Children are the latest victims to have been affected by the monkeypox outbreak, with one California toddler and another infant who is not an American resident but was tested in Washington being confirmed to have the virus.
WEBMD reports that officials are investigating how the children got the disease, which officials believe occurred through household transmission. The two cases are unrelated.
Both children have symptoms but are in good health and are receiving treatment, according to CNN. They are being treated with an antiviral medication called tecovirimat (TPOXX), which the US Centre for Disease Control (CDC) recommends for children under age eight because they are considered to be at higher risk.
While the monkeypox outbreak in more than 70 countries was declared a “global health emergency” by the World Health Organisation (WHO) on 23 July, the CDC warns that demand for the virus’ vaccine in the country is outpacing the nation’s supply as the outbreak escalates.
The US has ordered nearly 7m doses overall, but most of those won’t arrive for months, reports The New York Times.
WHO Director-General Tedros Adhanom Ghebreyesus issued the “global health emergency” declaration despite a lack of consensus among members of the organisation’s emergency committee. Nine members were against the designation with six in favour.
The emergency declaration means the outbreak is an “extraordinary event” that threatens to move into other countries and requires a co-ordinated global response, and serves as a plea to draw more global resources and attention to an outbreak, reports The Independent.
The outbreak “has spread around the world rapidly through new modes of transmission about which we understand too little and which meets the criteria in the international health regulations”, said Tedros, confirming 16,000 cases worldwide, with five deaths reported in Africa, according to TimesLIVE.
Meanwhile a study of more than 500 cases diagnosed worldwide suggests the disease is being missed and misdiagnosed frequently, as testing and vaccinations lag.
In the recently published report, which comes from roughly 100 different clinicians stationed around the world, the authors reveal some of the most common symptoms of monkeypox in the current outbreak may not always line up with what people expect to see.
“Most people have never had any training on monkeypox,” said lead study author Chloe Orkin, a professor of HIV Medicine at Queen Mary University of London. “The important thing is to help doctors to recognise it, so they don’t mistake it for a sexually transmitted infection.”
Orkin’s study, published in The New England Journal of Medicine, found that among 528 monkeypox patients identified in 16 countries between April and June, rashes were common (occurring 95% of the time). Some 73% of patients had anogenital lesions, while roughly 10% of patients had only one monkeypox lesion visible on them: 98% of the patients, who all agreed to be in the study, were gay or bisexual men, reflecting the fact that much of the monkeypox transmission in this outbreak has happened during sexual contact.
Some patients had trouble swallowing, or going to the toilet.
Cases ranged from very mild to so debilitatingly painful that it became impossible for the patients to use the toilet or swallow, Orkin said.
“People weren’t only presenting the skin problems,” she added, which is different from how the virus has been characterised in past outbreaks. “They were also presenting with problems inside the anus and inside the mouth. And sometimes these problems were so serious they had to be admitted to hospital for pain.”
Symptoms of monkeypox infection that showed up before people developed a rash included fevers (in 62% of patients), lethargy (41% of the time), muscle aches (31%), and headaches (27%). Among 70 patients who were hospitalised from the study, the most common issues patients had were severe anorectal pain (21 patients), skin infections (18 patients), and trouble swallowing (five patients).
Early treatment is critical, not only to help contain the virus, but also because the antiviral treatments that are available work best when administered early on in the course of an infection, reports Business Insider.
“It can easily be missed,” Orkin said. “And it does look as though it has been missed.”
Dr Lilian Abbo, from the University of Miami, expressed frustration last week that some patients in South Florida had to schedule multiple visits with different providers before they finally received a positive monkeypox diagnosis.
At least 2,323 cases have been diagnosed so far in the US, according to the CDC, most being in New York, followed by California, Illinois and then Florida.
Most cases are among gay or bisexual men, and men who have sex with men, and the numbers are expected to rise in coming weeks.
Clinicians aren’t sure whether the monkeypox that is circulating now is truly a different kind of virus from what they’ve seen in the past, or whether the different presentations are more reflective of how monkeypox is being passed from person to person (through skin to skin touching during sexual contact.)
Though monkeypox DNA was detected in the semen of some of the patients tested in this study, it’s still unclear what that find might mean for potential sexual transmission of this virus.
“You can find virus in semen, but it doesn’t necessarily mean that it’s a public health concern,” said Dr Lawrence Purpura, an infectious disease expert at Columbia University Irving Medical Center.
Purpura, who was not involved in this research and has studied viruses in semen including Ebola and COVID, said that “just detecting a virus doesn’t immediately raise the red flags that we should be worried about sexual transmission at this point, but it does, I think, give enough impetus to really study it – and study it quickly, to figure out if that is a potential risk”.
The CDC says more than cases of the virus have been reported in 74 countries since May, and there is anxiety about the number of vaccines available.
The US has ordered nearly 7m doses overall, but most of that won’t arrive for months. About 372,000 doses have been received by the federal government so far, and 156,000 doses have been distributed nationally.
“We don’t yet have all the vaccine that we would like right now,” said Dr Rochelle Walensky, the CDC director. The government made another 131,000 doses available to states and jurisdictions last week, reports The New York Times.
The Department of Health and Human Services has ordered millions of doses, with 2.5m coming later this year and 2.5m arriving next year.
“It’s like saying we have a tanker of water coming next week when the fire is happening today,” said Gregg Gonsalves, an epidemiologist at the Yale School of Public Health.
“Now we’re in a situation where it’s going to be exceedingly difficult, with limited supplies of the vaccine and still some problems with testing, to get this under control,” he added.
Globally, more than 13,000 monkeypox cases have been identified in 65 countries. Spain has reported more than 2,800 cases, followed by the US, Germany, and the UK.
“Our window of opportunity to control it is rapidly closing,” Anne Rimoin, PhD, an epidemiologist and monkeypox expert at the University of California, Los Angeles, told the Times.
"There are probably a lot more cases out there than we’re aware of,” she said.
The CDC has teamed up with five major commercial testing companies, including Labcorp and the Mayo Clinic, to expand the nation’s testing capacity. The US can now test about 70,000 samples per week, up from 6,000 at the beginning of the outbreak.
Jynneos, a vaccine with two doses that are given 28 days apart, is the only FDA-approved shot specifically for monkeypox. The vaccine is made by Bavarian Nordic, a company in Denmark, and the global supply has been limited.
The FDA recently inspected the company’s manufacturing facility and is deciding whether to approve an additional 780,000 doses created there, the Times reported.
“We’re diligently working to finish up our evaluation of the required information, anticipating the hopeful release of these doses before the end of July,” said Dr Peter Marks, director of the FDA’s Centre for Biologics Evaluation and Research.
Dr Rosamund Lewis, the WHO’s top monkeypox expert, said this week that 99% of all cases beyond Africa were in men.
Study details
Monkeypox Virus Infection in Humans across 16 Countries — April–June 2022
John Thornhill, Sapha Barkati, Sharon Walmsley, Juergen Rockstroh, Andrea Antinori, Luke B. Harrison, Romain Palich, Achyuta Nori, Iain Reeves, Maximillian Habibi, Vanessa Apea, Christoph Boesecke et al., for the SHARE-net Clinical Group.
Published in The New England Journal of Medicine on 21 July 2022
Abstract
Background
Before April 2022, monkeypox virus infection in humans was seldom reported outside African regions where it is endemic. Currently, cases are occurring worldwide. Transmission, risk factors, clinical presentation, and outcomes of infection are poorly defined.
Methods
We formed an international collaborative group of clinicians who contributed to an international case series to describe the presentation, clinical course, and outcomes of polymerase-chain-reaction–confirmed monkeypox virus infections.
Results
We report 528 infections diagnosed between April 27 and June 24, 2022, at 43 sites in 16 countries. Overall, 98% of the persons with infection were gay or bisexual men, 75% were White, and 41% had human immunodeficiency virus infection; the median age was 38 years. Transmission was suspected to have occurred through sexual activity in 95% of the persons with infection. In this case series, 95% of the persons presented with a rash (with 64% having <10 lesions), 73% had anogenital lesions, and 41% had mucosal lesions (with 54 having a single genital lesion). Common systemic features preceding the rash included fever (62%), lethargy (41%), myalgia (31%), and headache (27%); lymphadenopathy was also common (reported in 56%). Concomitant sexually transmitted infections were reported in 109 of 377 persons (29%) who were tested. Among the 23 persons with a clear exposure history, the median incubation period was 7 days (range, 3 to 20). Monkeypox virus DNA was detected in 29 of the 32 persons in whom seminal fluid was analysed. Antiviral treatment was given to 5% of the persons overall, and 70 (13%) were hospitalised; the reasons for hospitalisation were pain management, mostly for severe anorectal pain (21 persons); soft-tissue superinfection (18); pharyngitis limiting oral intake (5); eye lesions (2); acute kidney injury (2); myocarditis (2); and infection-control purposes (13). No deaths were reported.
Conclusions
In this case series, monkeypox manifested with a variety of dermatologic and systemic clinical findings. The simultaneous identification of cases outside areas where monkeypox has traditionally been endemic highlights the need for rapid identification and diagnosis of cases to contain further community spread.
WEBMD article – Two Children in U.S. Diagnosed with Monkeypox (Open access)
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