Outbreaks of monkeypox in several countries in non-endemic countries

 

monkeypox

Since 13 May 2022 12 non-MPV endemic Member States in three WHO regions have reported monkeypox cases to WHO. Epidemiological investigations are ongoing but the cases reported to date have no established travel links to endemic areas. Based on the current Available information cases are primarily but not limited to found among men who have sex with men (MSM) seeking treatment in primary care and sexual health clinics.

The purpose of this Disease Outbreak News is to raise awareness inform preparedness and response efforts and provide technical guidance for immediate recommended actions.

The situation is changing and WHO expects to detect more monkeypox cases as surveillance expands in non-endemic countries. Immediate action is focused on providing accurate information to those who may be most vulnerable to monkeypox to stop further spread. current Available evidence suggests that those at highest risk are those who had close physical contact with a monkeypox patient at the time of symptoms. WHO is also working to provide guidance to protect frontline health care providers and other health workers who may be at risk such as cleaner. WHO will provide more technical advice in the coming days.

Description of the outbreak

As of 13:00 on 21 May 92 laboratory-confirmed and 28 suspected monkeypox cases under investigation were reported to WHO from 12 Member States in the three WHO regions that are not circulating monkeypox virus ( Table 1 Figure 1). To date no related deaths have been reported.

Table 1.Monkeypox cases reported to WHO in non-endemic countries between 13-21 May 2022 at 13:00

Figure 1. Geographic distribution of confirmed and suspected cases of non-endemic monkeypox between May 13 and 21 2022 at 13:00.

To date reported cases have no travel links to endemic areas. Based on currently available information cases are primarily but not exclusively found among men who have sex with men (MSM) seeking care in primary care and sexual health clinics.

All samples confirmed by PCR to date have been identified as infected with the West African clade. Genome sequences of swab samples from confirmed cases in Portugal indicate that the monkeypox virus responsible for the current outbreak is related to an export from Nigeria to 2018 and 2019 UK Israel and Singapore.

The discovery of confirmed and suspected cases of monkeypox with no direct travel links to endemic areas is a highly unusual event. Surveillance in non-endemic areas has so far been limited but is now expanding. WHO expects to report more cases in non-endemic areas. Available information suggests that human-to-human transmission is occurring between people who have had close physical contact with symptomatic cases.

In addition to this new outbreak WHO continues to receive updates on the status of ongoing monkeypox case reporting through established surveillance mechanisms (Integrated Disease Surveillance and Response) for cases in endemic countries[1] summarized in Table 2.

[1] Monkeypox endemic countries are: Benin Cameroon Central African Republic Democratic Republic of Congo Gabon Ghana (found in animals only) Côte d'Ivoire Liberia Nigeria Republic of Congo Sierra Leone and South Sudan.

Table 2. Monkeypox cases in endemic countries between December 15 2021 and May 1 2022

For additional information seeWHO AFRO Weekly BulletinAbout outbreaks and other emergencies.

Epidemiology of the disease

Monkeypox is a viral zoonotic disease (a virus that spreads from animals to humans) with symptoms very similar to those seen in the past in smallpox patients although it is less severe clinically. It is caused by a monkeypox virus belonging to the genus Orthopoxvirus of the Poxviridae family. Have Two clades of monkeypox viruses: the West African clade and the Congo Basin (Central Africa) clade. The name monkeypox stems from the initial discovery of the virus in monkeys by a Danish laboratory in 1958. First human case identified in a child in the Democratic Republic of Congo 1970.

Monkeypox virus is transmitted from one person to another through close contact with foci of body fluids respiratory droplets and contaminated materials such as bedding. The incubation period for monkeypox is usually 6 to 13 days but it can be 5 to 21 days.

Various animals have been established to be susceptible to monkeypox virus. The natural history of monkeypox virus remains uncertain and further research is needed to determine the exact host and how the virus maintains circulation in nature. eating undercooked meat Other animal products from infected animals are a possible risk factor.

Monkeypox is usually self-limiting but can be severe in some individuals such as children pregnant women or people who are immunosuppressed due to other medical conditions. Human infection of the West African clade appears to cause less severe disease compared to the Congo Basin clade of infected cases The mortality rate was 3.6% compared with 10.6% in the Congo Basin branch.

It is possible that additional cases and further transmission will be detected in countries where cases are currently being reported and in other Member States. Any patient with suspected monkeypox should be investigated and if confirmed to be isolated until their lesions have scabbed the scab has fallen off and a new layer has formed A layer of skin has formed underneath.

Countries should be wary of signs associated with patients developing atypical rashes that progress in successive stages - macules papules vesicles pustules crusts at the same stage of development on all affected areas of the body - which may be associated with fever related Swollen lymph nodes back pain and muscle soreness. These individuals may present in a variety of community and medical settings including but not limited to primary care fever clinics sexual health services infectious disease units obstetrics urology emergency departments and dermatology. Clinic. Raising awareness among potentially affected communities as well as health care providers and laboratory staff is critical to identifying and preventing further secondary cases and effectively managing the current outbreak.

Considerations related to monitoring and reporting

In the current situation the primary goal of monkeypox surveillance and case investigation is to identify clusters of cases and sources of infection as quickly as possible to provide optimal clinical care to isolate cases to prevent further spread Identify and manage contacts And develop effective control and prevention methods based on the most common transmission routes.

In non-endemic countries one case is considered an outbreak. Because of the public health risks associated with a single monkeypox case clinicians should immediately report suspected cases to national or local public health authorities regardless of whether they are also exploring other potential diagnosis. Cases should be reported immediately according to the above case definitions or country-tailored case definitions. According to the International Health Regulations (IHR 2005) suspected and confirmed cases should be reported immediately to WHO through the IHR National Focal Point (NFP).

Countries should be alert for signs of unusual fever-related rash vesicular or pustular lesions or lymphadenopathy in a range of community and health care settings (including but not limited to primary care fever clinics sexual health services) Infectious Diseases Obstetrics and Dermatology Clinic. Surveillance for rash-like illness should be enhanced and guidance provided for collecting skin samples for confirmatory testing.

Reporting

Case reports should include at least the following information: Date of report; place of report; name age gender residence; date of first onset of symptoms; recent travel history; recent exposure to probable or confirmed cases; Confirmed case (if relevant); recent medical history of multiple or anonymous sexual partners; smallpox vaccination status; presence of rash; presence of other clinical signs or symptoms according to case definition; date of confirmation (when completed); method of confirmation (when completed); Genome Characterization (if any); other relevant clinical or laboratory findings especially to exclude common causes of rash based on case definitions; whether or not to be hospitalized; date of hospitalization (if completed); and results at the time of reporting.

During human monkeypox outbreaks close physical contact with an infected person is the most important risk factor for monkeypox virus infection. If monkeypox is suspected the investigation should include (i) clinical examination of the patient using appropriate infection prevention and control (IPC) Measures (ii) ask patients about possible sources of infection and the presence of similar illnesses in the patient's community and contacts and (iii) safely collect and send specimens for monkeypox laboratory testing. Include the minimum data to capture under "Reports" above. Exposure investigations should cover the period from 5 to 21 days prior to the onset of symptoms. Any suspected monkeypox patient should be quarantined during the presumed and known infectious period i.e the prodromal and rash phases of the disease respectively. Laboratory confirmation of suspected cases is important but should not delay implementation of public health action. Further investigation should be conducted into the patient's community or contacts for similar illnesses (also known as "reverse contacts") track").

Retrospective cases identified by active searches may no longer have clinical symptoms of monkeypox (recovered from acute illness) but may develop scarring and other sequelae. In addition to active cases it is important to collect epidemiological information from retrospective cases. Retrospective cases cannot be laboratory confirmed; however sera from retrospective cases can be collected and tested for anti-orthopoxvirus antibodies to help triage the cases.

Samples collected from suspected monkeypox patients or from animals suspected of being infected with monkeypox virus should be handled safely by trained staff in appropriately equipped laboratories. Strict compliance with national and international regulations on the transport of infectious substances during transport Samples are packaged and shipped to the testing laboratory. Careful planning is required to take into account the testing capacity of national laboratories. Clinical laboratories should be notified in advance of samples submitted from persons with suspected or confirmed monkeypox so that they can Minimize risk to laboratory staff and safely perform laboratory tests critical to clinical care where appropriate.

Contact tracing is a key public health measure to control the spread of infectious pathogens such as monkeypox virus. It can interrupt transmission and can also help people at higher risk for serious illness identify their exposure more quickly so their Health conditions can be monitored and they can seek medical attention sooner if symptoms develop. In the current situation contact identification and contact tracing should begin as soon as a suspected case is identified. Case patients should be interviewed for name and contact details information on all such persons. Contacts should be notified within 24 hours of identification.

A contact is defined as a person who has been in contact with a probable or confirmed monkeypox case with one or more of the following during the period from the onset of the first symptoms of the source case until all scabs have fallen off:

• Face-to-face contact (including healthcare workers without appropriate PPE)
• direct physical contact including sexual contact
• contact with contaminated materials such as clothing or bedding

Cases can be prompted to identify contacts in a variety of contexts including home workplace school/nursery sexual exposure healthcare house of worship transportation sports social gatherings and any other recalled interactions. Time sheet passenger list etc. can be used further Identify contacts.

Contacts should be monitored for symptoms/signs at least daily for 21 days from the time of last exposure to the patient or its contaminated material during infection. Signs/symptoms of concern include headache fever chills sore throat discomfort fatigue rash and Swollen lymph nodes. Contacts should have their temperature monitored twice a day. Asymptomatic contacts should not donate blood cells tissues organs breast milk or semen during symptom monitoring. Asymptomatic contacts can continue daily activities such as going to work and attending School (i.e no quarantine required) but should stay close to home during surveillance. However it may be prudent to exclude preschoolers from daycare or other group settings.

Surveillance options for public health authorities depend on available resources. Contacts can be passively or directly monitored.

In passive surveillance identified contacts are provided with information about signs/symptoms to monitor permitted activities and how to contact public health if signs/symptoms develop.

Active surveillance is when public health officials are responsible for checking at least once a day for self-reported signs/symptoms of the person being monitored.

Direct surveillance is a variant of active surveillance that involves at least daily physical visits or visual inspection via video for signs of disease.

Contacts with initial signs/symptoms other than rash should be isolated and closely observed for signs of rash over the next 7 days. If no rash develops contacts can resume temperature monitoring for the remainder of the 21 days. If a contact develops a rash they need Isolation was assessed as a suspected case and specimens were collected for laboratory analysis to detect monkeypox.

Monitoring exposed health workers and caregivers

Any health worker or family member who has cared for someone with probable or confirmed monkeypox should be alert for the development of symptoms that may suggest monkeypox infection especially within 21 days of the date of last care. Health workers should notify infection control Guiding occupational health and public health departments to conduct medical evaluations.

Health workers who have unprotected exposure (i.e not wearing appropriate personal protective equipment) to monkeypox patients or potentially contaminated materials need not be excluded from work if they are asymptomatic but should be actively monitored for symptoms including Measuring body temperature At least twice a day for 21 days after exposure. A health worker should be interviewed for evidence of any of the above relevant signs/symptoms before going to work each day.

Health care workers who care for or otherwise have direct or indirect exposure to monkeypox patients while adhering to recommended IPC measures may conduct self-monitoring or active surveillance at the discretion of local public health authorities.

Some countries may consider post-exposure vaccination (preferably within four days of exposure) of high-risk contacts (eg health workers including laboratory personnel).

Key information includes the following:

Prevention - People who have direct contact (including sexual contact) with an infected person can become infected with monkeypox. Measures to protect yourself include avoiding skin-to-skin or face-to-face contact with anyone with symptoms, practicing safe sex, keeping hands clean with soap and water or alcohol-based hand sanitizer, and practicing respiratory etiquette.

Testing and Treatment - If people develop a rash with a fever, or feel unwell or sick, they should contact their doctor and get tested for monkeypox. If someone is suspected or confirmed to have monkeypox, they should be isolated until the scabs fall off, and sexual activity, including oral sex, should be prohibited. During this time, patients can receive supportive care to relieve monkeypox symptoms. Anyone caring for someone with monkeypox should take appropriate personal protective measures, including wearing a mask and cleaning touched objects and surfaces.

Reporting - Any rashes that develop during travel or upon return should be reported to a doctor immediately, including information on any recent travel, sexual history, and smallpox vaccination history. Residents and travelers to monkeypox endemic countries should avoid contact with sick mammals such as rodents, marsupials, non-human primates (dead or alive) that may carry monkeypox virus, and should avoid eating or handling game (game).

Considerations for large gatherings

Media concerns have been raised about the spread of the monkeypox virus at large gatherings. Large gatherings can provide an enabling environment for monkeypox virus transmission because they involve close, prolonged, and frequent human-to-human interactions, which in turn expose participants to lesions, body fluids, respiratory droplets, and contaminated Material.

While the exact transmission mechanism of the current monkeypox outbreak is still under investigation and may differ from SARS-CoV-2, it is important to remember that the general precautions recommended for COVID-19 are also designed to be as protective as possible. Avoid the spread of monkeypox virus.

Additionally, anyone who meets the above definition of a suspected, probable, and confirmed case should not have close contact with others or participate in large gatherings.

WHO is closely monitoring the current monkeypox outbreak. While no specific action is currently required regarding holding, postponing or canceling rallies in areas where monkeypox cases have been identified, information may be shared with potential rally attendees to enable them to make informed decisions.

Considerations for Clinical Management and Healthcare Infection Prevention and Control

Health care workers caring for patients with suspected or confirmed monkeypox should use standard, contact, and droplet precautions. These precautions apply to all healthcare settings, including outpatient services and hospitals. Standard precautions include strict adherence to hand hygiene, proper disposal of contaminated medical equipment, clothing, waste, and cleaning and disinfection of surrounding surfaces.

It is recommended that suspected or confirmed cases be promptly isolated in a well-ventilated single room with a separate toilet and staff. In the absence of single rooms, cohorts (confirmed vs. confirmed, suspected vs. suspected) can be implemented, ensuring a minimum distance of 1 meter between patients. Recommended personal protective equipment (PPE) includes gloves, gowns, medical masks, and goggles - goggles or face shields . Patients should also be instructed to wear medical masks when in close contact (below 1m) with medical staff or other patients, if they can tolerate it. Additionally, bandages, sheets, or gowns can be used to cover the lesion to minimize potential contact with the lesion. PPE should be discarded before leaving the isolation area where the patient was admitted.

If an aerosol-generating procedure (AGP) is required for any reason (eg, aspiration or open aspiration of an airway sample, bronchoscopy, intubation, CPR) and cannot be postponed, a ventilator must be used ( FFP2 or EN-certified equivalent procedure or US NIOSH-certified N95) is used by healthcare workers instead of medical masks.

Isolation and transmission-based precautions should continue until symptoms resolve (including shedding and healing of rashes and scabs).

The use of drug countermeasures including specific antiviral drugs (eg, tecovir dipivoxil, which is approved for monkeypox but not yet widely used) can be considered part of a research protocol or a compassionate use protocol, especially for those who develop People with severe symptoms and with or at risk of adverse outcomes (such as those with immunosuppression). A monkeypox vaccine that is not yet widely available has recently been approved. Some countries may have smallpox vaccine products that can be considered based on national guidelines. Depending on the country, any requirements for vaccine products may be served by a limited number of national authorities. Countries should consider timely vaccinating close contacts as a post-exposure prophylaxis, or providing pre-exposure vaccination for specific groups of healthcare professionals.

Based on currently available information, WHO does not recommend that Member States take measures related to international travel for arriving and departing travellers.

WHO will provide interim technical guidance in the coming days.

More information

1. WHO monkeypox fact sheet
2. WHO monkeypox outbreak toolkit
3. HHS News 16 May 2022 Confirmed case of monkeypox in England - latest update
4. WHO disease outbreak news, monkeypox, United Kingdom of Great Britain and Northern Ireland, 16 May 2022
5. WHO disease outbreak news, monkeypox, United Kingdom of Great Britain and Northern Ireland, 8 July 2021
6. WHO disease outbreak news, monkeypox, all articles.
7. Weekly Epidemiological Record (WER) No. 11, March 16, 2018, Incidence of monkeypox in West and Central Africa, 1970-2017
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13. Public Health Agency of Canada confirms two cases of monkeypox
14. CDC media statement. CDC and health partners response to U.S. monkeypox cases, May 18, 2022
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16. UKHSA monkeypox guidelines
17. Portuguese Ministry of Health Press Release, 18 May 2022
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