Outbreak Alerts
Editor: Alyson Browett, MPH

Contributors: Christina Potter, MSPH, Eric Toner, MD, Rachel Vahey, MHS, and Lane Warmbrod, MS, MPH
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Recent Outbreak Update as of June 29, 2022 at 2pm EDT

As of 5pm EDT on June 28, there were 4,769 cumulative confirmed cases of monkeypox in 49 countries, territories, and areas where the virus is not endemic, according to the US CDC. As of 2pm EDT today, the Global.health database reports 4,780 confirmed cases and an additional 44 suspected cases. A majority of the cases are being reported in European countries. Notably, the trackers do not include year-to-date cases in endemic countries. No deaths have been reported in non-endemic countries. 

WHO DECLINES PHEIC DESIGNATION On June 25, World Health Organization (WHO) Director-General Dr. Tedros Adhanom Ghebreyesus announced the multi-country outbreak of monkeypox constitutes an “evolving health threat” but stopped short of declaring a Public Health Emergency of International Concern (PHEIC), based on 2 days of deliberation by the Emergency Committee

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. Though the Committee agreed that the outbreak requires coordinated action to stop the spread of the virus—including greater surveillance, improved diagnostics, community engagement and risk communication, and the appropriate use of therapeutics, vaccines, and public health measures such as contact tracing and isolation—there was disagreement among members about whether the event constitutes a PHEIC. 

The WHO said it will continue to monitor the outbreak and reconvene the Emergency Committee in the coming days or weeks if it grows in severity or reach, particularly if affecting new countries or new populations. A vast majority of confirmed cases so far have been among men who have sex with men (MSM), signaling the virus is being spread within close-knit communities. Additionally, the Committee said if there is evidence monkeypox has established itself within animal reservoirs outside of Africa, it will reconsider its recommendation regarding a PHEIC declaration to the Director-General.

Many public health experts were surprised that the WHO did not classify the monkeypox outbreak as a PHEIC since it appeared the Emergency Committee concluded the outbreak met all 3 criteria of being extraordinary, at risk of international spread, and in need of a coordinated response. The reasons for not declaring a PHEIC likely vary. Notably, monkeypox has been circulating in several African nations for decades with little international concern. In fact, Nigeria, where monkeypox is endemic, warned this week that the country’s number of confirmed cases could reach its highest level in 5 years if current infection trends persist.

GLOBAL ASSESSMENT In a June 27 situation update, the WHO assessed the overall risk at the global level as moderate, noting this is the first time that cases and clusters are being reported simultaneously in 5 WHO Regions. The agency assessed the risk in the European Region as high due to the geographically widespread outbreak in the region involving newly affected countries. The WHO this week also published guidance for host governments, public health authorities, organizers, and other decision-makers involved in the planning and delivery of small or large gatherings during the current monkeypox outbreak. While the agency calls for organizers to take a risk-based approach to managing close interactions—noting that it remains unclear whether monkeypox can be transmitted by asymptomatic individuals—it did not call for the postponement or cancellation of events.

EUROPEAN REGION RESPONSE In a joint surveillance bulletin released today, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe report that 4,178 cases of monkeypox have been identified in 31 European countries and areas as of June 28, with 3,082 of those being laboratory-confirmed. The report also contains epidemiological information, demographics and clinical descriptions of cases, and phylogenetic analysis. 

The European Commission announced on June 28 that it has delivered an initial 5,300 doses of Bavarian-Nordic’s (BN) smallpox vaccine to Spain, out of a total 109,090 doses procured. The BN vaccine, marketed as Imvanex in Europe and Jynneos in the US, is known to be effective against monkeypox. The vaccine is US FDA-approved for monkeypox, and the European Medicines Agency (EMA) this week began a review of the vaccine to extend its authorization to cover monkeypox in addition to smallpox.

US RESPONSE The US CDC activated its Emergency Operations Center (EOC) this week to respond to the US monkeypox outbreak. In a press release, the CDC said the action will allow the agency “to further increase operational support for the response to meet the outbreak’s evolving challenges.” As part of its overall monkeypox outbreak response, which includes ramping up testing capabilities nationwide, the White House announced a national monkeypox vaccine strategy to significantly expand the availability of the 2-dose Jynneos monkeypox vaccines and broaden eligibility, with the goal of slowing the spread of the virus. In addition to offering the vaccine to people who have had a known exposure to the virus, the vaccine will be available to MSM who have had multiple recent partners in gatherings where monkeypox virus is known to have been spreading or in geographic areas where monkeypox transmission is occurring. 

To date, the US Department of Health and Human Services (HHS) has distributed 9,000 doses of Jynneos vaccine to 32 states and jurisdictions, as well as 300 courses of antiviral treatments. HHS plans to allocate an additional 56,000 doses immediately and another 240,000 over the coming weeks. Notably, a combined 1.6 million doses is expected to become available over the coming months. Under a 4-tier distribution plan, areas with the highest monkeypox case rates will be prioritized. Due to a limited supply of the Jynneos vaccine, officials are considering whether to use another, older smallpox vaccine, ACAM2000, that is effective against monkeypox. However, that vaccine comes with risks because it is an attenuated live-virus vaccine, which is presumed to not be safe for use among certain populations, including pregnant people, older adults, and  immunocompromised people, such as those living with HIV.

Many public health experts fear time is running out to effectively stop the transmission of monkeypox before the disease becomes endemic in the US and Europe. Cases with no known link to chains of transmission indicate community spread is occurring, with people possibly spreading the virus without knowledge that they are infected and testing still difficult to obtain. Therefore, the official case count, in the US and globally, likely is an undercount