Outbreak Alerts
Monkeypox
Editor: Alyson Browett, MPH

Contributors: Christina Potter, MSPH, Eric Toner, MD, and Rachel Vahey, MHS
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EPI UPDATE As of 5pm EDT on July 26, there were 19,188 total confirmed cases of monkeypox in 76 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 552 new confirmed cases per day as of July 26. A majority of the confirmed cases continue to be reported in European countries, although the US currently is reporting the second most cases globally (3,590 confirmed).

From January 1 through July 22, 2022, 74 WHO Member States reported a total of 16,016 laboratory confirmed cases and 73 probable cases, including 5 deaths, according to a July 25 global trends report from the WHO. No deaths have been reported in countries not historically reporting monkeypox. The WHO assessed the global risk as moderate, while also assessing the risk in the Africa, Americas, Eastern Mediterranean, and South-East Asia regions as moderate. The WHO assessed the risk in the European region as high and in the Western Pacific region as low-moderate. 
*The total number includes 18,861 cases in 70 countries not historically reporting monkeypox cases and 327 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. 

PHEIC DECLARATION Following the WHO’s July 23 declaration that the ongoing and widespread monkeypox outbreak qualifies as a Public Health Emergency of International Concern (PHEIC), many are wondering whether the agency’s highest level of alarm will prompt countries to mobilize attention and resources to help contain the outbreak. The window of opportunity to do so is closing, according to some public health experts and epidemiologists. Without increased vaccination, testing, isolation for those infected, and contact tracing, containment of the outbreak could take months, the virus could become entrenched in certain areas, and it could spread in additional populations. 

Some experts believe containment remains possible with widespread vaccination among the most affected communities—currently gay, bisexual, and other men who have sex with men (MSM)—but those vaccines remain in limited supply. Even in the US, where the government has delivered more than 300,000 doses of Bavarian Nordic’s Jynneos monkeypox vaccine, and another 786,000 doses will be made available to US states this week, demand is outstripping supply. Some US urban areas, as well as several nations, have shifted their vaccination strategies to focus on administering only the first dose of the 2-dose regimen to stretch supply. The European Union this week approved the Bavarian Nordic vaccine—known there as Imvanex—to be marketed for monkeypox. Additionally, the company is in talks to quickly ramp up its production capacity to meet global demand. 

The Africa CDC welcomed the PHEIC but warned that a monkeypox outbreak on the continent has continued to grow from one country to another with little international attention since 2020. The agency noted that critical tools to address the outbreak, including diagnostics, treatments, and vaccines, have not been made available to African Union member states. Some experts maintained that while vaccination can be used to help contain the current outbreak in countries not traditionally reporting cases, policymakers must recognize the need to vaccinate populations in African countries where the disease is endemic in order to achieve long-term containment. 

NEJM CASE STUDY The largest monkeypox case study to date, published July 21 in the New England Journal of Medicine, examined the characteristics of 528 monkeypox cases across 16 countries. Of the cases, 98% were gay or bisexual men with a median age of 38 years; 75% were White; and 41% had HIV infection. Of the cases included, 95% presented with a rash, 73% had anogenital lesions, 41% had mucosal lesions, 15% had anorectal pain, and 10% had only a single skin lesion in the genital area. Notably, this variety of clinical presentation differs from historical clinical characterizations and observations of monkeypox cases, leading the researchers to warn that some cases might be misdiagnosed as a sexually transmitted infection (STI), such as syphilis or herpes, leading to a delay in detection. 

The researchers emphasized the need for current international case definitions to be expanded to add symptoms that are not currently included, such as single ulcers or sores in the mouth or on the anal mucosa. Researchers also highlighted the need for rapid identification and diagnosis of cases to further mitigate viral spread. The UK Health Security Agency (UKHSA) this week published an updated case definition with an expanded symptom list based on clinical experience during the current outbreak, and the US CDC recently updated its case definition. To further inform case definitions, the WHO has developed clinical characterization case report forms (CRF) for healthcare workers to report clinical features of monkeypox among outpatient and hospitalized cases.

The NEJM study also reported that monkeypox transmission was suspected to have occurred through sexual activity in 95% of cases, leading to debate among some experts about whether the disease should be classified as an STI. However, most agree that monkeypox does not classify as an STI in the traditional sense—a disease transmitted primarily through semen or vaginal fluids—because close physical contact, with or without sexual activity, is how the virus is transmitted. Experts emphasize that monkeypox also can be spread by contact with respiratory droplets, skin lesions, or recently contaminated surfaces or objects, such as clothing or bedding.

US SITUATION The US—which, along with Spain, has the most monkeypox cases than any other non-endemic country—may need nearly US$7 billion to mount a robust response to the outbreak. A memo addressed to US President Joe Biden detailed several federal funding options to inform the administration’s conversations with US Congress members. Late last week, the White House published a set of research priorities to address the current outbreak. The Biden administration continues discussions over whether to declare the monkeypox outbreak a public health emergency and is expected to name a national monkeypox coordinator. Final decisions on both could be made as early as this week. 

US health officials also cautioned the federal government and other agencies responding to the outbreak to combat any homophobic stigma associated with monkeypox. Because the virus has so far been identified primarily among MSM, public health agencies can target messaging specifically to at-risk populations. However, that also risks stigmatizing or creating misconceptions that the virus only affects those communities. Additionally, New York City officials this week urged the WHO to rename monkeypox to avoid “the potentially devastating and stigmatizing effects” that messaging on the virus could have on already vulnerable communities.

US health officials also warned that the monkeypox virus presents a particularly profound risk to children and pregnant women, who are at a higher risk of adverse outcomes. The US CDC has identified at least 2 monkeypox cases among children and 1 case in a pregnant woman.