Saturday, July 03, 2021

ECDC CDTR: 3rd Monkeypox Case In the UK

Geographic Range of Monkeypox - Credit WHO  


Three weeks ago we learned -  more than two-weeks after the fact -  of an outbreak of Monkeypox in Wales from what appeared to be an off-hand comment by then-Health Secretary Matt Hancock while giving evidence to MPs on COVID (see UK Health Secretary: 2 Cases Of Monkeypox In Wales.  

Later that same day, the World Health Organization released an Outbreak Report On Monkeypox In UK ex Nigeria

Two cases were initially identified, with the first having recently returned from Nigeria, and the second being a household contact.  Disappointingly, both the UK and Wales governments and the PHE have remained mum on these cases, and have published no details. 

Citing a media report, 10 days ago CIDRAP published a brief report of a 3rd case, but again, I've seen no official confirmation from the UK. 

Yesterday the ECDC published an update, including details on this 3rd case, but again, the only cite they provide is the CIDRAP report, which is based on a local media report.  I have to assume someone at the ECDC has confirmed this information, at least verbally.  But ongoing lhe lack of an official statement from the UK is curious. 

Monkeypox  United Kingdom 

Opening date: 18 June 2021 Latest update: 2 July 2021 

Epidemiological summary 

In 2021, and as of 24 June, three cases of monkeypox have been reported in the United Kingdom. The index case was diagnosed on 24 May 2021. The patient travelled with family to the United Kingdom from the Delta State, Nigeria, on 8 May 2021. The individual was asymptomatic when travelling and developed a rash on 10 May. 

Since arrival in the United Kingdom, the patient spent 10 days in self-isolation with family in Wales, in compliance with the COVID-19 protocols. On 2 June 2021, a secondary case of monkeypox was reported. The patient is the child of the index case. They developed lesions on the arms, and swabs have tested positive for Orthopoxvirus, which can be considered clinically indicative of monkeypox infection. The patient was immediately isolated in an appropriate facility. Genetic analysis (PCR testing) revealed the West African clade of monkeypox virus. 

Monkeypox was confirmed on 31 May 2021. On 24 June 2021, the media, quoting official authorities, reported a third case of monkeypox within the same household. The first case has now fully recovered, is non-infectious, and has been discharged from hospital. The second and third cases remain in hospital.

Public health prevention and control measures, including isolation of the cases and contact tracing of all close contacts in the hospital and the community, are ongoing. Media report healthcare workers in close contact with the cases have been vaccinated with the smallpox vaccine. 

Background: In recent years, there have been four cases of monkeypox reported in the United Kingdom ±two imported cases from Nigeria in 2018, one imported case from Nigeria in 2019, and one case of nosocomial transmission reported in 2018. According to the weekly epidemiological report from the Nigeria Centre for Disease Control, in 2021, as of week 22, nine confirmed and 38 suspected cases of monkeypox have been reported in Nigeria. 

In 2020, three confirmed and 14 suspected cases of monkeypox were reported. 

Sources: WHO DON, media 

ECDC assessment 

The likelihood for further spread of the virus is very low due to the moderate transmissibility of the virus. However, infections among close contacts cannot be excluded, as demonstrated by the infections described above. ECDC has previously published a rapid risk assessment, Monkeypox cases in the UK imported by travellers returning from Nigeria, 2018, and a factsheet for health professionals on monkeypox.


ECDC is monitoring the event through its epidemic intelligence activities.

These two cases are the 5th, 6th, and 7th case reported in the UK since 2018, and while the risk to the public is arguably very low, Monkeypox can be transmitted from human-to-human, and is certainly on our watchlist of emerging infectious disease threats.   

Human monkeypox was first identified in 1970 in the DRC, and since then has sparked numerous small, sporadic outbreaks in the Congo Basin and Western Africa. It produces a remarkably `smallpox looking' illness in humans, albeit not as deadly. The CDC's Monkeypox website states:
The illness typically lasts for 2−4 weeks. In Africa, monkeypox has been shown to cause death in as many as 1 in 10 persons who contract the disease.
Humans can become infected in the wild from an animal bite or direct contact with the infected animal’s blood, body fluids, or lesions, but consumption of under cooked bushmeat is also suspected as an infection risk. Human-to-human transmission is also possible.  

This from the CDC’s Factsheet on Monkeypox:
The disease also can be spread from person to person, but it is much less infectious than smallpox. The virus is thought to be transmitted by large respiratory droplets during direct and prolonged face-to-face contact. In addition, monkeypox can be spread by direct contact with body fluids of an infected person or with virus-contaminated objects, such as bedding or clothing.
According to the CDC there are two distinct genetic groups (clades) of monkeypox virus—Central African and West African. West African monkeypox - such as has been spreading recently in Nigeria - is associated with milder disease, fewer deaths, and limited human-to-human transmission.
The more severe form of Monkeypox is most commonly found in the Central Africa countries of the DRC and the CAR - where outbreaks have been on the rise for years - presumably because smallpox vaccinations (which provided up to 85% protection) were halted in the late 1970s.
We've seen scattered exported cases of Monkeypox turn up in the UK, Israel, and Singapore over the past few years, although none has sparked any significant local transmission.  We do keep track of it because it has at least some potential to spread, particularly as immunity from smallpox vaccinations - which were halted 40 years ago - wanes. 

Although monkeypox is normally restricted to small outbreaks in Africa, in 2003 we saw a rare outbreak in the United States when a Texas animal distributor imported hundreds of small animals from Ghana, which in turn infected prairie dogs that were subsequently sold to the public (see MMWR Update On Monkeypox 2003).

By the time that outbreak was quashed, the U.S. saw 37 confirmed, 12 probable, and 22 suspected human cases. Among the confirmed cases 5 were categorized as being severely ill, while 9 were hospitalized for > 48 hrs; although no patients died (cite).

For more background on Monkeypox, you may wish to revisit these recent blogs: