Health Security Update
Editor: Alyson Browett, MPH

Contributors: Christina Potter, MSPH and Lane Warmbrod, MS, MPH
The Johns Hopkins Center for Health Security will be analyzing and providing updates, as needed, on the monkeypox outbreaks that have been identified in the UK, Portugal, and Spain. If you would like to receive these updates, please sign up here.

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MONKEYPOX OUTBREAKS Public health experts worldwide are on alert over several outbreaks of confirmed and suspected monkeypox in the UK, Portugal, and Spain. The seemingly unconnected clusters raise concerns there is more than one chain of transmission. The WHO said extensive contact tracing and viral sequencing of the confirmed cases is underway. European health authorities are monitoring for additional suspected cases. The US CDC expressed concern over the cases and the potential that the disease has spread outside of the UK, saying the clusters are atypical for monkeypox.

The UK Health Security Agency (UKHSA) has confirmed 9 monkeypox cases since May 6. The UKHSA reported its first case on May 7 in an individual in England with recent travel history to Nigeria, where monkeypox is endemic. Several people who were on the same flight as that individual on May 4 are being monitored for symptoms for 21 days, including 6 people in the US. On May 14, the UKHSA reported 2 additional monkeypox cases in London among individuals who live in the same household but who have no connection to the initial case. Another unconfirmed case is linked to that household. On May 16, the UKHSA announced 4 more confirmed cases, 3 in London and 1 linked case in the northeast of England. These 4 individuals have no known connection with the previous 3 cases announced on May 7 and 14, none had recent travel to endemic nations, and all appear to have been infected in London. These 4 individuals identify as gay, bisexual, or other men who have sex with men (MSM), and common contacts have been identified for 2 of the 4 cases.

Today, the UKHSA announced 2 additional confirmed monkeypox cases, one in London and another in the southeast of England. Neither case has known connections to previous cases. The UKHSA said evidence suggests there may be community transmission of monkeypox occurring via close contact and urged MSM to quickly report any unusual rashes or lesions to a health clinic. Community transmission of monkeypox in humans is rare, and the disease has not previously been described as sexually transmitted, so this limited initial evidence raises concerns.

Portugal’s health ministry said today it has confirmed 5 monkeypox cases and is investigating at least 15 suspected cases, all in the Lisbon and Val do Tejo region. All the confirmed cases involve men with ulcerative lesions. Additionally, health authorities in Spain also issued an alert, saying they have identified at least 8 suspected cases with symptoms consistent with monkeypox, all in the Madrid region. Information on whether the confirmed and suspected cases in Portugal and Spain are among MSM is not currently available.

Monkeypox is a rare viral infection that is thought to typically spread from close person-to-person contact through large respiratory droplets, direct contact with skin lesions or bodily fluids, or indirect contact via contaminated clothing or linens. Symptoms include fever and chills, headache, muscle aches, swollen lymph nodes, and a rash similar to chickenpox that can spread throughout the body and notably on the palms of the hands.
There is no treatment or vaccine specifically for the disease, although smallpox vaccine has been shown to be effective in stopping transmission when used in a ring vaccination strategy, and some antivirals might be useful in severe cases. Symptoms of monkeypox usually spontaneously resolve within 14-21 days but can be severe and require medical care. The case-fatality rate of monkeypox in Africa ranges from 1% to 10%, with the highest risk of death among children.

Two distinct clades of monkeypox virus have been identified—Congo Basin and West African clades—with the former found to be more transmissible and virulent. While monkeypox typically is found in West and Central Africa, experts have seen epidemiological changes in recent years, including shifts in the age and geographic distribution of cases. WHO officials stressed the need to better understand how monkeypox is transmitted and invest in tools for prevention and treatment.