Outbreak Alerts
Editor: Alyson Browett, MPH

Contributors: Noelle Huhn, MSPH, Christina Potter, MSPH, Eric Toner, MD, and Rachel Vahey, MHS
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EPI UPDATE As of 5pm EDT on August 9, there were 31,800 total confirmed cases of monkeypox in 89 countries, territories, and areas, according to the US CDC.* Based on data from Global.health, Our World In Data shows a 7-day average of 883 new confirmed cases per day as of August 9. The US is reporting the most cases of any country globally, with 9,492 confirmed cases. A majority of the confirmed cases continue to be reported in the European region, with the following countries reporting more than 2,000 cases: Spain (5,162), Germany (2,982), UK (2,914), and France (2,423). In the UK, officials report that recent data suggests the growth of the outbreak has slowed, but new cases continue to be confirmed daily. Brazil is the only other country currently reporting more than 2,000 confirmed cases (2,131).

From January 1 through August 9, 2022, 90 WHO Member States report a total of 29,833 laboratory confirmed cases and 97 probable cases, including 11 deaths, according to an August 10 global trends report from the WHO.
*The total number includes 31,425 cases in 82 countries not historically reporting monkeypox cases and 375 cases in 7 countries historically reporting monkeypox cases. The CDC map only includes cases confirmed as monkeypox virus or orthopoxvirus through laboratory testing and are year-to-date totals.

VACCINE ACCESS Monkeypox has long been endemic in parts of West and Central Africa, but the virus has been spreading outside of those regions since at least May. The number of confirmed cases continues to rise worldwide, in countries both historically and not historically reporting cases. Scientists are beginning to gain an understanding that sustained human-to-human monkeypox transmission began to occur around 2016-2017, based on genomic analyses. There are several vaccines that could be used to target monkeypox, most of which were developed for smallpox, but more data are needed to confirm the extent to which they provide sufficient protection against monkeypox in humans. About half of the countries currently reporting monkeypox cases have obtained doses of one of those vaccines, called MVA-BN, and the other half are in talks with the WHO about their supply needs. There are about 16.4 million total doses of the MVA-BN vaccine—administered in 2 doses 4 weeks apart and marketed by Bavarian-Nordic under the name Jynneos in the US and Imvanex in Europe—but mostly in bulk form, meaning the doses must be placed into vials to be distributed and used. Additionally, much uncertainty exists over Bavarian-Nordic’s abilities to fill and finish the current supply and manufacture more doses. 

To be clear, no vaccine doses are available in African nations where the virus is endemic, and many experts say that if those nations had gained access to vaccines earlier—including through donations of near-expired doses from wealthier nations—the current global emergency might not be happening. Wealthier nations that are reporting the largest outbreaks have quickly obtained doses, with the US having 1.1 million available doses, the UK 100,000, Spain 5,300, and Portugal, Germany, and Belgium close behind. The WHO is urging nations with larger vaccine supplies to donate to lower-income countries in need, but inequities in vaccine access and distribution continue, just as during the COVID-19 pandemic. 

US VACCINATION STRATEGY In an effort to increase the total number of available monkeypox vaccine doses in the US—the nation with the largest supply of vaccines—the FDA this week issued an emergency use authorization (EUA) for the Jynneos vaccine to allow healthcare providers to administer the vaccine by intradermal, instead of subcutaneous, injection among individuals 18 years of age and older who are determined to be at high risk for monkeypox infection. The agency said the action will allow the remaining 400,000 vials of vaccine to be split by up to 5-fold into about 2 million additional doses. The unusual step constitutes acknowledgement that there are not enough doses to cover the estimated 1.6-1.7 million US residents considered to be at highest risk of contracting monkeypox, primarily men who have been exposed to monkeypox, men with HIV, men who have a higher risk of contracting HIV, and men who have multiple male sexual partners. Vaccinating that group would require nearly 3.5 million shots, and about 670,000 have already been shipped to states and other jurisdictions. There also is concern that more doses will be needed if the virus spreads into other close-knit or congregate networks, including people in prison, unhoused populations, or sex workers.

Robert Fenton, the nation’s monkeypox response coordinator, stressed the approach would not impact safety or efficacy, but some public health experts, physicians, and former FDA officials expressed concern over the FDA’s plan, warning of potential pitfalls and calling for several challenges to be addressed. Some say there is not enough data about the vaccine’s effectiveness against monkeypox, when administered intradermally or subcutaneously, and underline the need for real-world effectiveness studies. Others urge additional support from HHS to train healthcare workers in intradermal administration and supply the necessary tools, including specialized needles. Still others call for additional public health messaging to warn vaccine recipients of potential local injection site reactions after intradermal administration and to avoid further confusion amid the ongoing public health emergency. In further actions to stretch available vaccine supplies, and against FDA recommendations, some states and jurisdictions—including Florida, Massachusetts, New York, and Washington, DC—are prioritizing first doses of vaccine until additional doses become available. 

The EUA also allows for use of the Jynneos vaccine in people younger than 18 years of age who are determined to be at high risk of monkeypox infection, although the vaccine would be administered by subcutaneous injection in those individuals. The CDC provides interim clinical considerations for the Jynneos vaccine and ACAM2000, an older vaccine licensed for smallpox and made available for the prevention of monkeypox under an Expanded Access Investigational New Drug application (EA-IND).

TREATMENT ACCESS Healthcare providers, monkeypox patients, and advocates say the antiviral tecovirimat, marketed as TPOXX, remains difficult to obtain for the off-label treatment of monkeypox, even after the US HHS declared a public health emergency. Providers must fill out recently simplified but still extensive paperwork to obtain the drug through an Expanded Access Investigational New Drug (EA-IND) protocol. Supplies of TPOXX, which is approved for the treatment of smallpox, are held entirely within the Strategic National Stockpile instead of being available through pharmacies. Writing in the New England Journal of Medicine (NEJM), US health officials this week defended their decision to continue to collect data on the drug’s safety and efficacy against monkeypox in humans through the EA-IND and noted randomized, controlled trials (RCTs) are under development. The manufacturer of TPOXX, Siga Technologies, said this week the US Biomedical Advanced Research and Development Authority (BARDA), part of the office of the Administration for Strategic Preparedness and Response at US HHS, exercised an option under an existing contract to procure US$26 million of the intravenous formulation of the drug, with delivery by next year. The IV formulation, which was FDA-approved to treat smallpox on May 18 of this year, is a better option for individuals who are unable to swallow the oral capsules. 

SCHOOLS & CONGREGATE SETTINGS According to the WHO, of the 19,301 monkeypox cases where age was available, there were 102 (0.5%) cases reported aged 0-17, out of which 26 (0.1%) were aged 0-4. Additionally, males between 18-44 years old continue to be disproportionately affected by this outbreak, as they account for 76.8% of cases. Therefore, public health experts are urging colleges and universities to prepare for the possibility of monkeypox outbreaks as students return to campuses. Several universities—including Georgetown University, George Washington University, the University of Texas at Austin, Bucknell University, and West Chester University—have already recorded cases, and others are working with campus, local, and state health authorities to prepare for, identify, and manage cases

Additionally, the case of a day- and home healthcare worker in Illinois who was diagnosed with monkeypox further raised concerns over the possibility of the virus spreading in congregate settings. However, public health experts note that monkeypox is not as transmissible as the virus that causes COVID-19. While schools, daycare centers, and other facilities where people congregate should be aware of and prepared for outbreaks, the virus is only spread through close contact, including direct contact with rashes, scabs, and bodily fluids of infected individuals; respiratory droplets during prolonged face-to-face contact; the touching of objects or fabrics that previously used by an infected person; or being scratched or bit by an infected animal. 

DISPROPORTIONATE RACIAL/ETHNIC IMPACT Data published August 5 by the US CDC provides epidemiological and clinical details of 1,195 monkeypox cases reported to the agency through July 27. Among these, 99% of cases were among men; among men with available information, 94% reported male-to-male sexual or close intimate contact during the 3 weeks before symptom onset. Among the 88% of cases with available data, 41% were among non-Hispanic White (White) persons, 28% among Hispanic or Latino (Hispanic) persons, and 26% among non-Hispanic Black or African American (Black) persons. The disease is disproportionately affecting Hispanic/Latino and Black/African American people, with 54% of cases with data reported among these populations, which together represent about one-third of the US population. The proportion of cases among Black people has grown in recent weeks, according to the analysis. In Georgia, 82% of cases are among Black or African American people as of August 9, according to data compiled by the state Department of Public Health. The data spotlight longstanding racial and ethnic disparities in access to care, for conditions from HIV to COVID-19, and highlight the need for public health agencies to reach out into these communities with prevention messaging and resources.

FEAR & STIGMA Fear, stigma, and homophobia surrounding the monkeypox outbreak are on the rise. On television, some commentators are openly mocking monkeypox patients, engaging in aggressive stigmatization reminiscent of the initial homophobic response to HIV/AIDS in the 1980s. In Washington, DC, this week, a gay couple was attacked in an apparent hate crime when assailants punched them repeatedly and yelled homophobic slurs that referenced monkeypox. And in Brazil, at least 10 monkeys have been poisoned in the past week, leading the WHO to issue a statement reminding people that despite the virus’s name, monkeys are not to blame for the current outbreak. Advocates have urged the WHO to rename the disease to avoid such misunderstandings. In June, a group of scientists, led by several from Africa, proposed renaming the monkeypox virus clades to avoid discrimination and stigmatization. While the WHO is open to renaming the virus, the process would take time. Public health experts and advocates urge health officials, politicians, and others to continue to provide fact-based, targeted messaging, provide support to at-risk and affected populations, and to do so without stigma and discrimination.