U.S. Becoming Epicenter of Monkeypox Outbreak

The United States has had the most reported monkeypox cases of any country in world, with 10,392 cases as of Aug. 10, 2022.¹ The next closest nation is Spain, with 5,162 cases.²

Monkeypox is spreading almost exclusively among men who have sex with men, it usually is self-limiting, and there have been no reported deaths in the U.S. cases. However, there are growing concerns that the virus could establish an endemic presence, threatening those at higher risk of adverse outcomes, such as children under 8 years of age, pregnant women, people with eczema or atopic dermatitis, and those who are immunocompromised.

“We’re also seeing cases in women and, now, in children,” said Sandra Fryhofer, MD, chair of American Medical Association Board of Trustees.³ “Anyone and everyone, regardless of gender identity or sexual orientation, is at risk if they’ve had close skin-to-skin contact with someone who has it or if they’ve been exposed to contaminated materials, including towels, sheets, and other personal items. It can also be passed, though not as easily, in respiratory secretions, which means you can get it from prolonged face-to-face contact with an infected person. And this does include kissing.”

The incubation period for monkeypox typically is in the one- to two-weeks range, with patients having flu-like symptoms, fever, and swollen lymph nodes before the rash begins. However, this outbreak has been marked by some atypical initial presentations, making it harder to diagnose by physicians who rarely have seen the disease.

“You’re infectious once any symptoms begin, and remain infectious until the scabs fall off and a fresh layer of skin forms,” Fryhofer said. “Illness typically lasts about two to four weeks.”

Emergency Actions

Monkeypox was declared a public health emergency in the United States on August 4, and federal officials are taking emergency measures to maximize the supply of available vaccine.

For example, on August 9, the Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for Jynneos monkeypox vaccine.⁴

“The EUA allows healthcare providers to administer the vaccine by intradermal injection for individuals ages 18 years and older who are at high risk for monkeypox infection, which will result in an up to five-fold increase in the total number of doses available for use,” the FDA stated. “The EUA also allows for use of the vaccine in individuals younger than 18 years old who are at high risk of monkeypox infection. In these individuals Jynneos is administered by subcutaneous injection.”

The Centers for Disease Control and Prevention also has updated it monkeypox vaccination recommendations and posted infection control guidelines for hospitalization that include:^5,6

• Standard precautions should be applied for all patient care, including for patients with suspected monkeypox. If a patient seeking care is suspected to have monkeypox, infection prevention and control personnel should be notified immediately.

• Activities that could resuspend dried material from lesions, e.g., use of portable fans, dry dusting, sweeping, or vacuuming should be avoided.

• A patient with suspected or confirmed monkeypox infection should be placed in a single-person room; special air handling is not required. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Transport and movement of the patient outside of the room should be limited to medically essential purposes. If the patient is transported outside of their room, they should use well-fitting source control (e.g., medical mask) and have any exposed skin lesions covered with a sheet or gown.

• Intubation and extubation, and any procedures likely to spread oral secretions, should be performed in an airborne infection isolation room.

• Personal protective equipment used by healthcare personnel who enter the patient’s room should include gowns, gloves, eye protection, and an N95 respirator.

Cases Increase 10-Fold

The first cases appeared with seeming simultaneity in the United States and other countries with nonendemic monkeypox in May. The rapid rate of increase in the United States since then is alarming. Again as of August 10, states with the most cases include New York (2,132), California (1,892), Florida (1,018), Texas (780), Georgia (775), and Illinois (717). The only state reporting zero cases was Wyoming.

For comparison on the rapid increase in U.S. cases, on July 13, 2022 — about a month earlier than the August 10 report, there were 1,053 monkey cases. The United States has had close to a 10-fold increase in a four-week period. Internationally, as of August 9, there were 31,800 cases in 89 countries, 82 of which have not historically reported monkeypox.

Generally, increases in other countries are not as dramatic as in the United States, raising questions about the public health response here. The effort to not stigmatize gay men may have to some degree undermined clear communications about how to stop transmission, which occurs through skin contact rather than via body fluids like a typical sexually transmitted disease.

“[The] public health establishment has often seemed more fearful of their responses to monkeypox prevention messaging than of the virus itself,” a recently published commentary argues.⁷ “Crucially, they have often failed to communicate emerging scientific theories that if men avoid anal sex — or perhaps use a condom during intercourse — they might at least limit some of the most devastating monkeypox symptoms, including severe proctitis.” The commentary recommended “reducing our number of partners, skipping sex parties, practicing monogamy, and even being abstinent.”

REFERENCES

1. Centers for Disease Control Prevention. Monkeypox: 2022 U.S. map & case count. Aug. 10, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html
2. Centers for Disease Control Prevention. 2022 monkeypox outbreak global map. Aug. 9, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html
3. American Medical Association. Monkeypox symptoms, vaccines, cases, testing, PPE & more with Sandra Fryhofer, MD. Published Aug. 8, 2022. https://www.ama-assn.org/delivering-care/public-health/monkeypox-symptoms-vaccines-cases-testing-ppe-more-sandra-fryhofer-md
4. Food and Drug Administration. Monkeypox update: FDA authorizes emergency use of JYNNEOS vaccine to increase vaccine supply. Published Aug. 9, 2022. https://www.fda.gov/news-events/press-announcements/monkeypox-update-fda-authorizes-emergency-use-jynneos-vaccine-increase-vaccine-supply
5. Centers for Disease Control Prevention. Interim clinical considerations for use of JYNNEOS and ACAM2000 vaccines during the 2022 U.S. monkeypox outbreak. Updated Aug. 9, 2022. https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html?ACSTrackingID=USCDC_1052-DM87705&ACSTrackingLabel=Reminder%20Today%3A%20CDC%20COCA%20Call%3A%20CDC%20and%20FDA%20Update%3A%20Interim%20Clinical%20Considerations%20for%20Monkeypox%20Vaccination&deliveryName=USCDC_1052-DM87705
6. Centers for Disease Control Prevention. Infection prevention and control of monkeypox in healthcare settings. Updated Aug. 11, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html
7. Ryan B. Opinion: Gay men can fight monkeypox ourselves — by changing how we have sex. The Washington Post. Published Aug. 11, 2022. https://www.washingtonpost.com/opinions/2022/08/11/monkeypox-gay-sex-guidelines/