Editor: Alyson Browett, MPH

Contributors: Christina Potter, MSPH, Eric Toner, MD, Rachel Vahey, MHS, and Lane Warmbrod, MS, MPH

Call for Papers: In 2023, Health Security will devote a supplement to Global Catastrophic Biological Risks (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, 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

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As of 5pm EDT on June 23, there were 3,504 cumulative confirmed cases of monkeypox in 44 non-endemic countries, according to the US CDC. As of 1pm EDT today, the Global.health database reports 3,552 confirmed cases and an additional 109 suspected cases. The case totals represent a near doubling of the number of cases reported one week ago. Notably, the trackers do not include year-to-date cases in endemic countries. No deaths have been reported in the new outbreaks. 

The World Health Organization (WHO) on June 23 convened an Emergency Committee under the International Health Regulations (IHR) to review whether the ongoing monkeypox epidemic constitutes a Public Health Emergency of International Concern (PHEIC). It is unclear when a decision will be announced.

The PHEIC designation is the WHO’s highest level of alert, showing an event constitutes an extraordinary public health risk to other countries through international spread and requires a coordinated international response. Since the revised IHR entered into force in 2007, the WHO has declared 6 PHEICs, including the ongoing COVID-19 pandemic. Several experts from Africa criticized the delay to call an Emergency Committee meeting on monkeypox, saying the disease already constitutes a crisis in parts of the continent and highlighting the seeming reluctance to address diseases when they are affecting low-income nations. However, other experts and responders welcomed the attention, saying more political will and funding to—hopefully equitably—address the disease in both endemic and non-endemic countries would benefit all.

Genomic sequencing of isolates from cases in Europe and the US suggest that monkeypox may have been silently circulating among humans since 2018. Specifically, researchers at the London School of Hygiene & Tropical Medicine (LSHTM) support a hypothesis that the disease may have found its way into close-knit sexual networks, in which a small fraction of individuals have disproportionately large numbers of partners. Around that time, experts believe the virus mutated to become more adept at spreading from person-to-person. A research team from Portugal found that a 2022 viral variant differed significantly from a 2018-19 isolate by nearly 50 variations, an unexpected finding that could signal the virus is changing more rapidly than previously believed. If monkeypox has found a new host in humans, as appears to have happened, the virus could also jump back into a new animal host, potentially giving rise to future outbreaks.

In its latest outbreak update (June 17), the WHO noted it is removing the distinction between endemic and non-endemic countries in its reporting in order to reflect the need for a unified global response to the disease. The agency also assessed the risk at the global level as moderate but said it is highly likely that additional cases with no identified chain of transmission will occur, including in countries that have not yet reported cases. Already this week, at least 3 additional countries reported new cases: South Korea and Singapore, the first for the Southeast Asia region, as well as South Africa.

Europe is the most affected region in the current outbreak, reporting more than 2,700 of the total global cases. In a June 22 joint surveillance bulletin, the WHO and the European Centre for Disease Prevention and Control (ECDC) reported that for 1,799 cases from 20 countries for which case data were reported, the majority were male (99.4%) and between 31-40 years old (44.1%). Among cases with known HIV status, 41% were HIV-positive. 

The UK Health Security Agency (UKHSA) this week published a strategy to offer the Smallpox Modified Vaccinia Ankara–Bavarian Nordic (MVA-BN) vaccine, which is known to be effective against monkeypox, to certain men deemed to be at higher risk of contracting the disease. According to the guidance, men who have multiple partners or participate in group sex may be able to receive vaccination. 

In North America, cities in both Canada and the US are offering the Jynneos vaccine to gay, bisexual, and other men who have sex with men (MSM). Men who have been exposed to monkeypox or who are at higher risk of the disease can receive vaccination in Ottawa, Montreal, and Toronto. The New York City Department of Health this week rolled out vaccinations for gay, bisexual, or other adult MSM who have had multiple or anonymous sex partners in the past 14 days. Appointment slots for the limited vaccine supply filled quickly, and the department asked people to check back on June 26 for additional information. If the WHO declares monkeypox a PHEIC, more countries likely will begin targeted vaccination strategies to help contain the outbreak. However, MVA-BN vaccines are in short supply and production capacity is limited, which may impact countries' abilities to respond. 

According to the US CDC, local transmission of monkeypox is occurring in the country, in addition to cases among people who traveled abroad, with nearly half of domestic cases believed to be acquired locally. US health officials also said they are developing a protocol to use the Jynneos vaccine in children, if needed. The vaccine currently is approved for use in adults. Additionally, officials said the federal government is involving commercial laboratory companies to expand the number of testing sites throughout the country, although they acknowledged the need to do more. Public health experts have criticized the US government’s efforts to address the monkeypox outbreak, saying it mirrors the slow response to the COVID-19 pandemic. Some administration officials have expressed concern that the government’s sluggish response raises doubts about the nation’s future pandemic preparedness.