Outbreak Alerts
Monkeypox
Editor: Alyson Browett, MPH

Contributors: Christina Potter, MSPH, Eric Toner, MD, Rachel Vahey, MHS, and Lane Warmbrod, MS, MPH
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Recent Outbreaks Update as of July 19, 2022 at 3pm EDT

As of 5pm EDT on July 19, there were 14,511 cumulative confirmed cases of monkeypox in 70 countries, territories, and areas, according to the US CDC.* We expect the global cumulative incidence to surpass 15,000 in the next 1-2 days, 11 weeks after the first case in the current outbreak was reported.

A majority of the confirmed cases continue to be reported in European countries, with Spain (3,125), the UK (2,137), and Germany (2,033) making up the 1st, 2nd, and 4th spots, respectively. This week, the US moved into 3rd position, reporting 2,107 confirmed cases, 2.27 times the number reported this time last week. No deaths have been reported in countries not historically reporting monkeypox, while 5 deaths have been reported in African countries. 

Based on data from Global.health,** Our World In Data shows a 7-day average of 473 daily confirmed cases as of July 19. The 7-day rolling average of daily confirmed cases appears to have peaked at 537 on July 13 but appears to be leveling out.
*The total number includes 14,268 cases in 64 countries not historically reporting monkeypox cases and 243 cases in 6 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.
**Global.health data only include countries that have not historically reported monkeypox cases. 

WHO EMERGENCY COMMITTEE With many experts expressing concern that the confirmed number of cases likely is an undercount and that the window is closing to contain the global monkeypox outbreak, the WHO Emergency Committee is set to meet again July 21 to decide whether the outbreak now constitutes a Public Health Emergency of International Concern (PHEIC). The committee first met at the end of June but decided at that time the outbreak did not qualify as a PHEIC, WHO’s highest level of alert for events that show extraordinary public health risk to other countries through international spread and require coordinated international responses.

SEXUAL HEALTH CLINICS Sexual health clinics that are on the frontlines of diagnosing many of the cases—the majority of which are occurring in men who have sex with men (MSM)—say they are preparing for the possibility that monkeypox will become endemic. The clinics are best suited to identify, test, and treat monkeypox cases, but they already are under-resourced after years of financial neglect, according to sexual health experts in the US and UK. 

Although monkeypox is not historically considered to be a sexually transmitted infection (STI)—experts believe the virus is typically transmitted through skin-to-skin or close face-to-face contact—public health authorities are struggling with messaging surrounding prevention, trying to strike a balance between encouraging people to have fewer sexual partners while not stigmatizing specific communities. A study published in Eurosurveillance last week found a large proportion of semen, saliva, urine, and feces samples taken from 12 monkeypox patients in Barcelona, Spain, contained DNA of the poxvirus. Though the study suggests monkeypox transmission might be viable through sexual fluids or saliva, the presence of viral DNA does not mean infectious virus is present.
 
US TESTING & TREATMENT US CDC Director Dr. Rochelle Walensky this week remained optimistic that the monkeypox outbreak can be contained and defended CDC’s response, saying “dramatic progress” has been made to educate the public and healthcare providers and increase testing and vaccine access. 

The CDC is working to ramp up the nation’s testing capacity, which is up to 70,000 samples per week versus 6,000 samples at the beginning of the outbreak. Aegis Science and Sonic Healthcare USA (Sonic) this week became the fourth and fifth commercial laboratories to announce monkeypox testing availability. Still, anecdotal evidence shows people continue to face major challenges to obtaining testing and treatment for monkeypox. Additionally, physicians face challenges in obtaining the smallpox treatment tecovirimat (TPOXX) for their patients due to cumbersome paperwork because the drug is not approved for monkeypox but available under expanded access Investigational New Drug (EA-IND) protocol. The US Department of Health and Human Services (HHS) and US FDA have said they are working to make the drug more easily accessible. 

VACCINE SUPPLY & ACCESS As of July 15, the US government said more than 300,000 doses of the Jynneos smallpox vaccine are available to states and jurisdictions. About 156,000 of those doses had been shipped, with about 100,000 of those delivered last week. The government expects to add about 780,000 additional doses from a Bavarian Nordic facility in Denmark that recently passed US FDA inspection to the available supply by the end of July. In total, the US government has ordered nearly 7 million vaccine doses, but most of those will not be ready until late this year or next year. 

Vaccine supply has been unable to keep up with demand, especially in New York City, San Francisco, and other areas. Notably, New York City announced it will only offer first doses of the 2-dose primary series until supplies increase. The move is not in line with FDA and CDC recommendations, which call for the vaccine doses to be administered 28 days apart. Both the UK and Canada are taking a similar approach to administering first doses to as many people as possible before offering second doses. 

In Europe, health authorities have delivered about 25,000 vaccine doses to 6 EU member states. The European Commission announced July 18 it has ordered an additional 54,000 doses of Jynneos from Bavarian Nordic, after placing an initial order of 110,000 doses in June. Both Spain and France last week updated their vaccination strategies to include pre-exposure vaccination for high-risk populations. Portugal announced the vaccine will be offered as post-exposure prophylaxis, preferably within 4 but up to 14 days after exposure, with people who were previously vaccinated against smallpox receiving only 1 dose of Jynneos. 

The world has known of the potential threat of resurgent monkeypox for decades. Now, as the number of new cases continues to rise, the international community must come up with a plan to make vaccination for monkeypox—with either the Jynneos monkeypox or ACAM2000 smallpox vaccines—widely available and avoid the inequity experienced during the COVID-19 pandemic. Additionally, increased access to diagnostic testing, treatment, and targeted education campaigns that minimize stigma are quickly needed. A determination from the WHO Emergency Committee on whether the monkeypox outbreak constitutes a PHEIC and any recommendations on how to better manage the global public health response are expected later this week.