Avian Flu Diary: UKHSA Announces 71 Additional Monkeypox Cases

Monkeypox Virus - Credit CDC PHIL

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Monkeypox in humans - outside of endemic regions of Africa - was, until quite recently, viewed as an extremely rare event. Cases invariably had recent travel history to endemic countries, or were close contacts of a recent returnee (see here, here, here and here).

At the same time, over the past decade we've seen warning signs that Monkeypox was gaining transmissibility in Africa and could eventually become a more widespread concern.

A 2016 study (see EID Journal:Extended H-2-H Transmission during a Monkeypox Outbreak) looked at a large 2013 outbreak of Monkeypox in the DRC and suggested that the virus's epidemiological characteristics may be changing; citing a higher attack rate, longer chains of infection, and more pronounced community spread than had earlier reports.

Like all viruses, Monkeypox continues to evolve (albeit slowly) and diversify, as discussed in the 2014 EID Journal article Genomic Variability of Monkeypox Virus among Humans, Democratic Republic of the Congo, where the authors cautioned:

Small genetic changes could favor adaptation to a human host, and this potential is greatest for pathogens with moderate transmission rates (such as MPXV) (40). The ability to spread rapidly and efficiently from human to human could enhance spread by travelers to new regions.

Following the 2017 abrupt reappearance and subsequent spread of Monkeypox in Nigeria after nearly 40 years, the WHO released a 2020 report (see WHO: Modelling Human-to-Human Transmission of Monkeypox) which warned:

This transmission pattern is likely due to the worldwide decline in orthopoxvirus immunity, following cessation of smallpox vaccination, once smallpox was declared eradicated in 1980. Monkeypox could therefore emerge as the most important orthopoxvirus infection in humans. We use mathematical modelling to argue that, in a population with diminishing herd immunity against orthopoxvirus species, the epidemic potential of monkeypox will continue increasing.

We now find ourselves very early into the investigation of a global outbreak of Monkeypox, with over 500 cases reported from more than 2 dozen non-endemic countries. The full scale and scope of this outbreak has yet to be determined, but it is likely much greater than these numbers would suggest.

Leading the pack is the UK - which today announced 71 new cases - raising them to 172 confirmed cases. This unhappy record is likely due to their aggressive surveillance and testing, but their Health Security Agency is gearing up for a protracted fight.

Monkeypox cases confirmed in England – latest updates
Latest updates on cases of monkeypox identified by the UK Health Security Agency (UKHSA).

Last updated
31 May 2022

Seventy-one additional monkeypox cases identified in England

The UK Health Security Agency (UKHSA) has detected 71 additional cases of monkeypox in England.

The latest cases, as of 29 May, bring the total number confirmed in England since 7 May to 172.

There are currently 4 confirmed cases in Scotland, 2 in Northern Ireland and 1 in Wales, taking the UK total to 179.

The risk to the UK population remains low, but we are asking people to be alert to any new rashes or lesions, which would appear like spots, ulcers or blisters, on any part of their body.

Although this advice applies to everyone, the majority of the cases identified to date have been among men who are gay, bisexual and men who have sex with men, so we are asking these people in particular to be aware of the symptoms, particularly if they have recently had a new sexual partner.

You should call NHS 111 or a sexual health centre immediately if you have a rash with blisters and either, you:
have been in close contact with someone who has or might have monkeypox (even if they have not been tested yet) in the past 3 weeks
have been to west or central Africa in the past 3 weeks
are a man who has sex with men
Tell the person you speak to if you have had close contact with someone who has or might have monkeypox, or if you’ve recently travelled to central or west Africa.

Do not go to a sexual health clinic without contacting them first. Stay at home and avoid close contact with other people until you’ve been told what to do.

Additionally, today, UKHSA has published guidance principles agreed across all 4 UK nations on how to effectively limit transmission of monkeypox and limit onward transmission when cases are identified.

This includes advice and protocols for those testing positive for monkeypox, their close contacts and anyone involved in their treatment or care, including healthcare workers. The principles are already in use in response to the outbreak, and today’s publication confirms the UK’s aligned response.

Dr Ruth Milton, Senior Medical Advisor at UKHSA, said:
We are continuing to work closely with our colleagues in Scotland, Wales and Northern Ireland to ensure we are aligned in our approach to reducing the risk of transmission of monkeypox in the UK.

We are reminding people to look out for new spots, ulcers or blisters on any part of their body. If anyone suspects they might have these, particularly if they have recently had a new sexual partner, they should limit their contact with others and contact NHS 111 or their local sexual health service as soon as possible, though please phone ahead before attending in person. This will help us to limit the virus being passed on.
UKHSA health protection teams are contacting people considered to be high-risk contacts of confirmed cases and are advising those who have been risk assessed and remain well to isolate at home for up to 21 days.

UKHSA has also purchased over 20,000 doses of a safe smallpox vaccine called Imvanex (supplied by Bavarian Nordic) and this is being offered to identified close contacts of those diagnosed with monkeypox to reduce the risk of symptomatic infection and severe illness.

As mentioned above, the UKHSA has released new guidance (primarily for healthcare professionals) to respond to this outbreak which has been agreed upon by the UK’s 4 public health agencies ( UK Health Security Agency (UKHSA), Public Health Scotland (PHS), Public Health Wales (PHW) and Public Health Agency Northern Ireland (PHA)).

I've only reproduced some excerpts from the document, follow the link to read it in its entirety. I'll have more after the break.

Guidance
Principles for monkeypox control in the UK: 4 nations consensus statement

(EXCERPT)

Strategic aims
to suppress the transmission of monkeypox in the community and aim for eradication (decreasing Rt below 1) by targeting public health measures to the highest risks for transmission
to protect against spread of infection in hospitals and healthcare settings and to healthcare workers assessing and managing patients
to enable safe functioning of NHS services, including those services which can diagnose and manage cases, in the context of community transmission of monkeypox
Audience

Professionals – to inform development of operational guidance in UKHSA, NHS and other organisations.

Assumptions about transmission and biology

These assumptions are based on the available data and expert opinion and are aligned with the World Health Organization. They will be regularly reviewed using the evidence generated in the incident response.
For individuals with infection who are well, ambulatory, and have either prodrome or rash, the highest risk transmission routes are direct contact, droplet or fomite. Transmission seen so far in this outbreak is consistent with close direct contact.
There is currently no evidence that individuals are infectious before the onset of the prodromal illness.
For individuals with infection who have evidence of lower respiratory tract involvement or severe systemic illness requiring hospitalisation, the possibility of airborne transmission has not been excluded.
It remains important to reduce the risk of fomite transmission. The risk can be substantially reduced by following agreed cleaning methods based on standard cleaning and disinfection, or by washing clothes or domestic equipment with standard detergents and cleaning products. Within healthcare, please refer to local country national infection prevention and control manual / guidance for decontamination.
Waste management and decontamination practice should follow best practice and be based on all the available evidence on safe handling of all waste in accordance with country specific legislation and regulations.
The highest risk period for onwards infection is from the onset of the prodrome until the lesions have scabbed over and the scabs have fallen off.
Deroofing procedures and throat swabs are not considered to be aerosol generating procedures (AGPs) but may cause droplets. The list of AGPs is available in the national infection prevention and control manual.
There is no available evidence on monkeypox in genital excretions and a precautionary approach for the use of condoms for 8 weeks after infection is recommended, (this will be updated as evidence emerges), in addition to abstaining from sex while symptomatic including during the prodromal phase and while lesions are present.
The disease in healthy adults is primarily self-limiting and with a relatively low mortality. There is remaining uncertainty over potentially increased severity in children and in individuals who are highly immunocompromised or pregnant.
Implications

Risk assessment and consideration of the hierarchy of controls will help determine the level of personal protective equipment (PPE) to use.

For possible/probable cases, the minimum PPE is:

gloves
fluid repellent surgical facemask (FRSM) (an FRSM should be replaced with an FFP3 respirator and eye protection if the case presents with a lower respiratory tract infection with a cough and / or changes on their chest x-ray indicating lower respiratory tract infection)
apron
eye protections is required if there is a risk of splash to the face and eyes (for example when taking diagnostic tests)
For confirmed cases requiring ongoing clinical management (for example inpatient care or repeated assessment of an individual who is clinically unwell or deteriorating), for the minimum recommended PPE for healthcare workers is:

fit-tested FFP3 respirator
eye protection
long sleeved, fluid repellent, disposable gown
gloves
The above PPE will be used as the basis for contact classification.

(Continue . . . )

There remain a great many unanswered questions about the recent evolution, characteristics, and future course of the Monkeypox virus (see Multi-country outbreak of Monkeypox virus: genetic divergence and first signs of microevolution on https://virological.org/).

Which means that the above Assumptions about transmission and biology may have to change over time (as did early assumptions about COVID).

Based on what we know right now, Monkeypox should be containable through aggressive public health measures, including isolation of cases, contact tracing, and (if needed) ring vaccination.