Updates and summaries of guidelines are included in the current issue of Disease Outbreak News, which is an update to the previously released issue of 29 May.
Outbreak in a Second’s Notice
Since the 13th of May 2022, and as of the 2nd of June 2022, the World Health Organization (WHO) has received reports of or identified 780 laboratory confirmed cases of monkeypox from 27 Member States spread throughout four WHO areas that are not endemic for monkeypox virus. Investigations on an epidemiological scale are currently being carried out.
The majority of cases that have been reported up to this point have been presented through sexual health or other health services in primary or secondary health care facilities. The people who have been affected by these cases have been men who have sex with other men, though this is not always the case (MSM).
The West African clade of the virus has been identified from samples of confirmed cases so far; however, the majority of confirmed cases with a travel history reported visiting countries in Europe and North America, as opposed to West or Central Africa, where the monkeypox virus is found in endemic levels.
It is highly unusual for individuals to test positive for monkeypox who have not recently visited an endemic region; in fact, the detection of even a single case of monkeypox in a place where the disease is not normally seen constitutes an outbreak.
Although the vast majority of cases are not related with travel from endemic areas, certain Member States are reporting modest numbers of cases among travellers from Nigeria. This is consistent with what has been seen in the past.
The sudden and unexpected appearance of monkeypox simultaneously in several non-endemic countries suggests that there may have been undetected transmission for some unknown period of time followed by recent amplifier events. This hypothesis is supported by the fact that the sudden and unexpected appearance of monkeypox was completely unexpected.
Given that this is the first time that a large number of monkeypox cases and clusters have been recorded concurrently in both non-endemic and endemic nations in vastly different WHO geographical zones, the World Health Organization has determined that the risk at the global level is moderate.
The WHO continues to receive up-to-date information on the situation in countries where the disease is endemic.
Description of the Outbreak
In 27 non-endemic countries in four WHO regions, WHO had been notified of 780 laboratory-confirmed cases as of June 2, 2022, under the International Health Regulations (IHR). Since the Disease Outbreak News of May 29th, when a total of 257 cases were recorded, there has been an increase of 523 laboratory confirmed cases (+203 percent). A monkeypox outbreak in non-endemic nations has resulted in no deaths as of 2 June 2022, while cases and deaths have been reported in endemic countries (see Table 2).
PCR experiments have yielded early results that place the monkeypox virus strains seen in Europe and other non-endemic regions in the West African clade, although more research is needed.
In non-endemic countries, WHO received reports or identifications of cases of monkeypox between May 13 and June 2, 2022 (Figure 1 and Table 1). Most instances (n=688; 88%) were found in the WHO European Region (20 Countries). More than 80% of confirmed cases have come from the Americas, 10% from the Eastern Mediterranean, and 3% from the Western Pacific.
The case count fluctuates when new information is gathered and WHO verifies the data in compliance with the standards of the IHR.
Confirmed instances have shown a wide range of clinical symptoms up until now. For the most part, the cases in this outbreak don’t exhibit the usual symptoms of monkeypox. So far in this outbreak, vaginal and peri-anal sores, fever, swelling lymph nodes, and pain while swallowing have all been reported as prevalent symptoms.
The local anogenital distribution of rash (with vesicular, pustular or ulcerated lesions) can sometimes emerge first without reliably spreading to other areas of the body, even though oral sores and fever and swollen lymph nodes are common features. Close physical contact during sexual interaction is often the likely route of transmission in cases when a genital or peri-anal rash first appears.
There have been reports of monkeypox instances where pustules begin before the onset of constitutional symptoms (such as a fever), as well as cases where lesions appear at distinct phases of development, both of which are unusual. Aside from patients who were hospitalised for the sole goal of being isolated, few other cases of hospitalisation were documented. Primary and secondary infections were among the complication-causing factors that necessitated in-patient care.
Not only does WHO continue to receive updates on current outbreaks of monkeypox in endemic countries in Africa through established surveillance procedures, but there have also been reports from non-endemic countries (Integrated Disease Surveillance and Response). A total of 1408 suspected and 44 confirmed cases, as well as 66 deaths, were recorded from seven endemic nations between January and June of this year (Table 2).
Cameroon, Central African Republic, Democratic Republic of Congo, Gabon, Ghana (only found in animals), Cote d’Ivoire, Liberia, Nigeria, Republic of the Congo, and Sierra Leone are among the nations where monkeypox is endemic. In the past, Benin and South Sudan have been recorded importers. Cameroon and Nigeria are currently reporting cases of the West African clade.
More monkeypox cases are expected as the outbreak advances and surveillance expands in endemic and non-endemic countries, according to the World Health Organisation.
Public Health Response
This monkeypox outbreak’s information exchange is supported by WHO. Many Member States have launched a comprehensive case finding, contact tracing, laboratory investigation, clinical management and isolation as well as execution of infection and prevention and control measures at the World Health Organization (WHO) and many Member States.
Attempts are being made to sequence the monkeypox virus’s deoxyribonucleic acid (DNA). Genome sequencing of the monkeypox virus has been reported in several European nations (Belgium; France; Germany; Israel; Italy; the Netherlands; Portugal; Slovenia; Spain; Switzerland; and the United States). Preliminary results from PCR testing suggest that the monkeypox virus genes found belong to the West African clade, although the inquiry is still underway.
Some Member States are 2022 Monkeypox Outbreak
To help Member States with surveillance, laboratory diagnosis and testing, case investigation and contact tracing, clinical care, vaccinations and immunisation, risk communication and community participation, interim advice is being created.
In the near future, WHO will publish interim recommendations on the clinical care and infection control of monkeypox, as well as on vaccinations and immunisation.
WHO Risk Management
Since several monkeypox cases and clusters have been recorded simultaneously in non-endemic and endemic nations in widely diverse WHO geographical zones, the worldwide public health risk is now assessed as moderate.
In the beginning, the majority of cases were found in men who self-identified as being part of a wider sexual network. Human-to-human transmission was facilitated by frequent meetings between people in close proximity and/or with physical contact, as evidenced by the abrupt appearance and large geographic spread of many cases that first appeared to be sporadic. If the virus continues to spread unnoticed, it could lead to additional outbreaks.
Furthermore, the true number of cases may be underestimated due to a lack of epidemiological and laboratory data. In part, this may be attributed to a lack of early clinical detection of an infection previously believed to occur mostly in West and Central Africa, insufficient surveillance, and a lack of widely available diagnostics in some countries Given the number of nations reporting monkeypox cases across various WHO regions, it is quite likely that the virus will spread to further countries.
During sex, close proximity or direct physical contact (such as face-to-face or skin-to-skin contact) with people who may have infectious lesions such as mucocutaneous ulcers, respiratory droplets (and possibly short-range aerosols) or contact with contaminated materials can result in human-to-human transmission (e.g., linens, bedding, electronics, clothing).
Public health risks are minor at present time, but this virus has the potential to become a widespread human disease if it takes advantage of the opportunity to establish itself in non-endemic nations. Infection prevention and control (IPC) procedures and suitable personal protective equipment (PPE) can potentially pose a risk to health professionals if they aren’t used properly.
Health care-associated illnesses have been identified in the past in both endemic and non-endemic areas, albeit no cases have been reported in the present outbreak. Children and immunocompromised individuals have a larger risk of serious illness and death than the general population, therefore spreading the vaccine to these populations could have a greater influence on their health.
According to the research, those with HIV who are on antiretrovirals and have a healthy immune system have not reported a more severe course; those who are not on treatment or are immunosuppressed may have a more severe course. Pregnancy-related monkeypox infection is unknown, but a small number of studies have shown that the foetus may suffer if infected.
The West African clade has been detected in all non-endemic countries where samples have been confirmed by PCR. West Africa (WA) and the Congo Basin (CB) are the only two regions where monkeypox is endemic. WA strains have been linked to lower overall mortality rates (3%), but the CB strains have been linked to more severe disease (CFRs of 1-10%) in African populations. These estimates are based on infections in a mainly younger population.
Cross-protection between smallpox and monkeypox has been demonstrated through vaccination. As a result of the cessation of smallpox vaccination programmes following the disease’s eradication and the subsequent disappearance of the original (first generation) smallpox vaccinations, only those under the age of 40 or 50 will enjoy immunity from smallpox immunisation. Additionally, it’s possible that the vaccine’s effectiveness has dwindled over time.
Vaccines for smallpox and monkeypox are being used in a restricted number of countries to protect close contacts from the disease. Smallpox vaccines have been demonstrated to protect against monkeypox, but a vaccine against monkeypox has also been licenced. The vaccinia virus strain serves as the basis for this vaccination (known generically as modified vaccinia Ankara Bavarian Nordic strain, or MVA-BN).
In Canada and the United States, this vaccine has been authorised for use in the prevention of monkeypox. This vaccine has been given the green light for smallpox prevention in the European Union. Recently, both the United States and the European Union approved an antiviral for the treatment of orthopoxviruses. UN specialists have met to assess the most recent data on smallpox and monkeypox vaccines, as well as to offer advice on their use.