Multi-country monkeypox outbreak: situation update – who. int

This current Disease Outbreak News on the multi-country monkeypox outbreak is an up-date to the previously published Disease Outbreak News of 10 June, with updated data, some further details on surveillance and reporting, One Health, gatherings, Risk communication and community engagement and International travel and points of entry.

In this edition, we are removing the distinction between endemic and non-endemic countries, reporting on countries together where possible, to reflect the unified response that is needed.

Break out at a glance

Since 1 January 2022, cases of monkeypox have been reported to WHO from 42 Member States across five WHO regions (the Regions of the Americas, Africa, Europe, Eastern Mediterranean, and Western Pacific). As of 15 June, a total of 2103 laboratory confirmed cases and one probable case, including 1 death, have been reported to WHO. The outbreak of monkeypox continues in order to primarily affect men who have sex with men who have reported recent sex with new or multiple partners.

While epidemiological investigations are ongoing, most reported cases in the recent outbreak possess presented through sexual health or other health services in primary or secondary health care facilities, with the history of travel primarily to countries in Europe, and North America or even other countries rather than to countries where the virus was not historically known to be present, plus increasingly, recent travel locally or no travel at all.

Confirmation of one case of monkeypox, in a country, is considered an break out. The unexpected appearance associated with monkeypox in several areas in the initial absence of epidemiological links to areas that have historically reported monkeypox, suggests that there may have been undetected transmission for some time.

WHO assesses the risk at the global level as moderate considering this is the first time that will many monkeypox cases and clusters are reported concurrently in many countries in widely disparate WHO geographical areas, balanced against the particular fact that mortality has remained low in the current outbreak.

Description of the outbreak

Between 1 January to 15 June 2022, a cumulative total of 2103 laboratory confirmed instances, one probable case, plus one death have been reported to WHO from 42 countries in five WHO Regions. The majority of situations (98%) have been documented since May 2022 (Figure 1).

Figure 1: Confirmed cases of monkeypox by THAT region from January 2022 to 15 June 2022, data as of 15 June 2022 17: 00 CEST

Note: the data for the current epi week are incomplete and should be interpreted cautiously.

The majority (84%) of confirmed cases (n=1773) are from the WHO European Region. Confirmed cases have also already been reported from your African Region (n=64; 3%), the Area of the Americas (n=245; 12%), Eastern Mediterranean Region (n=14; < 1%) and Western Pacific Region (n=7; < 1%). Of instances reported (468 out 2103 confirmed cases) from 14 countries for which demographic information and personal characteristics are available, 99% are usually reported in men aged 0 to 65 years (Interquartile range: 32 in order to 43 years; median age 37 years), of which most self-identify as men that have sex with other men.

Figure 2 and Table 1 show the number associated with cases of monkeypox by country, reported to or identified by WHO through 1 January through fifteen June 2022, 5 PM CEST.  

The case count is fluctuating as more information becomes available plus data are verified under the International Health Regulations (IHR 2005).

In previous updates, we included suspected situations and deaths within the African Region. We are now focusing primarily on verified and probable cases, including deaths among confirmed and probable cases.

Figure 2 . Geographic distribution of cases of monkeypox reported to or identified by WHO ELSE from official public sources, between 1 January plus 15 June 2022, 5 PM CEST, (n=2103).

Figure one: Confirmed cases of monkeypox by WHO region from January 2022 to 15 June 2022, data as of 15 June 2022 17: 00 CEST

To date, the clinical presentation of monkeypox instances associated with this outbreak offers been variable. Many situations in this outbreak are not presenting with the classically described clinical picture for                              monkeypox (fever, swollen lymph nodes, followed by a centrifugal evolving rash). Atypical features described include: presentation of only a few or even just a single lesion; lesions that begin in the particular genital or perineal/perianal area and do not spread further; skin lesions appearing at different (asynchronous) stages of development; and the appearance of lesions before the onset of fever, malaise and other constitutional symptoms. The modes associated with transmission during sexual contact remain unknown; while it is recognized that close physical plus intimate skin-to-skin or face-to-face contact can lead in order to transmission (through direct get in touch with infectious skin or even lesions), it is not clear what role sexual bodily fluids, such as semen and vaginal fluids, play in the transmission of monkeypox.

Currently, the public health risk at the global level is assessed as moderate considering this is the first time that monkeypox cases and clusters are reported concurrently within many countries in widely disparate WHO geographical areas, balanced against the fact that mortality has remained low in the current outbreak.

In apparently newly affected countries, cases have mainly, but not exclusively, been confirmed amongst men who self-identify as men who have sex with men, participating in extended sexual networks. Person to person transmission will be ongoing, still primarily occurring in one demographic plus social group. It is likely that the actual number of instances remains an underestimate. This particular may in part become due to the lack of early clinical recognition of an infectious disease previously thought to occur mostly in West and Central Africa, a non-severe clinical presentation for the majority of cases, limited surveillance, plus a lack of widely available diagnostics. While efforts are usually underway to address these gaps, it is important to remain vigilant with regard to monkeypox in all population groups to prevent onward transmission.

At present, transmission in evidently newly affected countries is usually primarily linked to current sexual contacts. There is definitely the high likelihood that will further cases will end up being found without identified chains of transmission, including potentially in other population groups. Given the number of countries across several WHICH regions reporting cases associated with monkeypox, it is highly likely that other countries will identify cases and there will be further spread of the virus. Human-to-human transmission occurs through close or direct physical contact (face-to-face, skin-to-skin, mouth-to-mouth, mouth-to-skin) with infectious lesions or mucocutaneous ulcers including during sexual activity, respiratory droplets (and possibly short-range aerosols), or even contact with contaminated materials (e. g., linens, bedding, electronics, clothing, sex toys).

The particular current risk for the particular general public remains low. There is a risk to health workers if they are in get in touch with a case while not really wearing appropriate personal protective equipment (PPE) to prevent tranny; though not yet reported in this current break out, the risk of wellness care-associated infections has been documented in the past. Should monkeypox begin to spread more widely to and within more vulnerable organizations, there is the potential for greater health ­­­impact as the risk of severe illness and mortality is recognized to be higher in immunocompromised individuals, including persons with poorly controlled HIV infection. While infection along with monkeypox during pregnancy is not fully understood, limited data suggest that infection may lead to adverse outcomes for the foetus or newborn infant and for the mother.

To date, all cases identified in newly affected nations whose samples were confirmed by PCR have already been identified as being infected with the West Africa clade. There are two known clades of monkeypox virus, one first recognized in West Africa (WA) and one in the Congo Basin (CB) region. The WA clade has within the past been related to an overall lower case fatality ratio (CFR) of < 1% while the CB clade appears in order to more frequently cause severe disease with a CFR previously reported of up to about 10%; both estimates are based on infections among a generally younger population in the particular African setting. In the period following the eradication of smallpox, more people were immune to orthopoxviruses through exposure to smallpox or receipt of smallpox vaccine. Therefore , initially most early cases of human monkeypox were among children who were vulnerable and therefore at risk of a lot more severe disease.

Vaccination against smallpox was shown in the past to be cross-protective against monkeypox. Today, any continuing immunity through prior smallpox vaccination would in most cases just be present in persons over the age of 42 to 50 years or even older, depending on the particular country, since smallpox vaccination programmes ended worldwide in 1980 after the eradication associated with smallpox. Protection for those who were vaccinated may have waned over time. The particular original (first generation) smallpox vaccines through the eradication programme are no longer available to the general public.

Smallpox and monkeypox vaccines, where available, are being deployed within a few countries to manage close contacts. Second- plus third-generation smallpox vaccines have been developed to have an improved safety profile and one has been approved for prevention of monkeypox. This vaccine is based on a strain of vaccinia virus (known generically because modified vaccinia Ankara Bavarian Nordic strain, or MVA-BN). This vaccine has been approved for prevention of monkeypox in Canada plus the United States associated with America. In the European Union, this vaccine has already been approved for prevention of smallpox under exceptional circumstances. An antiviral agent, tecovirimat, has been approved by the European Medicines Agency, Health Canada, and the United Says Food and Drug Administration for the treatment associated with smallpox. It is also approved in the European Union regarding treatment of monkeypox. WHO ALSO has convened experts to review the latest data on smallpox and monkeypox vaccines, and to provide guidance on how and within what circumstances they can be used.

The advice provided hereafter by the particular WHO on actions required to respond to the multi-country monkeypox  outbreak, is dependent on its technical work, and informed by consultations with the following existing WHO advisory bodies: the Strategic and Technical Advisory Group on Infectious Hazards (STAG-IH); the ad-hoc Strategic Advisory Group of Experts on Immunization (SAGE) working group on smallpox and monkeypox vaccines; the Emergencies Social Science Technical Working Group; the Advisory Committee on Variola Virus Research; WHO Research & Development (R& D) Blueprint consultation: Monkeypox research; the Scientific Advisory Group for the particular Origins of Novel Pathogens (SAGO); as well since by the outcome of ad-hoc meetings of experts.

All countries should be on the alert for signals related to patients presenting with a rash that progresses in sequential stages – macules, papules, vesicles, pustules, scabs, at the same stage of development over all affected areas of the particular body – that may be associated with fever, enlarged lymph nodes, back pain, and muscle aches. During this current outbreak, many individuals are presenting with atypical symptoms, which includes a localized rash that may present as little as one lesion.   The appearance of lesions might be asynchronous and individuals may have primarily or exclusively peri-genital and/or peri-anal distribution associated with local, painful swollen lymph nodes. Some patients may also present with sexually transmitted infections and should become tested and treated appropriately. These individuals may present to various community plus health care settings which includes but not limited in order to primary and secondary care, fever clinics, sexual health services, infectious disease units, obstetrics and gynaecology, emergency departments and dermatology clinics.

Increasing awareness among potentially affected communities, as well because health care providers and laboratory workers, is essential for identifying and preventing further cases and effective management of the current outbreak.

Any individual meeting the definition intended for a suspected case must be offered testing. The decision to test should be centered on both clinical plus epidemiological factors, linked to a good assessment of the likelihood of infection. Due to the range of conditions that cause skin rashes and because clinical presentation may more often be atypical in this outbreak, it may be challenging to differentiate monkeypox solely based on the medical presentation.

Caring for patients along with suspected or confirmed monkeypox requires early recognition via screening adapted to nearby settings, prompt isolation plus rapid implementation of appropriate IPC measures (standard and transmission-based precautions, including the particular addition of respirator use for health workers caring for patients with suspected/confirmed monkeypox, and an emphasis on safe handling of linen and management associated with the environment), physical examination of patient, testing to confirm diagnosis, symptomatic management of patients with mild or even uncomplicated monkeypox and monitoring for and treatment associated with complications and life-threatening conditions such as progression of skin lesions, secondary bacterial infection of skin lesions, ocular lesions, and rarely, severe dehydration, severe pneumonia or sepsis. Patients with less severe monkeypox who else isolate at home require careful assessment of the ability to safely isolate and maintain required IPC precautions in their home to avoid transmission to some other household and community members.

Precautions (isolation) should remain in place until lesions have crusted, scabs have fallen off plus a fresh layer associated with skin has formed underneath.

Information should reach those who need it most during upcoming small and large gatherings, particularly among social and sexual networks where presently there may be close, frequent or prolonged physical or sex contact, particularly if this involves more than a single partner. All efforts should be made to avoid unnecessary stigmatization of individuals and communities potentially affected by monkeypox.

WHO is closely checking the situation and supporting international coordination working with Member States and partners.

For associated WHO documents, please see the Information section below. Key updates from these types of documents as well since highlights from documents below development are provided beneath for ease of reference.

Surveillance and reporting 

As per IHR (2005) Article 6, a minimum data set (formatted as a case report form) for confirming under IHR has been developed and shared along with Member States. The information will be compiled plus shared publicly in aggregate form on a regular basis through WHO information products. A separate in-depth Case Investigation and Contact Tracing Form (CIF) to get Member States has already been also shared with Member Declares. This form can be used pertaining to investigation of exposure risks and transmission dynamics of cases and secondary infection risk in contacts. WHO is working to identify Member States who might be interested in sharing these detailed data, or analyses, to inform the global understanding of the current outbreak. A protocol to support implementation of the CIF can be being also finalized.

WHO has furthermore implemented the Case Reporting Form (CRF) and CIF in the Go. Data platform to facilitate local capture, analysis, and/or sharing of the relevant data. Analysis of transmission stores and network visualization have got been used in past outbreaks to identify clusters, understand patterns of exposure, and quantify viral transmission across different settings. In the context of the current monkeypox outbreak, understanding these patterns of transmission will end up being critical not only within finding which control measures are effective, but will allow for the characterization of the particular extent of respiratory transmitting and determining if multiple introductions (human or zoonotic) have occurred. To date, limited tools are available for countries to be able to graph these types of chains of transmission plus identify clusters or contexts of transmission in real time. This presents an opportunity meant for Go. Data to become used by Member Claims, partners, and institutions to enhance outbreak response activities, mainly in the generation, visualization, and analysis of their chains of transmission. Through its “visualization” feature, Go. Data will allow countries to visualize, in real-time, chains of transmission which will facilitate the supervising of disease progression as well as the identification of potential new situations that are missed through undetected circulation of the virus or new circulating clades. The Go. Data monkeypox outbreak template and associated metadata description can end up being obtained upon request simply by emailing [email protected] , and technical assistance for implementation is obtainable from WHO.

Laboratory testing and sample management

Details can be found in Laboratory screening for the monkeypox virus: Interim guidance (23 May 2022)

Risk communication and community engagement

Communicating monkeypox related risks and engaging at-risk and affected areas, community leaders, civil society organizations, and health treatment providers, including those in sexual health clinics, upon prevention, detection and care, is essential for avoiding further secondary cases and effective management from the present outbreak. Providing public wellness advice on how the disease transmits, its symptoms and preventive measures plus targeting community engagement in order to the population groups who are most at danger, is critical to minimize distribute. Communication must be direct, explicit and engaging for the particular intended audience.

Anyone who provides direct contact, (e. g., face-to-face, skin-to-skin, mouth-to-mouth, mouth-to-skin) including but not limited to sexual contact, with an infected person can get monkeypox. Steps for self-protection include avoiding sexual connection with someone with a localized anogenital rash or skin lesions and limiting the number of sex partners; avoiding close contact with someone who has symptoms consistent with possible monkeypox contamination and avoid sharing associated with personal items (e. gary the gadget guy. eating utensils, clothing, electronic devices, bedding); keeping hands clean with water and soap or alcohol-based gels; and maintaining respiratory etiquette.

If a person develops symptoms such as a rash along with blisters on face, hands, feet, eyes, mouth, and/or genitals and peri-anal places; fever; swollen lymph nodes; headaches; muscle aches; plus fatigue they should contact their health care provider and get tested designed for monkeypox. If someone is certainly suspected or confirmed because having monkeypox, they should separate, be tested, undergo scientific evaluation to assess just for complications, avoid skin-to-skin and face-to-face contact with others and avoid sex, including receptive and insertive oral, anal, or vaginal lovemaking intercourse, until all lesions have crusted, the scabs have fallen off plus a fresh layer of skin has formed beneath. During this period, cases could get supportive treatment to ease monkeypox symptoms. Anyone caring for a person sick with monkeypox should make use of appropriate personal protective measures as mentioned above. As a precaution, WHO suggests the use of condoms consistently during sexual acts (receptive and insertive oral/anal/vaginal) for 12 weeks post recovery to reduce the particular potential transmission of monkeypox for which the risk is since yet not known.

Residents and travellers to countries that have long experienced monkeypox ought to avoid contact with ill mammals such as rodents, marsupials, non-human primates (dead or alive) that could harbour monkeypox virus plus should refrain from eating or handling wild game (bush meat). In the previous outbreak in 2003 in the United States of America, owners associated with pet prairie dogs were infected through contact with their infected pets. Therefore, persons with monkeypox within any setting ought to be mindful of the theoretical risk of exposing animals, for example those who may be kept as pets in the household.

WHO is continually updating its content by means of Monkeypox Q& A, public communication platforms and additional materials. Please refer in order to the WHO Guidance and Public Health Recommendations section below.

Gatherings

Gatherings and events exactly where physical contact, including sex, may be involved may represent a conducive environment for the transmission of monkeypox virus if they entail close, prolonged or even frequent interactions among people, which in turn could expose attendees to contact with lesions, body fluids, respiratory droplets plus contaminated materials.

Planned gatherings within areas where monkeypox cases have been detected can become safely maintained with a few precautions and sharing associated with information as required. Furthermore, such events can end up being used as opportunities to conduct outreach with general public health information for specific population groups. It is important to communicate earlier, often, consistently through identified and trusted communication channels and in language and terminology used by the affected populations. Public health authorities and event managers should work together in order to ensure targeted information reaches event-goers before, during plus after the event. Operating closely with community-based and civil society organisations that will have direct and trusted relationship with affected populations is highly recommended.

The following precautionary measures can be considered to reduce risk of monkeypox transmission connected with this kind of events:

• Event organizers should be aware of the particular epidemiology of monkeypox in the host area, its modes of transmission plus prevention, and what action needs to be taken if a person develops signs and symptoms compatible with monkeypox, including where appropriate treatment can be sought. This info should be distributed to prospective attendees and all those involved in the event planning and delivery.
• Gatherings should be used as opportunities for information outreach and community engagement; attention should also become dedicated to the social context in which the event takes place, with the focus on individual danger behaviours associated with side events and unplanned congregations (i. e.. gatherings within bars and pubs, house parties, private spaces, etc. ).
• People with signs and signs and symptoms consistent with monkeypox need to refrain from close get in touch with any other individual plus should avoid attending events. They should follow guidance issued by relevant wellness authorities.
• Although monkeypox and COVID-19 spread between people differently, some of the COVID-19 measures applied throughout social gatherings such as keeping a physical distance and practicing regular handwashing are also effective against the particular transmission of monkeypox computer virus; as such, they should be continued; skin-to-skin and face-to-face contact should be discouraged.
• Close contact along with someone who has signs or symptoms consistent with monkeypox should be avoided, including not having intimate or sexual get in touch with.
• Attendance lists for participants in gatherings could be introduced, if applicable, to facilitate contact tracing in the event that a monkeypox case is identified.
• Staff responsible for dealing with attendees who fall ill at the occasion must be provided with details on how to manage people with signs and signs and symptoms consistent with monkeypox.
• Attendees should always be reminded to apply individual-level responsibility to their decisions and actions, with the aim of preserving their health, that associated with the people they interact with, and ultimately that of their community. This will be especially important for spontaneous or unplanned gatherings.

As it is standard practice with regard to mass gatherings, and even more so during the COVID-19 pandemic, authorities and event organizers are invited to apply the WHOM recommended risk-based approach to decision-making, and tailor it to the large or small social events under consideration. In the context of the current outbreak, monkeypox-associated risks should be regarded as and factored in.

One Health

Various wild mammals happen to be identified because susceptible to monkeypox disease in areas that possess long experienced monkeypox. These include rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates, among others. Some species might have asymptomatic infection. Other species, such as monkeys and great apes, show skin rashes typical associated with those found in humans. Thus far, there is no documented evidence of domestic animals or livestock being affected by monkeypox malware. There is also simply no documented evidence of human-to-animal transmission of monkeypox. However, right now there remains a hypothetical risk of human-to-animal transmission; since such appropriate measures such as physical distancing of persons with monkeypox from domestic pets, proper waste management to prevent the particular disease from being carried from infected humans in order to susceptible animals at home (including pets), in zoos plus wildlife reserves, and to peri-domestic animals, especially rodents.

International travel and points of entry

Based on available information at this time, WHO does not recommend that Member States adopt any   measures that interfere with international traffic for either incoming or outgoing travellers.

Any individual feeling unwell, including fever along with rash-like illness, or becoming considered a suspected or even confirmed case of monkeypox by jurisdictional health authorities, should avoid undertaking any travel, including international or local travel, until   no longer considered a public health risk by a health care provider or public health unit. Any individual which has developed a rash-like illness during travel or even upon return should immediately report to a health professional, providing information about all recent travel, immunization history including whether they have got received smallpox vaccine or other vaccines (e. g. measles-mumps-rubella, varicella zoster shot, to support making the diagnosis), and information on close contacts as per WHO HAVE interim guidance on surveillance, case investigation and contact tracing for monkeypox (please refer to the EXACTLY WHO Guidance and Public Wellness Recommendations section below). Individuals who are actually identified as contacts of monkeypox instances and, therefore, are subject to health monitoring, should avoid undertaking any travel, including international, until completion of their health monitoring period.

Public wellness officials should work with travel operators and open public health counterparts in various other locations to make contact with passengers and others who may have had close contact along with an infectious person while travelling. Health promotion plus risk communication materials ought to be available at factors of entry, including information on how to identify signs and symptoms consistent with monkeypox; on the precautionary steps recommended to prevent the spread; and on how to seek medical care in the place of destination when needed.

WHO SEEM TO urges all Member Says, health authorities at almost all levels, clinicians, health and interpersonal sector partners, and academic, research and commercial companions to respond quickly in order to contain local spread plus, by extension, the multi-country outbreak of monkeypox. Rapid action must be taken before the virus can end up being allowed to establish itself as a human pathogen with efficient person-to-person tranny in areas in any kind of previously affected or newly affected areas.