Monkeypox Spread
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Monkeypox Spread:
The 2022 monkeypox outbreak began in May and was a significant global health event. The first confirmed case was traced to an individual with travel links to Nigeria, where the disease is endemic, and was detected on May 6, 2022, in the United Kingdom. This initial case sparked concerns as it began an outbreak spanning several countries and continents.
From May 18 onward, monkeypox cases were reported in multiple regions, including Europe, North and South America, Asia, Africa, and Australia. Previously confined to certain areas of Central and West Africa, the disease spread more widely during this outbreak, with cases detected in areas where the virus was not commonly seen.
By July 15, 12,590 confirmed cases had been recorded, with 12 deaths recorded. The World Health Organization (WHO) acknowledged the growing concern but, as of June 27, did not declare it a Public Health Emergency of International Concern (PHEIC). Instead, the WHO categorized the situation as an “evolving health threat,” suggesting the outbreak was being closely monitored but did not yet warrant the highest level of international health alert.
The spread of the virus sparked increased attention on public health measures, including tracking and managing close contacts. The global community began working together to contain the outbreak, with measures including vaccines and antiviral treatments being discussed and deployed.
The outbreak marked the first time the disease has spread widely outside Central and West Africa. Cases have mainly but not exclusively been identified amongst men who have sex with men (MSM). Still, health authorities emphasized that anyone can catch the disease, particularly if they have close contact with a symptomatic person. Initial WHO assessments expressed the expectation that the outbreak would be contained and have a low impact on the general population in affected countries. A more recent statement acknowledged that undetected transmission had occurred for some time and called for urgent action to reduce transmission.
Monkeypox is a viral infection that manifests a week or two after exposure to fever and other non-specific symptoms. It then produces a rash with blisters that can last for a couple of weeks before usually clearing up. In infections before the current outbreak, 1–3% of people with known diseases have died (without treatment). Cases in children are more likely to be severe.
Monkeypox is an infectious viral disease that can occur in humans and other animals. Symptoms include fever, swollen lymph nodes, and a rash that forms blisters and then crusts over. The time from exposure to onset of symptoms ranges from 5 to 21 days. The duration of symptoms is typically 2 to 4 weeks. There may be mild symptoms, but they may occur without known symptoms. The classic presentation of fever and muscle pains, followed by swollen glands with lesions at the same stage, is not expected in all outbreaks. Cases may be severe, especially in children, pregnant women, or people with suppressed immune systems.
There is no known cure. A study in 1988 found that the smallpox vaccine was around 85% protective in preventing infection in close contact and lessening the severity of the disease. A newer smallpox and monkeypox vaccine based on modified vaccinia Ankara has been approved but has limited availability. Other measures include regular hand washing and avoiding sick people and other animals. Antiviral drugs, including cidofovir and tecovirimat, vaccinia immune globulin, and the smallpox vaccine, may be used during outbreaks. The illness is usually mild, and most infected will recover within a few weeks without treatment. Estimates of the risk of death vary from 1% to 10%, although very few deaths as a consequence of monkeypox have been recorded since 2017.
Monkeypox is endemic to West and Central Africa. Before the 2022 outbreak, the United Kingdom had recorded only seven previous cases of monkeypox, all of which were imported issues from Africa or healthcare workers involved in their treatment. The first three cases were in 2018, followed by another point in 2019, and three more in 2021. The only major monkeypox outbreak recorded in a Western country before 2022 was the 2003 Midwest monkeypox outbreak in the United States. That one did not feature community transmission.
According to the World Health Organization, this outbreak occurred in West Africa. There is a reported case fatality rate of 1%. Portuguese researchers first published the genomic sequence of the virus associated with this outbreak on May 19. They confirmed that the monkeypox virus was of the West African cladeCladeated to other previous international epidemics in 2018–19.
Types of pox
There are two known subtypes of pox:
- Clade I is endemic to Central Africa and tends to cause more serious illness than Clade II. Recent outbreaks of CladeCladeve have been less deadly.
- Clade II is endemic to East Africa. There has been a global outbreak of clade II pox since 2022. It is less likely to be fatal than cladeCladehat. What are the symptoms of the pox?
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Symptoms of pox include:
- Rash, skin ulcers, or blisters.
- Fever.
- Swollen lymph nodes.
- Chills.
- Headache.
- Muscle aches.
- Fatigue.
Not everyone with pox develops all the symptoms. Different ways you might experience symptoms include:
- Only a rash (no other symptoms), or other symptoms developing later.
- Flu-like symptoms, then a rash. Some people don’t get a rash at all.
What does the pox rash look like?
The rash caused by pox can appear as sores on your mouth, face, hands, feet, penis, vagina, or anus (butthole). Some people have a widespread rash, but others only have a few bumps or blisters.
Mpox rash can go through several stages over two to four weeks:
- It may start as flat, red bumps. These can be painful.
- The bumps become raised.
- The bumps turn into blisters.
- The blisters fill with pus.
- The blisters crust over and fall off.
What causes mpox?
An infection with the monkeypox virus (Orthopoxvirus monkeypox) causes pox. Viruses are small pieces of genetic information in a protective coating. The virus that causes pox is a member of the genus Orthopoxvirus.
How do you get mpox?
Mpox can spread through:
- Direct contact with pox sores or scabs (from an animal or person).
- Contact with saliva (spit), respiratory secretions from your nose or mouth (mucus), blood, or other bodily fluids (from an animal or person).
- Contact with materials like clothing, bedding, and towels an infected person uses is dismal.
- Vertical transmission — from a pregnant person to their fetus during pregnancy or at birth.
Specific situations that can spread pox include:
- Close, intimate contact, like cuddling, kissing, or sex. Though less likely, it’s possible that you could spread pox by talking, sneezing, or coughing very close to others.
- Skin-to-skin contact sharing personal items, like towels, bedding, or sex toys.
- Bites or scratches from an infected animal.
- They are eating the meat of an infected animal.
What are the risk factors for pox?
Anyone can get mpox. The global outbreak appears to be disproportionately affecting men who have sex with men (MSM). On the other hand, in the Clade I outbreak in the Democratic Republic of Congo, children under 15 years old make up more than half the cases.
In the U.S., you might be at a higher risk of exposure if:
- Someone you’ve had sex within the past two weeks has been diagnosed with pox.
- You’ve had sex at a sex club, bathhouse, or another commercial sex venue in the past six months.
- You’ve had sex at an event or location where pox was spreading.
- You have a sex partner who’s been in any of the above situations.
- You’ve been diagnosed with one or more sexually transmitted infections (STIs) in the past six months. This includes acute HIV, gonorrhea, syphilis, chancroid, or chlamydia.
- You’ve had sex with more than one person in the past six months.
You might be more likely to get severely ill with pox if you:
- Have a weakened immune system, especially if HIV causes it.
- Have a history of eczema.
- Are pregnant.
Babies younger than 1 year old are also at a higher risk for severe illness.
What are the complications of pox?
Complications caused by pox can include:
- Bacterial infections can lead to sepsis.
- Loss of vision or eye damage from pox ocular infections.
- Myopericarditis (inflammation around your heart).
- Encephalitis (inflammation in your brain).
- Pneumonia.
- Respiratory distress (extreme difficulty breathing and getting oxygen to your body).
- Severe scarring.
The 2022 outbreak has a different spread pattern than prior monkeypox outbreaks outside Africa. Genetic evidence suggests the outbreak likely started in Nigeria. Given the unusually high frequency of human-to-human transmission observed in this event and the probable community transmission without a history of traveling to endemic areas, the spread of the virus through close contact is more likely, with a message during sexual activities being the most common route. Most cases have been in men. A significant proportion of cases, although not all, are in men who have sex with men (MSM), notably in Canada, Spain, and the UK, with many cases diagnosed in sexual health clinics. Cases are primarily in young and middle-aged men. This points to transmission due to close contact during sex as one transmission route. The European Centre for Disease Prevention and Control (ECDC) considers the monkeypox virus moderately transmissible among humans. According to the center, the most common transmission among MSM who contracted the virus is likely through sexual activity due to intimate contact with infected skin lesions. The ECDC rates the likelihood of information due to close contact, including sexual contact, as “high,” but without close contact, the possibility of communication between individuals is considered low. In Nature, Anne Rimoin and Raina MacIntyre speculate that the higher percentage of MSM affected is a result of a coincidental introduction to the community and then sexual activity constituting “close contact” rather than the virus itself becoming sexually transmitted. Monkeypox is not primarily a sexually transmitted disease.
On May 23, David Heymann, an advisor for the World Health Organization, said that the plausible theory of how the outbreak started was transmitted during sexual intercourse of gay and bisexual men at two raves in Belgium and Spain. On May 25, The Guardian stated that many scientists suspect the disease was circulating in the UK and Europe before reaching the MSM community, possibly misdiagnosed or detected only in isolated cases; four cases were diagnosed in 2018 and 2019, all in individuals recently arrived from Nigeria.
The UK Human Animal Infections and Risk Surveillance (HAIRS) group warned that the virus could become endemic in wildlife.
Smallpox vaccines containing vaccinia, such as Imvanex (Jynneos), can provide around 85% effectiveness against monkeypox. This protection level is calculated from studies using smallpox vaccines tested in late 1980 in Africa. The UKHSA has begun using Imvanex as post-exposure prophylaxis for close contact with known cases. According to the CDC, the vaccination with Jynneos/Imvanex is “[a]dministered as two subcutaneous injections four weeks apart.”
On May 25, disease experts from the NICD in South Africa said they saw no need for mass vaccination because they believe cases will not explode as they did in the COVID-19 pandemic.
In reaction to the current outbreak of monkeypox, several countries have stated they are buying vaccines and releasing vaccines from national stockpiles for use in the episode. There is a new concern about a vaccine shortage as the demand exceeds the supply. In May 2022, the US, Spain, Germany, and the UK announced smallpox vaccine purchases.
On May 24, Centers for Disease Control (CDC) Deputy Director Jennifer McQuiston confirmed the United States is releasing some of their Jynneos vaccine supply from their Strategic National Stockpile for people who are “high-risk.”
On June 23, the New York City Department of Health announced a clinic at the Chelsea Sexual Health Clinic to offer the two-dose JYNNEOS vaccine to “…all gay, bisexual, and other men who have sex with men (cisgender or transgender) ages 18 and older who have had multiple or anonymous sex partners in the last 14 days.”
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