Benjamin Mateus
The number of confirmed and suspected cases of monkeypox infections globally has passed the 10,000 mark, according to official figures. As of July 14, there have been 11,042 total cases, of which 11,006 have been confirmed.
The daily figure has risen to over 500 cases on a seven-day rolling average. Europe continues to remain the epicenter of the global outbreak. Seventy-four non-endemic countries and territories (outside the central African region where monkeypox has existed for decades) have reported such cases, including eight on the African continent.
Spain has the highest case count, with 2,447 monkeypox infections. Germany and the UK are neck and neck with 1,790 and 1,789 cases, respectively. Case counts in France and Italy continue to climb, and Russia was the latest country across the Eurasian landmass that reported its first confirmed case.
North America, followed by Latin America, are other regions where monkeypox cases are soaring. The United States has reported 1,049 monkeypox infections, with approximately 76 cases per day on a moving average. Compared to last week, cases are up nearly 40 percent.
California, New York, Illinois and the District of Columbia have the highest infection rates. In New York City and San Francisco, the public health departments have said that their stock of monkeypox vaccines, made from the attenuated strain of the vaccinia virus, is exhausted.
With 484 monkeypox infections, Canada has seen a 60 percent jump in cases since July 4. Quebec has seen the lion’s share of cases, with 284. Ontario and British Columbia are also seeing a growing number of infections.
Brazil reported its first case back on June 8. Low single-digit daily infection numbers were being confirmed until the end of June when a sudden spike in cases was observed. The highest single-day count was on July 6, with 36 confirmed cases. In all, the country now has tallied 227 cases. Additionally, almost every country neighboring Brazil has also seen such cases reported to their respective public health departments. Mexico has also seen a sudden surge in cases recently.
The Director-General for the World Health Organization (WHO), Dr. Tedros Adhanom Ghebreyesus, affirmed at last Tuesday’s press briefing that the emergency committee for monkeypox would reconvene to examine the recent trends in infections and response by countries in deploying countermeasures against the virus.
On June 24, the emergency committee, in what amounted to be a split decision, favored not declaring the outbreak a pandemic and allowing more time to accrue while the WHO gathered further evidence on trends in cases and newly affected geographic regions. They noted that reconvening the committee would depend on several criteria, including case and death rates, spread outside affected LGBT communities, changes in the virulence of the virus and the establishment of the virus in animal populations.
They insisted that the WHO and national public health institutions work with the high-risk communities where cases remain predominately among men who have sex with men and workers at clubs and spas where such sexual activities occur. The emergency committee also recommended that health institutes work with vaccine developers and consult experts in the field to raise awareness about the disease and initiate the infrastructure for tracing, testing and treating infected and close contacts.
Professor Yaneer Bar-Yam, president of the New England Complex Systems Institute and co-founder of the World Health Network (WHN), has been rightly critical of the WHO for its delay in declaring the monkeypox outbreak a public health emergency of international concern. The WHN had preemptively declared monkeypox a pandemic on June 22, ahead of the initial emergency committee meeting, to bring pressure on the global health organization.
Bar-Yam, who had in late January 2020 raised concerns about the WHO’s slowness in alerting the world of the threat posed by the rapidly growing global transmission of COVID-19, said recently, during an online webinar to discuss the monkeypox pandemic, “The reason to declare monkeypox a pandemic is to alert everyone to take action to prevent more cases from happening. That is the essential motivation. If you [WHO] tell everyone everything is ok, then everyone will go about their usual business.”
He added, “The countries where cases are occurring are limiting the testing and interventions with a focus on men who have sex with men and that community and known exposures. As we know from other pandemics, there is an undercounting and lack of clarity of what transmission is taking place, and we have a challenge of knowing the true magnitude.”
Guest speaker Dr. Kavita Patel, a family medicine physician in Washington D.C. and former Obama administration director of policy for the White House Office of Intergovernmental Affairs and Public Engagement, spoke about the lack of familiarity among physicians and health institutes about monkeypox infections.
“Unless a patient raises concerns directly about a rash and monkeypox, most won’t entertain the diagnosis,” she said. “There are so many gaps in education now,” both in health care and at the community level. She added there was a significant need to implement testing and vaccine clinics immediately.
Dr. Patel also told listeners that with LabCorp signing on, there are now five US commercial laboratories, Aegis Science, LabCorp, Mayo Clinic Laboratories, Quest Diagnostic and Sonic Healthcare, that can run PCR tests for monkeypox. Yet, she noted, “US capacity is about 60,000 tests per week which are not enough.” Also, the testing and turnaround on these specimens can be laborious, and may take up to three days, further delaying the diagnosis and enabling the continued spread of the virus.
Dr. Patel added, “This has been what we have needed quickly to keep it contained and use a ring vaccination strategy—a post-prophylaxis strategy [where the vaccines are given after exposure to the pathogen to decrease the severity of the disease]. If we had better, more widely available testing, we would have had a better ability. Now, in New York City, D.C. and San Francisco, we have run out of Jynneos [monkeypox vaccine manufactured by Bavarian Nordic]. We are turning to the smallpox vaccine, but it is very difficult to use because of its terrible side effects.”
The manufacturer of the monkeypox vaccine is presently undergoing system modifications at its plants, and production of the vaccines will be limited for the next several quarters. Modeling the monkeypox virus cases leads to estimates that the UK could expect 60,000 cases per day by the end of 2022 and, conceivably, a half-million cases or more by the end of September.
Epidemiologist Dr. Eric Feigl-Ding, a co-founder of the WHN, warned that though the number of cases remains small, it is growing at about 40 to 50 percent per week, or 10-fold growth over six weeks. He said, “Case counts are increasing from 300 to 400 daily cases a week on seven-day averages. The US broke the 1,000 barrier and cases are accelerating.”
He criticized the CDC’s arbitrary and mechanical risk categorization that labeled intermediate risk as anyone in close contact with an infected person for more than six hours without a mask. The panel urged listeners to understand that all transmission routes were viable and to be aware that smallpox, which is in the same family of viruses as monkeypox, can be passed on through airborne transmission.
Bar-Yam added, “Masking is a good idea, but there is no guidance for it. Masks are important, and these need to be acknowledged. There seem to be competing factions at the CDC on what they recommend. The confusion is dangerous, and clear guidance is required.” The WHN-sponsored panel strongly urged everyone to mask and noted that the CDC had previously endorsed their use for monkeypox.
In concluding his initial remarks, Feigl-Ding warned that as cases of monkeypox in communities accelerated, with schools set to open this fall, the likelihood of these infections spreading among children was a major problem as the virus is most dangerous to the youngest. They also have never previously received the smallpox vaccine, meaning they are immunologically naïve to the virus and lack any previous protection.
Bar-Yam explained the evidence for disease severity in children comes from clinical experience in Africa, where the virus is endemic. In population-based studies on monkeypox, pediatric patients made the bulk of those admitted to hospitals and ICUs. He also warned that the consequences of monkeypox infection in immunocompromised patients and pregnant women could be catastrophic.
The panelists also raised the following caveats about the Jynneos vaccine. Though it is safe in the immunocompromised, it hasn’t been evaluated in pregnant or breastfeeding women and is also not authorized in those under 18, the most vulnerable population.
On a question from the audience about health systems becoming vectors of transmission for the monkeypox virus, Dr. Patel said she was very concerned about this issue. Considering the lack of awareness at most health institutions on the signs and symptoms of monkeypox and the slow turnaround in test results, she said this was a genuine possibility. Hospitals should take precautions against airborne transmission of monkeypox. Dr. Patel said, “If patients test negative for COVID, health care providers will let routine procedures slide.” She urged that those on the frontline of health care settings should receive the monkeypox vaccines to protect them and their patients.
Bar-Yam summarized, “A WHO declaration of a pandemic would be significant. But there remains a vacuum of leadership.” He reflected, “I sat at a recent WHO meeting. They didn’t go into using masks or travel testing. Though they did say it isn’t just sexual transmission and anyone can get infected, they did not convey the message of urgency. The need to identify cases quickly was not well communicated. There is a desire to maintain calm. However, this is interpreted as the sense that there is no urgency. To solve this problem, we must first communicate the urgency [to act].”
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