US monkeypox cases reported, as Spain and Portugal report infections

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Jhe United States on Wednesday confirmed a case of monkeypox infection in a man who recently traveled to Canada. It is not yet known if the man, who lives in Massachusetts and who drove to Canada, is linked to the growing outbreak of monkeypox cases in Europe.

The case was announced in a statement posted on the Massachusetts Department of Public Health website. Confirmatory tests have been carried out by the Centers for Disease Control and Prevention, which warned earlier on Wednesday that cases in this country were likely to begin to be detected.

“Given that we have now seen confirmed cases from Portugal, suspected cases from Spain, we are seeing this expansion of confirmed and suspected cases around the world, we feel that no one has the arms around that to find out how big and expansive it could be. And given the amount of travel between the United States and Europe, I’m very confident that we’re going to see cases in the United States,” said Jennifer McQuiston, deputy director of the Pathogens and High Consequence Pathologies Division. from the CDC.

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McQuiston said in an email Wednesday that it has not yet been determined whether the Massachusetts case is part of the growing European outbreak.

The development adds the US and possibly Canada to a growing list of countries reporting cases of monkeypox in an outbreak first spotted in the UK. The Public Health Agency of Canada said in a statement late Wednesday that no cases have been reported at this time.

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Maria Van Kerkhove, who heads the emerging diseases and zoonoses unit of the World Health Organization‘s health emergencies programme, said Spain had now confirmed some cases and more countries would join the list.

“We have had positive cases identified in the UK, Portugal and Spain. And we expect there will be more,” Van Kerkhove told STAT on Wednesday.

Earlier today, Spain announced it was investigating eight suspected cases, and Portugal said it was investigating more than 20 suspected cases, five of which have already been confirmed. It is currently unclear whether the outbreaks are linked to each other or to that of the UK, where nine confirmed cases and one probable case have been reported.

If they are connected, it is not yet clear whether the virus has spread from the UK to Europe, or vice versa. It is also not known how long the virus has been spreading in these countries. “Obviously it’s been going on for a few weeks,” Van Kerkhove said.

Most cases have been detected in men who are gay, bisexual or have sex with men, she confirmed, but cautioned against focusing too much on this fact.

“We find where we’re looking,” Van Kerkhove said, noting that countries have reached out to sexual health clinics to ask about patients with unusual rashes. It is important that other healthcare providers in other settings – GPs, dermatologists and others – are aware of the possibility that they may see cases of monkeypox so that if the virus spreads more widely, they take the proper precautions and these cases are not missed.

The details that have come to light so far raise the prospect of an even more geographically widespread outbreak, said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

“There could be dynamic transmission here that we just didn’t appreciate because of the potential number of contacts,” he said, adding that it will be important to collect information on the number of intimate contacts. patients have had and where these contacts may have come from. .

Tom Inglesby, director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, said a number of countries outside of central and west Africa, where monkeypox is more common, have experience to deal with introductions of the virus, so there is a possibility that outbreaks will be “relatively small”.

“I think it’s still likely, given the past,” Inglesby told STAT. “But on the other hand, it starts with a lot more anchoring, in a much more distributed way, and we don’t understand how it happened… in these networks.”

“This could have the potential to shift and will require quite a significant public education effort in affected communities and perhaps even more broadly, so that people recognize the possibility” of monkeypox infection, he said. -he declares.

The UK Health Security Agency said on Wednesday it had detected two more cases, bringing the number reported this month to nine. Prior to this outbreak, the UK had only detected seven cases of monkeypox. The last two cases had not traveled to countries where the monkeypox virus is endemic and have no known connection to any of the earlier cases “so it is possible that they acquired the infection from community transmission,” the agency said in a statement, adding that recent cases have primarily involved men who identify as gay, bisexual or who have sex with men.

The rapid accumulation of cases is ringing the alarm bells.

On Tuesday, the CDC signaled that it was concerned about the state of the outbreak in the UK and the possibility of cases being discovered in other countries.

“We’re concerned that this is very different from what we typically think of monkeypox,” McQuiston said. “We don’t understand how many more cases could exist in the UK, for example, with undefined chains of transmission. We have a feeling there may be some unusual methods of transmission, through intimate contact or some form of close personal contact that we have not previously associated with monkeypox.

The WHO, which previously designated monkeypox as a priority pathogen, hosted an expert meeting on monkeypox and orthopoxviruses – the extended family of smallpox viruses – early next week. Among the issues experts are likely to tackle is an apparent change in the epidemiology of the disease in countries where the virus is endemic that has occurred in recent years.

“We are seeing a change in the age distribution of cases. We are seeing a shift in the geographic distribution of cases,” said Michael Ryan, executive director of WHO’s Health Emergencies Programme. “We really need to understand this deep ecology. We really need to understand human behavior in these regions and we need to try to prevent disease from reaching humans in the first place. »

The monkeypox virus is related to the smallpox virus, which caused smallpox, a once dreaded disease that was declared eradicated in 1980. Symptoms of monkeypox are similar to but milder than smallpox.

Those infected develop flu-like symptoms – fever, body aches, chills – but also swollen lymph nodes. One to three days after the onset of fever, a characteristic rash appears, often starting on the face. Many conditions can cause rashes, but the monkeypox rash has some unusual features, including the fact that blisters can form on the palms of the hands.

In countries where it is endemic, the virus is believed to spread to people primarily from infected animals when people kill or prepare bushmeat for consumption.

Once the virus has reached humans, human-to-human transmission can occur via respiratory droplets – virus-laden saliva that can infect the mucous membranes of the eyes, nose and throat – or through contact with lesions of the monkeypox or bodily fluids, with the virus entering through small cuts in the skin. It can also be transmitted by contact with clothing or linens contaminated with material from monkeypox lesions.

Cases outside of Africa have been rare, although there was a large outbreak in the United States in 2003 that involved 47 confirmed and probable cases in six states. This outbreak, the first reported outside of Africa, has been attributed to the importation of small mammals from Ghana.

However, in recent years there have been slight increases in exported cases of monkeypox. The United States detected two in 2021, both in travelers returning from Nigeria. The UK has seen multiple importations in recent years and Israel and Singapore have also detected cases.

McQuiston said the number of cases exported from Nigeria in particular appears to be at odds with the number of cases reported in the country itself.

“I think we are concerned about the number of exported cases in travelers that we have seen. And to have so many over the past few years is just a sign to us that there is far more transmission of monkeypox in Nigeria than perhaps the [official] the numbers suggest,” she said.

“And I think it’s also a sign for us that the more traditional routes of transmission that we think of, like hunting wild animals, contact with bushmeat, living at this interface between the jungle and the small communities don’t seem to be a transmission driver in terms of what we see happening, and so that makes us cast a wider net on potential risk factors.

There is no licensed vaccine to protect against monkeypox, or specific drugs for the disease. But vaccines and drugs developed and stockpiled as protection against a return of smallpox are thought to be helpful. During the 2003 epidemic in the United States, the smallpox vaccine was used.

The WHO’s Van Kerkhove noted that some of these products have been licensed using what’s called the animal rule, where animal efficacy data is used as a surrogate because the absence of circulating smallpox means that the effectiveness of vaccines or drugs cannot be tested in people. As a result, such a product could only be used in a clinical trial, she said.

“There are options. We just need to make sure they are used appropriately. One of the things with vaccines is that we want to make sure that if vaccines are needed and used, they are used among the populations that need them the most. There is not enough supply of anything right now,” she said.

Still, she expressed confidence that the outbreak can be controlled.

“What we need to do now is focus on stopping the spread. And we can do that. We can do that with the right messaging, with the right testing…with supportive isolation and clinical care. if necessary, with the protection of health workers,” Van Kerkhove said.

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