Outbreak Alerts
Monkeypox
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 2, there were 25,391 total confirmed cases of monkeypox in 83 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 717 new confirmed cases per day as of August 2. A majority of the confirmed cases (15,926 as of August 2) continue to be reported in European countries. The US is reporting the most cases of any country globally, with 6,325 confirmed cases. 

From January 1 through August 3, 2022, 85 WHO Member States report a total of 25,054 laboratory confirmed cases and 122 probable cases, including 11 deaths (+6 over last week), according to a global trends report from the WHO. The first deaths outside of Africa were reported this week, with Spain confirming 2 deaths and India, Brazil, and Peru each confirming 1 death. Ghana also reported a monkeypox death.

A preprint study posted to medRxiv on July 26 estimates the reproduction number in the monkeypox outbreak outside of Africa to be 1.29 (95% CrI: 1.26, 1.33).
*The total number includes 25,047 cases in 76 countries not historically reporting monkeypox cases and 344 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.

EMERGENCY DECLARATIONS Since the WHO declared the monkeypox outbreak a Public Health Emergency of International Concern (PHEIC) on July 23, approximately 8,000 new cases have been confirmed in locations not historically reporting cases of the disease. The declaration is meant to help coalesce global response efforts by encouraging nations to share resources and information. But African health officials and physicians expressed dismay that they have been working on monkeypox for years with little interest or support from other regions where the disease was not endemic. Essentially, their warnings that monkeypox could pose a global threat fell on deaf ears until the virus began spreading in northern nations. 

In the US, public health officials are pressing the Biden administration to declare monkeypox a national public health emergency, which they say will help direct more money to states’ responses and facilitate the acquisition of vaccines and treatments. While the administration has not yet decided on an emergency declaration, US President Joe Biden this week appointed Robert Fenton, a long-serving Federal Emergency Management Agency (FEMA) official, as White House monkeypox coordinator, and Dr. Demetre Daskalakis, director of the Division of HIV Prevention at the US CDC, as his deputy. The announcement came as 3 states–New York, California, and Illinois–declared the monkeypox outbreak state emergencies. Several cities and counties nationwide also have declared local emergencies. The US monkeypox outbreak response is receiving heavy criticism from several US Congress members and public health experts. 

Around the globe, Australia last week declared monkeypox as a "communicable disease incident of national significance," which will allow for a more coordinated response. Meanwhile, public health officials in several Latin American nations–including Brazil, Mexico, and Peru–say their governments are not doing enough to raise awareness of monkeypox, deploy diagnostics, or acquire vaccines. 

VACCINE ACCESS Concerns are rising that poor nations are losing the race to acquire vaccines for monkeypox, with critics warning that the world is repeating the catastrophic inequity problems experienced during the COVID-19 pandemic. The WHO reportedly is developing a vaccine-sharing mechanism for affected countries, but there is little information on how it will operate and concerns that only asking nations to share is not enough. Currently, only one company, Bavarian Nordic, manufactures the newest monkeypox vaccine (MVA-BN, also known as Jynneos in the US, Imvanex in Europe, and Imvamune in Canada). There are concerns that with only 16.4 million doses currently available, annual production capacity at 30 million, and a planned closure of its European production plant until late 2022, the Danish company will be unable to meet demand without establishing licensing agreements to speed production. 

The US has acquired more vaccine doses than any other country, with more than 1.1 million doses currently available to states. Nevertheless, demand is outstripping supply in several jurisdictions, and some jurisdictions are lagging in requesting the vaccines allocated to them by the federal government, raising questions about how quickly at-risk populations can be protected. The US has supplies of another vaccine, ACAM2000, that is approved for smallpox and could be used against monkeypox, but the widespread use of that older vaccine is unlikely. Additionally, although the 2-dose Bavarian Nordic vaccine is US FDA-approved for use against monkeypox, there is no data available yet on the effectiveness of the vaccine in the current outbreak. 

CASES IN CHILDREN Health officials in the US have confirmed at least 5 monkeypox cases in children, right as the back-to-school season begins in most states. The US CDC has warned that children, especially those younger than age 8, are at increased risk of more severe monkeypox disease if infected, although data on pediatric cases is limited. Health officials are also warning colleges and universities to prepare for potential monkeypox outbreaks among students, who often reside and socialize in close-contact settings. The CDC has guidance on preventing monkeypox spread in congregate settings, as well as on isolation and prevention practices for people diagnosed with monkeypox.

GENOMIC DATA Genomic sequencing data on monkeypox shows there are possibly 2 distinct outbreaks occurring simultaneously. Most of the genomes sequenced globally in the 2022 outbreak fall into the B.1 lineage of the virus, however a small number of genomes belong to a distinct cluster from the A.2 lineage. The genomes in the A.2 lineage have been identified in the US (Florida, Texas, Virginia) and Thailand, but researchers in India recently reported on 2 genomes belonging to this cluster. The finding suggests these 2 cases are possibly not linked to the wider outbreak and there could be an additional cluster of human-to-human transmission that has potentially been unrecognized for years. The researchers also note it is too early to provide details about whether one lineage is more transmissible than the other.