Outbreak Alerts
Editor: Alyson Browett, MPH

Contributors: Noelle Huhn, MSPH, Christina Potter, MSPH, Eric Toner, MD, and Rachel Vahey, MHS
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FREE MONKEYPOX WEBINAR The American Public Health Association and the National Academy of Medicine are hosting a free webinar on Thursday, August 18, 2022, from 5pm to 6:30pm ET. A panel of experts will discuss the current state of the science of monkeypox, the disease epidemiology as we understand it today, available and emergent prevention options, critical research questions we need to answer, and what we should consider and plan for as we respond to this public health emergency. For additional information and to register, visit https://nam.edu/event/monkeypox-the-state-of-the-science/.
EPI UPDATE As of 5pm EDT on August 16, there were 38,019 total confirmed cases of monkeypox in 93 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 843 new confirmed cases per day as of August 16. The US is reporting the most cases of any country globally, with 12,688 confirmed cases, more than twice that of the next highest country of Spain (5,719). Four other countries are reporting more than 2,000 cases: Germany (3,186), UK (3,081), Brazil (2,893), and France (2,673). 

From January 1 through August 17, 2022, 93 WHO Member States report a total of 37,736 laboratory confirmed cases and 179 probable cases, including 12 deaths, according to an August 17 global trends report from the WHO. Over the past 4 weeks, the majority of cases were notified from the Americas (56.6%) and Europe (42.2%) regions.
*The total number includes 37,632 cases in 86 countries not historically reporting monkeypox cases and 387 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.

NAME CHANGE The WHO last week announced new names for the 2 branches of the monkeypox virus in an effort to move away from using geographic regions and align the names with current best practices. A WHO-convened ad hoc meeting of experts agreed to use Roman numerals and now refer to the former Congo Basin (Central African) clade as Clade one (I) and the former West African clade as Clade two (II). Additionally, the experts agreed that Clade II has 2 subclades, which will be referred to as Clade IIa and Clade IIb, the latter of which includes the group of variants largely circulating in the 2022 global outbreak. The WHO also announced it is collecting proposals from the public regarding the renaming of monkeypox, and dozens of submissions have already been made. Simultaneously, the International Committee on Taxonomy of Viruses is weighing whether to change the name of the virus, as some have concerns that a renaming could upset continuity in the scientific literature. Many experts—but not allargue the name should be changed because monkeys often are associated with the Global South and the word monkey is considered a racist slur against people of color. Additionally, the virus was first identified in monkeys, hence its name, but because it is widely believed that rodents are the natural viral reservoir, the name is considered a misnomer. 

VACCINE PRODUCTION & ACCESS Bavarian Nordic, the only company with a vaccine approved for monkeypox, cautioned this week that it is “no longer certain” it can meet rising global demand. The vaccine, MVA-BN, is known as Jynneos in the US, Imvanex in Europe, and Imvamune in Canada. Even with upgrades to its existing manufacturing plant in Denmark, the company said it is exploring the possibility of outsourcing some production, although there are no concrete negotiations at this time. Additionally, the Danish company is exploring a possible technology transfer to a US contract manufacturer, although that process could take 3-9 months to complete. Bavarian Nordic’s current annual production capacity is around 30-40 million doses, enough to vaccinate about 15 million people using the recommended 2-dose regimen. That supply could be stretched to cover up to 100 million people if other countries follow the US FDA’s move to cut each dose by one-fifth and administer it intradermally instead of subcutaneously. However, that plan faces challenges, public health experts warn. Specialized training and equipment is needed to split and administer doses under the skin. FDA officials recently defended their decision to stretch their limited supply of Jynneos in a letter to the Bavarian Nordic CEO, after he expressed concern over the plan.

There are at least 2 other vaccines that could be used against monkeypox, but one—ACAM2000—is not recommended for widespread use and the other is a Japanese vaccine that has had significant production issues. Currently, monkeypox is spreading primarily within networks of gay, bisexual, and other men who have sex with men (MSM). According to analysts, limiting vaccinations to only MSM who also have HIV or who are taking PrEP would encompass about 18 million people worldwide. Including healthcare workers would bring the total to about 62 million people, and if the virus begins spreading more widely among children, who are at greater risk of severe disease, the number requiring vaccination could rise to 1.5 billion. Higher-income countries have been scrambling to buy up current vaccine stocks, with the US securing the most doses, partially due to existing contracts for its Strategic National Stockpile. But most of those countries have seen only a fraction of their contracted doses. According to a leaked memo, the UK Health Security Agency said it will hold back some doses of its limited supply to administer to people with known exposures to the virus. Some vaccination campaigns across the UK currently are on hold after stocks ran out. The majority of low- and middle-income countries, including those in Africa where the disease has been endemic for years, have not secured any doses of the Bavarian Nordic, or other, vaccine. 

US VACCINE AVAILABILITY The Biden administration announced August 15 that it is accelerating the release of up to 442,000 doses—about 88,000 vials—of the Jynneos monkeypox vaccine to states and jurisdictions, several weeks ahead of schedule. Officials said the accelerated release was made possible because the US FDA authorized a plan to stretch supplies of the vaccine by splitting 1 dose into 5 and administering it just under the skin. Officials said the additional supply will help the government ensure doses are delivered to the places and administered to the people who need them most. But public health experts expressed concern that there is no nationwide data on who has received the vaccine or who has been diagnosed with the disease, and the available but limited state-level data provide evidence that inequities in access and disparities in infections persist. For example, in North Carolina, more than 70% of cases have been diagnosed among Black people, but only about 26% of vaccines have gone to Black people, according to the state health department. Washington, DC, officials said they plan to publish data in an online dashboard to enhance public communication about the disease but also provide transparency about who is getting vaccinated. 

Several jurisdictions and states—including Washington, DC, New York City, New Jersey, and North Dakota—recently expanded eligibility for the monkeypox vaccine. Several states have expressed frustration over how the Biden administration is distributing the vaccines, saying hundreds of doses have been misrouted, lost, or arrived without warning. The US government has faced growing criticism about how it has handled the monkeypox outbreak, including that lessons remain to be learned from the COVID-19 pandemic. The coming weeks will be instructive as to whether the virus can be contained and eliminated, although many epidemiologists, public health officials, and doctors fear time is running out to stop the virus from spreading more broadly within the US population.

TRANSMISSION DYNAMICS & CLINICAL PRESENTATION Several studies and anecdotes are raising concerns about the possibility of asymptomatic monkeypox virus transmission. In a retrospective study published August 16 in the Annals of Internal Medicine, French researchers describe the detection of virus on anorectal swabs collected from asymptomatic men in a sex health clinic to test for the sexually transmitted infections chlamydia and gonorrhea. Of 213 anal swabs gathered from asymptomatic men, 200 were tested for monkeypox virus using PCR and 13 (6.5%) of those were positive. The researchers noted that it is unknown whether this viral shedding is sufficient for viral transmission. If additional evidence determines asymptomatic transmission is occurring, they said the practice of ring vaccination of contacts of symptomatic monkeypox patients might not be sufficient to contain spread. Their findings coincide with another recent study reporting that 2 asymptomatic patients in Belgium were found to be infected with monkeypox virus. Additionally, a case report published in Emerging Infectious Diseases describes a patient who may have contracted the virus at a crowded gathering where people were dancing closely, many wearing shorts and sleeveless tops. The man reported no sexual contacts within the past 3 months, had no early symptoms (viral prodrome), and had a lesion pattern without anogenital involvement. The researchers, from Stanford University, also reported identifiable virus in saliva and nasopharyngeal swabs from the man, notable because the patient had no respiratory symptoms. 

Officials in Texas (US) this week reported the nation’s eighth documented pediatric case in a child under age 2. Other than a residual rash, the child has been asymptomatic and none of the child’s contacts have been identified as having monkeypox. Officials said they do not yet know how the child contracted monkeypox, noting that the child has not attended daycare or school. Experts agree that the possible modes of monkeypox virus transmission—including via contact with contaminated surfaces, especially porous materials—require additional investigation but that the majority of cases are being transmitted primarily through close skin-to-skin contact, including sexual activity.

HUMAN-TO-DOG TRANSMISSION In a correspondence published last week in The Lancet, French researchers describe the first case of a domesticated dog with confirmed monkeypox virus infection that likely was acquired through human transmission. The dog is owned by 2 men who have sex with men (MSM) who live together and are in a non-exclusive relationship. Both began to show symptoms of monkeypox 6 days after sex with other partners, and they were subsequently diagnosed with the virus. About 12 days after the men began to show symptoms, the dog presented with skin lesions and was confirmed by PCR test to have monkeypox infection. The men reported that their dog slept in the bed alongside them, and they were careful to isolate the dog from other pets and humans after they were diagnosed. 

Wild animals, including rodents and primates, are known to carry monkeypox virus in endemic countries, and transmission has been documented in prairie dogs in the US and captive primates in Europe. However, infection among domesticated animals, such as cats and dogs, has not been reported until now. The researchers called for additional investigation into secondary transmission of monkeypox via pets. The WHO called the case new, but not surprising, information, as the agency has been working with partners to address the issue. The case prompted the US CDC to update its monkeypox guidance to recommend that people with monkeypox avoid close contact with animals and that pets that have not been exposed to the virus be cared for in another location until the owner or owners fully recover.