#16,929
Not quite 3 months ago (May 14th) the UK reported 2 Monkeypox Cases In London, whose source of infection was unknown and under investigation. Both belonged to the same household, and while travel-related Monkeypox has been previously reported in the UK, neither had recent travel history out of the country.
Within 48 hours, the UK had Reported 4 More Monkeypox Cases (3 in London, 1 linked case in the Northeast of the country), all without recent travel history to West or Central Africa. Two days later, Portugal & Spain were reporting suspected cases.
Fast forward roughly 90 days and the global case count exceeds 28,000, while more than 7,500 cases have been identified in the United States. Both numbers are likely serious under counts, and both are expected to rise significantly in the weeks and months to come.
Over the past week we've seen the U.S. government declare Monkeypox a Public Health Emergency (PHE), and the CDC has released several HAN Advisories and guidance documents (see below) for clinicians and public health officials.
CDC HAN #472 - Update for Clinicians on Monkeypox in People with HIV, Children and Adolescents, and People who are Pregnant or Breastfeeding
CDC Technical Report & HAN #471 : Multi-National Monkeypox Outbreak, United States, 2022
Unfortunately, much of the public still seems to regard this as a `niche' or `lifestyle' disease - and unlikely to affect them, even though there is little reason to believe - that if it is not contained - that this virus will remain compartmentalized in the gay, bi-sexual, or MSM community forever.
On Friday the CDC published two new MMWR reports on Monkeypox. The first looks at the epidemiological and clinical characteristics of Monkeypox in the United States, and the second provides guidance on the prevention and treatment of Monkeypox in persons with HIV.
Due to their length I've only reproduced the links, summaries, and a few excerpts below. Follow the links to read them in their entirety.
Epidemiologic and Clinical Characteristics of Monkeypox Cases — United States, May 17–July 22, 2022
Early Release / August 5, 2022 / 71
David Philpott, MD1,2; Christine M. Hughes, MPH2; Karen A. Alroy, DVM3; Janna L. Kerins, VMD4; Jessica Pavlick, DrPH5; Lenore Asbel, MD6; Addie Crawley, MPH3; Alexandra P. Newman, DVM7; Hillary Spencer, MD1,4; Amanda Feldpausch, DVM5; Kelly Cogswell, MPH8; Kenneth R. Davis, MPH9; Jinlene Chen, MD10; Tiffany Henderson, MPH11; Katherine Murphy, MPH12; Meghan Barnes, MSPH13; Brandi Hopkins, MPH14; Mary-Margaret A. Fill, MD15; Anil T. Mangla, PhD16; Dana Perella, MPH6; Arti Barnes, MD17; Scott Hughes, PhD3; Jayne Griffith, MPH18; Abby L. Berns, MPH19; Lauren Milroy, MPH20; Haley Blake, MPH21; Maria M. Sievers, MPH22; Melissa Marzan-Rodriguez, DrPH23; Marco Tori, MD1,24; Stephanie R. Black, MD4; Erik Kopping, PhD3,25; Irene Ruberto, PhD26; Angela Maxted, DVM, PhD27; Anuj Sharma, MPH5; Kara Tarter, MPH28; Sydney A. Jones, PhD29,30; Brooklyn White, MPH31; Ryan Chatelain, MPH32; Mia Russo; Sarah Gillani, MPH16; Ethan Bornstein, MD1,8; Stephen L. White, PhD9; Shannon A. Johnson, MPH11; Emma Ortega, MPHTM12; Lori Saathoff-Huber, MPH17; Anam Syed, MPH5; Aprielle Wills, MPH3; Bridget J. Anderson, PhD7; Alexandra M. Oster, MD2; Athalia Christie, DrPH2; Jennifer McQuiston, DVM2; Andrea M. McCollum, PhD2; Agam K. Rao, MD2,*; María E. Negrón, DVM, PhD2,*; CDC Multinational Monkeypox Response Team (View author affiliations)View suggested citation
Summary
What is already known about this topic?
A global monkeypox outbreak began in 2022.
What is added by this report?
Among U.S. monkeypox cases with available data, 99% occurred in men, 94% of whom reported recent male-to-male sexual or close intimate contact; racial and ethnic minority groups appear to be disproportionately affected. Clinical presentations differed from typical monkeypox, with fewer persons experiencing prodrome and more experiencing genital rashes.
What are the implications for public health practice?
Public health efforts should prioritize gay, bisexual, and other men who have sex with men, who are currently disproportionately affected, for prevention and testing, address equity, and minimize stigma, while maintaining vigilance for transmission in other populations. Clinicians should test persons with rash consistent with monkeypox, regardless of whether the rash is disseminated or was preceded by prodrome
(SNIP)
Current findings indicate that community transmission of monkeypox is widespread and is disproportionately affecting gay, bisexual, and other men who have sex with men; this is consistent with data reported from other countries (3). Public health efforts to slow monkeypox transmission among gay, bisexual, and other men who have sex with men require addressing challenges that include homophobia, stigma, and discrimination.Although the largest proportion of cases have occurred in White persons, Black and Hispanic persons, who represent approximately one third (34%) of the general population (4), accounted for more than one half (54%) of monkeypox cases in persons for whom information on race and ethnicity is available; further, the proportion of cases among Black persons has increased during recent weeks.Ensuring equity in approaches to monkeypox testing, treatment, and prevention is critical, and taking actions to minimize stigma related to monkeypox can reduce barriers to seeking care and prevention. The data presented in this report provide insights into early transmission; however, ongoing surveillance is essential to monitor future transmission trends and assess the impacts among different communities.
Interim Guidance for Prevention and Treatment of Monkeypox in Persons with HIV Infection — United States, August 2022
Early Release / August 5, 2022 / 71
Jesse O’Shea, MD1,*; Thomas D. Filardo, MD1,2,*; Sapna Bamrah Morris, MD1; John Weiser, MD1; Brett Petersen, MD1; John T. Brooks, MD1 (View author affiliations)View suggested citation
Summary
What is already known about this topic?
A multinational monkeypox outbreak disproportionately affecting men who have sex with men, including persons with HIV infection, is ongoing worldwide.
What is added by this report?
CDC has developed clinical considerations for prevention and treatment of monkeypox in persons with HIV infection, including pre-exposure and postexposure prophylaxis with JYNNEOS vaccine, treatment with tecovirimat, and infection control.
What are the implications for public health practice?
Persons with advanced HIV might be at increased risk for severe monkeypox. Postexposure prophylaxis and antiviral treatments are available for persons with HIV infection. Prompt diagnosis and treatment and enhanced prevention efforts might reduce the risk for severe outcomes.
PDF [235K]
Monkeypox virus, an orthopoxvirus sharing clinical features with smallpox virus, is endemic in several countries in Central and West Africa. The last reported outbreak in the United States, in 2003, was linked to contact with infected prairie dogs that had been housed or transported with African rodents imported from Ghana (1). Since May 2022, the World Health Organization (WHO) has reported a multinational outbreak of monkeypox centered in Europe and North America, with approximately 25,000 cases reported worldwide; the current outbreak is disproportionately affecting gay, bisexual, and other men who have sex with men (MSM) (2).Monkeypox was declared a public health emergency in the United States on August 4, 2022.† Available summary surveillance data from the European Union, England, and the United States indicate that among MSM patients with monkeypox for whom HIV status is known, 28%–51% have HIV infection (3–10). Treatment of monkeypox with tecovirimat as a first-line agent is available through CDC for compassionate use through an investigational drug protocol.
No identified drug interactions would preclude coadministration of tecovirimat with antiretroviral therapy (ART) for HIV infection. Pre- and postexposure prophylaxis can be considered with JYNNEOS vaccine, if indicated. Although data are limited for monkeypox in patients with HIV, prompt diagnosis, treatment, and prevention might reduce the risk for adverse outcomes and limit monkeypox spread. Prevention and treatment considerations will be updated as more information becomes available.
While 2022's global Monkeypox epidemic is unprecedented, it did not come without ample warning.
In 2016, a 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 (possibly due to the waning smallpox vaccine derived immunity in the community).
The DRC had reported a 600% increase in cases over both 2011, and 2012. The authors also cite a higher attack rate, longer chains of infection, and more pronounced community spread than have earlier reports.Like all viruses, Monkeypox continues to evolve 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.And in a 2020 report, published by the Bulletin of the World Health Organization, researchers warned that our waning immunity to smallpox put society at greater risks of seeing Monkeypox epidemics (see WHO: Modelling Human-to-Human Transmission of Monkeypox).
Of course, Monkeypox was just one of many emerging threats (e.g. Ebola, MERS-CoV, Zika, Avian Flu, etc.) vying for our attention. Just as we can't know what natural disaster will strike next, we can't predict which emerging virus will spark the next global crisis.
Yet we can, and do, prepare for disasters. Even if we don't know what form they will take.
Using an `all-hazards' approach, we develop capacities and capabilities that can respond to any disaster; Fire departments, police departments, National guard, FEMA, and National Disaster Medical Assistance teams (DMAT) (to name a few).
COVID-19 has shown that pandemics can exact a huge cost, both in lives, and from the economy, making them a legitimate threat to national security.
Given the likelihood that pandemics and regional epidemics will only increase in frequency in the years ahead (see PNAS Research: Intensity and Frequency of Extreme Novel Epidemics), it is well past time to make pandemic preparedness (and prevention) a national priority.
And not just something we improvise when our backs are against the wall.
