PRI’s MPV (Monkeypox) Situation Update – September 27

Sep 27, 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: 25,162 (9.26.2022). (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) 

US Updates/News

Global Updates/News

Official Guidance Sources

Articles by Category

Epi/Transmission/Mitigation

Emergence and dissemination of monkeypox, an intimidating global public health problem (Ejaz et al., Journal of Infection and Public Health)

The monkeypox virus (MPXV) is the cause of a zoonotic infection similar to smallpox. Although it is endemic to Africa, it has recently begun to circulate in other parts of the world. In July 2022, the World Health Organization declared monkeypox an international public health emergency. This review aims to provide an overview of this neglected zoonotic pathogen. MPXV circulates as two distinct clades, the Central African and West African, with case fatality rates of 10.6% and 3.6%, respectively. The risk of infection is greater for those who work with animals or infected individuals. The virus’ entry into the human body provokes both natural and acquired immunity. Although natural killer cells, CD4 + T cells, and CD8 + T cells play an essential role in eradicating MPXV, there is still a gap in the understanding of the host immune response to the virus. Currently, there are no specific therapeutic guidelines for treating monkeypox; however, some antiviral drugs such as tecovirimat and cidofovir may help to abate the severity of the disease. The use of nonpharmaceutical interventions and immunization can reduce the risk of infection. Increased surveillance and identification of monkeypox cases are crucial to understand the constantly shifting epidemiology of this resurging and intimidating disease. The present review provides a detailed perspective on the emergence and circulation of MPXV in human populations, infection risks, human immune response, disease diagnosis and prevention strategies, and future implications, and highlights the importance of the research community engaging more with this disease for an effective global response.

Monkeypox in a Young Infant — Florida, 2022 (Saunders et al., MMWR)

In August 2022, the Florida Department of Health (FDOH) was notified of a suspected case of monkeypox in an infant aged <2 months who was admitted to a Florida hospital with a rash and cellulitis. The infant was initially evaluated in an emergency department (ED) for a raised erythematous rash on the arms, legs, and trunk which had been present for 5 days. A rash swab was collected for bacterial culture and yielded a negative test result. Varicella, herpes simplex virus, and HIV testing were also negative. The patient returned to the ED 2 days later, at which time the rash had progressed to include numerous, diffusely scattered papulovesicular lesions over the body, many with central umbilication. The infant was admitted to the hospital with a diagnosis of molluscum contagiosum and started on intravenous antibiotics for secondary bacterial cellulitis associated with having scratched a lesion on the arm. The lesions subsequently spread to the back, soles of feet, face, and eyelid and became pustular over the first few days of admission. Swabs from forehead and back lesions tested positive for Orthopoxvirus DNA and Clade II Monkeypox virus DNA by polymerase chain reaction 10 days after rash onset. The infant was treated with oral tecovirimat and Vaccinia Immune Globulin Intravenous. The infant had no history of travel, no history of acute infections in the 3 weeks preceding rash onset, no known immunocompromising conditions, did not attend a child care facility, and had no caregivers outside the home. One of their caregivers reported activities that placed him at high risk for monkeypox exposure during the 2 months preceding the infant’s illness and reported hematuria and fever, followed by a rash within the 3 weeks before the infant’s symptom onset. One day before the infant became symptomatic, caregiver B moved to another state and sought medical care for his symptoms. He received a positive Orthopoxvirus DNA test result 2 days after the infant’s positive test result, after which, he was lost to follow-up. Possible routes of transmission included shared bed linens and skin-to-skin contact through holding and daily care activities. In conclusion, clinical presentations in children with monkeypox have been similar to those in adults. Timely laboratory identification and thorough epidemiologic investigation are critical for effective public health response to monkeypox infection. In this case, contact tracing and postexposure prophylaxis vaccination of close contacts of the affected infant might have prevented further transmission to household members.

Viable Monkeypox virus in the environment of a patient room (Marimuthu et al., medRxiv)

This article is taken from a pre-print platform and has not completed peer review or been accepted for publication. Please keep these caveats in mind as you read it.

In this prospective environmental surveillance study, researchers aimed to investigate the air, surface, dust and water contamination of a room occupied by a patient infected with Monkeypox virus (MPXV) at various stages of his illness. The patient tested positive for MPXV from a throat swab and skin lesions. Environmental sampling was conducted in a negative pressure room with 12 unidirectional HEPA air changes per hour and daily cleaning of the surfaces. A total of 179 environmental samples were collected on days 7, 8, 13, and 21 of his illness. Air contamination was highest during week 1 of illness (up to 11 copies/L air), with a gradual decline over the weeks to less than 1 copies/L of air by day 21. Similarly, surface contamination peaked on day 8 of illness (1.25 x 104 copies/swab) and declined to the lowest contamination level by day 21 of illness. A similar trend was observed for vacuumed dust contamination, with the highest viral load observed on day 7 of illness (5.94 x 107 virus copies/sample) and lowest on day 21 of illness (2.83 x 103 to 2.29 x 105 virus copies/sample). Viable MPXV was isolated from surfaces (e.g., chair, toilet seat and dust from bed linen) and dust samples and no viable virus was isolated from the air and water samples. The recovery of viable virus from the chair and toilet seat correlated with the location of skin lesions of the study patient. In summary, swab and dust sampling showed extensive surface contamination of the hospital room occupied by a MPXV patient with the recovery of viable MPXV virus from certain surfaces. MPXV DNA was consistently detected in almost all air samplers, though they were not culturable. Surface, dust, and air contamination gradually declined after the first week of illness.

Two Cases of Monkeypox-Associated Encephalomyelitis — Colorado and the District of Columbia, July–August 2022 (Pastula et al., MMWR)

This report describes two cases of encephalomyelitis in patients with monkeypox disease that occurred during the current U.S. outbreak. Although neurologic complications of acute MPXV infections are rare, suspected cases should be reported to state, tribal, local, or territorial health departments to improve understanding of the range of clinical manifestations of and treatment options for MPXV infections during the current outbreak. Patients A and B had confirmed systemic MPXV infections with encephalomyelitis appearing within 5 and 9 days, respectively, of illness onset. The underlying pathology behind this is unclear but might represent either MPXV invasion of the CNS or a parainfectious autoimmune process triggered by systemic MPXV infection. Both patients had some clinical and radiographic features of acute disseminated encephalomyelitis (ADEM), typically a monophasic parainfectious autoimmune demyelinating disease of the CNS that primarily affects children but can also occur in adults.  In this report, neither patient was found to have MPXV nucleic acid in the CSF, which would have proven MPXV neuroinvasion. However, absence of detectable nucleic acid in the CSF is not uncommon among CNS viral infections. A CSF Orthopoxvirus immunoglobulin (Ig) M test for detection of virus-specific IgM antibodies, which could suggest viral neuroinvasion, was not performed because this test was not CLIA certified at the time of this report. Results of tests to look for the autoimmune CNS conditions NMOSD and MOGAD were negative. In patient A, neither the rash nor the neurologic condition was thought to be consistent with an active syphilis infection, and the cervical spinal canal stenosis did not fully explain his clinical condition. Given that the pathologic mechanism for encephalomyelitis in these two instances is unknown, the best diagnostic workup and treatment course for similar cases is unclear. For severe MPXV disease, tecovirimat is recommended as first-line antiviral therapy, although the degree of CNS penetration is unknown. For significant edema, demyelination, or an ADEM-like presentation, corticosteroids can be considered, although benefits should be weighed against the immunosuppressive risks during an active infection. In addition, for a suspected parainfectious autoimmune CNS process or ADEM-like presentation, empiric IVIG or PLEX (or PLEX followed by IVIG) can be considered. The role for anti-B–cell therapies such as rituximab is not known. The authors conclude that this report provides clinicians and public health professionals awareness of the range of possible clinical presentations of MPXV infections and potential treatments.

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

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. In summary, 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.

Neurologic Complications of Smallpox and Monkeypox: A Review (Billioux et al., JAMA Neurology)

In this article, researchers present findings from a literature review on orthopox viruses, which include both smallpox and monkeypox, with a focus on neurologic complications. The review covered the neurologic complications of smallpox; historical complications of smallpox vaccination; and the known neurologic complications of monkeypox, which include headaches and mood disturbances, as well as rare presentations of encephalitis, transverse myelitis, and seizures. In terms of monkeypox, very few neurologic complications of monkeypox have been described. Headache is a common presenting feature in both clades 1 and 2. Mood disturbance, including depression and anxiety, and neuropathic pain are frequent. The skin lesions themselves may cause painful sores and, depending on the site involved, can cause dysphagia, rectal pain with anal fissures, etc. It is not clear if some of the pain may be dermatomal—similar to that seen with varicella zoster—but the pain can be severe. Conjunctivitis occurred in approximately 20% of patients in a recent outbreak in the DRC, which could lead to decreased vision. This could also be a potential site for virologic seeding into the central nervous system. Monkeypox rarely causes encephalitis. This article highlights the handful of cases reported in the past including three cases of encephalitis with seizures that occurred in a cohort of 40 monkeypox cases in Nigeria, including 2 patients (a 28-day-old infant and a 43-year-old man with HIV/AIDS) who subsequently died. It is worth noting that the first case of encephalitis was associated with the clade 1, whereas the others were associated with clade 2. During the current outbreak, 3 cases of encephalitis have been reported in 2 male Spanish patients and 1 young male Indian patient, all of whom subsequently died. In the 2 Spanish patients, MPXV DNA was detected by PCR in the CSF, as well as antiorthopox immunoglobulin M (IgM) with enzyme-linked immunosorbent assay (ELISA). Authors conclude that monkeypox should be considered in high-risk populations who present with neurologic syndromes. Diagnosis may require serology and PCR testing of blood and spinal fluid. Antiviral therapy should be initiated early in the course of the illness.

Monkeypox Virus Transmission to Healthcare Worker through Needlestick Injury, Brazil (Carvalho et al., Emerging Infectious Diseases)

In nonendemic countries, monkeypox is rare, and standard infection control precautions are applied, suggesting HCWs are at low risk of acquiring MPXV; only 1 prior HCW case has been reported. Here, the authors describe MPXV transmission to a HCW in Brazil through a needlestick injury. On July 9, 2022, a female nurse in her 20s sustained a needlestick injury to her thumb from supplies used to collect cutaneous lesion samples from a monkeypox patient. The nurse was wearing personal protective equipment, including gown, gloves, goggles, and mask, and was gathering materials to discard in a sharps container when a needle perforated her glove; the puncture site was visible immediately. After 5 days, a nodule developed at the injury site (day 0 of symptoms); it later evolved into a painful vesicle. The nurse lived alone, denied recent travel, and reported having protected sexual intercourse only with her male partner. She had no other potential exposures. Overall, the nurse had 7 lesions: 1 each on the thumb (inoculation site) and palm of the right hand, dorsal left hand, and left thigh, and 3 on her face. MPXV was detectable in oropharyngeal samples despite the absence of respiratory symptoms. Of note, all collected specimens had detectable MPXV DNA throughout hospitalization. The nurse was discharged to outpatient care before complete lesion resolution. This case enabled observation of the natural progression of monkeypox through longitudinal clinical and laboratory monitoring of disease stages. The incubation period was 5 days. The transmission route might have influenced the absence of a prodromal phase in the nurse because needlestick transmission parallels bite or scratch transmission from MPXV-infected animals to humans; in those cases, a febrile prodrome is uncommon. In addition, the nurse experienced severe injury site pain, which coincides with a series of cases in the current outbreak in which most patients who acquired MPXV by sexual or intimate contact were hospitalized for severe anorectal pain. The pain similarity suggests that the primary MPXV inoculation site is associated with painful lesions and possible neural impairment. The authors conclude that this report describes clinical features of monkeypox, including extreme pain at the inoculation site and prolonged DNAemia, after needlestick transmission in a HCW.

Spatial modeling and ecological suitability of monkeypox disease in Southern Nigeria (Arotolu et al., PLoS ONE)

The reemergence of monkeypoxvirus (MPXV) in 2017 after about 39 years of no reported cases in Nigeria, and the recent incidence in countries such as the United States of America, United Kingdom, Singapore, and Israel which have been reportedly linked with travelers from Africa, have heightened concern that MPXV may have emerged to occupy the vacant ecological and immunological niche created by the extinct smallpox virus. This study was carried out to identify environmental conditions and areas that are environmentally suitable (risky areas) for MPXV in southern Nigeria. One hundred and sixteen (116) spatially unique MPXV occurrence data from 2017–2021 and corresponding environmental variables were spatially modeled by a maximum entropy algorithm to evaluate the contribution of the variables to the distribution of the viral disease. A variance inflation analysis was adopted to limit the number of environmental variables and minimize multicollinearity. The five variables that contributed to the suitability model for MPXV disease are precipitation of driest quarter (47%), elevation (26%), human population density (17%), minimum temperature in December (7%), and maximum temperature in March (3%). For validation, our model had a high AUC value of 0.92 and standard deviation of 0.009 indicating that it had excellent ability to predict the suitable areas for monkeypox disease. Categorized risk classes across southern states was also identified. A total of eight states were predicted to be at high risk of monkeypox outbreak occurrence. These findings can guide policymakers in resources allocation and distribution to effectively implement targeted control measures for MPXV outbreaks in southern Nigeria.

Vaccine

Modelling the protective effect of previous compulsory smallpox vaccination against human monkeypox infection: from hypothesis to a worst case scenario (Spath et al., International Journal of Infectious Diseases) 

Human monkeypox cases are escalating worldwide. Smallpox vaccination, compulsory in Austria until 1981, was reported to confer 85% cross-protection against monkeypox. To assess the impact of smallpox vaccine-induced protection, the age-dependent vaccine-induced immunity against human monkeypox and the probability of infection according to age in the general population of Vienna, Austria, were determined employing a modified Susceptible-Infected-Removed model. In the population born before 1981, the average vaccine-induced protective effect was calculated at 50.4%, whereas in the population born thereafter protection is lacking. The overall probability of infection after exposure to an infected patient was calculated at 73.8%, which exceeds the threshold value of 46.9% for an index patient to infect at least one other person (R≥1.0). Our modelling shows that, if no additional interventions are taken, the collective immunization status of the population alone will not suffice to contain human monkeypox. Although the majority of cases have occurred in a subpopulation, given the steadily increasing incidence, dissemination into the general population remains possible, as observed before with HIV. Our model emphasizes the need for adequate containment measures and may aid in specific risk assessment, as it can easily be adapted to other populations and cohorts worldwide.

Multi-Epitope-Based Vaccine Candidate for Monkeypox: An In Silico Approach (Abdi et al., Vaccines)

Currently, there are limited treatment options available for the monkeypox disease. We used a computational strategy to design a specific antigenic vaccine against pathogens. After using various immunoinformatic tools and filters, cytotoxic T-cell lymphocyte (CTL)-, helper T-cell lymphocyte (HTL)-, and interferon gamma (IFN-γ)-inducing epitopes, which comprised the vaccine, in addition to other parameters, such as antigenic and allergic profiles, were assessed to confirm the safety of the vaccine. However, vaccine interaction and stability with Toll-like receptors (TLRs) were assessed by dynamic simulation methods, and it was found that the constructed vaccine was stable. In addition, C-IMMSIM tools were used to determine the immune-response-triggering capabilities of the vaccine. These immunoinformatic findings reveal that constructed vaccine candidates may be capable of triggering an efficient immune response for monkeypox viral infections. However, experimental evaluation is required to verify the safety and immunogenic profile of constructed vaccines.

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