Outbreak Alerts
Editor: Alyson Browett, MPH

Contributors: Noelle Huhn, MSPH, Christina Potter, MSPH, Eric Toner, MD, and Rachel Vahey, MHS
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Additional Monkeypox Resources

CALL FOR PAPERS There is an opportunity to integrate Global Catastrophic Biological Risks (GCBRs) into pandemic preparedness policy and practice. In 2023, Health Security will devote a supplement to GCBRs. We encourage submissions of original research articles, case studies, and commentaries that discuss lessons learned from the COVID-19 pandemic response and/or key policy and technology advances that could prevent or better prepare for a future, potentially more severe, globally catastrophic infectious disease pandemic. The deadline is October 3, 2022. For more information: https://www.centerforhealthsecurity.org/our-work/journal/call-for-papers/index.html

EPI UPDATE As of 5pm EDT on August 23, there were 44,503 total confirmed cases of monkeypox in 96 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 598 new confirmed cases per day as of August 22. The global trend in newly reported cases appears to be declining, although the situation varies among and within countries. With all 50 states now reporting cases, the US is reporting the most cases of any country globally, with 15,908 confirmed cases, 2.5 times the number of the next highest country of Spain (6,284). Three other countries are reporting more than 3,000 cases: Brazil (3,788), Germany (3,329), and the UK (3,207). France (2,889), Peru (1,188), Canada (1,173), and the Netherlands (1,087) also are reporting more than 1,000 cases. 

According to an August 23 global trends report from the WHO, the majority of cases over the past 4 weeks were notified from the Americas (60.3%) and Europe (38.7%) regions.

FRACTIONAL DOSING VACCINATION STRATEGY Earlier this month, the US FDA authorized the Jynneos monkeypox vaccine—made by Bavarian-Nordic and also known as MVA, Imvamune, and Imvanex—to be administered by intradermal injection for adult patients who are determined to be at high risk for monkeypox infection. Usually, a full vial is delivered subcutaneously as a single dose. Because intradermal injection requires a smaller dose, the move potentially increases the total number of doses available for use by up to 5-fold. However, the Biden administration’s fractional dosing plan is running into real-world implementation challenges. Public health officials across the country are reporting that drawing 5 doses from each vial is proving difficult for many injectors, who instead are routinely only getting 3-4 doses. Health workers face several obstacles, including a lack of so-called low dead space syringes, a type of syringe that can help increase the number of doses withdrawn; vial caps that break before the full number of doses can be withdrawn, rendering the remaining doses useless; and difficulty learning how to inject intradermally, an uncommon skill. As a result of these challenges, health departments are scrambling to cancel and reschedule appointments and delaying plans to expand vaccination eligibility. While the federal government has claimed that additional supply will be available soon and that response efforts will be dynamic based on local vaccination reporting and other incoming information, some health officials have expressed feeling frustrated and out of the loop. Public health experts fear the fractional dosing strategy could amplify existing racial/ethnic disparities in who is infected with monkeypox and who is being vaccinated.  

Currently, there are only about 1.5 million doses of the Bavarian-Nordic vaccine in the 10 worst-affected countries, with most being held by the US. The WHO estimates 10 million doses are needed to protect those most at risk—currently men who have sex with men (MSM)—and contacts of infected individuals. Other nations have announced efforts to stretch their available doses through fractional administration, including the UK and Spain, with the EU last week approving the strategy for use among its member states. Some experts argue that an equitable global response would prioritize vaccinations in 11 African nations where monkeypox has been endemic for years. However, Africa has no doses of the vaccine. Still, vaccination of any population comes with uncertainties, as it is unknown whether or how long a 2-dose primary series vaccination will protect against monkeypox infection. Breakthrough infections after a single vaccine dose have been reported. In the coming weeks, the US National Institute of Allergy and Infectious Diseases (NIAID) plans to initiate a clinical trial evaluating dose-sparing regimens of Jynneos.

TECOVIRIMAT The Oxford University team that conducted one of the largest clinical trials of COVID-19 therapeutics has launched a trial, dubbed PLATINUM, to evaluate the efficacy and safety of tecovirimat, or TPOXX, to treat monkeypox. The antiviral treatment was originally developed for smallpox and is made by SIGA Technologies. The placebo-controlled randomized trial expects to include about 500 non-hospitalized patients and has already begun enrollment. Additionally, the US National Institute of Allergy and Infectious Diseases (NIAID) announced it will soon begin a placebo-controlled randomized clinical trial to evaluate TPOXX in more than 500 patients in the US, in collaboration with the AIDS Clinical Trials Group (ACTG). Patients co-infected with HIV will be included in the trial, although there are special considerations for the use of TPOXX in this population. NIAID also will begin a previously planned trial of the therapeutic, in collaboration with the National Institute for Biomedical Research, in adults and children with monkeypox in the Democratic Republic of the Congo.

Additionally, the US CDC released demographic information on 288 US monkeypox patients who have received TPOXX, which does not represent all patients receiving the therapy. According to the data gleaned from forms submitted under an Investigational New Drug (IND) protocol, the median age of patients is 37 years, 98.9% are men, and 40.2% are White, making up the largest racial/ethnic group. Notably, Blacks/African Americans and Hispanics/Latinos make up 65% of the monkeypox cases reported to the CDC. 

TRANSMISSION Epidemiologists and other health experts estimate that the majority of monkeypox patients in the current multicountry outbreak were infected through close, personal, often skin-to-skin contact with the rash, scabs, lesions, or bodily fluids of infected individuals, often through sexual encounters. However, monkeypox virus also can be transmitted via contact with contaminated objects or surfaces (ie, fomites). A report published August 19 in the US CDC’s Morbidity and Mortality Weekly Report (MMWR) notes that monkeypox virus DNA was identified from many objects and surfaces sampled in the household environment of 2 monkeypox patients 20 days into their isolation, indicating that some level of contamination occurred. Interestingly, no viable virus was found in the home. Findings of the paper underscore guidance urging persons living in or visiting the home of someone with monkeypox to follow appropriate precautions to avoid indirect exposure, including wearing a well-fitting mask; avoiding touching possibly contaminated surfaces; maintaining appropriate hand hygiene; avoiding shared eating utensils, clothing, bedding, or towels; and following home disinfection recommendations. The report called for additional investigations into the prevalence of surface contamination and the potential for transmission via fomites.

SCHOOLS & CONGREGATE SETTINGS As the beginning of the school year approaches, the US CDC recently updated its monkeypox guidance for schools, daycares, and other settings serving children and adolescents, institutions of higher education, congregate settings, and teens and young adults. Overall, facilities can follow their everyday operational guidance that reduces the transmission of infectious diseases. According to the agency, the risk of monkeypox to children and adolescents in the US is low; as of August 21, data show that out of a total of nearly 15,000 cases, 6 cases are in children 0 to 5 years old, 7 are in children 6 to 10 years old, and 4 are in children 11 to 15 years old. However, a larger number of cases have been recorded in older adolescents and young adults, with 134 cases among individuals aged 16 to 20 years and 884 cases among those aged 21 to 25. While symptoms among children and adolescents infected with monkeypox are similar to older individuals, children under age 8 are at increased risk of severe outcomes. Universities and colleges are rushing to educate their staff and students about monkeypox, raise awareness, implement testing and isolation strategies, and establish plans to address identified cases or outbreaks as students return to campuses. At least 5 campuses have confirmed cases among students this summer. Notably, Brazil has reported at least 77 cases of monkeypox in children and adolescents aged 0 to 17 years, 3.5% of the nation’s reported infections. Of these cases, 20 cases were identified among children aged 0 to 4 years. It is not clear how the children were infected. Globally, a small proportion of the total cases are among children.

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