Australia, Canada, US, UK, and 9 Additional European Countries: More Than 140 Community-Based Monkeypox Cases
According to the UK Health Security Agency, US CDC, and press sources citing ministries of health, more than 140 cases of monkeypox (including > 75 laboratory-confirmed; at least 18 hospitalized [primarily for isolation]) with multiple instances of community-based transmission have been reported since May 6, 2022, in the countries listed below. Of the cases with available information, more than 100 cases are in males (including approximately 55 cases aged 20-55 years), and 1 suspected case has been reported in a female. Most cases have been detected through sexual health services and are among men who have sex with men (MSM). Most cases are mild and present with lesions on the genitalia or perigenital areas; additional symptoms include rash, fever, painful lymph nodes, and oral ulcers. Possible transmission between sexual partners may be occurring, due to contact during sex with infectious skin and mucosal (including oral) lesions. The West African strain has been detected among cases with available data (mild disease with a 1% fatality rate vs. 10% with the Congo strain). Investigation (including genetic sequencing) of possible linkage among the outbreaks is underway. A draft genome sequence from a confirmed Portuguese case indicates the virus (West African strain) is most closely related to viruses associated with the exportation of monkeypox from Nigeria to the UK, Israel, and Singapore during 2018-2019. A case reported in Belgium with travel history to Portugal has been linked to this case based on genomic sequencing.· Australia: 2 confirmed cases in Melbourne, Victoria State and Sydney, New South Wales State, both with travel history to Europe (including the UK)
· Belgium: 3 cases (including 1 confirmed) in Antwerp and Flemish Brabant provinces, Flemish Region; 1 case with travel history to Lisbon, Portugal
· Canada: 22 cases (including 2 confirmed) in Quebec Province (including in Montreal)
· Canary Islands: 2 suspected cases (including on Grand Canary Island)
· France: 1 confirmed case in Île-de-France Region
· Germany: 1 confirmed case in Bavaria State
· Italy: 3 confirmed cases in Rome, Lazio Region; 1 case with travel history to Canary Islands
· Netherlands: 1 confirmed case
· Portugal: 34 cases (including 23 confirmed), mainly in the Lisbon and Tagus Valley region, including the city of Lisbon
· Spain: 50 cases (including 30 confirmed), mainly in Madrid as well in 5 additional autonomous communities; many cases linked to an adult sauna (establishment popular with MSM)
· Sweden: 1 confirmed case in Stockholm County
· UK: 20 confirmed cases in England (including in London, Newcastle upon Tyne, and southeast England)
· US: 2 cases (including 1 confirmed) in Massachusetts (linked to several suspected cases from Quebec Province, Canada) and New York City
The incubation period is typically 6 to 16 days (up to 21 days). Typical symptoms include fever, headache, muscle aches, back pain, swollen lymph nodes, chills, fatigue, followed by a uniformly evolving blistering rash (in contrast to a varicella or syphilis rash which appears in various stages of development). The patient is no longer infectious after the scabs fall off, which may take several weeks. Genital lesions have previously been uncommon and reflect a unique aspect of this outbreak.
Vaccination of high-risk close contacts should be considered. Jynneos (live, attenuated, nonreplicating vaccinia vaccine; Bavarian Nordic A/S; branded as Imvanex and Imvamune in Europe and Canada, respectively) is US FDA approved for use in adults aged ≥ 18 years at high risk for monkeypox infection but not for prophylaxis. ACAM2000 (live replicating vaccinia-virus vaccine; Emergent BioSolutions) is approved for smallpox but not monkeypox prevention; it is likely effective against monkeypox. ACAM2000 presents considerable toxicity including risk of myocarditis. Neither vaccine is commercially available in any country; both are stocked in the US Strategic National Stockpile. Populations worldwide aged younger than 50 years no longer benefit from the cross-protective immunity against orthopoxvirus diseases provided by prior smallpox vaccination programs. In the UK, vaccination (unknown brand) has been offered to health care workers and others with possible exposure; Imvamune is being purchased by Spain. Treatment for monkeypox is supportive, but persons at risk for dehydration may need hospitalization. The antiviral tecovirimat (TPOXX) is FDA-approved for smallpox treatment, and brincidofovir and cidofovir are under evaluation for prophylaxis or treatment of monkeypox and could be considered for severe cases. Persons who may be at risk, particularly MSM and those who have had close contact to persons with monkeypox-compatible symptoms or skin lesions, should immediately contact their health care provider (who should have a low threshold for alerting public health authorities). Risk of transmission is high between persons with close contact and low in persons without close contact. No restrictions against travel are recommended. For more information, see Monkeypox.
