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Last week the CDC held a COCA Call : Mpox - Clinical Management & Outbreaks, as reports of sporadic infections (clade IIb) continue across the nation (see CBS News S.F. officials monitor rise in domestic mpox cases as global outbreak spreads)At the same time a far more dangerous clade I mpox virus continues to rage in the DRC, which over the past 18 months has been blamed for more than 20,000 suspected mpox cases and more than 1,000 deaths.
CDC HAN Advisory #00501: Mpox Caused by H-2-H Transmission with Geographic Spread in the Democratic Republic of the Congo
ECDC Risk Assessment On Transmission & Spread of Clade I Mpox From The DRC
That study revealed a novel clade I sub-linage had emerged - most likely from a zoonotic introduction - with changes that may render current CDC tests unreliable.
A month later, in Preprint: Sustained Human Outbreak of a New MPXV Clade I Lineage in Eastern Democratic Republic of the Congo, we saw a further analysis, which called for this new lineage to be named Clade Ib, and warned of its potential to spread globally.
While that doesn't appear to have happened yet (based on limited reporting), we have been watching the incursion of Mpox into new regions, including a spike in cases recently reported in South Africa.
As we've seen with COVID, and other infectious disease reporting around the globe, surveillance and reporting on Mpox is often limited, or sometimes missing entirely. The WHO describes this situation below:
WHO continues to encourage all countries to ensure that mpox is a notifiable disease and to report mpox cases, including reporting when no cases have been detected (known as ‘zero-reporting’, as outlined in the Standing Recommendations on mpox issued by the WHO Director General).
This report does not highlight non-reporting countries. Therefore, it should be noted that an absence of reported cases from a country may be due to the country not reporting, rather than having no cases. Reporting to WHO has been declining, therefore, the decline in reported cases should be interpreted with caution.
Two days ago the WHO released their monthly Situation Report (#34) on the Multi-country outbreak of Mpox, which includes details on the recent South African outbreak. I've provided some excerpts (below), but you'll want to follow the link to read the full 17-page report.
External Situation Report 34, published 28 June 2024Data as received by WHO from national authorities as of 31 May 2024
Report highlights
(SNIP)
- In May 2024, a total of 646 new laboratory-confirmed cases of mpox and 15 deaths were reported to WHO from 26 countries, illustrating continuing transmission of mpox across the world. The most affected WHO regions, ordered by number of laboratory-confirmed cases, were the African Region, the European Region, the Region of the Americas, the Western Pacific Region and the South-East Asia Region. The Eastern Mediterranean region did not report any cases in May 2024.
- As reporting from countries to WHO has been declining, the current reported global data most likely underestimate the actual number of mpox cases.
- Within the African Region, the Democratic Republic of the Congo reported most (99%) of the confirmed mpox cases in the reporting month. With limited access to testing in rural areas, 18% of clinically compatible (reported as suspected) cases in the country are tested, therefore the confirmed case counts are underestimates of the true burden.
- This issue also features:An update on the mpox situation in South Africa;
- An update on vaccines and immunization for mpox, with information from partners.
- WHO welcomes the announcement by the Democratic Republic of the Congo national regulatory authority of the emergency authorization for use of MVA-BN and LC16 mpox vaccines, which will enable the country to import and deploy mpox vaccines for the national outbreak response.
Spotlight on South Africa
As of 26 June 2024, the Republic of South Africa had notified the WHO of 16 confirmed cases of mpox, including three deaths, during 2024. These cases were confirmed from 8 May 2024 to 23 June 2024 and 15 of the 16 patients were hospitalized. Prior to this, at the height of the multi-country outbreak, the Republic of South Africa had reported five mpox cases and no deaths from June 2022 to August 2022. The new reports represent the first mpox cases detected in the country since August 2022, and the first deaths altogether.
These cases have been reported from three (of nine) provinces: KwaZulu-Natal (eight cases; two deaths), Gauteng (seven cases; one death), and the Western Cape (one case). None of them had reported recent international travel or attendance at events or activities which may have introduced a higher risk of mpox.
The profiles of these cases reflect the well-described features of the 2022 - 2024 multi-country mpox outbreak. All these cases have been in men aged 23 to 43 years. Of these 16 cases, 11 cases were gay, bisexual or other men who have sex with men, and the most commonly reported context of likely exposure was sexual contact.
For the five patients whose samples had been sequenced to date, clade IIb monkeypox virus (MPXV) was confirmed. These cases all experienced extensive skin lesions, and 15 out of 16 cases progressed to severe disease requiring hospitalization. Eleven cases have been reported to be persons living with HIV (PLHIV), with either unmanaged or only recently diagnosed HIV infection. There have been three deaths among the 16 confirmed cases, resulting in a case fatality ratio (CFR) of 19%, much higher than the clade IIb mpox global CFR which was 0.2% overall as at the end of May 2024.This disproportionate burden of HIV, severe mpox disease, and deaths suggests that MPXV is likely circulating in the community and has reached the most susceptible individuals. In a context where there may be stigma associated with sexual behaviour and/or HIV infection, limited access to health care services willbe compounded by hesitancy to seek early diagnosis and care for mpox.
In the face of this unusual epidemiological picture, the country has promptly responded to this outbreak, initiating action across several response pillars: surveillance and diagnostics; case management; risk communication and community engagement (RCCE); vaccination; infection prevention and control; operations, finance and logistics, and research. Actions include:
• activation of incident management teams at national and provincial levels to coordinate the response;• development of national and provincial preparedness and response plans;• case investigation, contact tracing and contact follow-up for identified cases;• health worker training on mpox case management;• securing an initial reserve of antiviral treatment courses for severe cases;• establishment of a laboratory sample referral network for MPXV testing;• risk messaging both within the general community and among risk groups;• provision of policy guidance and initiation of processes to s(Continue . . . .)ecure vaccines for high-risk groups;• discussions on public health research objectives and studies to address key knowledge gaps.
Nearly every WHO DON or disease Situation Report contains diplomatic reminders to member nations of their `duty to report' these types of cases under the IHR 2005 agreement, but compliance remains spotty at best.
Increasingly, the `political' solution to the rise of inconvenient emerging infectious diseases - like Mpox, COVID, MERS-CoV, and novel influenza - is to limit testing, surveillance, and the reporting of cases, and even deaths.
