Monkeypox cases since 11 Nov 2021

Press Briefing by White House Monkeypox Response Team and Public Health Officials [The White House, 18 Aug 2022]

Via Teleconference

(August 18, 2022)
MR. FENTON: Good morning. I’m Bob Fenton, the White House Monkeypox Response Coordinator. Today, Secretary Becerra, Assistant Secretary O’Connell, and Dr. Walensky and I will provide a brief update and share some key announcements from the Biden administration’s whole-of-government response to the monkeypox outbreak. We’re also joined today by Dr. Peter Marks from FDA and my Deputy Coordinator, Dr. Daskalakis, for questions.

Before I turn it over to Secretary Becerra, I want to provide an update in our response efforts.
Last week, FDA and CDC acted to allow JYNNEOS vaccine to be administered intradermally, increasing the number of doses in each vial of vaccine by up to fivefold.

With the announcement, it increased our existing supply significantly without compromising safety or effectiveness. And as Dawn O’Connell will discuss shortly, we already aggressively are increasing access for jurisdictions to move vac- — to move more vaccine supply.

We’re focused on operationalizing the FDA decision. Since last week’s announcement, CDC has been working hard to provide help to providers and clinicians with training and other resources to administer the intradermal vaccines.

Already we’re seeing some of the country’s largest jurisdictions, big and small, adopt this strategy, including Los Angeles County and Fulton County, Georgia.

Overall, as of today, HHS has delivered nearly 1 million doses of vaccines to states and cities.
We rapidly scaled up supply of vaccine out in the field, and we are working to meet demand wherever we may find it.

In fact, we have the largest JYNNEOS vaccine program of any country in the globe. And we’re not done.

As Assistant Secretary O’Connell will discuss, we have accelerated Phase 4 of our national vaccine strategy. Starting Monday, an additional 1.8 million doses of vaccine will be available to jurisdictions for ordering.

Jurisdictions that are adopting the intradermal administration of vaccine and have used 90 percent of their current supply of vaccines will be able to order more doses. And as always, we’re getting those dors- — doses out the door to places as soon as they’re ordered.

In addition to getting vaccines out quickly to where they’re needed, we’re focused on helping states and local partners turn these doses into vaccinations, because more shots in arms is how we get the outbreak under control.

To that end, today we’re announcing that states and localities will be able to request and receive additional vaccines to support vaccination efforts at large LGBT events in the coming weeks and months.

HHS is launching a pilot program that will provide up to 50,000 doses from the national stockpile to be made available for Pride and other events that will have high attendance of gay and bisexual men. These doses will be on top of jurisdictions’ existing allocations and supply of vaccine.

As Dr. Walensky will discuss in more detail, CDC will also work closely with state and local health departments to ensure they have plans in place for these events, not just around vaccination but also testing and community engagement.

We’re already starting to work with jurisdictions on a number of events taking place in the coming days and weeks.

This is important; it’s innovative — the way that we will bolster local efforts to meet people where they are and mitigate the spread of monkeypox.

Before I turn it over to Secretary Becerra, I want to highlight another step we are taking to make it easier for individuals to access treatment for monkeypox.

Next week, HHS will be pre-positioning 50,000 courses of TPOXX across the country. That’s nearly five times as many treatment courses than confirmed cases in the U.S.

These courses will be made available to jurisdictions where the outbreak is most severe so individuals can get treatment more quickly from their healthcare providers.

In all, we are making a lot of progress on monkeypox. This is because of the hard work across government that is scaling access to vaccines and tests, educating the public, and ensures — ensuring jurisdictions are getting what they need.

This is a whole-of-government response that is built on a strong work by Dr. Panjabi and the National Security Council built that allowed us to rapidly accelerate our tools and resources.
Our feet remain on the gas to do everything we can to end this outbreak.

Let me stop there and turn it over to Secretary Becerra.

SECRETARY BECERRA: Thanks, Bob. Great to be with everyone again.

Let me start by saying: Most Americans still are learning about monkeypox — what it is and what it is not. CDC’s website can answer most of those questions.

Here’s what we do want all American’s to know: It’s important that we all take monkeypox seriously, and it’s critical that we do all we can to keep this dangerous virus from spreading.

Here, this team, we continue building on our efforts from the beginning to secure and make available safe and effective vaccines, treatments, and tests.

For the more than 60 jurisdictions that have reported approximately 13,500 cases of monkeypox across the country, we have, to date, made available more than 1 million doses of vaccine, more than 22,000 courses of TPOXX treatment, and capacity for 80,000 tests per week. And as Coordinator Fenton just mentioned, that number of vaccines will scale up dramatically.

Having declared monkeypox a public health emergency, having safely expanded our supply of effective vaccines, and every day receiving more fertile data about the outbreak from our many state and local partners, we now move into a new phase of our efforts.

The fluid and collaborative allocation of vaccines and treatments to our partners will continue as part of this latest phase, but we will also now surge and target vaccines and treatments when and where that can be most effective, as Administrator O’Connell and Director Walensky will detail.

We know we have more to do to mitigate the spread of this virus and to protect those at risk.
Our work with our state and local partners could be — could not be more critical than at this particular moment. We know that viruses don’t care about state lines. They don’t wait to spread.

And so we will continue to do all we can to work together, communicate, and share information. As I’ve said, we all have a role to play, and working together will lead to our collective success.

So, with that, let me now turn it over to Administrator Dawn O’Connell. Dawn?
MS. O’CONNELL: Secretary, thank you so much.

At ASPR, we continue to partner with our sister agencies, industries, and state and jurisdictional health leaders to accelerate access to vaccines and treatments and strengthen our response.

First, as we have done over the past three months, we continue to work with our manufacturer to accelerate the acquisition and delivery of vaccines to states and jurisdictions.

To date, as been mentioned already, we have shipped more than 700,000 vials of the JYNNEOS vaccine nationwide, including over 60,000 additional vials that have been shipped since the second and final round of ordering under Phase 3 opened on Monday. This represents more than 1 million doses currently delivered and available for use across the country.

On Monday, as Bob said, we will make approximately 360,000 vials, or up to 1.8 million more doses, available to states and jurisdictions.

This rounds out the distribution of the nearly 800,000 vials we received in late July.
In addition, as previously announced, we are accelerating the delivery of another 150,000 doses of vaccine that was initially supposed to come in October; it’ll now be coming in September — which represents up to 750,000 doses under the new FDA EUA.

We are also now receiving administration data from jurisdictions, which helps us ensure we are distributing vaccines equitably across the country while also making sure they get to those who need them most.

And we continue to explore all available options to increase the amount and speed at which we are able to deliver vaccines across the country.

On July 15th, when we announced an order with Bavarian Nordic for an additional 2.5 million vials of the JYNNEOS vaccine, we shared that those doses will be filled at a U.S.-based contract manufacturer using bulk vaccine already manufactured. We continue to work with Bavarian Nordic and the domestic contract manufacturer to advance that goal. We hope to be able to share additional details about that arrangement soon.

And, based on feedback from jurisdictions, the Strategic National Stockpile is making arrangements to deliver more vaccine to more locations, beyond the five in each jurisdiction they already deliver to. More on this as well in the coming weeks, but it represents another example of how this is not a static response. We are continuing to assess where we are, evaluate what we need, and make improvements in real time.

Today, as Bob mentioned, we are also announcing that we will make available 50,000 patient courses of the antiviral, TPOXX, for jurisdictions to begin ordering next week. This is nearly five times, as Bob mentioned, more courses than confirmed cases in the United States.

Starting next week, jurisdictions will be allocated courses of TPOXX using a formula that takes into account both the number of cases in their jurisdiction and the number of individuals who have the highest risk of contracting the virus, including individuals who have HIV or other immunocompromised conditions.

And, of course, this allocation is in addition to the over 22,000 courses ASPR has already deployed from the SNS upon request from jurisdictions.

We believe it is important for states and jurisdictions to be able to order and pre-position these doses for quick and easy access for patients who qualify for them.

As I mentioned at the top, so much of what we do is in partnership with our sister agencies, including the CDC. With that, it’s my pleasure to turn it over to Dr. Walensky.

DR. WALENSKY: Thank you, Administrator. And good morning, everyone.

Today, I’d like to provide the latest information on the current monkeypox outbreak as well as share a few updates on the work we are doing in CDC’s monkeypox response.

So, as of August 17th, over 39,000 cases have been detected globally in 94 countries. Here in the United States, there have been over 13,500 cases of monkeypox identified across 49 states, as well as Washington, D.C. and Puerto Rico.

Monkeypox case data reported to CDC show that 98 percent of cases are occurring in men. Of the more than 6,000 cases for which we have data on race and ethnicity, nearly 35 percent of cases are occurring among those who are white, 33 percent of cases are occurring among those who are Hispanic, and nearly 28 percent are occurring among those who are Black. The median age of cases is 35. And among cases with known recent sexual history and gender, 93 percent of cases were among men who reported recent sexual contact with other men.

Today, HHS is announcing a pilot program for additional vaccine allocations to state and local health departments whose jurisdictions are hosting events that draw a majority of people from the MSM community.

Jurisdictions hosting these events can request to receive additional vaccine allocations based on the size and nature of the event and the ability to reach attendees who are at the highest risk of monkeypox, a lar- — again, largely right now, men who are having sex with men. We’re asking the requests to include a component of how they will promote education and awareness, as well as how they will address health equity in delivery of both messaging as well as vaccine.

CDC and HHS will continue outreach efforts to educate and make resources available to everyone who needs them. As part of this effort, CDC will publish — be publishing a toolkit for health departments to assist with planning of these large events.

This toolkit, which has been developed based on the needs and feedback we’ve received from state and local health departments, includes ready-to-use resources to support local health department efforts when engaging with organizers of large events to provide and promote further monkeypox prevention strategies and key public health messages at large gatherings.

These events are important opportunities for people to connect with their community and to enjoy themselves. And they’re also a chance to provide public health messages and resources to otherwise hard-to-reach publications — populations — otherwise hard-to-reach populations.
That includes providing safer sex guidance that empowers people to make choices that can help them avoid monkeypox exposure, including temporarily limiting sexual partners, and messages about monkeypox symptoms and vaccines. They also provide education opportunities for communities about testing and treatment resources.

Now, I want to emphasize that while we are offering the vaccine at these events to those at high risk, this is a two-dose vaccine series, and receiving the vaccine at these events will not provide protection at the event itself.

Now, much of our work over the last many weeks has been related to the important outreach to clinicians and public health partners, and we have been focused on providing them with the necessary resources and education and tools that they need.

So, related to our announcement last week, some of our recent work has involved answering questions related to intradermal vaccine administration for the JYNNEOS monkeypox vaccine.

Importantly, intradermal administration is not a new vaccination method. Data suggests that the vaccine administration intradermally will produce the same immune response as the standard dose administered subcutaneously.

We also know many intradermal vaccines may require some training for vaccine providers. Now, many healthcare providers already have experience administering allergen testing or tuberculosis skin testing by this route. CDC has resources available to ensure that vaccine providers can receive training and refresh their skills if needed.

To be clear, we’re learning how well these vaccines work against monkeypox and in this specific outbreak. Although we anticipate vaccines will provide protection, temporarily reducing or avoiding behaviors that increase your risk of monkeypox exposure is important, especially between your first and second doses of vaccine. From what we know right now, we expect protection to be the highest two weeks after the second dose of the vaccine.

At CDC, we remain committed to providing the necessary guidance, education, and resources as we continue to respond to current — the current monkeypox outbreak. And we, of course, remain open to feedback on how and where we can provide tailored information to those at highest risk.

So, with that, I’ll say thank you. And I will turn things back to you, Kevin.

MR. MUNOZ: Thanks so much, Dr. Walensky.

We’re going to try to get through as many questions as possible, so keep your questions to one question.

First, let’s go to Chris Johnson at the Washington Blade.

All right. I think, Chris, you might be having some challenge. So, let’s go to the next question, and we’ll go — we’ll come back to you.

Jacqueline Howard at CNN.

Q Yes, thanks for taking my question. We’ve heard from the manufacturer that there are some concerns on the manufacturers’ end, as far as having its manufacturing capacity meet demand. So, my question is: Are you working to help find domestic manufacturing partners to help supply JYNNEOS doses? Or what are you doing to help meet demand just in case the capacity is not there? How would that impact how much vaccine we have? Thank you.

MR. FENTON: Dawn, do you want to start with an answer for that one?

MS. O’CONNELL: Sure, Bob. I’ll be happy to. And then, of course, feel free to jump in.

So, thank you, Jacqueline, for the question. We continue to work closely with Bavarian Nordic, the manufacturer. As you know, they’re a small manufacturer.

So, one of the first things we did as this monkeypox outbreak took hold was begin conversations with them about how they might expand that capacity. They currently have one active line in the Copenhagen area that we’re relying on for 2.5 million doses to be filled and finished. But when we ordered that second 2.5 million to be filled and finished, we made it a requirement that they work with a domestic U.S. contract manufacturing organization. And we continue to partner with Bavarian Nordic as they solidify that relationship.

We are also helping them in other ways consider manufacturing capacity increases — potentially working with a larger pharmaceutical company, for example. We don’t have anything to announce in particular at this time, but we are working very closely in support of Bavarian Nordic’s interest in increasing their capacity.

MR. MUNOZ: Thanks. Let’s try Chris Johnson again.

Q Hi, thank you so much. I just kind of want to build off of that regarding the reported issues that the manufacturer of JYNNEOS vaccine has said with the proposal, the strategy of administration for the vaccines announced last week by the administration.

It seems like we’re having a lot of contradictory information from various health officials. We have the federal government being critical of localities for opting to undergo a one-dose strategy. Now we have the manufacturer of the vaccine being critical of the federal government for the new vaccine implementation.

I mean, with so many, you know, contradictory information, how can the public be trust — be trustful of the information they’re getting from health officials?

MR. FENTON: Yeah, let me start — this is Bob Fenton — and then I’m going to turn it over to Rochelle Walensky at CDC to — and Dr. Peter Marks to talk about the dosing strategy.

I think anytime that you have change, you’re going to have the need to update, educate the community on those changes. And I think, last week, FDA with the EUA did a really good job of doing that, providing scientific data on those changes.

And then, what needs to happen is the training, which CDC is providing, to go to the intradermal shots for those that need help.

As I said in my opening comments, the day that we made that decision — the day that we made that decision, or the FDA made that decision, and we signaled the week before that this was being undertaken by FDA, there already were a number of jurisdictions that started the training in anticipation of that decision. And that day, there were organiza- — jurisdictions actually delivering the intradermal shot that day, and yet five- — up to fivefold the number of shots. And did that to — you know, to areas of high risk and did that to areas that — that, you know, made equity a factor in those decisions of where they vaccinated.

So, it is happening; it is being successful. We’ll continue to work with those that have questions.

But let me turn it over to Dr. Walensky and to Peter Marks to talk about the science behind the decision and any questions they’re getting as they’re providing technical assistance to jurisdictions.

DR. WALENSKY: Thank you very much. Maybe I’ll just add how closely we’re working with state and local health departments through this outbreak, really hand-in-glove, and in really fluid communication through this outbreak.

As articulated, we don’t yet know how well this vaccine will work in this outbreak. And as those data are evolving, as we had some resource constraints early on with vaccine, we were working closely with health departments as a way that they could maximize their coverage.

We’ve met with them to talk about what data might be available for one dose, which are really limited — and, in fact, if anything, concerning — in terms of how well it would work.

And so when the strategy for intradermal dosing, which we anticipate will work just as well as subcutaneous dosing, we again met closely with the health departments — Dr. Marks was on those calls — so that we could provide the data to them.

So, yes, this has been fluid, but we have been in close touch with our state and local health departments, providing them all the data and all the information that we have when we have it.

Dr. Marks, do you have anything to add there?

DR. MARKS: No, I just — I would just very briefly add that, you know, some of this was in response to seeing additional use of a one-dose delayed strategy, which was, as Dr. Walensky noted, very concerning because of the absence of data and the emergence of some data to suggest that that might be a strategy that is not as effective as we would like it to be.

So, this was done very carefully, with a lot of thought, and we are working very actively to make sure the community has the information that we reviewed and can see the thought process that we used to come to the conclusion that giving this intradermally provided the same kind of protection that giving it by the subcutaneous route.

MR. FENTON: And just real quick, let me just ask Dr. Daskalakis if he wants to add anything to what’s been said.

DR. DASKALAKIS: I would just add, just briefly, that it’s really also part of our job, I think from the perspective of governmental public health, to make sure that we’re communicating about the vaccine in a way that makes sense, that actually engenders trust in the population.

So I think our clear, sort of, view that this is equivalent, whether it is the intradermal dose or the subcutaneous dose, and the thorough review of the data that Dr. Marks and Dr. Walensky talk about, really give us the confidence to, I think, signal to folks that this strategy is not only important to protect themselves, but also to allow us to get more vaccines in arms.

So it’s safe, it’s equally effective, and also allows us to expa- — extend vaccine so that we can maximize protection in the community.

MR. MUNOZ: All right, next question. Let’s go to Sheryl Stolberg at the New York Times

Q Hi, thank you for taking my call. Dr. Walensky mentioned some events coming up, and there are two big ones coming on Labor Day weekend: Black Pride in Atlanta and also Southern Decadence in New Orleans, where monkeypox forced the cancellation of a concert. And we also have back to school — college, in particular — coming up.

And I’m wondering if maybe Dr. Walensky, or Dr. Daskalakis — Daskalakis can talk about specifically what are you doing to help officials in Atlanta and New Orleans, and how are you advising colleges and universities in handling the return to campus and dorm life.

DR. WALENSKY: Maybe I’ll start and pass it to Dr. Daskalakis. Thank you for that question, Sheryl.

Part of the motivation for this pilot is for those large events. There were actually a few before those large events. But we’ve been working closely with the jurisdictions, both in Fulton County and New Orleans, in anticipation of these events.

And specifically, we’re asking for plans for how the education will happen; how we can do more outreach; in some cases where they’re testing, we can make testing available, how we can make vaccine available; how we can do this in an equitable fashion so that we get messaging in — out in an equitable fashion but also vaccine out in an equitable fashion.

As I’m sure you can appreciate, these are opportunities for us to reach populations that we might otherwise not be able to reach, which we feel is a really good opportunity to get these messages out there.

So, not only are we working to set up vaccination stands and activities with personnel in the local health departments, but we’re also working hard to ensure that we have the right messaging for the right people during those events. And there are several other events, not just those that we’re closely working with — jurisdictions who are requesting our assistance ahead of time as well.

We do have messaging for our college campuses. We do have — which is very consistent with the messaging that is up on our website. And we’re, of course, carefully monitoring that as well.

Demetre, I don’t know if you — Dr. Daskalakis, I don’t know if you have anything to add.

DR. DASKALAKIS: I would just — I just want to emphasize the importance of really creating more opportunity for vaccine access. It’s really allowing us to do intervention such as this and pilots to try to get vaccine closer to where the people are rather than have people come to always try to find the vaccine.

So I think that also, Dr. Walensky — I think that the point that this is a multidomain intervention, it’s not just about vaccine, but also about clear communication about how the vaccine works, which I think you covered so well with the idea that first dose isn’t enough for protection; second dose is what you need, plus. But then also, there’s so many strategies that folks can use to prevent monkeypox exposure.

And so that package of interventions put in the right place means that it gets to the right people. So we’re really enthusiastic that increasing vaccine availability allows us a bridge to do such events like that.

And again, great, great collaboration with jurisdictions who I think are very enthusiastic about working with CDC and all of us on this topic.

MR. MUNOZ: Thanks both.

Let’s go to Pien Huang at NPR.

Q Hi, thanks for taking my question. I’ve been hearing from some states that the doses being sent this week are being counted using the intradermal dosing regimen. So, I just wanted to confirm how doses are being counted. You know, is every vial sent before this to be considered one dose? Every vial sent this week and after considered five? Just hoping for a clarification on that.

MR. FENTON: Yeah, let me start and then send it over to Dawn to provide some additional detail. So the doses that we provided this week were counted as doses based on the new intradermal strategy and the ability to get up to five doses per vial. That’s how they’ve been sent. And — and with the announcement of going to Phase 4, we’ll continue with that strategy if vaccine administration was at the 90 percent level. So if they’re providing the vaccine, especially to the at-risk community, then they would be able to continue to order.

What we want to do is accelerate this response, which is why we not only provide 3b but 3c at one time this week, and why we’re now moving forward with 4 is because those that are moving forward and vaccinating individuals at risk quickly, we want to be able to continue to provide the vaccine to protect as many people as possible.

Let me turn it over to Dawn from ASPR to add to that.

MS. O’CONNELL: Terrific, Bob. I actually think you covered it very, very well. What’s most important to us is to be able to get as many doses out as quickly as possible to those that need it. And the FDA EUA allowed us to do that with each vial turning into five doses. So we’ve been counting it that way. Since that change — so the beginning of Phase 3, second ordering tranche on Monday — we sent it out according to that new calculation.

We do know there are situations — in a pediatric indication, for example — where a single vial still will equal a single dose. And if a jurisdiction runs into some situations where they’ve administered more of those — and we would certainly hope for in an outbreak like this — you know, we’d be happy to work with them. We do understand that there are some circumstances where we will need to adjust slightly.

But for — you know, as a rule of thumb, it’s been now five doses per vial.

Thanks, Bob.

MR. MUNOZ: A couple more questions. Let’s go to Mike Stobbe at the Associated Press.

Q Hi, thank you for taking my call. I just was hoping for a little more clarity on the pilot project you announced. I heard at one point “50,000 doses.” At another point, I heard “50,000 courses.” “Courses” I take to mean two-dose series. Is it 50,000 courses or doses?
And how will you follow up? Like, if someone goes to an event and they — they are traveling from another place and they come in and then they leave, how will you follow up to make sure that they get that second dose? Thank you.

MR. FENTON: Yeah, so I think two different things announced. One was an announcement with regard to doses available for vaccine, and the ability to go into Phase 4 ordering started Monday for those that have vaccinated 90 percent.

The second thing that was discussed was pre-positioning of TPOXX, which is the treatment for those that are positive with monkeypox, and that’s the 50,000 courses.

So two different — you know, two different things: one vaccine, one medication.

As far as the events in providing one dose, we will work with the jurisdictions to make sure that there’s — that those individuals that were given one dose, if they travel back to their home of origin, that there’s a — that within their allotment, that there’s sufficient vaccine for a second dose.

Let me turn to Dawn or Dr. Walensky and see if they want to add anything to that.

MS. O’CONNELL: Bob, I think you nailed it. Rochelle, I’m not sure if there’s more that you wanted to add, but it is — in the TPOXX pre-positioning, it’s the 50,000 patient courses. In the special events, I believe it is the 50,000 doses. But, Rochelle, you might have more on that.
DR. WALENSKY: Yeah, no. What I was going to add is: We recognize that there are going to be some people who have traveled to large-scale events and that they’re going to have to receive dose one of their vaccine at the event, and then they will necessarily receive dose two at their local jurisdiction. And we anticipate that.

We’ve seen that before when we’ve had to do — when we’ve done mass vaccination, for example, with COVID. So we are prepared to collect the immunization data. And among the messaging that we will convey, as I noted before, is that people will understand that this is a two-dose vaccine and that they are getting their first dose at the event, that they will need to follow up for their second dose.

MR. MUNOZ: All right, two more questions. Let’s go to Cheyenne Haslett at ABC.

Q Hi. Thank you. I was wondering if you had any data on who is doing intradermal injections, if you’re keeping track of what providers are actually performing it that way, and if you can share that with us.

MR. FENTON: Yeah, the information is just coming in this week on that. I’ve been in contact with a number of providers that are doing intradermal doses. Los Angeles is doing a lot. We were just on a call with Philadelphia that’s doing that. Atlanta, there’s a number of them.

But let me turn to Dr. Walensky, who is starting to get a lot of data on that, and see if she wants to add anything. And then I know Dr. Daskalakis has also been on a number of calls with providers.

DR. WALENSKY: Thank you. Really, what I will say: The data are coming in. What we’re doing really — working really hard is to work with jurisdictions so they all get to this intradermal dosing.

As we see the administration come in — the administration data come in, we will also have a better sense. But ultimately, this is a precious resource that we want to be used efficiently and wisely, and that’s the purpose of this, without sacrificing anything on safety and effectiveness, as far as our data show so far. And so we’re really moving to get all jurisdictions to intradermal dosing.

MR. FENTON: Dr. Daskalakis, anything to add?

DR. DASKALAKIS: No, I think it’s covered well. Just, we’re hearing, you know — just, jurisdictions are very enthusiastically starting this. And I think, you know, the training provided by CDC and the technical support has been really important. So, you know, I think it’s exciting from the perspective of access. Thank you.

MR. MUNOZ: Last question. Let’s go to Krista Mahr at Politico.

Q Thanks so much for taking my question and for providing the updated data on the case breakdown of how this is impacting different communities really are. A question about that. You mentioned the events as a particular opportunity to get particularly at-risk communities. Can you please talk a little bit about more specific messaging that is going out to Black and Hispanic communities in particular, which are being disproportionately impacted in the outbreak? Thank you.

MR. FENTON: Yeah, let me start with Dr. Daskalakis and then go over to Dr. Walensky if she wants to add anything.

DR. DASKALAKIS: So I’ll start and say that we know really — working really closely with organizations and trusted messengers for those populations has been really critical. We continue to do the work and go deeper and deeper into engagement to make sure that messages are coming out.

And also, I think it’s important to note that many of the events that we’re focusing on that are coming down the pike, to foreshadow, are really events that do focus on populations who are overrepresented in this outbreak, including the trends that we’re seeing in — among Black and Latino individuals.

So I think it’s really about positioning both messaging and biomedical intervention where people can reach it, but then also making sure that we’re going to the right places and talking to the right people.

Dr. Walensky?

DR. WALENSKY: I don’t have much to add there except to say how closely we’re working and how critically important it is to collaborate with communities and people on the ground. And so we continue to do so and certainly welcome any other ideas of how, where we can do that outreach.

MR. FENTON: With that, I really appreciate everyone participating in today’s call and the questions. This is really a whole-of-community effort.

As you heard today, we’re accelerating our response to ensure that we’re able to vaccinate, provide testing, improve the ability to quickly treat and really focus on educating and communicating a whole of nation through this effort.

So, thank you for tuning in today. I appreciate your questions

How to Protect Against Monkeypox as School Starts [The New York Times, 17 Aug 2022]

How to Protect Against Monkeypox as School Starts
Experts say children are not at a high risk of infection. But they have advice to keep everyone — from toddlers to college kids — safe.

As children around the country head back to school for the third time since the Covid-19 pandemic began, a different infectious disease is now spreading globally: monkeypox. Almost every single state and territory in the United States has reported cases of monkeypox, with more than 11,000 confirmed cases nationwide. And news of a day care worker in Illinois testing positive earlier this month prompted some infectious disease specialists to warn there is potential for spread in group settings like schools and day cares.

But more than 98 percent of those infected with monkeypox are adult men who acquired the virus through intimate contact with other men — and so far, less than a dozen pediatric cases have been recorded in the U.S.

Confirmed Monkeypox Cases in the U.S.

Monkeypox is not spread as easily as Covid-19 or common childhood illnesses, said Dr. Ibukun Kalu, a pediatric infectious diseases specialist at the Duke University School of Medicine. It typically requires direct contact with an infected person’s rash. According to the Centers for Disease Control and Prevention, monkeypox can also spread by touching objects, fabrics and surfaces that have been used by someone with monkeypox and haven’t been cleaned, or by respiratory droplets expelled by an infected person during close face-to-face contact.

However, new data suggests that indirect contact and environmental contamination is not a major source of transmission. If someone with monkeypox comes to shared spaces like offices or schools, scientists have found that they do not leave behind enough live virus that can replicate and infect others.

Additionally, there is a vaccine and a treatment for monkeypox. The vaccine is not publicly available, but an emergency use authorization now allows children under 18 to receive the vaccine if they have been exposed or are at high risk of getting monkeypox.

Parents who are concerned about the virus may also be relieved to know that many pandemic precautions and behaviors can be repurposed to protect children against monkeypox: wearing masks in crowded indoor areas, avoiding sharing personal use items, increasing the frequency of hand washing and isolating at home when you’re sick.

It’s important to pay attention to new rashes and other symptoms, Dr. Kalu said. “Get your child assessed by a doctor if the rash starts spreading or is something you’ve not really seen on your child before.”

What to look out for
A monkeypox rash starts off as red lesions that can become raised and filled with pus. It can appear anywhere on the body, including the face, hands, feet and genitals, and sometimes resembles chickenpox (which is caused by an unrelated virus) or hand, foot and mouth disease, a common childhood rash that tends to circulate during back-to-school season.
Monkeypox cases in adults can also look like acne or sexually transmitted diseases such as herpes or syphilis, particularly if the rash is limited to just a few pustules.

Other symptoms of monkeypox include a fever, headaches, muscle aches, swollen lymph nodes and rectal pain or bleeding. Symptoms can appear up to three weeks after an exposure and last two to four weeks.

How to think about transmission risks
Though monkeypox is unlikely to spread widely in schools and day cares, parents should expect to hear of more cases spilling over to these and other settings if the disease continues to proliferate.

What to Know About the Monkeypox Virus

What is monkeypox? Monkeypox is a virus similar to smallpox, but symptoms are less severe. It was discovered in 1958, after outbreaks occurred in monkeys kept for research. The virus was primarily found in parts of Central and West Africa, but recently it has spread to dozens of countries and infected tens of thousands of people, overwhelmingly men who have sex with men.

What are the symptoms? People who get sick commonly experience a fever, headache, back and muscle aches, swollen lymph nodes, and exhaustion. A few days after getting a fever, most people also develop a rash that starts with flat red marks that become raised and filled with pus. On average, symptoms appear within six to 13 days of exposure, but can take up to three weeks.

How does it spread? The monkeypox virus can spread from person to person through close physical contact with infectious lesions or pustules, by touching items — like clothing or bedding — that previously touched the rash, or via the respiratory droplets produced by coughing or sneezing. Monkeypox can also be transmitted from mother to fetus via the placenta or through close contact during and after birth.

I fear I might have monkeypox. What should I do? There is no way to test for monkeypox if you have only flulike symptoms. But if you start to notice red lesions, you should contact an urgent care center or your primary care physician, who can order a monkeypox test. Isolate at home as soon as you develop symptoms, and wear high-quality masks if you must come in contact with others for medical care.

What is the treatment for monkeypox? If you get sick, the treatment for monkeypox generally involves symptom management. Tecovirimat, a hard-to-obtain antiviral drug also known as TPOXX, occasionally can be used for severe cases. The Jynneos vaccine, which protects against smallpox and monkeypox, can also help reduce symptoms, even if taken after exposure.

Who can get the vaccine? Jynneos vaccine is most commonly used to prevent monkeypox infections, and consists of two doses given four weeks apart. It has mostly been offered to health care workers and people who have had a confirmed or suspected exposure due to limited supplies, though new doses should become available in the coming months. A few states, including New York, have also made vaccines available among higher-risk populations.

I live in New York. Can I get the vaccine? Adult men who have sex with men and who have had multiple sexual partners in the past 14 days are eligible for a vaccine in New York City, as well as close contacts of infected people. Eligible people who have conditions that weaken the immune system or who have a history of dermatitis or eczema are also strongly encouraged to get vaccinated. People can book an appointment through this website.

“There will absolutely be cases that will occur in women, in children and in people who are pregnant,” said Dr. Jay Varma, a physician and epidemiologist who specializes in infectious diseases at Weill Cornell Medical School in New York City.

However, for now, children are more likely to pick up monkeypox from people they come into contact with at home than at school, Dr. Varma said. Still, a child who lives with someone with monkeypox could potentially bring the virus to their day care or school.

The activities that may put children at risk and the signs of infection that parents should look out for also differ by age. Here’s what to know.

If your children are in day care
Ages: 0 to 4
Because monkeypox spreads primarily through prolonged close contact, babies and toddlers could theoretically get monkeypox from caregivers who are sick — if they hug or kiss children, change dirty diapers with an exposed rash on their hands — or through contaminated toys, shared utensils and beds. However, most day cares already have policies to disinfect toys and surfaces, as well as avoid shared beds, linens or clothing. After the day care worker in Illinois tested positive for monkeypox, no cases were found in children or other staff members. All were offered the vaccine.

“I think the important thing to know is that monkeypox is extraordinarily rare in children, especially young children,” said Dr. Kristina Bryant, a pediatric infectious diseases specialist with Norton Children’s Hospital in Louisville, Ky., and a member of the American Academy of Pediatrics’ Committee on Infectious Diseases.

That said, parents should take any new rash seriously, particularly if it lasts for more than a few days or if it is accompanied by a fever, Dr. Bryant said. Though experts say it is far more likely to be the result of a common childhood illness such as hand, foot and mouth disease, monkeypox may be more severe in children younger than 8 years old, as well as in those who are immunocompromised or who have certain skin conditions like eczema.

Trust your “spidey sense,” said Dr. Joshua Schaffzin, director of infection prevention and control at Cincinnati Children’s Hospital Medical Center, and contact your child’s pediatrician if you are worried. They may be able to determine what is behind your child’s rash just by looking at a photo or scheduling a phone conversation.

Parents should keep children home if they have any kind of rash. “A child who has a fever and a rash should not be going to day care,” Dr. Schaffzin said.

If there is an exposure, your child’s day care staff should manage it much like they would manage other viruses, like norovirus, that spread via surfaces and person-to-person contact, Dr. Schaffzin said. That entails a thorough cleaning and ensuring any staff or children with symptoms stay home until they are no longer contagious, while carefully monitoring for symptoms in others.

If you have pre- or elementary schoolers
Ages: 4 to 10
As with day care, it is important to keep children with a rash and fever at home and encourage them to frequently wash their hands. “I think the protocols schools have in place have only gotten better since Covid,” Dr. Bryant said. “That’s the good news.”

Children in this age group also have a pretty good understanding of concepts like keeping their hands and bodies to themselves, and not sharing personal items — strategies that can help prevent the spread of more common back-to-school concerns, like head lice, as well as rare cases of monkeypox, Dr. Bryant said.

According to Dr. Bryant, it will also be important for parents and adults at home to be aware of their own health and be open about discussing the disease in an age-appropriate way with their children. If anyone gets infected with monkeypox, they should isolate in a room away from others to the extent it is possible, wear a well-fitting medical mask and cover their rash with long sleeves, pants or gloves.

“The cases in children have been linked to household transmission,” Dr. Bryant said. “So the best way to protect your children from monkeypox is for parents to protect themselves.”

If you have tweens or teens
Ages: 11 to 18
Older children who participate in close-contact sports like wrestling or activities that involve shared costumes or uniforms may be at higher risk for monkeypox compared to their peers.

But that does not mean students should discontinue these activities. As long as school administrators and parents are aware of which activities and areas have potential for virus transmission, and they communicate that clearly to students, monkeypox risks can be contained.

“Athletes are already encouraged to keep up on their personal hygiene and to check their skin for other infections like staph,” Dr. Kalu said. “I’m not really worried that playing sports is going to lead to lots of new monkeypox outbreaks in schools.”

Many schools use disinfectants to clean high-touch surfaces like workout equipment, separate uniforms into dirty or clean piles and handle potential contamination with gloves, all of which can help reduce virus transmission, Dr. Kalu said.

Parents may also start having sex talks with children around this age or earlier. For those who are having conversations about sex, you may want to bring up monkeypox proactively, since one of the main ways it is spreading right now is through intimate contact. Close physical contact during oral, anal or vaginal sex, as well as when kissing or cuddling, can spread the virus.

You can ask if your teen has heard about monkeypox and what they know. Make sure they understand what symptoms to look out for and how to engage in safe sex. (While condoms may reduce monkeypox transmission, they are unlikely to completely eliminate the risk. The Centers for Disease Control and Prevention has some guidance on safe sex for monkeypox, although it is not specific to young adults.)

If your children are in college
A handful of colleges and universities have recently reported monkeypox cases and launched public health campaigns around the disease as students and faculty return to campus in the fall. Although the risk of monkeypox transmission is still fairly low in classrooms, college students are more likely to be sexually active or to come in close contact with others in dorms and at parties, so their risk is more similar to that of other adults, Dr. Kalu said.

Students who are over 18 may be eligible for the monkeypox vaccine before they go to school — if they meet their state’s criteria, such as having had multiple sex partners in the past two weeks or if they are men who have sex with men.

If students develop a suspicious rash, they may be able to access monkeypox tests at their student health center. Concerned parents can also talk to campus officials about medical or emotional support available to students and find out whether there is an isolation protocol for those who test positive.

As Monkeypox Spreads, U.S. Declares a Health Emergency [The New York Times, 4 Aug 2022]

By Sheryl Gay Stolberg and Apoorva Mandavilli

The designation will free up emergency funds and lift some bureaucratic hurdles, but many experts fear containment may no longer be possible.

WASHINGTON — The Biden administration on Thursday declared the growing monkeypox outbreak a national health emergency, a rare designation signaling that the virus now represents a significant risk to Americans and setting in motion new measures aimed at containing the threat.

The declaration by Xavier Becerra, President Biden’s health secretary, marks just the fifth such national emergency since 2001, and comes as the country remains in a state of emergency over the coronavirus pandemic. The World Health Organization declared a global health emergency over the outbreak late last month.

Mr. Becerra’s announcement, at an afternoon news briefing where he was joined by a raft of other top health officials, gives federal agencies power to quickly direct money toward developing and evaluating vaccines and drugs, to gain access to emergency funding and to hire additional workers to help manage the outbreak, which began in May.

“We’re prepared to take our response to the next level in addressing this virus,” Mr. Becerra said, adding that “we urge every American to take monkeypox seriously, and to take responsibility to help us tackle this virus.”

Mr. Biden has faced intense pressure from public health experts and activists to move more aggressively to combat monkeypox, which has infected more than 6,600 people in the United States. Lawrence O. Gostin, a health law expert at Georgetown University, called Thursday’s declaration “a pivotal turning point in the monkeypox response, after a lackluster start.”

Supplies of the monkeypox vaccine, called Jynneos, have been severely constrained, and the administration has been criticized for moving too slowly to expand the number of doses. Less than a decade ago, the United States had 20 million Jynneos doses; by May, the vast majority of them had expired.

In echoes of the early coronavirus response, tests have been difficult to obtain, surveillance has been spotty and it has been challenging to get an accurate count of cases. The administration has also been faulted for not doing enough to educate people in the L.G.B.T.Q. community, who are at high risk, before gay pride celebrations in June.

“We have 5 percent of the world’s population and 25 percent of the world’s cases,” said Dr. Carlos del Rio, an infectious disease physician at Emory University in Atlanta. “That, to me, honestly, is a failure. We were caught sleeping at the wheel.”

To address the vaccine shortage, Dr. Robert Califf, the Food and Drug Administration commissioner, who joined Mr. Becerra on Thursday, said his agency was exploring a strategy that would expand the number of available Jynneos doses by administering the shots differently — into layers of the skin, rather than the fat underneath. If it works, one-fifth of the current dose could be used to protect against the virus.

Dr. Califf said the agency was optimistic about the idea and expected to make a final decision “within the next few days,” adding, “It’s important to note that overall safety and efficacy profile will not be sacrificed for this approach.”

What to Know About the Monkeypox Virus

Card 1 of 7
What is monkeypox? Monkeypox is a virus similar to smallpox, but symptoms are less severe. It was discovered in 1958, after outbreaks occurred in monkeys kept for research. The virus was primarily found in parts of Central and West Africa, but in recent weeks it has spread to dozens of countries and infected tens of thousands of people, overwhelmingly men who have sex with men. On July 23, the World Health Organization declared monkeypox a global health emergency.

What are the symptoms? People who get sick commonly experience a fever, headache, back and muscle aches, swollen lymph nodes, and exhaustion. A few days after getting a fever, most people also develop a rash that starts with flat red marks that become raised and filled with pus. On average, symptoms appear within six to 13 days of exposure, but can take up to three weeks.

How does it spread? The monkeypox virus can spread from person to person through close physical contact with infectious lesions or pustules, by touching items — like clothing or bedding — that previously touched the rash, or via the respiratory droplets produced by coughing or sneezing. Monkeypox can also be transmitted from mother to fetus via the placenta or through close contact during and after birth.

I fear I might have monkeypox. What should I do? There is no way to test for monkeypox if you have only flulike symptoms. But if you start to notice red lesions, you should contact an urgent care center or your primary care physician, who can order a monkeypox test. Isolate at home as soon as you develop symptoms, and wear high-quality masks if you must come in contact with others for medical care.

What is the treatment for monkeypox? If you get sick, the treatment for monkeypox generally involves symptom management. Tecovirimat, an antiviral drug also known as TPOXX, occasionally can be used for severe cases. The Jynneos vaccine, which protects against smallpox and monkeypox, can also help reduce symptoms, even if taken after exposure.

Who can get the vaccine? Jynneos vaccine is most commonly used to prevent monkeypox infections, and consists of two doses given four weeks apart. It has mostly been offered to health care workers and people who have had a confirmed or suspected monkeypox exposure due to limited supplies, though new doses should become available in the coming months. A few states, including New York, have also made vaccines available among higher-risk populations.

I live in New York. Can I get the vaccine? Adult men who have sex with men and who have had multiple sexual partners in the past 14 days are eligible for a vaccine in New York City, as well as close contacts of infected people. Eligible people who have conditions that weaken the immune system or who have a history of dermatitis or eczema are also strongly encouraged to get vaccinated. People can book an appointment through this website.

Under current regulations, doctors have to navigate byzantine rules to request tecovirimat, the drug recommended for treating the disease, for their patients. The declaration does not change those rules, and federal officials have said they believe the regulations are necessary to ensure that the drug is safe and effective in patients.

Monkeypox, a virus similar to smallpox but with symptoms that are less severe, has in the past primarily been found in parts of Central and West Africa. But in the current outbreak, the United States has the world’s largest number of monkeypox cases, and the virus is spreading fast. Less than a month ago, there were about 700 cases; now there are nearly 10 times that many.

More than 99 percent of people infected with monkeypox in this country are men who have sex with men, which has posed a delicate task for public health officials communicating with the public about the threat. They do not want to stigmatize gay people, as happened in the early days of the H.I.V./AIDS epidemic, but neither do they want to downplay their particular risk.

This week, Mr. Biden named a veteran emergency response official, Robert Fenton, and an infectious disease specialist, Dr. Demetre Daskalakis, to coordinate the response from the White House — a sign that the administration was stepping up its attention to the outbreak. Dr. Daskalakis, who is gay, has built deep credibility in the L.G.B.T.Q. community over his career. Both he and Mr. Fenton were on Thursday’s call.

Monkeypox is transmitted mostly during close physical contact. The infection is rarely fatal — no deaths have been reported in the United States — but it can be very painful. The number of cases is expected to rise as the virus continues to spread and as surveillance and testing improve, Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention, said on Thursday.

“Two things are happening at once that I think can account for the rise in cases that we’re seeing: One is more widely available testing, and two, potentially more infections that are actually happening,” Dr. Walensky said, adding that “it’s hard to disentangle those right now.”

The emergency declaration that Mr. Becerra issued on Thursday falls under a specific section of federal law that allows the health secretary to declare an emergency that generally lasts for 90 days, but may be extended. But it does not grant the F.D.A. authority to give emergency authorization to vaccines, tests and treatments; that requires a separate declaration.

“It should help galvanize more testing and more health care provider awareness, especially in places outside the big cities where the level of attention to this has been far less,” said Tom Inglesby, the director of the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health, who has helped the Biden administration with its coronavirus response.

Anne Rimoin, an epidemiologist at the University of California, Los Angeles, and a member of the W.H.O.’s advisory panel on monkeypox, said the declaration would send “a strong message that this is important, that it must be dealt with now.”

Dr. Rimoin is one of the scientific advisers who urged the W.H.O. to categorize monkeypox as a “public health emergency of international concern,” a designation the organization has used only seven times since 2007. With panelists divided on the matter, Dr. Tedros Adhanom Ghebreyesus, the W.H.O.’s director general, overruled the advisers to declare monkeypox a global emergency, a status currently held by only two other diseases, Covid-19 and polio.

In the United States, demands for stronger action against monkeypox have intensified recently and several states — California, Illinois and New York — have declared their own health emergencies. Recently, Representative Adam B. Schiff, Democrat of California, called on the Biden administration to step up the manufacturing and distribution of vaccines, and develop a long-term strategy for combating the virus.

Senator Patty Murray, Democrat of Washington and the chairwoman of the Senate health committee, pushed the Department of Health and Human Services to provide a detailed account of the steps it is taking the contain the outbreak.

Gay rights activists, who have been sharply critical of the administration, have been demanding an emergency declaration for weeks. “This is all too late,” said James Krellenstein, a founder of PrEP4All, an advocacy group that works to expand treatment for people with H.I.V. “I don’t really understand why they didn’t do this weeks ago.”

The F.D.A.’s plan to consider fractional doses of Jynneos took some federal scientists by surprise.
There is some data to suggest that injecting one-fifth of a regular dose of Jynneos between skin layers would be just as effective as the approach being used now, administering a full dose under the skin. The skin is rich in immune cells that mediate the response to vaccines, so this approach is sometimes used, especially with vaccines in short supply, although it requires more skill.

Researchers at the National Institutes of Health had planned to test the strategy for Jynneos in a clinical trial that was set to begin in a few weeks, with results expected later in the fall.

“That was our plan, so we’ll have to see how it fits into the new landscape, which has changed,” said Dr. Emily Erbelding, who directs the N.I.H.’s division of microbiology and infectious diseases. “We thought that there was a desire to get a more robust data set, but if it’s a race against time, then this is a different situation.”

“Things are moving fast,” she added.

Declaring an emergency gives the C.D.C. more access to information from health care providers and from states.

During the outbreak, federal health officials have regularly shared information on testing capacity or on the number of vaccines shipped to states. But the C.D.C.’s data on the number of cases lags that of local public health departments, and the number of people vaccinated, or their demographic information, is mostly unavailable.

“We are again really challenged by the fact that we at the agency have no authority to receive those data,” Dr. Walensky, the C.D.C.’s director, said recently at an event hosted by The Washington Post.

The agency is working to broaden its access to state data, but in the meantime, the information is spotty and unreliable. Local health departments are underfunded, understaffed and exhausted after more than two years of grappling with the Covid-19 pandemic.

“A declaration of this monkeypox outbreak as a public health emergency is important, but more important is to step up the level of federal, state and local coordination, fill our gaps in vaccine supply and get money appropriated from Congress to address this crisis,” said Gregg Gonsalves, an epidemiologist at the Yale School of Public Health and an adviser to the W.H.O. on monkeypox.

“Otherwise,” he said, “we’re talking about a new endemic virus sinking its roots into this country.”

Portugal records five monkeypox infections [Northern Beaches Review, 19 May 2022]

Portuguese authorities say they have identified five cases of the rare monkeypox infection and Spain's health services are testing 23 potential cases after the United Kingdom put Europe on alert for the virus.

The five Portuguese patients, out of 20 suspected cases, are all stable.

They are all men and they all live in the region of Lisbon and the Tagus Valley, the Portuguese health authorities said.

European health authorities are monitoring any outbreak of the disease since the UK has reported its first case of monkeypox on May 7 and found six more in the country since then.

Spain issued an alert earlier on Tuesday morning saying it had eight suspected cases under testing.

The figure rose to 23 cases by late afternoon, Madrid region health authorities said in a statement.

All cases remain unconfirmed.

In the US on Wednesday, state health officials in Massachusetts reported a case of monkeypox in a resident who had travelled to Canada, and investigators are looking into whether it is connected to the European outbreaks.

Monkeypox is a rare viral infection similar to human smallpox, although milder, first recorded in the Democratic Republic of Congo in the 1970s.

The number of cases in west Africa has increased in the last decade.

Symptoms include fever, headaches and skin rashes starting on the face and spreading to the rest of the body.

It is not particularly infectious between people, Spanish health authorities said, and most people infected recover within a few weeks although severe cases have been reported.

Four of the cases detected in the UK self-identified as gay, bi-sexual or other men who have sex with men, the UK Health Security Agency said, adding evidence suggested there may be a transmission in the community.

The agency in the UK urged men who are gay and bisexual to be aware of any unusual rashes or lesions and to contact a sexual health service without delay.

The newspaper El Pais quoted the head of public health in the Madrid region, Elena Andradas, as saying, "22 of the 23 suspected cases have reported having had sex with other men in recent weeks".

Portugal's DGS health authority did not release any information on the sexual orientation of the monkeypox patients or suspected patients.

The two countries sent out alerts to health professionals in order to identify more possible cases.

Massachusetts public health officials confirm case of monkeypox [Mass.gov, 18 May 2022]

The confirmed case poses no risk to the general public

BOSTON — The Massachusetts Department of Public Health (DPH) today confirmed a single case of monkeypox virus infection in an adult male with recent travel to Canada. Initial testing was completed late Tuesday at the State Public Health Laboratory in Jamaica Plain and confirmatory testing was completed today at the US Centers for Disease Control and Prevention (CDC). DPH is working closely with the CDC, relevant local boards of health, and the patient’s health care providers to identify individuals who may have been in contact with the patient while he was infectious. This contact tracing approach is the most appropriate given the nature and transmission of the virus. The case poses no risk to the public, and the individual is hospitalized and in good condition.

Monkeypox is a rare but potentially serious viral illness that typically begins with flu-like illness and swelling of the lymph nodes and progresses to a rash on the face and body. Most infections last 2-to-4 weeks. In parts of central and west Africa where monkeypox occurs, people can be exposed through bites or scratches from rodents and small mammals, preparing wild game, or having contact with an infected animal or possibly animal products.
The virus does not spread easily between people; transmission can occur through contact with body fluids, monkeypox sores, items that have been contaminated with fluids or sores (clothing, bedding, etc.), or through respiratory droplets following prolonged face-to-face contact.

No monkeypox cases have previously been identified in the United States in 2022; Texas and Maryland each reported a case in 2021 in people with recent travel to Nigeria. Since early May 2022, the United Kingdom has identified 9 cases of monkeypox; the first case had recently traveled to Nigeria. None of the other cases have reported recent travel. UK health officials report that the most recent cases in the UK are in men who have sex with men.

Based on findings of the Massachusetts case and the recent cases in the UK, clinicians should consider a diagnosis of monkeypox in people who present with an otherwise unexplained rash and 1) traveled, in the last 30 days, to a country that has recently had confirmed or suspected cases of monkeypox 2) report contact with a person or people with confirmed or suspected monkeypox, or 3) is a man who reports sexual contact with other men. This clinical guidance is consistent with recommendations from UK health officials and US federal health officials, based on identified cases.

Suspected cases may present with early flu-like symptoms and progress to lesions that may begin on one site on the body and spread to other parts. Illness could be clinically confused with a sexually transmitted infection like syphilis or herpes, or with varicella zoster virus. The CDC plans to issue public information soon on poxvirus infections which, when available, will be found here.

Rare monkeypox case confirmed in Massachusetts [The Washington Post, 18 May 2022]

By Meryl Kornfield and Hannah Knowles

Massachusetts health authorities confirmed a case of monkeypox Wednesday after the Centers for Disease Control and Prevention said it was monitoring the possible spread of the rare but potentially serious viral illness.

A man who recently traveled to Canada was tested for the virus Tuesday, and the infection was confirmed by the CDC on Wednesday, the Massachusetts Department of Public Health said in a statement. The news comes the same day that British and Portuguese health authorities reported clusters of cases, heightening concerns that monkeypox is spreading undetected outside of central and West Africa, where it is typically found.

The CDC is monitoring six Americans after they sat on a plane near a British patient, CDC medical officer Agam Rao told The Post on Wednesday. None of the patients have shown signs of monkeypox symptoms.

What is monkeypox, the rare virus now confirmed in the U.S. and Europe?
U.S. officials said clinicians should consider a diagnosis of monkeypox in people with an otherwise unexplained rash who traveled to a country that had a confirmed case, had contact with someone who may be infected or is a man who had sexual contact with other men.

Experts are trying to determine how the virus is spreading and how the cases may be connected. Past outbreaks of monkeypox have typically been limited to small groups, said Tom Inglesby, director of the Johns Hopkins Center for Health Security.

“So I think the risk to the general public at this point, from the information we have, is very, very low,” he said.

Still, the latest outbreak is unusual, Inglesby said, with cases popping up in several countries simultaneously.

“We don’t really have the sense yet of what’s driving it. … There isn’t a travel link that’s identified that brings these cases all together,” he said.

Two newly confirmed cases in Britain, one in London and one in southeast England, have no travel links to a country where monkeypox is endemic, indicating possible community transmission, according to the British Health Security Agency.

British health authorities said Wednesday that nine infections have been confirmed in England since May 6, “with recent cases predominantly in gay, bisexual or men who have sex with men.” Two cases that were confirmed Saturday were found among a family unit with no connection to others who later become infected.

The agency is advising people in those groups to be especially “alert to any unusual rashes or lesions on any part of their body.” Monkeypox could transmit through physical contact during sex, the agency said, as well as other close contact with someone infected, such as touching clothing and linens the person has used.

Portuguese health officials also announced confirmed cases of monkeypox Wednesday. Portugal’s Directorate-General of Health said more than 20 “suspected cases” were identified this month, five of which were confirmed.

The number of cases detected in such a short period is unprecedented, said Jamie Lloyd-Smith, a University of California at Los Angeles professor who has studied zoonotic viruses, or infections transmissible from animals to humans, for 20 years.

“It is surprising to see monkeypox appearing to spread internationally like this,” Lloyd-Smith said, adding that it is also “not impossible under the existing paradigm for how monkeypox spreads.”
Monkeypox does not have epidemic-causing transmission potential, such as that of the coronavirus. Also, unlike covid-19, the disease is more noticeable, making detection easier.
Monkeypox causes a milder infection than smallpox. The viral illness most often begins with flu-like symptoms and swelling of the lymph nodes. Eventually, “pox,” fluid-filled blisters, spread across a person’s body.

The Massachusetts case is the first in the United States this year. The other most recent case was confirmed in November, when a Maryland resident who had recently returned from Nigeria contracted the infection and had mild symptoms. Another case was detected in July after a Dallas resident traveling from Nigeria flew through two U.S. airports. No other cases were found at the time.

In 2003, U.S. health authorities identified 47 confirmed and probable cases in six states in the first outbreak of monkeypox in the Western Hemisphere that was later linked to a shipment of infected rodents from Africa.

Rare case of monkeypox reported in England, UKHSA says [CNN, 8 May 2022]

By Martin Goillandeau

(CNN)A rare case of monkeypox has been diagnosed in a patient in England, the UK Health Security Agency said in a statement Saturday.

Monkeypox is a rare viral infection which does not spread easily between people, the agency said, qualifying the overall risk to the general public as "very low."

"The infection can be spread when someone is in close contact with an infected person; however, there is a very low risk of transmission to the general population," the statement read.
The patient is believed to have contracted the infection in Nigeria, the UKHSA said, before recently traveling to the UK. He or she is receiving treatment in London at the expert infectious disease and isolation unit at the Guy's and St Thomas' NHS Foundation Trust.

Per the UKHSA, initial symptoms include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion.

The UKHSA said it would contact people "who might have been in close contact with the individual to provide information and health advice," as a precautionary measure.

Monkeypox is a relative of smallpox, which was eradicated in 1979, but is less transmissible and less deadly. According to the US Centers for Disease Control and Prevention, "The main difference between symptoms of smallpox and monkeypox is that monkeypox causes lymph nodes to swell while smallpox does not."

Rodents, including animals kept as pets, and monkeys can carry monkeypox and transmit it to people. The CDC investigated one case in a traveler to Dallas last year.

Forty-seven people in the US were infected with the virus in 2003 in an outbreak traced to a shipment of small mammals from Ghana sold as pets. There was a smaller outbreak in Britain in 2018.

Monkeypox - United States of America [World Health Organization, 25 Nov 2021]

On 16 November 2021, the IHR National Focal Point of the United States of America (USA) notified PAHO/WHO of an imported case of human monkeypox in Maryland, USA. The patient is an adult, resident of the USA, with recent travel history to Nigeria.

The individual was in Lagos, Nigeria when they developed a rash. On 6 November, they travelled from Lagos, Nigeria to Istanbul, Turkey and, on 7 November, from Istanbul to Washington, D.C, USA. The patient has not been vaccinated against smallpox in the past and is currently in isolation in Maryland.

Samples of skin lesions were positive on 13 November by real-time polymerase chain reaction (RT-PCR) assays for orthopoxvirus-generic and non-variola orthopoxvirus at the Maryland laboratory of the Laboratory Response Network (LRN). On 16 November, the USA Centers for Disease Control and Prevention (US CDC) confirmed the diagnosis on the same two lesion specimens by PCR assays for monkeypox, and also, specifically for the West African clade of monkeypox, the strain that re-emerged in Nigeria since 2017.

At this time, while the patient had remained in Lagos throughout the stay in Nigeria, the source of infection for this case is unknown.

This is the second time that an imported human monkeypox case has been detected in a traveler to the USA. The first imported human case in a traveler from Nigeria was reported on 15 July 2021 (for more information on the first case, please see the Disease Outbreak News published on 27 July 2021). In addition to these two cases, since 2018, six importations of human cases of monkeypox have been reported in non-endemic countries in travelers from Nigeria to Israel (one case), Singapore (one case) and the United Kingdom of Great Britain and Northern Ireland (four cases). The frequency of global travel indicates that further exported cases may be expected among travelers from endemic areas / countries. Additionally, there may be cases that are undetected, misdiagnosed, or not reported.

Public health response
The USA CDC is working with their international health counterparts, state, and local health officials to assess potential risks and to contact airline passengers and others who may have had contact with the patient on flights from Nigeria to Turkey and onwards to the USA, in transit, or after arrival in the USA. Travelers on these flights were required to wear masks due to the ongoing COVID-19 pandemic, the risk of spread of monkeypox via respiratory droplets to others on these flights is therefore considered low.

Public health measures are being taken, including isolation and continued monitoring of the patient’s clinical recovery. Possible contacts are being notified for assessment and monitoring by their local or state health department. Post-exposure vaccination with a smallpox vaccine within 14 days of the last contact with the case may be recommended for cases who are at intermediate and high risk.

Healthcare providers have been advised to be vigilant to poxvirus-like lesions, particularly among travelers returning from Nigeria. Because of the public health risks associated with a single case of monkeypox, clinicians should report suspected cases immediately to state or local public health authorities regardless of whether they are also exploring other potential diagnoses.

WHO risk assessment
Monkeypox is a sylvatic zoonosis with incidental human infections that usually occur sporadically in forested parts of Central and West Africa. It is caused by the monkeypox virus (MPXV) that belongs to the Orthopoxvirus family. Genomic sequencing shows there are two monkeypox clades – Congo Basin and West African and there have been observed differences in human pathogenicity and mortality in the two geographic areas. Both clades can be transmitted by contact and droplet exposure via exhaled large droplets or contact with fomites such as bedding; infection can be fatal in humans.

The incubation period for monkeypox is usually from 6 to 13 days but can range from 5 to 21 days. The disease is often self-limiting with signs and symptoms usually resolving spontaneously within two to four weeks. Signs and symptoms can be mild or severe, and lesions can be painful. Immune deficiency, young age, and pregnancy appear to be risk factors for severe disease. The case fatality ratio (CFR) for the West African clade has been reported to be around 1%. The recent outbreak in Nigeria recorded a higher CFR related to underlying conditions which may lead to immunodeficiency. A case fatality ratio of up to 11% (in individuals without prior smallpox vaccination) has been reported for the Congo basin clade.

Since 2017, a monkeypox outbreak has been occurring in Nigeria with 218 cases confirmed to date. In addition to Nigeria, outbreaks have also been reported in nine other countries in central and western Africa since 1970. These include Cameroon, Central African Republic, Cote d'Ivoire, Democratic Republic of the Congo, Gabon, Liberia, Republic of Congo, Sierra Leone, and Sudan. Sporadic small outbreaks continue to occur in some of these countries including Cameroon and the Central African Republic. However, the vast majority of cases continue to be reported in the Democratic Republic of the Congo, with 2780 cases and 72 deaths (CFR 2.6%) reported between 1 January through 31 October 2021.

While a new vaccine has been approved for the prevention of monkeypox, and traditional smallpox vaccine has been demonstrated to provide protection, these vaccines are not widely available. Increased susceptibility of humans to monkeypox is thought to be related to waning immunity due to cessation of smallpox immunization. Contact with live and dead animals through hunting and consumption of wild game or use of animal-derived products are presumed sources of human infection. Milder cases of monkeypox in adults could go undetected, misdiagnosed, or unreported and represent a risk of human-to-human transmission.

There is likely to be little immunity to infection in those exposed as endemic disease is geographically limited to West and Central Africa and populations worldwide under the age of 40 or 50 years no longer benefit from the protection afforded by prior smallpox vaccination programmes. There is no specific treatment for monkeypox disease, and care is symptom-based optimal care. In some circumstances, treatment approved for smallpox may be offered on a compassionate or emergency use basis.

WHO advice
Any illness during travel in an endemic area or upon return should be reported to a health professional, including information about all recent travel and immunization history. Residents and travelers to endemic countries should avoid contact with sick, dead, or live animals that could harbor monkeypox virus (mammals including rodents, primates) and should refrain from eating or handling wild game or use of products derived from animals. The importance of hand hygiene using soap and water, or alcohol-based sanitizer should be emphasized.

A patient with monkeypox should be isolated during the infectious period, just prior to and including the rash stage of the infection and until all lesions have crusted and fallen off. Timely contact tracing, surveillance measures and raising awareness of endemic and imported emerging diseases among health care providers are essential parts of preventing secondary cases and effective management of monkeypox outbreaks.

Treatment for monkeypox is optimal care based on the patient’s symptoms and clinical condition.

Health care workers caring for patients with suspected or confirmed monkeypox should implement standard, contact and droplet infection control precautions. Samples taken from people and animals with suspected monkeypox virus infection should be handled by trained staff working in suitably equipped laboratories.

WHO does not recommend any restriction for travel to or trade with Nigeria, Turkey or the USA based on available information at this point in time.

5 things to know about monkeypox after a new case appeared in US [STAT, 11 Nov 2021]

By Helen Branswell

F or the second time this year, the United States has an imported case of monkeypox. A traveler from Maryland who had recently returned from Nigeria has been diagnosed with the dangerous illness, the Centers for Disease Control and Prevention said Wednesday.

The unidentified person is in isolation in Maryland, the CDC said in a statement. The Maryland Department of Health said in a statement that the individual has mild symptoms and is not in the hospital.

The earlier U.S. case this year occurred in Texas in July, also in a person who had traveled to Nigeria. There were no secondary cases from the Texas patient, though more than 200 people who had contact with the individual were monitored.

The CDC said it is working with the airline on which the passenger traveled, as well as state and local health authorities in the Washington, D.C., area to identify other passengers and people who may have been in contact with the infected person.

But the agency said it believes the risk of transmission during travel will have been lowered because people on flights are currently required to wear masks.

In recent years there have been a number of reports of exported monkeypox cases cropping up around the globe. Here are some facts about this rare disease:
The virus
Monkeypox is caused by a virus that is related to smallpox; both are Orthopox viruses.
Smallpox, once a common scourge, was declared eradicated in 1980.

Its name suggests it comes from monkeys, but that in fact is not the case. While the first time the virus was seen to cause an outbreak was in 1958, in a colony of research monkeys, the true reservoir of the virus remains unknown. A number of African rodent species are known to be susceptible to the virus and have been seen to be involved in its transmission. (More on this in a bit.)

The disease in humans
The incubation period for the disease — the time from exposure to the onset of illness — ranges from five to 21 days. People who are infected initially develop mild, flu-like illness — headache, fever, chills, and swollen lymph nodes. But a few days later, a rash will appear, often starting on the face. The rash will typically spread to other parts of the body, though mainly the extremities. Palms of the hands and soles of the feet are frequently affected.

Scarring lesions will form in a stage of the disease that can last between two and six weeks.
The disease can be deadly. In Africa, monkeypox has been fatal in about 1 in 10 cases, with severe disease and death more likely among children.

Spread to and among people
The virus transmits to people from infected animals, entering through cuts in the skin, the respiratory tract, or the mucous membranes around the eyes or in the nose and mouth.

A large outbreak in the United States in 2003 — the first time monkeypox was reported outside of Africa — saw 47 confirmed and probable cases reported from six different states.

The outbreak was linked to infected exotic pets imported from Ghana, which in turn infected some prairie dogs sold as pets.

Person-to-person transmission can occur, and is thought to occur mainly through virus-laced droplets. But direct contact with lesions or bodily fluids from an infected person, or indirect contact via contaminated clothing or linens, can also result in transmission.

Where it is found
The virus appears to be present in a belt of countries in West and Central Africa, with locally acquired cases reported from Sierra Leone, Liberia, Côte d’Ivoire, Nigeria, Cameroon, Gabon, Central African Republic, the Republic of Congo, and the Democratic Republic of the Congo.

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The United States, the United Kingdom, Israel, Benin, South Sudan, and Singapore have reported imported cases of monkeypox.

An unintended consequence of smallpox eradication
The WHO suggests that the risk of contracting monkeypox in countries where it is found may be greater in people middle-aged and younger — people who were not vaccinated against smallpox in childhood.

The eradication of smallpox led to the termination of routine smallpox vaccination around the world, which may have contributed to the increase in human cases in Nigeria that has been observed since 2017, Australian scientists suggested in a paper published earlier this year.