Since 13 May 2022, and as of 2 June 2022, 780 laboratory confirmed cases of monkeypox have been reported to or identified by WHO from 27 Member States across four WHO regions that are not endemic for monkeypox virus. Epidemiological investigations are ongoing. Most reported cases so far have been presented through sexual health or other health services in primary or secondary health care facilities and have involved mainly, but not exclusively, men who have sex with men (MSM).
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While the West African clade of the virus has been identified from samples of cases so far, most confirmed cases with travel history reported travel to countries in Europe and North America, rather than West or Central Africa where the monkeypox virus is endemic. The confirmation of monkeypox in persons who have not travelled to an endemic area is atypical, and even one case of monkeypox in a non-endemic country is considered an outbreak. While most cases are not associated with travel from endemic areas, Member States are also reporting small numbers of cases in travelers from Nigeria, as has been observed before.
The sudden and unexpected appearance of monkeypox simultaneously in several non-endemic countries suggests that there might have been undetected transmission for some unknown duration of time followed by recent amplifier events.
WHO assesses the risk at the global level as moderate considering this is the first time that many monkeypox cases and clusters are reported concurrently in non-endemic and endemic countries in widely disparate WHO geographical areas.
As of 2 June 2022, 780 laboratory confirmed cases have been notified to WHO under the International Health Regulations (IHR) or identified by WHO from official public sources in 27 non-endemic countries in four WHO Regions. This represents an increase of 523 laboratory confirmed cases (+203%) since the Disease Outbreak News of 29 May, when a total of 257 cases were reported. As of 2 June 2022, there have been no deaths associated within the current monkeypox outbreak in non-endemic countries, however, cases and deaths continue to be reported from endemic countries (see Table 2).
While investigations are ongoing, preliminary data from polymerase chain reaction (PCR) assays indicate that the monkeypox virus strains detected in Europe and other non-endemic areas belong to the West African clade.
Figure 1 and Table 1 show the geographical distribution of monkeypox cases reported to or identified by WHO between 13 May to 2 June 2022 in non-endemic countries. The majority of cases (n=688; 88%), were reported from the WHO European Region (20 Countries). Confirmed cases have also been reported from the Region of the Americas (n=80; 10%), Eastern Mediterranean Region (n=9; 1%) and Western Pacific Region (n=3;
Figure 1. Geographic distribution of cases of monkeypox in non-endemic countries reported to or identified by WHO from official public sources, between 13 May and 2 June 2022, 5 PM CEST.
To date, the clinical presentation of confirmed cases has been variable. Many cases in this outbreak are not presenting with the classical clinical picture for monkeypox. In cases described thus far in this outbreak, common presenting symptoms include genital and peri-anal lesions, fever, swollen lymph nodes, and pain when swallowing. While oral sores remain a common feature in combination with fever and swollen lymph nodes, the local anogenital distribution of rash (with vesicular, pustular or ulcerated lesions) sometimes appears first without consistently spreading to other parts of the body. This initial presentation of a genital or peri-anal rash in many cases suggests close physical contact as the likely route of transmission during sexual contact. Some cases have also been described as having pustules appear before constitutional symptoms (e.g., fever) and having lesions at different stages of development, both of which are atypical of how monkeypox has presented historically. Apart from patients hospitalized for the purpose of isolation, few hospitalizations have been reported. Complications leading to hospitalization have included the need to provide adequate pain management and the need to treat secondary infections.
In addition to the cases reported from or identified in non-endemic countries, WHO continues to receive updates on the status of ongoing monkeypox outbreaks in endemic countries[1] in the African region through established surveillance mechanisms (Integrated Disease Surveillance and Response). From January to 1 June 2022, 1408 suspected and 44 confirmed cases including 66 deaths were reported from seven endemic countries (Table 2).
Table 2. Cases of monkeypox in the WHO African Region reported to WHO from 1 January 2022 to 1 June 2022For additional information please refer to WHO AFRO Weekly Bulletin on Outbreaks and Other Emergencies here.
WHO continues to support sharing of information about this outbreak of monkeypox. Clinical and public health incident response has been activated at WHO and in many Member States to coordinate comprehensive case finding, contact tracing, laboratory investigation, clinical management, isolation, and implementation of infection and prevention and control measures.
Genomic sequencing of viral deoxyribonucleic acid (DNA) of the monkeypox virus, where available, is being undertaken. Several European countries (Belgium, France, Germany, Israel, Italy, the Netherlands, Portugal, Slovenia, Spain, Switzerland and the United States of America) have published full-length or partial genome sequences of the monkeypox virus found in the current outbreak. While investigations are ongoing, preliminary data from PCR assays indicate that the monkeypox virus genes detected belong to the West African clade.
Currently, the public health risk at the global level is assessed as moderate considering this is the first time that many monkeypox cases and clusters are reported concurrently in non-endemic and endemic countries in widely disparate WHO geographical areas.
Additionally, as epidemiological and laboratory information are still limited, the actual number of cases is likely an underestimate. This may in part be due to the lack of early clinical recognition of an infection previously known to occur mostly in West and Central Africa, limited surveillance, and a lack of widely available diagnostics in some countries. Given the number of countries across several WHO regions reporting cases of monkeypox, it is highly likely that other countries will identify cases and there will be further spread of the virus.
Although the current risk to human health and for the general public remains low, the public health risk could become high if this virus exploits the opportunity to establish itself in non-endemic countries as a widespread human pathogen. There is also a risk to health workers if they are not using adequate infection prevention and control (IPC) measures or wearing appropriate personal protective equipment (PPE) when necessary, to prevent transmission. Though not reported in this current outbreak, the risk of health care associated infections has been documented in the past in both endemic and non-endemic areas. There is the potential for increased health impact with wider dissemination in vulnerable groups, as the risk of severe disease and mortality is recognized to be higher among children and immunocompromised individuals. There is limited data among people living with HIV, but those who take antiretrovirals and have a robust immune system have not reported a more severe course; those people living with HIV who are not on treatment or remain immunosuppressed may have a more severe course, as documented in the literature. Infection with monkeypox in pregnancy is poorly understood, although limited data suggest that infection may lead to adverse outcomes for the foetus.
To date, all cases identified in non-endemic countries whose samples were confirmed by PCR have been identified as being infected with the West African clade. There are two known clades of monkeypox, one endemic to West Africa (WA) and one to the Congo Basin (CB) region. The WA clade has in the past been associated with an overall lower mortality rate of
Vaccination against smallpox was shown in the past to be cross-protective against monkeypox. However, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, depending on the country, since smallpox vaccination programmes ended worldwide in 1980 after the eradication of smallpox. The original (first generation) smallpox vaccines from the eradication programme are no longer available to the general public. In addition, protection for those who were vaccinated may have waned over time.
Smallpox and monkeypox vaccines, where available, are being deployed in a limited number of countries to manage close contacts. While smallpox vaccines have been shown to be protective against monkeypox, there is also one vaccine approved for prevention of monkeypox. This vaccine is based on a strain of vaccinia virus (known generically as modified vaccinia Ankara Bavarian Nordic strain, or MVA-BN). This vaccine has been approved for prevention of monkeypox in Canada and the United States of America. In the European Union, this vaccine has been approved for prevention of smallpox. An antiviral to treat orthopoxviruses has been also recently approved in the United States of America and in the European Union. WHO has convened experts to review the latest data on smallpox and monkeypox vaccines, and to provide guidance on how and in what circumstances they should be used.
The advice provided hereafter by the WHO on actions required to respond to the multi-country monkeypox outbreak, is based 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 Origins of Novel Pathogens (SAGO); as well as by the outcome of ad-hoc experts meetings. 2ff7e9595c
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