countries/territories/areas (hereafter ‘countries’[i]) in all six WHO Regions (Table 1). Since the last edition published on 7 September 2022, 8757 new cases (16.5% increase in total cases) and five new deaths have been reported. In the past seven days, 23 countries reported an increase in the weekly number of cases, with the highest increase reported in Chile. Three new countries also reported their first case in the past seven days: Guam (12 September), Ukraine (15 September), and Bahrain (16 September). Overall, 33 countries have not reported new cases for over 21 days, the maximum incubation period of the disease. (WHO Sit Rep – Latest 9/21/2022 / Dashboard)
  • US: Total confirmed MPV cases: 24,203 (9.20.2022). (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) 
  • In a recent Science perspective piece titled “Monkeypox: The consequences of neglecting a disease, anywhere” Nigerian scientists Oyewale Tomori and Dimie Ogoina discuss how the epidemiology of the disease has evolved and the implications of the global inaction to the outbreak in Africa over the years.

US Updates/News

  • What to know about neurological symptoms from monkeypox (The Hill) In a paper published in the journal JAMA Neurology, doctors review the neurologic complications associated with monkeypox and smallpox cases, and they note the known neurological symptoms from monkeypox, which include headaches and mood disturbances. There’s also the possibility for postvaccinal encephalomyelitis, where there is inflammation in the brain and spinal cord after vaccination. 

Global Updates/News

  • Hong Kong to start monkeypox vaccination on October 5 (Reuters) Hong Kong will launch a monkeypox vaccination programme for “high-risk groups” from Oct. 5 following the discovery of an imported case of monkeypox this month, the city’s Department of Health said on Wednesday. 
  • Monkeypox: NHS offers tecovirimat for severe or complicated cases (BMJ) The antiviral drug tecovirimat can be offered to symptomatic monkeypox patients who have been admitted to hospital in the UK with severe or complicated infection, chief medical officer Chris Whitty has said. In an alert to NHS trusts and clinical commissioning groups, Whitty said supply of the treatment was being managed by specialist regional adult infectious disease centres.
  • Portugal approves preventive monkeypox vaccination for risk groups (Yahoo News) Portugal’s health authority widened its monkeypox vaccination strategy to include preventive shots for groups most at risk and approved the use of smaller doses, an approach known as “dose-sparing”, due to limited supplies, it said on Wednesday.

Official Guidance Sources

Articles by Category

Epi/Transmission/Mitigation

Health Care Personnel Exposures to Subsequently Laboratory-Confirmed Monkeypox Patients — Colorado, 2022 (Marshall et al., CDC MMWR)

The US CDC currently recommends that HCP wear a gown, gloves, eye protection, and an N95 (or higher-level) respirator while caring for patients with suspected or confirmed monkeypox to protect themselves from infection. The Colorado Department of Public Health and Environment (CDPHE) evaluated HCP exposures and personal protective equipment (PPE) use in health care settings during care of patients who subsequently received a diagnosis of Orthopoxvirus infection (presumptive monkeypox determined by a polymerase chain reaction [PCR] DNA assay) or monkeypox (real-time PCR assay and genetic sequencing performed by CDC). During May 1–July 31, 2022, a total of 313 HCP interacted with patients with subsequently diagnosed monkeypox infections while wearing various combinations of PPE; 23% wore all recommended PPE during their exposures. Twenty-eight percent of exposed HCP were considered to have had high- or intermediate-risk exposures and were therefore eligible to receive postexposure prophylaxis (PEP) with the JYNNEOS vaccine; among those, 48% (12% of all exposed HCP) received the vaccine. PPE use varied by facility type: HCP in sexually transmitted infection (STI) clinics and community health centers reported the highest adherence to recommended PPE use, and primary and urgent care settings reported the lowest adherence. No HCP developed a monkeypox infection during the 21 days after exposure. These results suggest that the risk for transmission of monkeypox in health care settings is low. Infection prevention training is important in all health care settings, and these findings can guide future updates to PPE recommendations and risk classification in health care settings.

Monkeypox outbreak in a correctional center in North eastern Nigeria (Pembi et al., Journal of Infection)

In this article, researchers report the first outbreak of Monkeypox occurring in a prison in Nigeria, in which the predominant route of transmission seems to be person-to-person contact. On the 2nd of March 2022, Adamawa State Ministry of Health was notified of inmates with rashes occurring in Yola prison and a joint rapid response team (RRT) from the State Field Office and the World Health Organization (WHO) initiated outbreak investigations. An initial head count identified 21 affected individuals under 40 years old. Some inmates had almost recovered at the time of examination, while others had just started to have symptoms, indicating the outbreak had lingered for several weeks before the investigation. The index case had a rash three months before the visit and cases had occurred over 18 weeks. Inmates were undernourished and untidy, had fever, rashes, body weaknesses and sometimes had collapsed. Rashes involved the face, head, neck, trunk, buttocks, the extremities, and genitalia. All participants had enlarged inguinal and some cervical lymph nodes, which were firm, non-fluctuant and tender. Individuals with overt infections were isolated and inmates were monitored for signs and symptoms of infection. A visit 72 hours later identified further seven cases and one further case was reported from the specialist hospital. Two of the five samples tested at the National Reference Laboratory were PCR-positive for monkeypox. Author note that, similar to a previous published report from Spain (Orxiv et al), most inmates in Yola lived under conditions that could facilitate human-to-human transmission, and potentially sexual transmission. However, authors conclude that the living conditions could also maintain zoonotic transmission and the actual route of infection remains conjectural, but difficult to identify while investigating the outbreak in a confined population with high contact intensity.

Genitourinary Lesions Due to Monkeypox (Gomez-Garbari et al., European Urology)

Since May 2022, 31 000 cases of monkeypox infection have been reported in nonendemic areas. The objective of this study was to describe a series of cases of monkeypox with genitourinary involvement. This was a prospective observational descriptive study of male patients with confirmed MPXV infection and genital area involvement. All the patients with confirmed MPXV disease at our hospital and genitourinary symptoms between May and August 2022 were invited to participate in the study. A total of 14 patients were recruited. The median age was 42 yr. Of these patients, 43% sought a consultation for genitourinary symptomatology, and 71% had engaged in sex with other men. Eight patients (57%) were positive for human immunodeficiency virus, one diagnosed synchronously; the remainder had a median CD4 count of 663/μl. Six patients (43%) had a different sexually transmitted disease. Penile oedema was present in 43% of patients and two patients required surgical exploration. The authors conclude that genitourinary involvement is frequent in monkeypox disease and is often the reason for the consultation visit.

Diagnosis and Management of Monkeypox: A Review for the Emergency Clinician (Nispen et al., Annals of Emergency Medicine)

The outbreak of monkeypox in May and June 2022 is the largest outside of central and western Africa since the 2003 outbreak in the United States. Monkeypox, like smallpox, is caused by an orthopoxvirus, though its clinical manifestations tend to be less severe. It is characterized by a prodromal flu-like illness with lymphadenopathy followed by a centrifugally spreading rash, sometimes involving the face, palms, soles, and oral mucosa. Although the vast majority of cases resolve with symptomatic management, a small number of patients can suffer severe outcomes including, but not limited to, secondary bacterial skin infections, pneumonitis, ocular sequelae, encephalitis, hypovolemia, and death. Local, state, and federal health authorities should be involved in the care of people under investigation for this illness. With confirmed cases worldwide and the possibility of community spread, emergency clinicians need to be aware of the manifestations and management of this disease, both to treat those with the disease as well as to provide education to those exposed and at risk of infection.

The Current Multicountry Monkeypox Outbreak: What Water Professionals Should Know (Maal-Bared et al., ACS ES&T)

Recent water sector safety concerns during the COVID-19 pandemic highlight the need for industry-focused reviews of emerging pathogens to support evidence-based utility decision-making. Between May 7 and August 20, 2022, more than 41 358 cases of human monkeypox were reported globally from over 87 countries in which the disease is not endemic. Given that the presence and persistence of monkeypox virus (MPXV) in feces, water, and wastewater has not been investigated, we summarize the available evidence on MPXV and related orthopoxviruses to provide sector-wide recommendations and identify knowledge gaps. On the basis of the information available to date, this outbreak is unlikely to pose an exposure and transmission risk from wastewater, biosolids, or water due to the absence of any evidence to date that suggests that infectious MPXV is present in wastewater or biosolids or has caused human cases, clusters, or outbreaks from exposure to these sources. In addition, remaining smallpox vaccine immunity in the population, availability of vaccines and treatments, susceptibility of poxviruses to disinfection (e.g., UV and chlorine), and evidence from health care confirming the efficacy of infection control measures all suggest that current treatment and recommended wastewater worker protection practices are sufficient to protect public and occupational health.

Public Health Emergency of International Concern declared by the World Health Organization for Monkeypox (Sah et al., Global Security: Health, Science and Policy)

Monkeypox (MPX) was a rare endemic disease in western and central Africa. In 1970, the first detected case of human MPX was reported in the Democratic Republic of Congo, and it was detected outside Africa in 2003. Currently, there are about 31,799 confirmed MPX cases which led the WHO to declare the disease a public health emergency of international concern which is considered the seventh deceleration by the WHO between 2009 and 2022. Herein, we aim to review the history behind the outbreak of the disease, its mode of transmission, and the target of WHO deceleration, while providing recommendations for disease prevention. The disease is prevalent mostly in the United States with a total case number of 10,676 which is considered a high-risk country. Meanwhile, other countries are at moderate risk. The disease can be transmitted directly through contact with different body fluids, infectious lesions, or sexual activity. We conclude that there should be high public awareness to stop the transmission of the disease. In addition, there is a great need to follow the instructions provided by public health institutions since vaccines, till now, are available only for high-risk populations secondary to their shortage.

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) 

As of August 26, 2022, there are over 47,000 cases of monkeypox globally (Centers for Disease Control & Prevention, 2022a). As of August 26, 2022, there are currently over 17,000 cases of monkeypox in the U.S., with all states documenting at least one case (Centers for Disease Control & Prevention, 2022b). On August 4, 2022, the U.S. Department of Health and Human Services declared the monkeypox outbreak a public health emergency. Most cases in the U.S. are among those assigned male at birth (AMAB). Among AMAB, 99% reported male-to-male sexual contact, men who have sex with men (MSM) and transgender women are disproportionately affected by monkeypox (Centers for Disease Control and Prevention, 2022f). However, monkeypox can impact members of any community regardless of their sex, gender identity, or sexual orientation (Daskalakis et al., 2022). Monkeypox is transmitted from skin-to-skin contact (direct contact with lesions or body fluids), respiratory secretions through prolonged face-to-face contact, and fomite transmission. Monkeypox can spread from skin-to-skin and face-to-face contact that often occurs during sexual encounters, such as from kissing, oral sex, and anal sex; however, it is not exclusively sexually transmissible (Centers for Disease Control & Prevention, 2022c). In addition to being vaccinated, the U.S. Centers for Disease Control and Prevention (CDC) has recommended those at risk to reduce or avoid behaviors that increase monkeypox exposure, including but not limited to abstaining from risk exposure until two weeks after the second dose of the vaccine, avoiding kissing, limiting the number of sex partners, and wearing clothes or fetish gear (e.g., leather or latex) during sex to limit skin-to-skin contact with partners with monkeypox-unknown or monkeypox-positive status (Centers for Disease Control & Prevention, 2022e). However, it is uncertain whether MSM and transgender women in the U.S. are engaging in monkeypox exposure mitigation behaviors. Given the monkeypox outbreak in the U.S. is rapidly evolving, no known research has assessed behavioral changes to mitigate monkeypox exposure—including among MSM and transgender women. The CDC notes that social, behavioral, communication, and health equity research is needed to inform and improve the implementation of monkeypox prevention programs (Centers for Disease Control and Prevention, 2022f). This study aimed to examine U.S. MSM and transgender women’s behavioral changes and employed exposure mitigation strategies due to the ongoing monkeypox outbreak. 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 outbreak in a correctional center in North eastern Nigeria (Pembi et al., Journal of Infection)

Orvix et al 1 report that Monkeypox in Spain is associated with person-to-person transmission and that infected individuals are more likely to have concomitant sexually transmitted infections, pointing to a potential sexual transmission. Monkeypox, is the most prevalent orthopoxvirus 2 since the eradication of smallpox and has long been reported from Africa, with outbreaks in Central and West Africa, corresponding to the Congo Basin and the West African clades (renamed clades 1 and 2, respectively). 3 Although infection in Africa is zoonotic, human-to-human transmission is the predominant route of transmission for outbreaks outside Africa,4 with most infections occurring after meeting in conglomerate settings and close contact. Until recently, clusters outside Africa were associated with travel, notably in Europe and the Americas. 5 However, in the last decade numerous outbreaks outside the African continent do not have clear travel linkages and there is considerable debate on whether sexual behavior is a route of transmission or merely a marker of behavioral patterns. There has also been an increase of cases reported from Africa, 2 and Monkeypox reemerged in Nigeria in 2017. 6 The first case of Monkeypox in Adamawa State, in the Northeast, was only reported in January 2022 and human-to-human transmission is considered to be rare. Up to now, most cases are less than 40 years old, born after the cessation of the smallpox vaccination.3 Here, we report the first outbreak of Monkeypox occurring in a prison in Nigeria, in which the predominant route of transmission seems to be person-to-person contact. To our knowledge, Monkeypox outbreaks have not been reported from prisons anywhere in the world. 

Vaccine

Prevention of monkeypox with vaccines: a rapid review  (Poland et al., The Lancet Infectious Diseases)

The largest outbreak of monkeypox in history began in May, 2022, and has rapidly spread across the globe ever since. The purpose of this Review is to briefly describe human immune responses to orthopoxviruses; provide an overview of the vaccines available to combat this outbreak; and discuss the various clinical data and animal studies evaluating protective immunity to monkeypox elicited by vaccinia virus-based smallpox vaccines, address ongoing concerns regarding the outbreak, and provide suggestions for the appropriate use of vaccines as an outbreak control measure. Data showing clinical effectiveness (~85%) of smallpox vaccines against monkeypox come from surveillance studies conducted in central Africa in the 1980s and later during outbreaks in the same area. These data are supported by a large number of animal studies (primarily in non-human primates) with live virus challenge by various inoculation routes. These studies uniformly showed a high degree of protection and immunity against monkeypox virus following vaccination with various smallpox vaccines. Smallpox vaccines represent an effective countermeasure that can be used to control monkeypox outbreaks. However, smallpox vaccines do cause side-effects and the replication-competent, second-generation vaccines have contraindications. Third-generation vaccines, although safer for use in immunocompromised populations, require two doses, which is an impediment to rapid outbreak response. Lessons learned from the COVID-19 pandemic should be used to inform our collective response to this monkeypox outbreak and to future outbreaks.

Monkeypox in Patient Immunized with ACAM2000 Smallpox Vaccine During 2022 Outbreak (Turner et al., Emerging Infectious Diseases)

The authors report a patient in Washington, USA, who contracted monkeypox despite being successfully immunized against smallpox with the ACAM2000 smallpox vaccine 8 years earlier. The patient was a previously healthy 34-year-old man who had sex with men came to a walk-in sexually transmitted infections clinic because of a 4-day history of malaise, fatigue, and headache and a 2-day history of 4 painless penile lesions. The patient had sought evaluation at a local emergency department 2 days before he visited the clinic. Results for testing performed in the emergency department were negative for Neisseria gonorrhea, Chlamydia trachomatis, and herpes simplex virus. His constitutional symptoms improved over the next 2 days. However, his penile ulcers progressed into white papular lesions, prompting him to seek reevaluation. In the previous 90 days, he reported penetrative anal and receptive oral sexual intercourse with 13–14 new partners, denying any condom use. His last sexual intercourse was 11 days before he sought care, when he engaged in unprotected anal-insertive sex with a single anonymous partner at a local Pride event. Because of his military service, he was vaccinated against smallpox with ACAM2000 smallpox vaccine in March 2014, with documented vaccine take. He denied recent travel outside Washington or exposure to sick contacts. Clinically the patient did well, only requiring supportive care with oral acetaminophen for constitutional symptoms, which resolved 10 days after symptom onset. The rash continued to evolve, coalesced, and developed a pustular appearance 6 days after onset of constitutional symptoms. The lesion ulcerated on day 16, and ultimately dissipated without residual scarring. In conclusion, although the mild manifestations in this patient might be attributable to his vaccination against smallpox, it did not prevent infection.

Public Perceptions of the Emerging Human Monkeypox Disease and Vaccination in Riyadh, Saudi Arabia: A Cross-Sectional Study (Meo et al., Vaccines)

The human monkeypox disease is caused by the monkeypox virus (MPXV), which is a zoonotic disease. In the year 2022, the prevalence of monkeypox cases swiftly increased worldwide and the disease has now been declared a global public health emergency. The present study aimed to assess the public’s perceptions and knowledge of and attitudes toward monkeypox in Riyadh, Saudi Arabia. This questionnaire-based cross-sectional study was conducted from 15 May to 15 July 2022. The participants’ perceptions, knowledge, and attitudes were collected via a 28-item-based questionnaire survey. The survey was based on 1020 participants (554 (54.3%) were females, and 466 (45.7%) were males). The results reveal that out of 1020 participants, 799 (78.3%) respondents believed that monkeypox disease has developed into a pandemic situation, and 798 (78.2%) suggested that the disease is most common in Western and Central Africa. Further analysis shows that 692 (67.8%) respondents agreed that monkeypox cases are increasing worldwide, 798 (21.8%) believed that monkeypox is commonly transmitted through direct contact, and 545 (53.4%) of respondents reported that it is easily transmitted from human to human. Moreover, 693 (67.9%) participants mentioned that monkeypox disease is spreading more widely as people travel from one country to another, while 807 (79.1%) participants were aware that smallpox and monkeypox have similar clinical features. Furthermore, the majority of participants (p = 0.033) agreed that health officials should start a vaccination campaign to combat monkeypox. Regarding preventive measures and vaccination campaigns, 641 (62.8%) participants suggested that health officials should take public preventive measures and 446 (43.7%) recommended that health officials start vaccination campaigns against monkeypox. The knowledge of human monkeypox among the general population in Riyadh, Saudi Arabia was satisfactory for all ages, genders, levels of education, and economic groups. Moreover, the majority of participants proposed adopting preventive measures and starting a vaccination campaign to combat monkeypox disease. The knowledge of monkeypox in the public domain is a key factor to improve the public‘s capacity to minimize the disease burden and fight against viral infectious diseases at regional and global levels.

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