This News of the outbreak of the multinational smallpox outbreak is an update of the previously published editions and offers an update on the epidemiological situation, more information on the use of therapeutics, as well as on the results of the International Health Regulations (2005 ). Emergency Committee regarding the multinational smallpox outbreak held on June 23rd.
Outbreak at a glance
From 1 January to 22 June 2022, 3413 confirmed laboratory cases and one death of 50 countries / territories in five WHO Regions have been reported to the WHO.
Description of the outbreak
The majority of confirmed laboratory cases (2933/3413; 86%) were reported to the WHO European Region. Other regions reporting cases include: the African region (73/3413, 2%), the Americas region (381/3413, 11%), the Eastern Mediterranean region (15/3413, <1%) and the Western Pacific region (11/3413, <1%). 3413, <1%). One death was reported in Nigeria in the second quarter of 2022.
The number of cases is expected to change as more information becomes available daily and the data are verified in accordance with the International Health Regulations (2005) (IHR 2005) (Table 1).
Figure 1. Geographic distribution of confirmed cases of monkeypox reported or identified by the WHO from official public sources, between January 1 and June 22, 2022, 17:00 CEST, (n = 3413)
Table 1. Confirmed cases of monkeypox by WHO region and country from 1 January 2022 to 22 June 2022, 17:00 CEST
Global risk is assessed as moderate globally, given that this is the first time that cases and groups have been reported simultaneously in five WHO Regions. At the regional level, the risk is considered high in the European Region due to its report of a geographically widespread outbreak involving several recently affected countries, as well as a somewhat atypical clinical presentation of cases. In other WHO Regions, the risk is considered moderate given the epidemiological patterns, the possible risk of importing cases and the capabilities to detect cases and respond to the outbreak. In recently affected countries, this is the first time that cases are confirmed mainly, but not exclusively, among men who have had recent sexual contact with a new or multiple partner.
The unexpected appearance of monkeypox and the widespread geographical spread of the cases indicate that the monkeypox virus may have been circulating below levels detectable by surveillance systems and that sustained human-to-human transmission could having been undetected for a period of time. Transmission routes of monkeypox virus include person-to-person contact through direct contact with infectious skin or mucocutaneous lesions, respiratory drops (and possibly short-range aerosols), or indirect contact with contaminated objects or materials. , also described as fomite transmission. Vertical transmission (from mother to child) has also been documented. Although it is known that close physical contact can lead to transmission, it is unclear whether sexual transmission occurs through semen / vaginal fluids, research is currently underway to understand this. In addition, the likelihood of sustained community transmission and the extent to which a presymptomatic or asymptomatic infection may occur as the period of infection is unknown, as well as the spread of monkeypox virus among people, cannot be ruled out. with multiple sexual partners in interconnected relationships. networks and the likely role of mass meetings.
The clinical presentation of cases of monkeypox associated with this outbreak has been atypical compared to previously documented reports: many cases in recently affected areas do not present the clinically described clinical picture of monkeypox (fever, swollen lymph nodes, continued of centrifugal eruption). .
The atypical features described include:
- presentation of a few or even a single injury
- absence of skin lesions in some cases, with anal pain and bleeding
- lesions in the genital or perineal / perianal area that do not extend further
- lesions that appear at different stages of development (asynchronous).
- the appearance of lesions before the onset of fever, malaise, and other constitutional symptoms (absence of prodromal period).
The actual number of cases is likely to be underestimated, in part due to the lack of early clinical recognition of a previously known infection in only a handful of countries, and limited improved surveillance mechanisms in many countries for an earlier disease. “unknown” to most. health systems. Infections associated with healthcare cannot be ruled out (although they have not been demonstrated so far in the current outbreak). There is a potential for increased health impact with a wider spread in vulnerable groups, as mortality was previously reported to be higher among children and young adults, and immunocompromised individuals, including people living with uncontrolled HIV infection are especially at risk for serious illness.
The risk is also represented by the difficulties involved in the widespread lack of availability of laboratory diagnostics, antivirals and vaccines, as well as to ensure adequate biosecurity and biosecurity in diagnostic, clinical and reference laboratories wherever they have occurred. cases.
A large part of the population is vulnerable to the monkeypox virus, as smallpox vaccination, which is expected to provide some protection against smallpox, has been discontinued since the 1980s. Only a relatively small number of military, front-line health professionals and laboratory workers have been vaccinated against smallpox in recent years. A third-generation MVA vaccine was approved for use by the European Agency for Smallpox. The use authorization provided by Health Canada and the U.S. Food and Drug Administration (FDA) includes an indication for the prevention of monkeypox. An antiviral agent, tecovirimate, has been approved by the European Medicines Agency, Health Canada and the United States FDA for the treatment of smallpox. It is also approved for use in the European Union for the treatment of monkeypox.
All countries should be alert to signs related to patients with an eruption that progresses in sequential stages (macules, papules, vesicles, pustules, crusts, in the same stage of development in all affected areas of the body) that may be associated. with fever, enlarged lymph nodes, back pain, and muscle aches.
In addition, during this current outbreak, many people present with atypical symptoms that include a localized rash that may include just one injury. The onset of lesions may be asynchronous, and individuals may have primary or exclusively perigenital and / or perianal distribution associated with local inflamed and painful lymph nodes. Some patients may also have sexually transmitted infections and should be tested and treated appropriately. These people may be presented in a variety of community and health care settings, including, but are not limited to, primary and secondary care, fever clinics, sexual health services, infectious disease units, obstetrics and gynecology, emergency services. , surgical specialties and dermatology clinics.
Clinical management and infection prevention and control (IPC) in health and community settings
Care for patients with suspicion or confirmation of monkeypox requires early recognition using screening protocols adapted to the local environment, rapid, isolation, and rapid implementation of appropriate CPI measures (standard, transmission-based precautions, including addition of the use of respirators for health workers caring for patients with suspected / or smallpox of the monkey, and an emphasis on safe handling of clothing and environmental management), tests to confirm the diagnosis, symptomatic treatment of patients with mild or uncomplicated smallpox and follow-up and treatment of life-threatening complications and conditions, such as the progression of skin lesions, secondary bacterial infection of skin lesions, eye lesions, and rarely severe dehydration, severe pneumonia, or sepsis. Patients with less severe monkeypox who are isolated at home require a careful assessment of their ability to isolate and maintain the necessary CPI precautions in their home to prevent transmission to other members of the home and community.
To allow for reliable evaluations of interventions, randomized trials using CORE protocols are the preferred approach. Unless there are compelling reasons not to do so, every effort should be made to implement randomized trial designs. Placebo-controlled studies are feasible, especially in low-risk individuals. Harmonized data collection for safety and clinical outcomes using the WHO Global Clinical Platform for Monkeypox would represent a minimum desirable data set in the context of an outbreak, including the current event.
Precautions (insulation measures and CPI) should be maintained until the lesions have formed a crust, the crusts have fallen off, and a new layer of skin has formed underneath.
Laboratory testing and sample management
Anyone who meets the definition of a suspicious case must be offered evidence. The decision to take the test should be based on both clinical and epidemiological factors, linked to an assessment of the likelihood of infection. Because of the variety of conditions that cause rashes and because the clinical presentation may be more often atypical in this outbreak, it may be difficult to differentiate smallpox from the monkey solely on the basis of the clinical presentation.
Risk communication and community participation
Communicating the risks associated with monkeypox and involving at-risk and affected communities, community leaders, civil society organizations, and health care providers, including those in sexual health clinics, in prevention, detection, and care is essential. to prevent secondary cases and effective management. of the current outbreak.
For more information on risk communication for contacts, suspects and confirmed …