Shiloh
Editor, Senior Moderator
Source: https://www.cdc.gov/mmwr/volumes/71/wr/mm7123e1.htm?s_cid=mm7123e1_w
Monkeypox Outbreak — Nine States, May 2022
Weekly / June 10, 2022 / 71(23);764–769
On June 3, 2022, this report was posted online as an MMWR Early Release.
Please note: This report has been corrected.
Faisal S. Minhaj, PharmD[SUP]1[/SUP][SUP],2[/SUP]; Yasmin P. Ogale, PhD[SUP]1[/SUP][SUP],3[/SUP]; Florence Whitehill, DVM[SUP]1[/SUP][SUP],2[/SUP]; Jordan Schultz, MPH[SUP]4[/SUP]; Mary Foote, MD[SUP]5[/SUP]; Whitni Davidson, MPH[SUP]2[/SUP]; Christine M. Hughes, MPH[SUP]2[/SUP]; Kimberly Wilkins[SUP]2[/SUP]; Laura Bachmann, MD[SUP]3[/SUP]; Ryan Chatelain, MPH[SUP]6[/SUP]; Marisa A.P. Donnelly, PhD[SUP]1[/SUP]; Rafael Mendoza, MPH[SUP]7[/SUP]; Barbara L. Downes, MS[SUP]8[/SUP]; Mellisa Roskosky, PhD[SUP]1[/SUP][SUP],9[/SUP]; Meghan Barnes, MSPH[SUP]10[/SUP]; Glen R. Gallagher, PhD[SUP]4[/SUP]; Nesli Basgoz, MD[SUP]11[/SUP]; Victoria Ruiz, PhD[SUP]5[/SUP]; Nang Thu Thu Kyaw, PhD[SUP]1[/SUP][SUP],5[/SUP]; Amanda Feldpausch, DVM[SUP]12[/SUP]; Amy Valderrama, PhD[SUP]13[/SUP]; Francisco Alvarado-Ramy, MD[SUP]14[/SUP]; Chad H. Dowell, MS[SUP]15[/SUP]; Catherine C. Chow, MD[SUP]16[/SUP]; Yu Li, PhD[SUP]2[/SUP]; Laura Quilter, MD[SUP]3[/SUP]; John Brooks, MD[SUP]17[/SUP]; Demetre C. Daskalakis, MD[SUP]17[/SUP]; R. Paul McClung, MD[SUP]3[/SUP]; Brett W. Petersen, MD[SUP]2[/SUP]; Inger Damon, MD, PhD[SUP]2[/SUP]; Christina Hutson, PhD[SUP]2[/SUP]; Jennifer McQuiston, DVM[SUP]2[/SUP]; Agam K. Rao, MD[SUP]2[/SUP]; Ermias Belay, MD[SUP]2[/SUP]; Andrea M. McCollum, PhD[SUP]2[/SUP]; Monkeypox Response Team 2022 (View author affiliations)
Summary
What is already known about this topic?
Monkeypox, a rare disease caused by infection with Monkeypox virus, is endemic in several Central and West African countries. Cases in persons outside Africa are often linked to international travel or imported animals.
What is added by this report?
CDC is tracking multiple reported U.S. monkeypox cases, and monitoring cases in persons in countries without endemic monkeypox and with no known travel links to an endemic area; current epidemiology suggests person-to-person community spread.
What are the implications for public health practice?
CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread.
On May 17, 2022, the Massachusetts Department of Public Health (MDPH) Laboratory Response Network (LRN) laboratory confirmed the presence of orthopoxvirus DNA via real-time polymerase chain reaction (PCR) from lesion swabs obtained from a Massachusetts resident. Orthopoxviruses include Monkeypox virus, the causative agent of monkeypox. Subsequent real-time PCR testing at CDC on May 18 confirmed that the patient was infected with the West African clade of Monkeypox virus. Since then, confirmed cases* have been reported by nine states. In addition, 28 countries and territories,[SUP]†[/SUP] none of which has endemic monkeypox, have reported laboratory-confirmed cases. On May 17, CDC, in coordination with state and local jurisdictions, initiated an emergency response to identify, monitor, and investigate additional monkeypox cases in the United States. This response has included releasing a Health Alert Network (HAN) Health Advisory, developing interim public health and clinical recommendations, releasing guidance for LRN testing, hosting clinician and public health partner outreach calls, disseminating health communication messages to the public, developing protocols for use and release of medical countermeasures, and facilitating delivery of vaccine postexposure prophylaxis (PEP) and antivirals that have been stockpiled by the U.S. government for preparedness and response purposes. On May 19, a call center was established to provide guidance to states for the evaluation of possible cases of monkeypox, including recommendations for clinical diagnosis and orthopoxvirus testing. The call center also gathers information about possible cases to identify interjurisdictional linkages. As of May 31, this investigation has identified 17[SUP]§[/SUP] cases in the United States; most cases (16) were diagnosed in persons who identify as gay, bisexual, or men who have sex with men (MSM). Ongoing investigation suggests person-to-person community transmission, and CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread. Public health authorities are identifying cases and conducting investigations to determine possible sources and prevent further spread. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.[SUP]¶[/SUP]
Monkeypox, a zoonotic disease for which the animal reservoir is unknown (1), is endemic in several Central and West African countries. There are two clades of Monkeypox virus, West African, and Congo Basin, the latter causing more severe illness (1,2). The last United States monkeypox outbreak was secondary to imported small mammals from Ghana in 2003**; however, since monkeypox reemerged in Nigeria in 2017, isolated cases outside Africa have been reported either among persons with recent travel to Nigeria or among secondary contacts of persons with travel-associated cases (2,3). Patients with monkeypox typically experience a febrile prodrome 5–13 days after exposure (range = 4–17 days), which often includes lymphadenopathy, malaise, headache, and muscle aches; this prodrome might depend on the nature of exposure (4). The prodrome is followed 1–4 days later by the onset of a characteristic deep-seated, vesicular or pustular skin rash with a centrifugal distribution (Figure); the lesions are well circumscribed and often umbilicate or become confluent, progressing over time to scabs. The rash can be disseminated. Some recent cases have begun atypically, with lesions in the genital and perianal region and without subjective fever or other prodromal symptoms. For this reason, cases might be confused with more commonly seen infections such as varicella zoster or sexually transmitted infections (STIs) (e.g., genital herpes or syphilis). The case-fatality ratio for the West African clade of monkeypox is reported to be 1% and might be higher in immunocompromised persons (1,5,6).
A person is considered infectious from the onset of illness until all lesions have crusted over, those crusts have separated, and a fresh layer of healthy skin has formed under the crust. Human-to-human transmission occurs by direct contact with infected body fluids or lesions, via infectious fomites, or through respiratory secretions, that typically require prolonged interaction (1). Historically, documented reports of human-to-human transmission have been among household contacts and shared housing inhabitants (e.g., in prisons), and health care providers who have had close, sustained contact with a patient or patient fomites (e.g., bedding) (6,7).
Investigation and Results
United Kingdom. The United Kingdom Health Security Agency (UKHSA) announced a confirmed monkeypox case on May 7, 2022, in a traveler returning from Nigeria. On May 14 and 16, UKHSA announced a second unrelated cluster of two cases and a third clustered group of four cases identified at sexual health clinics; the four-case cluster involved persons who identify as gay, bisexual, or MSM.
Massachusetts. On May 4, a Massachusetts resident developed an anogenital rash 3 days after returning from international travel. This rash progressed to vesicles and pustules and spread to the face and trunk; the patient sought medical care four times at outpatient clinics during May 4–12, during which time common causes were ruled out. The patient was hospitalized on May 12 for management of refractory perianal pain from the rash. Prompted by UKHSA’s announcement regarding the recent monkeypox cases, clinicians notified the MDPH and CDC for testing. On May 17, the patient received a diagnosis of confirmed Orthopoxvirus by the Massachusetts LRN laboratory, and CDC confirmed Monkeypox virus West African clade the following day. The local hospital infection prevention team, MDPH, and CDC responded to identify contacts and determine exposure risk, facilitate PEP with one of two orthopoxvirus vaccines (ACAM2000[SUP]††[/SUP] or JYNNEOS[SUP]§§[/SUP]), and provide guidance on infection prevention and control. Outbreak case definitions were created (Table 1). Exposure risk assessment tools used during investigation of a 2021 travel-associated monkeypox case in Texas (8) were adapted to monitor cases and determine criteria for recommending PEP.
New York. On May 4, a traveler returning to New York City (NYC) was evaluated for an oral lesion, and a new painful, perianal rash; the patient was tested and treated for a presumed common STI and sent home. The rash spread, progressing to pustules, and the patient was seen again and treated for a different STI; all testing results were ultimately negative. On May 19, after the announcement of the monkeypox case in Massachusetts, a clinician caring for the NYC patient notified the NYC Department of Health and Mental Hygiene (NYC DOHMH) about the possibility of monkeypox. The patient received a positive orthopoxvirus test result at the NYC LRN laboratory and continued to isolate at home. NYC DOHMH began identifying contacts, determining exposure risk, and facilitating PEP for at-risk contacts.
Other U.S. states. Over the next 5 days from the identification of the NYC case, multiple states received notifications from clinicians about suspected monkeypox cases; on May 23, an incident command structure was created within CDC’s National Center for Emerging and Zoonotic Infectious Diseases to respond to this outbreak. As of May 31, nine states (California, Colorado, Florida, Georgia, Massachusetts, New York, Utah, Virginia, and Washington) have reported 17 patients with confirmed orthopoxvirus infections, which until proven otherwise, are considered to be Monkeypox virus during this outbreak response (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/117901).
Fourteen patients of the 17 patients reported international travel involving 11 different countries during the 21 days preceding symptom onset, and 16 of the 17 patients identified as MSM. All patients were adults (average age = 40 years; range = 28–61 years), and all had rash onset dates during May 1–27; three patients were immunocompromised. Diagnosis of an orthopoxvirus infection occurred an average of 11 days after rash onset (range = 0–21 days) (Supplementary Figure 2, https://stacks.cdc.gov/view/cdc/117900). In addition to skin rash, patients commonly reported chills (12), fatigue or malaise (11), and lymphadenopathy (nine); fever was reported in seven patients (Table 2). Twelve patients reported prodromal symptoms before rash onset such as fatigue, fever, or headache. Among eight patients, the rash started in the genital or perianal area. All but one patient developed a disseminated rash, occurring on the arms, trunk, legs, and face.
Public Health Response...
Monkeypox Outbreak — Nine States, May 2022
Weekly / June 10, 2022 / 71(23);764–769
On June 3, 2022, this report was posted online as an MMWR Early Release.
Please note: This report has been corrected.
Faisal S. Minhaj, PharmD[SUP]1[/SUP][SUP],2[/SUP]; Yasmin P. Ogale, PhD[SUP]1[/SUP][SUP],3[/SUP]; Florence Whitehill, DVM[SUP]1[/SUP][SUP],2[/SUP]; Jordan Schultz, MPH[SUP]4[/SUP]; Mary Foote, MD[SUP]5[/SUP]; Whitni Davidson, MPH[SUP]2[/SUP]; Christine M. Hughes, MPH[SUP]2[/SUP]; Kimberly Wilkins[SUP]2[/SUP]; Laura Bachmann, MD[SUP]3[/SUP]; Ryan Chatelain, MPH[SUP]6[/SUP]; Marisa A.P. Donnelly, PhD[SUP]1[/SUP]; Rafael Mendoza, MPH[SUP]7[/SUP]; Barbara L. Downes, MS[SUP]8[/SUP]; Mellisa Roskosky, PhD[SUP]1[/SUP][SUP],9[/SUP]; Meghan Barnes, MSPH[SUP]10[/SUP]; Glen R. Gallagher, PhD[SUP]4[/SUP]; Nesli Basgoz, MD[SUP]11[/SUP]; Victoria Ruiz, PhD[SUP]5[/SUP]; Nang Thu Thu Kyaw, PhD[SUP]1[/SUP][SUP],5[/SUP]; Amanda Feldpausch, DVM[SUP]12[/SUP]; Amy Valderrama, PhD[SUP]13[/SUP]; Francisco Alvarado-Ramy, MD[SUP]14[/SUP]; Chad H. Dowell, MS[SUP]15[/SUP]; Catherine C. Chow, MD[SUP]16[/SUP]; Yu Li, PhD[SUP]2[/SUP]; Laura Quilter, MD[SUP]3[/SUP]; John Brooks, MD[SUP]17[/SUP]; Demetre C. Daskalakis, MD[SUP]17[/SUP]; R. Paul McClung, MD[SUP]3[/SUP]; Brett W. Petersen, MD[SUP]2[/SUP]; Inger Damon, MD, PhD[SUP]2[/SUP]; Christina Hutson, PhD[SUP]2[/SUP]; Jennifer McQuiston, DVM[SUP]2[/SUP]; Agam K. Rao, MD[SUP]2[/SUP]; Ermias Belay, MD[SUP]2[/SUP]; Andrea M. McCollum, PhD[SUP]2[/SUP]; Monkeypox Response Team 2022 (View author affiliations)
Summary
What is already known about this topic?
Monkeypox, a rare disease caused by infection with Monkeypox virus, is endemic in several Central and West African countries. Cases in persons outside Africa are often linked to international travel or imported animals.
What is added by this report?
CDC is tracking multiple reported U.S. monkeypox cases, and monitoring cases in persons in countries without endemic monkeypox and with no known travel links to an endemic area; current epidemiology suggests person-to-person community spread.
What are the implications for public health practice?
CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread.
On May 17, 2022, the Massachusetts Department of Public Health (MDPH) Laboratory Response Network (LRN) laboratory confirmed the presence of orthopoxvirus DNA via real-time polymerase chain reaction (PCR) from lesion swabs obtained from a Massachusetts resident. Orthopoxviruses include Monkeypox virus, the causative agent of monkeypox. Subsequent real-time PCR testing at CDC on May 18 confirmed that the patient was infected with the West African clade of Monkeypox virus. Since then, confirmed cases* have been reported by nine states. In addition, 28 countries and territories,[SUP]†[/SUP] none of which has endemic monkeypox, have reported laboratory-confirmed cases. On May 17, CDC, in coordination with state and local jurisdictions, initiated an emergency response to identify, monitor, and investigate additional monkeypox cases in the United States. This response has included releasing a Health Alert Network (HAN) Health Advisory, developing interim public health and clinical recommendations, releasing guidance for LRN testing, hosting clinician and public health partner outreach calls, disseminating health communication messages to the public, developing protocols for use and release of medical countermeasures, and facilitating delivery of vaccine postexposure prophylaxis (PEP) and antivirals that have been stockpiled by the U.S. government for preparedness and response purposes. On May 19, a call center was established to provide guidance to states for the evaluation of possible cases of monkeypox, including recommendations for clinical diagnosis and orthopoxvirus testing. The call center also gathers information about possible cases to identify interjurisdictional linkages. As of May 31, this investigation has identified 17[SUP]§[/SUP] cases in the United States; most cases (16) were diagnosed in persons who identify as gay, bisexual, or men who have sex with men (MSM). Ongoing investigation suggests person-to-person community transmission, and CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread. Public health authorities are identifying cases and conducting investigations to determine possible sources and prevent further spread. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.[SUP]¶[/SUP]
Monkeypox, a zoonotic disease for which the animal reservoir is unknown (1), is endemic in several Central and West African countries. There are two clades of Monkeypox virus, West African, and Congo Basin, the latter causing more severe illness (1,2). The last United States monkeypox outbreak was secondary to imported small mammals from Ghana in 2003**; however, since monkeypox reemerged in Nigeria in 2017, isolated cases outside Africa have been reported either among persons with recent travel to Nigeria or among secondary contacts of persons with travel-associated cases (2,3). Patients with monkeypox typically experience a febrile prodrome 5–13 days after exposure (range = 4–17 days), which often includes lymphadenopathy, malaise, headache, and muscle aches; this prodrome might depend on the nature of exposure (4). The prodrome is followed 1–4 days later by the onset of a characteristic deep-seated, vesicular or pustular skin rash with a centrifugal distribution (Figure); the lesions are well circumscribed and often umbilicate or become confluent, progressing over time to scabs. The rash can be disseminated. Some recent cases have begun atypically, with lesions in the genital and perianal region and without subjective fever or other prodromal symptoms. For this reason, cases might be confused with more commonly seen infections such as varicella zoster or sexually transmitted infections (STIs) (e.g., genital herpes or syphilis). The case-fatality ratio for the West African clade of monkeypox is reported to be 1% and might be higher in immunocompromised persons (1,5,6).
A person is considered infectious from the onset of illness until all lesions have crusted over, those crusts have separated, and a fresh layer of healthy skin has formed under the crust. Human-to-human transmission occurs by direct contact with infected body fluids or lesions, via infectious fomites, or through respiratory secretions, that typically require prolonged interaction (1). Historically, documented reports of human-to-human transmission have been among household contacts and shared housing inhabitants (e.g., in prisons), and health care providers who have had close, sustained contact with a patient or patient fomites (e.g., bedding) (6,7).
Investigation and Results
United Kingdom. The United Kingdom Health Security Agency (UKHSA) announced a confirmed monkeypox case on May 7, 2022, in a traveler returning from Nigeria. On May 14 and 16, UKHSA announced a second unrelated cluster of two cases and a third clustered group of four cases identified at sexual health clinics; the four-case cluster involved persons who identify as gay, bisexual, or MSM.
Massachusetts. On May 4, a Massachusetts resident developed an anogenital rash 3 days after returning from international travel. This rash progressed to vesicles and pustules and spread to the face and trunk; the patient sought medical care four times at outpatient clinics during May 4–12, during which time common causes were ruled out. The patient was hospitalized on May 12 for management of refractory perianal pain from the rash. Prompted by UKHSA’s announcement regarding the recent monkeypox cases, clinicians notified the MDPH and CDC for testing. On May 17, the patient received a diagnosis of confirmed Orthopoxvirus by the Massachusetts LRN laboratory, and CDC confirmed Monkeypox virus West African clade the following day. The local hospital infection prevention team, MDPH, and CDC responded to identify contacts and determine exposure risk, facilitate PEP with one of two orthopoxvirus vaccines (ACAM2000[SUP]††[/SUP] or JYNNEOS[SUP]§§[/SUP]), and provide guidance on infection prevention and control. Outbreak case definitions were created (Table 1). Exposure risk assessment tools used during investigation of a 2021 travel-associated monkeypox case in Texas (8) were adapted to monitor cases and determine criteria for recommending PEP.
New York. On May 4, a traveler returning to New York City (NYC) was evaluated for an oral lesion, and a new painful, perianal rash; the patient was tested and treated for a presumed common STI and sent home. The rash spread, progressing to pustules, and the patient was seen again and treated for a different STI; all testing results were ultimately negative. On May 19, after the announcement of the monkeypox case in Massachusetts, a clinician caring for the NYC patient notified the NYC Department of Health and Mental Hygiene (NYC DOHMH) about the possibility of monkeypox. The patient received a positive orthopoxvirus test result at the NYC LRN laboratory and continued to isolate at home. NYC DOHMH began identifying contacts, determining exposure risk, and facilitating PEP for at-risk contacts.
Other U.S. states. Over the next 5 days from the identification of the NYC case, multiple states received notifications from clinicians about suspected monkeypox cases; on May 23, an incident command structure was created within CDC’s National Center for Emerging and Zoonotic Infectious Diseases to respond to this outbreak. As of May 31, nine states (California, Colorado, Florida, Georgia, Massachusetts, New York, Utah, Virginia, and Washington) have reported 17 patients with confirmed orthopoxvirus infections, which until proven otherwise, are considered to be Monkeypox virus during this outbreak response (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/117901).
Fourteen patients of the 17 patients reported international travel involving 11 different countries during the 21 days preceding symptom onset, and 16 of the 17 patients identified as MSM. All patients were adults (average age = 40 years; range = 28–61 years), and all had rash onset dates during May 1–27; three patients were immunocompromised. Diagnosis of an orthopoxvirus infection occurred an average of 11 days after rash onset (range = 0–21 days) (Supplementary Figure 2, https://stacks.cdc.gov/view/cdc/117900). In addition to skin rash, patients commonly reported chills (12), fatigue or malaise (11), and lymphadenopathy (nine); fever was reported in seven patients (Table 2). Twelve patients reported prodromal symptoms before rash onset such as fatigue, fever, or headache. Among eight patients, the rash started in the genital or perianal area. All but one patient developed a disseminated rash, occurring on the arms, trunk, legs, and face.
Public Health Response...