POST 256. June 10, 2022. MONKEYPOX. “This is one of the rare diseases in which you can vaccinate somebody after they’ve been infected, before they have symptoms, and block the disease,”… “We would have to really screw things up not to be able to contain this..”

“Luciana Borio, a former director of medical and biodefense preparedness at the National Security Council, said the country should recall a lesson from the testing fiasco at the beginning of the Covid-19 pandemic and bring commercial diagnostic testing companies into the response.”

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“More than 30 cases of monkeypox have now been reported around the U.S.

According to the Centers for Disease Control and Prevention (CDC), there are now 31 confirmed monkeypox and orthopoxvirus cases nationwide.

New York leads the 13 states with reported infections, confirming seven. California has six, Florida has four and Colorado has three.

Illinois and Utah have two cases each.

There is one case reported in Washington state, Virginia, Pennsylvania, Massachusetts, Hawaii, Georgia and the District of Columbia.

The World Health Organization (WHO) said Sunday that more than two dozen countries where monkeypox virus is not endemic have reported 780 cases.

However, no monkeypox deaths outside of Africa have been identified…

Monkeypox spreads when there is close contact with an infected individual, but it is not yet known whether it is being transmitted now exclusively by sex…

It also remains unclear if people could spread monkeypox without symptoms or if the disease might be airborne.

Traditionally, monkeypox virus is spread by touching or getting bitten by infected wild animals in western and central Africa.” (A)

“World Health Organization Director-General Tedros Adhanom Ghebreyesus cautioned Wednesday that the window to contain the global monkeypox outbreak may be narrowing.

“Multiple epidemics around the world would constitute a pandemic. But experts aren’t betting on that outcome — WHO leaders and disease experts agree it’s not too late to reverse the trend.

“There’s still a window of opportunity to prevent the onward spread of monkeypox in those at highest risk right now,” Dr. Rosamund Lewis, the WHO’s technical lead on monkeypox, said at the briefing.

Two smallpox vaccines — both approved by the Food and Drug Administration — may be key to the prevention effort. The U.S. government’s preferred shot, called Jynneos, is specifically approved for use against monkeypox.

“This is one of the rare diseases in which you can vaccinate somebody after they’ve been infected, before they have symptoms, and block the disease,” said Eric Toner, a senior scholar at the Johns Hopkins Center for Health Security.

“We would have to really screw things up not to be able to contain this,” he added…

In the current outbreak, the primary driver of transmission seems to be skin-to-skin contact between people, often involving exposure to infected people’s rashes or lesions.

“Right now we’re more at risk for the virus maybe becoming endemic due to ongoing human-to-human transmission and our inability to stop the transmission cycle,” Roess said.

Several factors are involved in that cycle. For one, some monkeypox cases are hard to identify. Patients develop rashes that can be confused with chickenpox, syphilis or herpes, but in some cases it may be limited to the genital area, making it harder to detect.

Second, disease experts worry that the U.S. isn’t processing tests quickly enough to identify new cases in a timely manner.

“It still does take a few days from the time someone is identified to the time that we can confirm their diagnosis,” Roess said.

Dr. Stuart Isaacs, an associate professor of medicine at the University of Pennsylvania, said the virus could have “epidemic potential” in the U.S. — meaning there would be a major surge in cases — if a single infected person spread monkeypox to more than one other person on average. That hasn’t been the case in the past, and the U.S. has recorded fewer than 40 cases thus far.

“We’re still too early to really say definitively that this [outbreak] isn’t going to explode, although the likelihood is still very low,” Isaacs said.

“The reason this is endemic in Africa is there’s animal reservoirs,” he added. “The virus is propagating and spreading among animals, and then it jumps into humans or nonhuman primates every now and then.”

In the past, Roess said, countries outside Africa quickly halted monkeypox outbreaks through testing and contact tracing, but the current outbreak is unprecedentedly large and widespread.

Experts don’t yet know whether its scale is a clue that monkeypox has evolved to get better at human-to-human transmission or whether countries are simply uncovering the extent of an outbreak that went undetected for some time.

Already, the monkeypox outbreak may meet the formal definition of a pandemic: The virus is spreading from person to person in at least two countries, and there are community-level outbreaks in several parts of the world. 

“But generally, when we talk about pandemics, we talk about diseases in which everyone is significantly at risk in every country or almost every country,” Toner said. “So far, this has not reached that threshold, and I don’t think it ever will.”

Roess said the fact that the Covid-19 pandemic isn’t over likely makes global health leaders wary of an emergency declaration.

“There’s a lot of hesitation to declare this a pandemic,” she said.

A reason for optimism, however, is that this version of monkeypox isn’t usually life-threatening. Although monkeypox rashes can be painful and cause scarring, experts said, doctors know how to treat them with smallpox antivirals and supportive care. No deaths have been reported in non-endemic countries thus far.

“We should be raising alarms and studying this and understanding this,” Isaacs said. “But we’re not at a panic stage yet.” (B)

“The monkeypox virus, which has now been diagnosed in hundreds of people in 26 countries, may have been quietly circulating for years before its sudden emergence worldwide, some scientists speculate.

Infectious disease experts and scientists at genetic labs are urgently looking for clues to explain why a virus that has been found in West Africa for half a century and typically doesn’t spread readily from person to person made such a dramatic and troubling appearance in the past month.

“There may have been undetected transmission for a while,” said Dr. Rosamund Lewis, the World Health Organization’s technical lead for monkeypox during a briefing Wednesday. “What we don’t know is how long that may have been. We don’t know if it’s weeks, months or possibly a couple of years.”…

“What’s likely happened is an endemic infectious disease from Africa found its way into a social and sexual network and then was greatly aided by major amplification events like raves in Belgium to disseminate around the world,” Dr. Amesh A. Adalja, a senior scholar at the Johns Hopkins Center for Health Security, said.

“And then,” Adalja added, “because it’s being transmitted through close contact in sexual encounters, many of the lesions are getting mistaken for other sexually transmitted infections, which may be delaying diagnosis.”..

“Whenever you start looking for a disease that’s new in a population, you find many, many more cases,” Dr. David Heymann, a professor at the London School of Hygiene and Tropical Medicine who formerly led the WHO’s Programme on Emerging and other Communicable Diseases, told NBC News.

Heymann supported the theory that the disease may have been present in some populations for several years outside the 11 Central and West Africa countries where the virus has become endemic. Cases may be circulating stealthily among people outside the global gay community, he suggested.

“The concern is looking in only one population rather than looking more broadly,” he said.;

Van Ranst said the coming days of the outbreak will be critical for controlling the disease. As of June 1, there were 643 confirmed cases, according to the WHO. If by next week the cumulative case count follows an exponential curve and hits perhaps 4,000, “then this is not under control,” he said.

If the figure instead only increases to about 1,000, then the outbreak is likely only expanding linearly, which bodes well for global control of the virus, Van Ranst said.” (C)

“As the number of monkeypox cases climbs amid an ongoing global outbreak, US health officials said Friday that they are ramping up testing and contact tracing and expanding access to vaccines and treatments.

As part of those efforts, about 1,200 doses of vaccine for monkeypox have been offered in the United States, said Dr. Raj Panjabi, White House senior director for global health security and biodefense.

“We want to ensure that people with high-risk exposures have rapid access to vaccines and, if they become sick, can receive appropriate treatment. To date, we’ve delivered around 1,200 vaccines,” Panjabi said. “And 100 treatment courses to eight jurisdictions, and we have more to offer states.”

Health care workers in Massachusetts treating monkeypox patients were among the first to receive vaccinations to protect them against the virus.

In the United States, the two-dose Jynneos vaccine is licensed to prevent smallpox and specifically to prevent monkeypox. Another smallpox vaccine licensed in the United States, ACAM2000, can also be used for monkeypox.

To date, more than 120 PCR orthopox tests have been performed across the United States as part of monitoring the outbreak.

“This is just a fraction of what’s available,” Panjabi said, adding that 67 labs across 46 states — part of a network known as the Laboratory Response Network — have the “collective ability” to perform more than 1,000 tests per day.

“So what we’re working on now is to ensure that that testing capacity is used,” he said. People with monkeypox symptoms are encouraged to see a health care provider, and providers are urged to test if they suspect that someone might have monkeypox…

“The high proportion of initial cases diagnosed in this outbreak in persons who identify as gay, bisexual, or other MSM, might simply reflect an early introduction of monkeypox into interconnected social networks; this finding might also reflect ascertainment bias because of strong, established relationships between some MSM and clinical providers with robust STI services and broad knowledge of infectious diseases, including uncommon conditions,” CDC researchers wrote in the report.

“However, infections are often not confined to certain geographies or population groups; because close physical contact with infected persons can spread monkeypox, any person, irrespective of gender or sexual orientation, can acquire and spread monkeypox.”..

Rosamund Lewis, WHO’s technical lead for monkeypox, said Tuesday that this outbreak is different from previous ones because “we’re seeing cases all appearing in a relatively short period of time.”  (D)

“Infectious disease specialists are growing increasingly concerned by the U.S. strategy for testing for monkeypox, warning that it’s creating a bottleneck and squandering the limited time the country may have to get the outbreak under control.

Under the current system, specimens must be sent to one of 74 laboratories across the country before being sent to the Centers for Disease Control and Prevention. Experts who spoke with STAT argue the United States should be testing more broadly for monkeypox, allowing more labs to become part of the process.

“Every single day that we’re not fixing the testing bottleneck, every single day that we’re not getting on top of getting the information out to the networks that need to be aware of this, is time that we are losing in terms of that window closing on containment,” said Boghuma Titanji, an assistant professor of infectious diseases at Emory University…

Jennifer Nuzzo, director of Brown University’s new Center for Pandemic Preparedness and Response, said the current system makes sense for a smaller outbreak, but doesn’t suit the needs of clinicians who should be actively looking for monkeypox infections.

“This two-step process is not going to scale,” she said in an interview. “This is a cumbersome process. When you have something that’s spreading in ways that we’re not able to see — in the sense that we’re finding cases without known contacts or known links of transmission — it really feels like we’re in a different mode of the response.” ..

“That level of community spread is not being detected, and we cannot help people make good risk decisions, we cannot help people protect their loved ones and sex partners unless we know what’s going on,” said Joseph Osmundson, a molecular microbiologist at New York University…

Currently if a medical worker suspects a patient has monkeypox, someone has to contact the state health department and send a swab from the patient to a facility in what’s called the Laboratory Response Network, which was set up to test for biological or chemical threats. These laboratories can determine if the sample is positive for an orthopoxvirus — the family to which monkeypox and smallpox belong. The combined orthopox testing capacity for this network is nearly 7,000 tests per week at 74 labs in 46 states, the CDC has said.

If the sample tests positive, the CDC conducts confirmatory testing. The CDC has said its two-step method has been sufficient thus far, and stressed that a positive orthopox test was being treated as a presumed monkeypox infection, activating all of the clinical and containment measures that a final diagnosis requires. That includes contact tracing, vaccination of high-risk contacts, and access to antiviral drugs for the patient, if warranted.

Ranu Dhillon, an instructor of global health at Harvard Medical School, said the testing system ought to be designed to normalize monkeypox testing, so that the net can be cast more broadly to find more cases. Dhillon, who works part of his time at a community hospital in Vallejo, Calif., said that as it stands now, he would need to clear the ordering of a test with the head of his hospital’s lab.

“It would be a process, it would be a discussion,” he said. “I think the sooner we move to normalizing, the better to lower that professional stress or awkwardness of requesting a test for something that you’ve never seen [before]…. You have to be able to screen widely as we learn from Covid and have a lot of tests come back negative. That’s how you’re going to find the ones that are positive.”…

Luciana Borio, a former director of medical and biodefense preparedness at the National Security Council, said the country should recall a lesson from the testing fiasco at the beginning of the Covid-19 pandemic and bring commercial diagnostic testing companies into the response.

“We need to open up testing and bring testing to where it’s normally done. We learned that from Covid, right?” said Borio, who is a senior fellow for global health at the Council on Foreign relations. “It’s a lot more efficient.”

It will undoubtedly take time for companies to make and validate tests. But that work should be underway, she said.

“It has to start now — if it hasn’t already,” Borio said. “And it will take how long it takes. But we shouldn’t be debating whether it’s needed.”” (E)

“As global monkeypox cases continue to rise, public-health officials and researchers are questioning whether the current outbreaks can be contained. The World Health Organization (WHO) has said that the situation is unlikely to escalate into a full-blown pandemic. But there are now more than 1,000 confirmed infections in nearly 30 countries where outbreaks do not usually occur (see ‘Unusual spread’).

Countries including Canada, the United Kingdom and the United States have begun implementing a strategy called ‘ring vaccination’ to try to halt the spread of the virus. This involves administering smallpox vaccines — which are thought to be effective against monkeypox because the viruses are related — to people who have been exposed to monkeypox through close contact with an infected person.

But there are unknowns and challenges that come with this strategy, says Natalie Dean, a biostatistician at Emory University in Atlanta, Georgia. Although the vaccines are considered safe and effective for use in people with smallpox infection, they have had limited testing against monkeypox. The strategy also relies on rigorous contact tracing, which might not be implemented in every country, and people must agree to be inoculated with vaccines that can trigger rare, but serious, side effects.

Ring vaccination can be a powerful tool, Dean says, but to be effective, it needs to be used early — while case numbers are still manageable. “As the numbers crop up and you think about the number of contacts each individual has, the logistics just become more complicated.” She adds that there is a narrowing window of opportunity to prevent the virus from gaining a more permanent foothold in human or animal populations in countries where the global outbreaks are occurring.

These concerns were heightened on 3 June, when the US Centers for Disease Control and Prevention (CDC) reported genomic data showing that there are at least two strains of the monkeypox virus responsible for the outbreaks. This finding suggests that the virus might have been circulating internationally for longer than was thought. But Andrea McCollum, an epidemiologist who heads the poxvirus team at the CDC in Atlanta, Georgia, says that, although the new genomic data do not change the agency’s efforts to contain the virus, they will complicate the investigation into the outbreak’s origins.

Some countries maintain stockpiles of smallpox vaccines, mainly because public-health officials have been worried that variola — the virus that causes smallpox, which was eradicated more than 40 years ago and that kills about 30% of the people who get it — could be weaponized or accidentally released from laboratories where samples are still kept. Two main types of smallpox vaccine are available today. Each contains a live poxvirus, called vaccinia virus, that is closely related to the smallpox virus. ‘Second-generation’ vaccines can cause rare but serious side effects because they contain vaccinia that can replicate in a person’s cells. ‘Third-generation’ versions have fewer side effects because they contain a weakened virus…

Unlike their response to COVID-19, public-health officials aren’t currently mulling a mass-vaccination campaign for monkeypox. That’s because countries have stockpiled more second-generation smallpox vaccines than third-generation versions — and the side effects of the second-generation ones prevent them from being given to children, pregnant individuals, people who are immunocompromised or those with one of a spectrum of skin conditions that are classified as ‘eczema’. Third-generation vaccines, which fewer countries have access to, have fewer side effects and could therefore be given to more people.

At the moment, the risk posed by monkeypox to the general public isn’t high enough to warrant mass vaccination, given the side effects and availability issues, says Daniel Bausch, the director of emerging threats and global health security at FIND, the global alliance for diagnostics in Geneva, Switzerland. But if the virus starts spreading in vulnerable populations, such as pregnant people or children, or if it turns out to have a higher fatality rate than expected, the risk–benefit calculation could change…

So far, the United States has been offering either a second- or third-generation smallpox vaccine regimen to people at ‘high’ or ‘intermediate’ exposure risk, which the CDC defines as a person who had “unprotected contact” with the skin or bodily fluids of a person with monkeypox, or who was within 1.8 metres (6 feet) of an infected person. Smallpox vaccines are thought to protect against monkeypox infection if administered within four days of exposure, according to the CDC…

Even if more nations procure smallpox vaccines and begin a ring vaccination campaign, there is a large difference between theory and reality when it comes to implementing the strategy, MacIntyre warns. In theory, monkeypox is conducive to a ring vaccination campaign because it spreads slower than most human viruses and has a long incubation period. But in reality, the success of this approach relies on robust testing and contact-tracing infrastructure, as well as the ability to quickly vaccinate any high-risk contacts, she says…

To stop the spread of the virus, health officials will probably need to look beyond vaccination and focus on quarantine and isolation, as well as community education, he adds. As Bausch wrote in a 2021 comment about Ebola in Nature Medicine3, although ring vaccination has had its successes, “it is far from a panacea”. (G)

The Centers for Disease Control and Prevention (CDC) removed a mask recommendation from its monkeypox travel alert.

The agency told Fox News on Tuesday it took that part of the notice out late on Monday “because it caused confusion.”

“Travel Health Notices inform travelers and clinicians about current health issues that impact travelers’ health, like disease outbreaks, special events or gatherings and natural disasters, in destinations around the world,” the CDC continued. “In countries where there is a current monkeypox outbreak, CDC continues to recommend masking in high-risk situations including for household contacts and healthcare workers, or for other people who may be in close contact with a person who has been confirmed with monkeypox.”

In the initial CDC travel alert, it said wearing a mask can “help protect you from many diseases, including monkeypox.”

Now, its website advises travelers to avoid contact with dead or live wild animals and sick people, including those with skin lesions or genital lesions.

This 2003 electron microscope image made available by the Centers for Disease Control and Prevention shows mature, oval-shaped monkeypox virions, left, and spherical immature virions, right, obtained from a sample of human skin associated with the 2003 prairie dog outbreak. Monkeypox, a disease that rarely appears outside Africa, has been identified by European and American health authorities in recent days.

This 2003 electron microscope image made available by the Centers for Disease Control and Prevention shows mature, oval-shaped monkeypox virions, left, and spherical immature virions, right, obtained from a sample of human skin associated with the 2003 prairie dog outbreak. Monkeypox, a disease that rarely appears outside Africa, has been identified by European and American health authorities in recent days. (Cynthia S. Goldsmith, Russell Regner/CDC via AP)

In addition, people should avoid eating or preparing meat from wild game or using products derived from wild animals from Africa and avoid contact with contaminated materials used by sick people or that came into contact with infected animals.

The CDC raised its alert level for monkeypox to level 2 on Monday.

As of June 3, there have been 35 reported monkeypox cases across the country.

Hundreds have been reported in Europe and numerous other countries globally.

Although the majority of new monkeypox cases have been seen in gay or bisexual men, experts caution that anyone is at potential risk.

People normally become infected with the monkeypox virus through contact with the skin lesions or bodily fluids of infected animals or humans – including respiratory droplets – or through contact with materials contaminated with the virus.

Monkeypox, which is related to smallpox, has milder symptoms.

Some of those symptoms include fever, chills, rash and aches, before lesions develop.” (H)

“The spread of monkeypox through small virus particles that linger in the air “has not been reported,” the US Centers for Disease Control and Prevention said in guidance posted Thursday. It may spread through “saliva or respiratory secretions” during face-to-face contact, but these secretions “drop out of the air quickly,” and studies have found that this method of transmission seems uncommon.

Unlike other viral diseases like Covid-19 and measles, the monkeypox virus isn’t subject to “airborne transmission,” which involves small particles that linger in the air or spread on air currents, the CDC notes. “In instances where people who have monkeypox have travelled on airplanes, no known cases of monkeypox occurred in people seated around them, even on long international flights.”

But because of the potential for monkeypox to spread through respiratory secretions, the agency “recommends that people infected with monkeypox wear a mask if they must be around others in their homes if close, face-to-face contact is likely.”

Masks are also recommended for health care workers and others who may be in close contact with an infected person.

Previous CDC guidance had said that wearing a mask could help protect travelers from monkeypox, but that recommendation was removed late Monday because “it caused confusion,” the agency said.” (I)

“Public health experts currently do not expect the virus to become a major health threat, but are concerned about the recent spread.

“I think any time there’s an outbreak that is ongoing with no evidence of control, I think we should be concerned,” Dr. Wafaa El-Sadr, a professor of epidemiology and medicine at Columbia University Mailman School of Public Health in New York, told ABC News. “I think that’s different from being panic-stricken. But I think the continued increase in numbers of cases of monkeypox and continued increase in countries reporting cases is certainly of concern.”

If the outbreak isn’t contained, this means the virus could be ever-present in a community, circulating at low levels.

But Dr. Scott Roberts, an assistant professor and the associate medical director of infection prevention at Yale School of Medicine, said he does not envision the outbreak as being similar to the COVID-19 pandemic because of the different mechanisms of spread.

COVID-19 generally spreads through the air via tiny droplets and can require as little as 15 minutes of face-to-face contact. In the current outbreak, most of the spread has come from coming into contact with infected people’s lesions.

“It’s not like you’ll pass someone in the elevator, and you’ll get monkeypox,” Roberts told ABC News. “That’s pretty unlikely. The classic COVID definition was within six feet for 15 minutes. This one is more like within six feet for three hours, is what the CDC has said, or contact with the infected lesions.”…

But, most importantly, they said the virus is not spreading uncontrollably yet.” (J)


POST 254. June 2, 2022. MONKEYPOX, “Massachusetts General Hospital this week began vaccinating a small group of workers against monkeypox — the first time the new medicine has been used in this country outside of clinical trials. The workers were in close contact with a man diagnosed with the virus and hospitalized at Mass General from May 12 to May 20. The patient was the first person in the United States to be tied to an ongoing outbreak of the rare virus in Europe and North America.”


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