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2022–2023 mpox outbreak

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2022 monkeypox outbreak
  Endemic West African clade
  Endemic Congo Basin (Central African) clade
  Both clades recorded
  West African clade outbreak in 2022
DiseaseHuman monkeypox
Virus strainMonkeypox virus (MPV), West African clade, 2017–2019 outbreak subclade[1]
SourceTravel from Nigeria (presumed/hypothesis)[2][3]
Location22 countries (see § Cases per country)
First outbreakLondon, England
Date4 May 2022 – ongoing (2 years, 7 months, and 12 days)
Confirmed cases242
Suspected cases‡84
Severe casesAt least 31 hospitalised
Deaths
0
‡Suspected cases have not been confirmed by laboratory tests as being due to this strain, although some other strains may have been ruled out.

An ongoing outbreak of monkeypox was confirmed on 6 May 2022, beginning with a British resident who, after travelling to Nigeria (where the disease is endemic), presented symptoms consistent with monkeypox on 29 April 2022. The resident returned to the United Kingdom on 4 May, creating the country's index case of the outbreak.[4]

Monkeypox is a viral infection that manifests a week or two after exposure with fever and other non-specific symptoms, and then produces a rash that can last for a couple of weeks before usually clearing up.[4] Cases in children are more likely to be severe. [5]

The origin of several of the cases of monkeypox in the United Kingdom is unknown. Some monitors saw community transmission taking place in the London area as of mid-May.[6] Further initial cases of the virus were reported in North East and South East England,[7] as well as one in Scotland.[8] From 18 May onwards, cases were reported from an increasing number of countries and regions, predominantly in Europe, but also in North America, the Middle East and Australia.[9][10][11]

Background

These paragraphs are an excerpt from Monkeypox.

Mpox (/ˈɛmpɒks/, EM-poks; formerly known as monkeypox)[12] is an infectious viral disease that can occur in humans and other animals. Symptoms include a rash that forms blisters and then crusts over, fever, and swollen lymph nodes. The illness is usually mild, and most infected individuals recover within a few weeks without treatment. The time from exposure to the onset of symptoms ranges from three to seventeen days, and symptoms typically last from two to four weeks. However, cases may be severe, especially in children, pregnant women, or people with suppressed immune systems.[13][14][15]

The disease is caused by the monkeypox virus, a zoonotic virus in the genus Orthopoxvirus. The variola virus, which causes smallpox, is also in this genus.[16] Human-to-human transmission can occur through direct contact with infected skin or body fluids, including sexual contact.[16] People remain infectious from the onset of symptoms until all the lesions have scabbed and healed.[13] The virus may spread from infected animals through handling infected meat or via bites or scratches.[13] Diagnosis can be confirmed by polymerase chain reaction (PCR) testing a lesion for the virus's DNA.[16]

Vaccination is recommended for those at high risk of infection.[16] No vaccine has been developed specifically against mpox, but smallpox vaccines have been found to be effective.[17] There is no specific treatment for the disease, so the aim of treatment is to manage the symptoms and prevent complications.[16][18] Antiviral drugs such as tecovirimat can be used to treat mpox,[16] although their effectiveness has not been proved.[19]

This outbreak is of the West African clade, which has a reported case fatality rate of 1% according to the World Health Organization.[20]

Monkeypox is endemic to West and Central Africa.[21][22] Prior to the 2022 outbreak, the United Kingdom had recorded only seven previous cases of monkeypox,[23] all of which were imported cases from Africa or healthcare workers involved in their treatment. The first three such cases were in 2018,[23] followed by a further case in 2019[24] and three more in 2021.[25] The only major monkeypox outbreak to be recorded in a Western country prior to 2022 was the 2003 Midwest monkeypox outbreak in the United States. That one did not feature community transmission.[26][27]

According to David Heymann, an advisor for the World Health Organization, the leading theory of how the outbreak started is transmission during sexual intercourse of gay and bisexual men at two raves in Belgium and Spain.[28]

Initially reported cases in United Kingdom

Guy's Hospital, where the April case was hospitalised
Stages of monkeypox lesion development

In early May 2022, the case was reported of a British resident who travelled to Lagos and Delta State in Nigeria,[29] in areas where monkeypox is considered to be an endemic disease. The patient developed symptoms of monkeypox, including a rash, on 29 April while still in Nigeria. They subsequently flew back to the United Kingdom, arriving on 4 May.[23]

They presented to hospital later the same day. Monkeypox infection was immediately suspected, and the patient was hospitalised at Guy's Hospital[23] and isolated, then tested positive for the virus on 6 May.[29] Testing of patient swab samples by polymerase chain reaction revealed the outbreak to be of the West African clade of monkeypox, which is the less deadly of the two known monkeypox variants with a case fatality rate of around 1%.[29]

Extensive contact tracing of people who had been in contact with the index case both on the international flight from Nigeria to the United Kingdom and within the country following their arrival was carried out, with potential contacts advised to remain aware of the symptoms of monkeypox and immediately isolate if any were to develop within 21 days of the contact event.[29] Following this contact tracing effort, the World Health Organization (WHO) considered further transmission of the virus within the United Kingdom to be of "minimal" risk.[29]

Contact tracing in response to the case was extended to Scotland on 14 May according to Public Health Scotland. A "small number" of people in Scotland were ordered to self-isolate following close contact with the person initially reported to have been infected, although overall risk to the general public remained "very low".[23]

Two new cases of monkeypox were confirmed by the UK Health Security Agency (UKHSA) on 12 May, both of which were in London.[30] These two lived together in the same household, with no known link between either of them and either the index case or travel to endemic regions. One of the new cases was hospitalised at St Mary's Hospital, while the other case with milder symptoms was said to be self-isolating at home.[30]

Four cases of monkeypox were confirmed by the UKHSA on 17 May, in three Londoners and a person in North East England who had previously travelled to London.[31] None of these new cases had any known contact history with the previous three confirmed cases, suggesting that wider community transmission of the virus was now underway in the London area. The UKHSA stated that the risk to the general public remained "very low".[31][6] Patients with active monkeypox infection were confirmed to be hospitalised at the Royal Victoria Infirmary in Newcastle upon Tyne and at the Royal Free Hospital and Guy's Hospital in London.[31]

Multi-country outbreak

On 18 May in Portugal, 14 cases of monkeypox were reported by health authorities out of total of 20 suspected cases. Two samples' test results were pending.[32] In Spain, there are seven confirmed cases as of 18 May.[33] On the same day, the United States confirmed its first 2022 case of monkeypox and Canada reported 13 suspected cases.[34][35]

On 19 May, Sweden and Belgium reported their first cases of monkeypox,[36][37] while Italy confirmed its first case in a traveller who had arrived from the Canary Islands.[38] A suspected case was reported in France.[39] A genomic analysis conducted on a case in Portugal places the virus infecting that patient in the West African clade, finding it most closely related to viruses associated with cases exported from Nigeria in 2018 and 2019.[40] Current sequencing error prevents exact placement of the virus within the group of these Nigerian viruses.[1]

Following the detection of a case in Massachusetts the previous day, the United States on 19 May placed a $119 million order with Bavarian Nordic, with an option to buy $180 million more, for up to 13 million vaccines against smallpox.[41] On 20 May, the US Department of Health and Human Services said the order was part of a standard preparedness effort and not a response to recent events. A spokesperson said, "BARDA has worked with industry to develop and purchase vaccines and treatments for a potential smallpox emergency, some of which may also be used to respond to monkeypox."[42] Separately, Bavarian Nordic stated an unidentified European country had placed an order for "Imvanex" vaccines in response to the monkeypox outbreak.[42]

On 20 May, Australia reported its first suspected case, in a man who fell ill after returning from travel in the UK.[43] A second case was also confirmed on the same day. The cases were identified as being in Melbourne and Sydney. Both recently returned from travel in Europe and the UK.[44] Germany, France and the Netherlands confirmed their first cases on the same day.[45][46][47] The three confirmed cases in Belgium were linked to the Darklands fetish festival in Antwerp.[48] Also on 20 May, Belgium became the first country to introduce a mandatory quarantine for people infected with monkeypox (21 days). Close contacts of infected people do not have to self-isolate, but are told to stay vigilant.[49][50]

Also on 20 May, Health Secretary of the UK Sajid Javid reported that another eleven cases had been confirmed, bringing the total in the country to twenty. A representative of the UKHSA urged watchfulness among men who have sex with men, who have made up a disproportionate number of cases in the UK and Europe.[51] The UK Health Security Agency (UKHSA) advised people who have had close contact with a person infected with monkeypox to self-isolate for 21 days. Self-isolation is not mandatory.[52]

On 21 May, Switzerland and Israel confirmed their first cases.[53][10] Spain reported 23 new cases linked to a gay bathhouse in Madrid, bringing the country's total to 30.[54] Several infections may also be linked to the Maspalomas Gay Pride Festival in Gran Canaria.[55][56] On the same date, Norwegian authorities initiated contact tracing after a person who had visited Norway earlier in the month had tested positive back in his home country (an undisclosed European country).[57][58] A suspected case was reported in Greece, but it was later confirmed to be chickenpox.[59]

On 22 May, Austria confirmed its first case.[60]

On 23 May, Denmark reported its first case in a man who had returned home from the Canary Islands,[61][62] and the following day the second case was confirmed in a person that also had returned home from Spain.[63] Dr. Sue Hopkins, the chief medical adviser for the UK Health Security Agency, announced that 37 new monkeypox cases had been confirmed, more than doubling the total confirmed in the UK to 57 cases.[64] In Canada, Quebec announced a total of 15 confirmed cases in the province.[65]

On 24 May, the first case of monkeypox has been confirmed in the Czech Republic in a person who was at a music festival in Belgium at the beginning of May.[66][67] On the same day, United Arab Emirates reported its first case, detected in a 29-year-old female visitor from West Africa.[68] Also on that day, Slovenia confirmed its first case, a man from Canary Islands,[69] while Switzerland reported its second case, a female in the Canton of Geneva.[70]

Research

Transmission changes

This outbreak was the first time that community transmission of monkeypox was recorded outside of Africa, and the first known cases in, and of transmission between, men who have sex with men (MSM).[71]

In Nature, Anne Rimoin and Raina MacIntyre speculate that the higher percentage of MSM affected is a result of coincidental introduction to the community and then sexual activity constituting "close contact" rather than the virus itself becoming sexually transmitted.[72]

The European Centre for Disease Prevention and Control (ECDC) states that "The monkeypox virus is considered to have moderate transmissibility among humans and can be transmitted through droplets and/or contact with infected lesions. Transmission between sexual partners, due to intimate contact during sex with infectious skin lesions seems the likely mode of transmission among MSM."[71] The ECDC rates likelihood of transmission due to close contact, including sexual contact, as "high", but, without close contact, considers the risk to the wider public "low".[71]

Genomic changes

The genomic sequence of the virus associated with this outbreak was first published on 19 May by Portuguese researchers.[73] The research confirmed that the monkeypox virus was of the West African clade, related to other previous international outbreaks in 2018–19.[74] Further investigation of the genomic sequence may yield more information regarding "epidemiology, sources of infection, and transmission patterns."[73]

Genomic sequencing of a Belgian patient with monkeypox indicated similar results.[75] Further genome data and analysis is expected.[74]

Vaccination

The smallpox vaccine Imvanex (Jynneos) is 85% effective against monkeypox.[76] The UKHSA has begun using Imvanex as post-exposure prophylaxis for close contacts of known cases.[77]

Responses

UN agencies

On 20 May, the World Health Organization (WHO) convened an emergency meeting of independent advisers to discuss the outbreak and assess the threat level.[78] Its European chief, Hans Kluge, expressed concern that infections could accelerate in Europe as people gather for parties and festivals over the summer. The WHO is expected to provide an update on sequencing of the virus genome from different cases to determine the cause.[79]

UNAIDS urged communicators to avoid stigma by taking an evidence-based approach, reiterated that the disease can affect anyone and that risk is by no means limited to men who have sex with men.[80]

Nations

  •  Bangladesh: The Directorate General of Health Services (DGHS) has issued warnings at every port in the country to prevent the spread of monkeypox. According to the Directorate spokesperson Nazmul Islam, the DGHS has asked all air, land and sea ports to be alert. Suspected cases are instructed to be sent to an infectious disease hospital and kept in isolation.[81][82]
  •  Belgium: The Risk Assessment Group (RAG) and health authorities declared that those infected with monkeypox must self-isolate for 21 days.[83]
  •  Brazil: The Brazilian Ministry of Health started monitoring the Brazilian patient in Germany, requesting more information from the German Ministry of Health. It also created groups of biologists to monitor monkeys and medical groups to monitor possible cases.[84] The Minister of Health of Brazil, Marcelo Queiroga and his entourage are in Portugal to reach an agreement on medical exchanges in public health and bioethics. After the trip to Portugal, the minister will participate in the 75th World Health Assembly, thus having his return monitored by the proximity to Europe.[85]
  •  Fiji: The country's Centre for Disease Control and Border Health Protection Unit are monitoring the situation. The Ministry of Health has put in place infection prevention protocols at the border.[86][87]
  •  Germany: Fabian Leendertz of the Robert Koch Institute described the outbreak as an epidemic that won't last long: "The cases can be well isolated via contact tracing and there are also drugs and effective vaccines that can be used if necessary."[79]
  •  India: Union Health Minister Mansukh Mandaviya directed the National Centre for Disease Control and the ICMR to keep a close watch and monitor the situation. The Union Health Ministry has also directed airport and port health officers to be vigilant, according to official sources. They have been instructed to isolate and send samples to the National Institute of Virology of any sick passenger with a travel history to infected countries.[88]
  •  Ireland: The Health Service Executive (HSE) has set up a multidisciplinary incident management team to prepare for the possible arrival of monkeypox, and infectious diseases experts are on alert for patients with symptoms of the virus.[89]
  •  Luxembourg: On 21 May, the Ministry of Health said that they are monitoring the situation with its European partners. All suspected cases and persons with symptoms indicative of monkeypox are instructed to contact the National Infectious Diseases Department of the HLC and refrain from close contact activities until the infection has resolved.[90]
  •  Philippines: Health Secretary Francisco Duque III said that the Philippines was intensifying its border control measures amid the threat of the monkeypox virus.[91]
  •  United Kingdom: On 22 May, Education Secretary Nadhim Zahawi said "we're taking it very, very seriously" and that the UK government had already started purchasing smallpox vaccines.[92]
  •  United States: On 22 May, President Joe Biden commented "they haven't told me the level of exposure yet but it is something that everybody should be concerned about". National security advisor Jake Sullivan told reporters the US has a vaccine that is relevant to treating monkeypox.[93] On 24 May, Centers for Disease Control (CDC) Deputy Director Jennifer McQuiston confirmed the United States is in the process of releasing some of their Jynneos monkeypox vaccine supply from their Strategic National Stockpile for people who are "high-risk".[94] On 25 May, the CDC issued an alert for gay and bisexual men to be especially vigilant.[95][96]

Non-governmental organisations

The Terrence Higgins Trust and British Association for Sexual Health and HIV (BASHH) expressed concern about the impact on sexual health services in the United Kingdom.[97][98] Misinformation spread online,[99] including on Weibo.[100]

Cases per country

Cases per country and territory (outside of endemic African countries)
Country Confirmed Suspected Total Last update First confirmed case
 Argentina 1 — 1 23 May 2022[101] 23 May 2022[102]
 Australia 2 — 2 20 May 2022[11] 20 May 2022[25]
 Austria 1 — 1 22 May 2022[60][103] 22 May 2022[60]
 Belgium 6 1 7 25 May 2022[104] 19 May 2022[37]
 Canada 15 1 16 24 May 2022[105][106] 19 May 2022[107]
 Czech Republic 1 — 1 24 May 2022[108] 24 May 2022[108]
 Denmark 2 3 5 24 May 2022[109][110] 23 May 2022[62][111]
 Finland 1 — 1 25 May 2022[112] 25 May 2022[113]
 France 7 — 7 25 May 2022[114] 20 May 2022[46]
 Germany 10 — 10 25 May 2022[115][116] 20 May 2022[45]
 Israel 1 — 1 22 May 2022[117] 21 May 2022[10]
 Italy 6 2 8 24 May 2022[118][119] 19 May 2022[120]
 Morocco — 3 3 23 May 2022[121] —
 Netherlands 12 — 12 25 May 2022[122] 20 May 2022[47]
 Portugal 49 — 49 25 May 2022[123] 18 May 2022[32]
 Slovenia 2 — 2 25 May 2022[124][125] 24 May 2022[125][126]
 Spain 51 68 119 25 May 2022[127] 18 May 2022[128]
 Sweden 2 — 2 25 May 2022[129][130][131] 19 May 2022[130][131]
  Switzerland 2 — 2 24 May 2022[132] 21 May 2022[53][133]
 United Arab Emirates 1 — 1 24 May 2022[9] 24 May 2022[9][134]
 United Kingdom 78 — 78 25 May 2022[135] 6 May 2022[136]
 United States 2 6 8 24 May 2022[137][138][139] 18 May 2022[140][141]
Total 246 84 330

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