EPI UPDATE As of August 30, 48,895 total confirmed cases and 301 probable cases, including 15 deaths, have been reported to the WHO from 101 Member States across all 6 WHO regions. The US reports the most cases of any country globally, with 18,417 confirmed cases. The next 5 countries include Spain (6,543), Brazil (4,493), France (3,547), Germany (3,455), and the UK (3,279). Three other countries—Peru, Canada, and the Netherlands—have reported more than 1,000 cases. According to an August 31 global trends report from the WHO, the number of weekly reported new cases globally increased by 13.7% in week 34 (August 22-28) (n=6,746 cases) compared to week 33 (August 15-21) (n=5,931 cases). The majority of cases over the past 4 weeks were notified from the Americas (66.9%) and European (32.3%) regions.

As of August 30, US states reporting the highest number of cases are California (3,291), New York (3,273), Florida (1,870), Texas (1,642) and Georgia (1,387). As of August 24, 74,481 total specimens have been tested in the US with a cumulative test positivity rate of 32.4%, despite submitted specimens falling far short of current test capacity. The majority of cases continue to be among men, with a high disease burden falling on Black/African-American and Hispanic/Latino individuals.

US RESPONSE The pace of newly reported monkeypox cases is slowing in some major US cities, and across the country more broadly, but experts are cautiously optimistic that the downward trend will continue. During the week of August 18-24, an average of 337 new monkeypox cases were reported each day in the US, down 24%—or more than 100 cases per day—from the week of August 4-10, according to US CDC data. Several factors are playing a role in this decreasing trend, including more widely accessible vaccination campaigns, more targeted communication strategies, and behavioral changes among those most at risk, including gay, bisexual, and other men who have sex with men (MSM). According to the results of a recent survey of gay, bisexual, and other MSM published August 26 in the Morbidity and Mortality Weekly Report (MMWR), about one half reported reducing their number of sex partners, one-time sexual encounters, and use of dating apps because of the monkeypox outbreak. Another MMWR report published the same day supports public health messaging encouraging MSM to reduce their number of sex partners, at least until they are fully vaccinated. Notably, as of now, a majority of the vaccine doses administered have been first doses, according to the CDC. 

While there is notable progress, experts caution that the outbreak remains dynamic and urge sustained aggressive and equitable public health efforts to quickly contain the outbreak. One concern is that while there is now enough vaccine supply to vaccinate MSM in the US, Black and Hispanic people are disproportionately contracting monkeypox virus but fewer are accessing vaccination, according to CDC data. Among states reporting racial/ethnic data, the proportion of cases among Black and Hispanic people is higher than their share of the total population in most states. Epidemiologists and infectious disease experts are concerned that the longer these disparities go unaddressed, the likelihood increases that the virus will become endemic, spillover into animal populations, or spread more widely, such as into prisons and other settings. According to one report, US states have recorded at least 31 monkeypox cases among children under age 18, increasing the risk the virus could cause outbreaks in daycare centers or schools. 

Recognizing these possibilities, the White House Monkeypox Response Team on August 30 announced new actions to provide additional vaccines and support to states and cities holding events that convene large groups of LGBTQI+ individuals and to surge vaccine availability and other prevention resources to communities of color. Additionally, the US HHS announced US$11 million to support the first U.S.-based fill and finish manufacturing of the Jynneos smallpox and monkeypox vaccine at Grand River Aseptic Manufacturing (GRAM) in Grand Rapids, Michigan. HHS also recently announced several efforts to increase access to 2 FDA-approved smallpox antivirals that might be effective against monkeypox infection. The agency’s Biomedical Advanced Research and Development Authority (BARDA) exercised an option on an existing contract to acquire additional intravenous (IV) doses of tecovirimat, also known as TPOXX, and signed a 10-year contract worth up to US$680 million for up to 1.7 million courses of brincidofovir, marketed as Tembexa.

Still, monkeypox is a serious disease that can be dangerous and is not well understood. This week, Texas health officials reported the death of a person with monkeypox, in what appears to be the nation’s first fatal case of the disease. The individual was an adult who was severely immunocompromised, and an investigation into what role monkeypox played in the death is ongoing. 

EUROPE RESPONSE Health officials in Europe are expressing optimism that the monkeypox outbreak has peaked on the continent, with several nations showing a week-on-week decline in cases, and are holding out hope that transmission can be halted. WHO Regional Director for Europe Dr. Hans Kluge said there are encouraging early signs of declining trends in new cases in France, Germany, Portugal, Spain, and the United Kingdom, but he encouraged all nations to remain vigilant and continue their commitments to end sustained human-to-human monkeypox transmission in the region. Because supplies of the Bavarian Nordic monkeypox vaccine remain limited on the continent, health officials suspect early detection of cases, allowing people to quickly isolate, and behavioral changes are significant factors behind the slowdown in new cases. In particular, men who have sex with men (MSM), the community in which monkeypox is primarily spreading in the global outbreak, are much more informed about the disease and taking steps to prevent exposure. WHO Europe recently published 2 policy briefs discussing considerations for control and elimination of monkeypox and for planning vaccination programs.

VACCINE ACCESS Bavarian Nordic has pledged to take steps to increase production of its monkeypox vaccine—known as BN-MVA, Jynneos, Imvanex, and Imvamune in various parts of the world—including exploring the possibility of using expired doses to help bridge gaps between supply and demand. Most of those expired doses are in the US, where federal regulators would have to clear their use if they are deemed to be still effective. Additionally, US, EU, and UK regulators have approved changing the way the vaccine is administered, allowing intradermal administration that increases the number of usable doses 5-fold. The WHO estimates 10 million vaccine doses are needed globally for individuals at highest risk, with a current focus on men who have sex with men (MSM) and contacts of known cases. But concern is growing that wealthier nations are buying up available vaccine supplies, repeating the inequities experienced accessing vaccines against COVID-19 and treatments for HIV. African nations still have no monkeypox vaccine doses, nor do several hard-hit countries, including Brazil and Peru. While some lessons from the HIV and COVID-19 pandemics have proven useful in the monkeypox global emergency, many more commitments must be made to improve the monkeypox response on an international scale. 

CLINICAL PRESENTATION Nigerian researchers in 2017 first noticed an unusual pattern of monkeypox virus presentation among young men, many of whom had genital lesions. Yet the report went unnoticed in wealthier nations, where monkeypox was rare. So when the first few dozen monkeypox cases were identified in Europe with atypical presentation, physicians were surprised. Now, based on a report published in the New England Journal of Medicine (NEJM) describing 528 infections diagnosed between April 27 and June 24, 2022, at 43 sites in 16 countries, several national health agencies have altered their case definitions and reporting forms to include atypical signs and symptoms, including single pox lesions, lesions in the throat or rectum, an absence of skin lesions, or lesions that appear prior to instead of after a prodrome syndrome that could include fever and fatigue. But some agencies, including the US CDC, have been reluctant to change definitions or behavior change recommendations without additional data from further studies, which take time to conduct. Those delays can have serious implications for patients, many of whom report facing fear, stigma, and other difficulties when seeking testing for suspected monkeypox symptoms.