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Mpox 2022
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Post-exposure vaccine effectiveness and contact management in the mpox outbreak, Madrid, Spain, May to August 2022
Laura Montero Morales , José Francisco Barbas del Buey , Marcos Alonso García , Noelia Cenamor Largo , Alba Nieto Juliá , María C Vázquez Torres , Susana Jiménez Bueno , Andrés Aragón Peña , Elisa Gil Montalbán , Jesús Íñigo Martínez , María Alonso Colón , Araceli Arce Arnáez and on behalf of Madrid Surveillance Network and Vaccination Centre of Madrid RegionBackgroundAppropriate vaccination strategies have been key to controlling the outbreak of mpox outside endemic areas in 2022, yet few studies have provided information on mpox vaccine effectiveness (VE).
AimTo assess VE after one dose of a third-generation smallpox vaccine against mpox when given as post-exposure prophylaxis (PEP) within 14 days.
MethodsA survival analysis in a prospective cohort of close contacts of laboratory-confirmed mpox cases was conducted from the beginning of the outbreak in the region of Madrid in May 2022. The study included contacts of cases in this region diagnosed between 17 May and 15 August 2022. Follow up was up to 49 days. A multivariate proportional hazard model was used to evaluate VE in the presence of confounding and interaction.
ResultsInformation was obtained from 484 close contacts, of which 230 were vaccinated within 14 days of exposure. Of the close contacts, 57 became ill during follow-up, eight vaccinated and 49 unvaccinated. The adjusted effectiveness of the vaccine was 88.8% (95% CI: 76.0–94.7). Among sexual contacts, VE was 93.6% (95% CI: 72.1–98.5) for non-cohabitants and 88.6% (95% CI: 66.1–96.2) for cohabitants.
ConclusionPost-exposure prophylaxis of close contacts of mpox cases is an effective measure that can contribute to reducing the number of cases and eventually the symptoms of breakthrough infections. The continued use of PEP together with pre-exposure prophylaxis by vaccination and other population-targeted prevention measures are key factors in controlling an mpox outbreak.
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Mpox outbreak among men who have sex with men in Amsterdam and Rotterdam, the Netherlands: no evidence for undetected transmission prior to May 2022, a retrospective study
Henry J de Vries , Hannelore M Götz , Sylvia Bruisten , Annemiek A van der Eijk , Maria Prins , Bas B Oude Munnink , Matthijs RA Welkers , Marcel Jonges , Richard Molenkamp , Brenda M Westerhuis , Leonard Schuele , Arjen Stam , Marjan Boter , Elske Hoornenborg , Daphne Mulders , Mariken van den Lubben and Marion KoopmansSince May 2022, over 21,000 mpox cases have been reported from 29 EU/EEA countries, predominantly among men who have sex with men (MSM). The Netherlands was the fourth most affected country in Europe, with more than 1,200 cases and a crude notification rate of 70.7 per million population. The first national case was reported on 10 May, yet potential prior transmission remains unknown. Insight into prolonged undetected transmission can help to understand the current outbreak dynamics and aid future public health interventions. We performed a retrospective study and phylogenetic analysis to elucidate whether undetected transmission of human mpox virus (hMPXV) occurred before the first reported cases in Amsterdam and Rotterdam. In 401 anorectal and ulcer samples from visitors to centres for sexual health in Amsterdam or Rotterdam dating back to 14 February 2022, we identified two new cases, the earliest from 6 May. This coincides with the first cases reported in the United Kingdom, Spain and Portugal. We found no evidence of widespread hMPXV transmission in Dutch sexual networks of MSM before May 2022. Likely, the mpox outbreak expanded across Europe within a short period in the spring of 2022 through an international highly intertwined network of sexually active MSM.
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Persistent morbidity in Clade IIb mpox patients: interim results of a long-term follow-up study, Belgium, June to November 2022
Nicole Berens-Riha , Stefanie Bracke , Jojanneke Rutgers , Christophe Burm , Liesbeth Van Gestel , Matilde Hens , Chris Kenyon , Emmanuel Bottieau , Patrick Soentjens , Isabel Brosius , Marjan Van Esbroeck , Koen Vercauteren , Johan van Griensven , Christophe van Dijck , Laurens Liesenborghs and ITM monkeypox study groupWhile mpox was well characterised during the 2022 global Clade IIb outbreak, little is known about persistent morbidity. We present interim results of a prospective cohort study of 95 mpox patients assessed 3–20 weeks post-symptom onset. Two-thirds of participants had residual morbidity, including 25 with persistent anorectal and 18 with genital symptoms. Loss of physical fitness, new-onset/worsened fatigue and mental health problems were reported in 36, 19 and 11 patients, respectively. These findings require attention by healthcare providers.
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Outcomes of post-exposure vaccination by modified vaccinia Ankara to prevent mpox (formerly monkeypox): a retrospective observational study in Lyon, France, June to August 2022
Modified vaccinia virus Ankara vaccine (MVA-BN; Bavarian Nordic) is recommended to contacts of mpox cases up to 14 days post-exposure but the effectiveness of this strategy is unknown. Among 108 adults (≥ 18 years old) who received one dose of MVA-BN after exposure to mpox, 11 (10%) cases of breakthrough mpox were observed. Sexual exposure was associated with the risk of breakthrough mpox (p = 0.0179). Samples taken from vaccinated breakthrough mpox cases had similar rates of infectious virus isolation than unvaccinated mpox cases.
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Mpox (formerly monkeypox) in women: epidemiological features and clinical characteristics of mpox cases in Spain, April to November 2022
Alberto Vallejo-Plaza , Francisco Rodríguez-Cabrera , Victoria Hernando Sebastián , Bernardo R Guzmán Herrador , Patricia Santágueda Balader , Lucía García San Miguel Rodríguez-Alarcón , Asunción Díaz Franco , Ana Garzón Sánchez , María José Sierra Moros , Spanish Monkeypox Response Network , Fernando Simón Soria and Berta Suárez RodríguezOver 79,000 confirmed cases of mpox were notified worldwide between May and November 2022, most of them in men who have sex with men. Cases in women, for whom mpox might pose different risks, are rare, and Spain has reported more than one third of those in Europe. Using surveillance data, our study found similar time trends, but differences in delay of diagnosis, sexual transmission and signs and symptoms between men and women.
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Results of an interventional HIV testing programme in the context of a mpox (formerly monkeypox) vaccination campaign in Latium Region, Italy, August to October 2022
HIV testing was offered to 2,185 people receiving mpox (formerly monkeypox) vaccination, who reported not being HIV positive. Among them 390 were current PrEP users, and 131 had taken PrEP in the past. Of 958 individuals consenting testing, six were newly diagnosed with HIV. Two patients had symptomatic primary HIV infection. None of the six patients had ever taken PrEP. Mpox vaccination represents an important opportunity for HIV testing and counselling about risk reduction and PrEP.
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Severe mpox (formerly monkeypox) disease in five patients after recent vaccination with MVA-BN vaccine, Belgium, July to October 2022
Nicole Berens-Riha , Tessa De Block , Jojanneke Rutgers , Johan Michiels , Liesbeth Van Gestel , Matilde Hens , ITM monkeypox study group , Chris Kenyon , Emmanuel Bottieau , Patrick Soentjens , Johan van Griensven , Isabel Brosius , Kevin K Ariën , Marjan Van Esbroeck , Antonio Mauro Rezende , Koen Vercauteren and Laurens LiesenborghsVaccination is important in containing the 2022 mpox (formerly monkeypox) epidemic. We describe five Belgian patients with localised severe symptoms of proctitis and penile oedema, occurring between 4 and 35 days after post-exposure preventive vaccination or after one- or two-dose off-label pre-exposure preventive vaccination with MVA-BN vaccine. Genome sequencing did not reveal evidence for immune escape variants. Healthcare workers and those at risk should be aware of possible infections occurring shortly after vaccination and the need for other preventive measures.
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Evaluation of 11 commercially available PCR kits for the detection of monkeypox virus DNA, Berlin, July to September 2022
Before the international spread of monkeypox in May 2022, PCR kits for the detection of orthopoxviruses, and specifically monkeypox virus, were rarely available. Here we describe the evaluation of 11 recently developed commercially available PCR kits for the detection of monkeypox virus DNA. All tested kits are currently intended for research use only and clinical performance still needs to be assessed in more detail, but all were suitable for diagnostics of monkeypox virus, with variations in specificity rather than sensitivity.
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High monkeypox vaccine acceptance among male users of smartphone-based online gay-dating apps in Europe, 30 July to 12 August 2022
We assess monkeypox vaccination acceptance among male adults in the European Region. We conducted an online survey through two dating apps targeting men who have sex with men, from 30 July to 12 August 2022. We developed Bayesian hierarchical logistic regression models to investigate monkeypox vaccination acceptance. Overall crude vaccination acceptance was 82% and higher in north-western compared to south-eastern European regions. Acceptance strongly rose with perception of increased disease severity and transmission risk, and in individuals linked to healthcare.
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Very low risk of monkeypox among staff and students after exposure to a confirmed case in educational settings, England, May to July 2022
We investigated a secondary school (11–16 year-olds), a primary school (5–11 year-olds), reception year (4–5 year-olds) and a nursery (2–5 year-olds) following confirmed monkeypox in an adult in each educational setting during June and July 2022. MVA-BN vaccine was offered up to 14 days post exposure to 186 children < 12 years and 21 were vaccinated. No secondary cases occurred among at least 340 exposed students and more than 100 exposed staff during the 28-day follow-up period.
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The risk of reverse zoonotic transmission to pet animals during the current global monkeypox outbreak, United Kingdom, June to mid-September 2022
We report results of surveillance between June and mid-September 2022 of pet animals living in households of confirmed human monkeypox (MPX) cases. Since surveillance commenced, 154 animals from 40 households with a confirmed human MPX case were reported to the United Kingdom Animal and Plant Health Agency. No animals with clinical signs of MPX were identified. While a risk of transmission exists to pets from owners with a confirmed MPX virus infection, we assess this risk to be low.
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A large multi-country outbreak of monkeypox across 41 countries in the WHO European Region, 7 March to 23 August 2022
Aisling M Vaughan , Orlando Cenciarelli , Soledad Colombe , Luís Alves de Sousa , Natalie Fischer , Celine M Gossner , Jeff Pires , Giuditta Scardina , Gudrun Aspelund , Margarita Avercenko , Sara Bengtsson , Paula Blomquist , Anna Caraglia , Emilie Chazelle , Orna Cohen , Asuncion Diaz , Christina Dillon , Irina Dontsenko , Katja Kotkavaara , Mario Fafangel , Federica Ferraro , Richard Firth , Jannik Fonager , Christina Frank , Mireia G Carrasco , Kassiani Gkolfinopoulou , Marte Petrikke Grenersen , Bernardo R Guzmán Herrador , Judit Henczkó , Elske Hoornenborg , Derval Igoe , Maja Ilić , Klaus Jansen , Denisa-Georgiana Janță , Tone Bjordal Johansen , Ana Kasradze , Anders Koch , Jan Kyncl , João Vieira Martins , Andrew McAuley , Kassiani Mellou , Zsuzsanna Molnár , Zohar Mor , Joël Mossong , Alina Novacek , Hana Orlikova , Iva Pem Novosel , Maria K Rossi , Malgorzata Sadkowska-Todys , Clare Sawyer , Daniela Schmid , Anca Sîrbu , Klara Sondén , Arnaud Tarantola , Margarida Tavares , Marianna Thordardottir , Veronika Učakar , Catharina Van Ewijk , Juta Varjas , Anne Vergison , Roberto Vivancos , Karolina Zakrzewska , Richard Pebody and Joana M HaussigFollowing the report of a non-travel-associated cluster of monkeypox cases by the United Kingdom in May 2022, 41 countries across the WHO European Region have reported 21,098 cases and two deaths by 23 August 2022. Nowcasting suggests a plateauing in case notifications. Most cases (97%) are MSM, with atypical rash-illness presentation. Spread is mainly through close contact during sexual activities. Few cases are reported among women and children. Targeted interventions of at-risk groups are needed to stop further transmission.
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Isolation of viable monkeypox virus from anal and urethral swabs, Italy, May to July 2022
Anal and urethral samples from confirmed cases of monkeypox were screened for monkeypox virus (MPXV) by real-time PCR. Isolation of the virus was subsequently attempted in cell culture. Actively-replicating virus was demonstrated in 13 of 18 and 11 of 15 PCR-positive anal and urethral swabs, respectively, collected within 7 days from symptoms onset. Two asymptomatic secondary cases had detectable MPXV genetic material in urethral secretion and for one, MPXV was successfully isolated, supporting a potential MPXV sexual transmission hypothesis.
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Monkeypox DNA levels correlate with virus infectivity in clinical samples, Israel, 2022
Nir Paran , Yfat Yahalom-Ronen , Ohad Shifman , Shirley Lazar , Ronen Ben-Ami , Michal Yakubovsky , Itzchak Levy , Anat Wieder-Feinsod , Sharon Amit , Michal Katzir , Noga Carmi-Oren , Ariela Levcovich , Mirit Hershman-Sarafov , Alona Paz , Rebecca Thomas , Hadas Tamir , Lilach Cherry-Mimran , Noam Erez , Sharon Melamed , Moria Barlev-Gross , Shay Karmi , Boaz Politi , Hagit Achdout , Shay Weiss , Haim Levy , Ofir Schuster , Adi Beth-Din and Tomer IsraelyThe current monkeypox virus global spread and lack of data regarding clinical specimens’ infectivity call for examining virus infectivity, and whether this correlates with results from PCR, the available diagnostic tool. We show strong correlation between viral DNA amount in clinical specimens and virus infectivity toward BSC-1 cell line. Moreover, we define a PCR threshold value (Cq ≥ 35, ≤ 4,300 DNA copies/mL), corresponding to negative viral cultures, which may assist risk-assessment and decision-making regarding protective-measures and guidelines for patients with monkeypox.
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Monkeypox self-diagnosis abilities, determinants of vaccination and self-isolation intention after diagnosis among MSM, the Netherlands, July 2022
Monkeypox is a zoonotic disease and leads to a smallpox-like disease in humans. The current epidemic in European countries requires informed responses. We investigated the ability to self-diagnose a potential infection, and determinants of vaccination and self-isolation intention after diagnosis among 394 MSM in the Netherlands. We found that about half were able to self-diagnose monkeypox, that 70% had a high intention to get vaccinated and 44% to self-isolate after monkeypox diagnosis. Determinants went beyond mere risk behaviour criteria.
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The relevance of multiple clinical specimens in the diagnosis of monkeypox virus, Spain, June 2022
A monkeypox virus (MPXV) outbreak has been ongoing worldwide since May 2022. The role of specimens other than skin lesions for MPXV diagnosis is unknown. We evaluated 140 different clinical specimens by real-time PCR. The highest positivity rates (97%) were from skin lesions of any part of the body, followed by plasma, pharyngeal and anal swabs. Testing specimens from multiple sites may improve the sensitivity and reduce false-negative test results.
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Monkeypox: another test for PCR
More LessMonkeypox was declared a public health emergency of international concern by the World Health Organization (WHO) on 23 July 2022. Between 1 January and 23 July 2022, 16,016 laboratory confirmed cases of monkeypox and five deaths were reported to WHO from 75 countries on all continents. Public health authorities are proactively identifying cases and tracing their contacts to contain its spread. As with COVID-19, PCR is the only method capable of being deployed at sufficient speed to provide timely feedback on any public health interventions. However, at this point, there is little information on how those PCR assays are being standardised between laboratories. A likely reason is that testing is still limited on a global scale and that detection, not quantification, of monkeypox virus DNA is the main clinical requirement. Yet we should not be complacent about PCR performance. As testing requirements increase rapidly and specimens become more diverse, it would be prudent to ensure PCR accuracy from the outset to support harmonisation and ease regulatory conformance. Lessons from COVID-19 should aid implementation with appropriate material, documentary and methodological standards offering dynamic mechanisms to ensure testing that most accurately guides public health decisions.
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Paediatric monkeypox patient with unknown source of infection, the Netherlands, June 2022
Since May 2022, an international monkeypox (MPX) outbreak has been ongoing in more than 50 countries. While most cases are men who have sex with men, transmission is not restricted to this population. In this report, we describe the case of a male child younger than 10 years with MPX in the Netherlands. Despite thorough source tracing, a likely source of infection has not been identified. No secondary cases were identified in close contacts.
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Frequent detection of monkeypox virus DNA in saliva, semen, and other clinical samples from 12 patients, Barcelona, Spain, May to June 2022
A monkeypox (MPX) outbreak has expanded worldwide since May 2022. We tested 147 clinical samples collected at different time points from 12 patients by real-time PCR. MPX DNA was detected in saliva from all cases, sometimes with high viral loads. Other samples were frequently positive: rectal swab (11/12 cases), nasopharyngeal swab (10/12 cases), semen (7/9 cases), urine (9/12 cases) and faeces (8/12 cases). These results improve knowledge on virus shedding and the possible role of bodily fluids in disease transmission.
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