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Mpox 2022
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Mpox outbreak in France: epidemiological characteristics and sexual behaviour of cases aged 15 years or older, 2022
Catarina Krug , Arnaud Tarantola , Emilie Chazelle , Erica Fougère , Annie Velter , Anne Guinard , Yvan Souares , Anna Mercier , Céline François , Katia Hamdad , Laetitia Tan-Lhernould , Anita Balestier , Hana Lahbib , Nicolas Etien , Pascale Bernillon , Virginie De Lauzun , Julien Durand , Myriam Fayad , Investigation Team , Henriette De Valk , François Beck , Didier Che , Bruno Coignard , Florence Lot and Alexandra MaillesBackgroundLocally-acquired mpox cases were rarely reported outside Africa until May 2022, when locally-acquired-mpox cases occurred in various European countries.
AimWe describe the mpox epidemic in France, including demographic and behavioural changes among a subset of cases, during its course.
MethodsData were retrieved from the enhanced national surveillance system until 30 September 2022. Laboratory-confirmed cases tested positive for monkeypox virus or orthopoxviruses by PCR; non-laboratory-confirmed cases had clinical symptoms and an epidemiological link to a laboratory-confirmed case. A subset of ≥ 15-year-old male cases, notified until 1 August, was interviewed for epidemiological, clinical and sexual behaviour information. Association of symptom-onset month with quantitative outcomes was evaluated by t- or Wilcoxon tests, and with binary outcomes, by Pearson’s chi-squared or Fisher exact tests.
ResultsA total of 4,856 mpox cases were notified, mostly in Île-de-France region (62%; 3,025/4,855). Cases aged ≥ 15 years were predominantly male (97%; 4,668/4,812), with 37 years (range: 15–81) as mean age. Between May and July, among the subset interviewed, mpox cases increased in regions other than Île-de-France, and mean age rose from 35 (range: 21–64) to 38 years (range: 16–75; p = 0.007). Proportions of cases attending men-who-have-sex-with-men (MSM) meeting venues declined from 60% (55/91) to 46% (164/359; p = 0.012); median number of sexual partners decreased from four (interquartile range (IQR): 1–10) to two (IQR: 1–4; p < 0.001).
ConclusionChanges in cases’ characteristics during the epidemic, could reflect virus spread from people who were more to less behaviourally vulnerable to mpox between May and July, or MSM reducing numbers of sexual partners as recommended.
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Role of the National Immunisation Technical Advisory Groups in 13 European countries in the decision-making process on vaccine recommendations
In Europe, National Immunisation Technical Advisory Groups (NITAGs) were established in most countries to promote evidence-informed decision-making in introducing new or improved vaccines or changing recommendations for existing ones. Still, the role, activities and outcomes of NITAGs have not been optimally implemented across Europe. Within the European Joint Action on Vaccination (EU-JAV), we conducted a survey to collect information on decision-making process including the main criteria for the introduction of new vaccines or changes to recommendations on their use. Between December 2021 and January 2022, 13 of the 28 European countries invited participated in an online survey. The criteria ranked as most relevant were disease burden and availability of financial resources. Only one country specified that the NITAG recommendations were binding for the government or the health authority. Vaccinations more often reported for introduction or recommendation changes were those against herpes zoster, influenza, human papillomavirus infection, pneumococcal and meningococcal disease. The planned changes will mainly address children and adolescents (2–18 years) and adults (≥ 45–65 years). Our findings show potential overlaps in the activities of NITAGs between countries; and therefore, collaboration between NITAGs may lead to optimisation of the workload and better use of resources.
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Task Force for a rapid response to an outbreak of severe acute hepatitis of unknown aetiology in children in Portugal in 2022
Berta Grau-Pujol , João Vieira Martins , Isabel Goncalves , Fernanda Rodrigues , Rita de Sousa , Dina Oliveira , Joana Bettencourt , Diana Mendes , Inês Mateus de Cunha , Sara Pocinho , Ana Firme , Benvinda Estela dos Santos , André Peralta Santos , Maria João Albuquerque , Pedro Pinto-Leite , Rui Tato Marinho and Paula VasconcelosOn 5 April 2022, the United Kingdom reported an increase of cases of severe acute hepatitis of unknown aetiology in children, several needing hospitalisation and some required liver transplant or died. Thereafter, 35 countries reported probable cases, almost half of them in Europe. Facing the alert, on 28 April, Portugal created a multidisciplinary Task Force (TF) for rapid detection of probable cases and response. The experts of the TF came from various disciplines: clinicians, laboratory experts, epidemiologists, public health experts and national and international communication. Moreover, Portugal adopted the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) case definition and recommendations. By 31 December 2022, 28 probable cases of severe acute hepatitis of unknown aetiology were reported: 16 male and 17 aged under 2 years. Of these cases, 23 were hospitalised but none required liver transplant or died. Adenovirus was detected from nine of 26 tested cases. No association was observed between adenovirus infection and hospital admission after adjusting for age, sex and region in a binomial regression model. The TF in Portugal may have contributed to increase awareness among clinicians, enabling early detection and prompt management of the outbreak.
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Estimated incubation period distributions of mpox using cases from two international European festivals and outbreaks in a club in Berlin, May to June 2022
Sarah E McFarland , Ulrich Marcus , Lukas Hemmers , Fuminari Miura , Jesús Iñigo Martínez , Fernando Martín Martínez , Elisa Gil Montalbán , Emilie Chazelle , Alexandra Mailles , Yassoungo Silue , Naïma Hammami , Amaryl Lecompte , Nicolas Ledent , Wim Vanden Berghe , Laurens Liesenborghs , Dorien Van den Bossche , Paul R Cleary , Jacco Wallinga , Eve P Robinson , Tone Bjordal Johansen , Antra Bormane , Tanya Melillo , Cornelia Seidl , Liza Coyer , Ronja Boberg , Annette Jurke , Dirk Werber and Alexander BartelBackgroundSince May 2022, an mpox outbreak affecting primarily men who have sex with men (MSM) has occurred in numerous non-endemic countries worldwide. As MSM frequently reported multiple sexual encounters in this outbreak, reliably determining the time of infection is difficult; consequently, estimation of the incubation period is challenging.
AimWe aimed to provide valid and precise estimates of the incubation period distribution of mpox by using cases associated with early outbreak settings where infection likely occurred.
MethodsColleagues in European countries were invited to provide information on exposure intervals and date of symptom onset for mpox cases who attended a fetish festival in Antwerp, Belgium, a gay pride festival in Gran Canaria, Spain or a particular club in Berlin, Germany, where early mpox outbreaks occurred. Cases of these outbreaks were pooled; doubly censored models using the log-normal, Weibull and Gamma distributions were fitted to estimate the incubation period distribution.
ResultsWe included data on 122 laboratory-confirmed cases from 10 European countries. Depending on the distribution used, the median incubation period ranged between 8 and 9 days, with 5th and 95th percentiles ranging from 2 to 3 and from 20 to 23 days, respectively. The shortest interval that included 50% of incubation periods spanned 8 days (4–11 days).
ConclusionCurrent public health management of close contacts should consider that in approximately 5% of cases, the incubation period exceeds the commonly used monitoring period of 21 days.
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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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