Situation Report: Monkeypox

BY JOHN P. MAHER, MD, MPH

Situation Report as of early August, 2022

Caveat: This article is labeled as a “situation report (or “sit-rep”) for good reasons. When we started on it, we knew the topic, Monkeypox, was in its early phases of epidemiologic development, was dynamically changing day-by-day, and could have different outcomes depending on multiple variables. We did not realize, however, just how fast and how radically things could (and would) get out of hand, nor all the parallels with the very early days of the HIV/AIDS pandemic. And so, this is nowhere near the end of the story. Rather it is a report on the situation as we know it, in the last week of July while events continue to occur and be reported rapidly.

Despite the near universal concerns over the ongoing repetitive new global waves of SARS CoV-2, Mother Nature, aided by the never-ending activities of human nature, has tossed us another curve ball. This time in the form of another contagious viral disease known as Monkeypox. Monkeypox is not a new entity for us. Many of our readers will recall the 2003 outbreak which occurred in the US midwest after 800 African mammals, including infected rodents, were imported from Ghana for sale, and passed their infection on to “pet prairie dogs,” resulting in 47 known human cases spread out among 6 US states (IL, IN, KS, MO, OH, WI). This was the first time any human cases had been reported outside of Africa according to the CDC.

Until now, Monkeypox disease (hereinafter, MPX) had been considered a rare, tropical, viral zoonotic disease, caused by Monkeypox virus (MPXV), a virus from the same family as smallpox (genus: orthopoxvirus) but which is generally much less severe. The CDC website lists 12 separate orthopox viruses, including variola and vaccinia as well as several named for the specific mammals they target. Despite its name, monkeys are not considered the natural reservoir of MPX virus. The main reservoir is suspected to be local rodents, prompting some to conjecture that halting the “bushmeat” underground and gray market trade and consumption of wild animals might halt the ongoing exposures. Given their cultural and economic situations, that is unlikely to happen in Africa.

Poxviruses are described as brick or oval-shaped viruses with large double-stranded DNA genomes which tend to result in skin lesions such as nodules, pustules, and/or disseminated rash which, in MPX, is frequently described as “ulcerative lesions.”

Until the current outbreak (epidemic, now pandemic?) MPX had been considered rare except in Africa where it has persisted endemically in two virus forms (“clades”): the milder West African, or Nigerian, clade; and the Democratic Republic of Congo (DRC) clade which is the more severe form and carries a greater case fatality rate there (estimates vary from 3.7% up to 10%).

Little was heard about MPX for quite a while, despite a new outbreak in Nigeria in 2017 which got little world attention at the time despite the data showing over 440 suspected cases there spread among 30 of their states between September 2017 and May 2021. However, in July 2021, a US resident returning from Nigeria was hospitalized in Dallas, Texas, with MPX. This prompted a collaborative public health contact tracing effort by airlines, CDC, and state and local health officials to identify 200 of the patient’s fellow passengers from two flights, as possible contacts to the sick person. Around that same time, similar cases and response actions were happening in the UK, Israel, and Singapore. Officials were waking up to the fact that something was happening.

Still, the usual “keep calm and don’t create a panic” mentality continued in place, resulting in all the usual platitudes. Instead

of admitting they didn’t really know how this happened, or that there was insufficient information at that time to identify the method of exposure and transmission, the media and the public were basically reassured there was no danger, no need to worry, the disease is spread by exposure to rodents, it takes prolonged contact, not spread casually, it’s a mild disease, it will all be over shortly. It was reported that “people at risk for MPX are those who get bitten by an infected animal or have contact with the animal’s rash, blood, or body fluids or that it can also be transmitted personto-person through respiratory or direct contact, and contact with contaminated bedding or clothing.”

Not all of that has been definitively proven as yet.

As cases continued to increase in Africa, the US CDC issued an official Travel Alert on 9/30/21 regarding the DRC outbreak and at the same time the WHO reported there were over 8000 cases in Africa in 2021.

In November 2021, another US case was identified in a Maryland man returning from Nigeria. Then, in April 2022, a case was diagnosed in Massachusetts in a man returning from a trip to Canada. About that time, in England, a representative of the UK Health Security Agency (UKHSA) mentioned that “the high proportion of cases in the current outbreak in England that are gay or bisexual (51%) is highly suggestive of spread in sexual networks.” To anyone experienced in public health, the similar references to international travel should have been an early warning sign that these individual cases may have been “sentinel events.”

Case reports continued to come in and totals increased. Reports from various sources in different nations started to identify events which might now be labeled “super-spreader events,” e.g., international “raves” which were held in two European nations (Spain and Portugal), and a 4-day gay “fetish festival” held in Belgium in early May, 2022.

The nearly asymptotic case report curve (q.v.) has been visibly very impressive, but as with all early data needs to be evaluated carefully. It is not uncommon for such a trend to be seen early in the history of a new disease, as people become aware of the signs and symptoms, seek medical care, and get diagnosed, and doctors develop a higher index of suspicion watching out for such patients. One problem is whether these are all new cases, as opposed to old or ongoing cases just now getting identified and reported. Also, on a global scale, how many nations have the sophisticated health lab technology to distinguish MPX from varicella, measles, syphilis, etc.? Still the numbers, and the rate of increase must grab one’s attention both because of the numbers themselves, because they are multi-national, and because they increased by nearly 7-fold each month between May and July this year.

Two other aspects which need attention: there are reports of finding MPX virus in semen, saliva, and perianal tissues. No proof has been offered so far as we know, that these are live/active, infectious viruses, but the implications would be very important and need to be addressed. In addition, a small number of women, as well as a couple of babies, have been diagnosed with MPX, and at least one report has identified the environmental contamination by MPX virus in the homes/rooms of known patients. Again all these things need to be studied and answered.

At this point we leave the further issues of elucidation of treatment, prevention, which antivirals and vaccines are available and what should be the public health/governmental approach to outbreak control, to those better qualified and more up-to-date in the indications, side effects, and contra-indications of those approaches. Readers are referred to the appropriate professional and online resources for specifics. We will close, however, with two pieces of the latest “breaking news” on the topic: (a) the first arrived on Saturday, July 23rd, announcing the Biden Administration is reorganizing the federal health department to create an independent division that would lead the nation’s pandemic response, amid frustrations with the CDC — this 1000 person team known as Office of the Assistant Secretary for Preparedness and Response (ASPR), as a new separate division, will mobilize a coordinated national response more quickly and stably during future disasters and emergencies while equipping us with greater hiring and contracting capabilities.” (b) which arrived in our in-box early this afternoon (7/24/22), announcing that: At a 7/23 news conference held by WHO Director

General, Dr. Tedros Adhanom Ghebreyesus, held following a second meeting of their Emergency Committee under the International Health Regulations, at which he officially declared: “the global monkeypox outbreak represents a public health emergency of international concern” and announced a set of recommendations for 4 groups of member nations, varying somewhat depending on whether those groups had recent cases, active transmission (people-to-people or animalto-people), and/or the technological capacity to produce vaccines, antivirals, etc.

The transcript and full details of his announcement are available at https://WHO.int/director-general/speeches.