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| Image: BBC, 30 July 2022 |
28 July 2022
I have declared the unfolding situation regarding monkeypox (MPX) in Australia to be a Communicable Disease Incident of National Significance.
This follows the World Health Organization (WHO) declaring the global situation regarding MPX to be a public health emergency of international concern.
The latest data from 1 January to 28 July 2022 as reported by the US Centers for Disease Control and Prevention (US CDC) indicates there have been 20,311 MPX cases in 71 countries (including Australia) that have not historically reported MPX.
In Australia, there have been 44 cases – the majority of which have been within returned international travellers.
It is important to note that although I have declared MPX to be a Communicable Disease Incident of National Significance, it is far less harmful than COVID-19 and there have been no deaths reported during the current outbreak outside of countries where the virus is endemic.[inoperative statement as of 30.07.22]
MPX is also not transmitted in the same way as COVID-19 – and is far less transmissible.
The decision to declare MPX a Communicable Disease Incident of National Significance was made under the Emergency Response Plan for Communicable Disease Incidents of National Significance, in consultation with the Australian Health Protection Principal Committee.
Since May, Australian Government Department of Health and Aged Care public health experts have engaged with at-risk communities in partnership with key stakeholders and have been working very closely with their counterparts in state and territory health departments to ensure our response to MPX has been swift and coordinated.
The National Incident Centre has been activated to provide enhanced national coordination to assist states and territories to effectively manage the outbreaks within their jurisdictions.
MPX’s rash and flu-like symptoms are relatively mild, and in most cases, resolve themselves within two to four weeks without the need for specific treatments.
Most cases of MPX in Australia have been among people aged 21 to 40 years. The experience internationally and in Australia to date is most cases have been among gay, bisexual and other men who have sex with men.
Although MPX is not usually considered a sexually transmissible infection, physical contact with an infected person during sexual intercourse carries a significant risk of transmission and intimate physical contact such as hugging, kissing and sexual activities represent a risk of infection, with infectious skin sores being the likely mode of transmission.
The rash usually occurs on the face before spreading to other parts of the body, including the palms of the hands and the soles of the feet. However, in this outbreak it is being seen especially on the genital and perianal regions of affected people.
The rash can vary from person to person and take on the appearance of pimples, blisters or sores. The flu-like symptoms often include fever, chills, body aches, headaches, swollen lymph nodes and tiredness.
The National Medical Stockpile has available stock of MPX treatments, such as antivirals, for states and territories to access on request.
The Australian Technical Advisory Group on Immunisation (ATAGI) has updated clinical guidance on vaccination against monkeypox using the ACAM2000 vaccine to include the use of MVA-BN vaccine to prepare for supplies of the third-generation vaccine being made available in Australia.
Further information about monkeypox is available from the Department of Health and Aged Care’s website www.health.gov.au/health-topics/monkeypox-mpx
NOTE
As of 28 July 2022 there were 45 cases (confirmed and probable) of MPX in Australia. This includes 25 in New South Wales, 16 in Victoria, 2 in the Australian Capital Territory, 1 in Queensland and 1 in South Australia [Australian Dept. of Health, 29 July 2022].
Eleven days later, on 8 August, it was reported that the number of cases has risen to 58 cases, with 33 of those cases being found in NSW. All but two cases appear to have been contracted overseas.
The Lancet, 30 July 2022:
WHO's declaration on July 23 that the current monkeypox outbreak constitutes a Public Health Emergency of International Concern (PHEIC) was unprecedented. It is the seventh such declaration, but the first made against the advice of a majority of the emergency committee (nine were against, six were for). Dr Tedros’ decision is a brave one. It needs to serve as a global wake-up call. The question is whether it will prompt the escalated efforts required to control the outbreak.
Dr Tedros gave three broad reasons for his decision. “We have an outbreak that 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.” The details make for a compelling case. So far this year, up to July 22, 16016 cases have been reported from 75 countries. Where monkeypox is endemic, such as in DR Congo, large new outbreaks have been reported in diverse populations. Outside of west and central Africa, the outbreak is concentrated, for now, in men-who-have-sex-with-men (MSM). Why the disease's epidemiology has changed is still unclear, as are many other aspects of the outbreak. Recent case series from non-endemic countries have shown differences in clinical features compared with previous reports. Lethargy and fever seem to be less common, and several patients have no prodromal symptoms. Skin lesions are found predominantly in genital or perianal areas. Transmission is known to occur through skin-to-skin contact, but monkeypox DNA has been found in patients’ seminal fluid—whether it represents replication-competent virus remains unknown. The rapid worldwide spread of a disease, for reasons we are unsure of, was clearly an over-riding concern for Dr Tedros. An urgent energised research effort is now needed to understand these and other issues related to the outbreak.
Countries must strengthen public health preparedness and response. Case definitions should be updated and harmonised as new data emerge, with heightened surveillance, case detection, and contact tracing. Patients need to be supported in isolation and treatment, and targeted immunisation might be needed for people at high risk of exposure. Recent experience with COVID-19 might help countries institute these measures but many health systems are at breaking point already. There is a risk too that the public is fatigued by talk of pandemics and their control. Misinformation about monkeypox has already begun to circulate. The public need to be engaged and targeted risk-communication strategies developed. Monkeypox is not COVID-19. The R0 is around 1, and transmission mechanisms are entirely different. The clade of monkeypox that seems to be responsible for the outbreak largely causes mild self-limiting illness, although patients have been admitted to hospital, mainly for pain. Ensuring wide understanding of these points is key for managing public anxiety.
Engagement among many MSM has been high since the outbreak started, and this population is—as ever—keen to take care of its health (and do their part to protect others). Countries that criminalise homosexuality and marginalise LGBTI+ communities risk both patients’ wellbeing and chances of controlling transmission. Stigma and discrimination need to be fought. It would be wrong to categorise monkeypox as a disease of MSM.
The expedited pathways for research, development, regulatory approval, and manufacturing of medical countermeasures developed for COVID-19 should be repurposed for monkeypox. A lack of diagnostic tests is hampering case identification in some countries. Tecovirimat, originally produced to treat smallpox, has been licenced by European regulators for monkeypox, but not yet by the US FDA. Other promising treatments, such as cidofovir and brincidofovir, require clinical study. A monkeypox vaccine (sold as Imvanex in Europe and Jynneos in the USA) has been approved, but supplies of both treatments and vaccines are extremely limited. WHO will have to take a much more muscular approach to ensure global access and avoid the inequities of the COVID-19 response.
Whether or not you agree with WHO's decision, there has undoubtedly been a missed opportunity. Monkeypox is not new. It has been causing illness and death in large numbers for decades. Specialists have long called for affordable countermeasures, strengthened surveillance, and more study. But like Ebola and Zika, monkeypox only commands global attention when it hits high-income countries with predominantly White populations. As a result, the window of opportunity to prevent monkeypox becoming established in communities worldwide is closing. Now is a key moment. It warrants the strongest medical, scientific, and political global effort.
BACKGROUND
Key facts
Vaccines used during the smallpox eradication programme also provided protection against monkeypox. Newer vaccines have been developed of which one has been approved for prevention of monkeypox
Monkeypox is caused by monkeypox virus, a member of the Orthopoxvirus genus in the family Poxviridae.
Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. Severe cases can occur. In recent times, the case fatality ratio has been around 3–6%.
Monkeypox is transmitted to humans through close contact with an infected person or animal, or with material contaminated with the virus.
Monkeypox virus is transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding.
Monkeypox is a viral zoonotic disease that occurs primarily in tropical rainforest areas of central and west Africa and is occasionally exported to other regions.
An antiviral agent developed for the treatment of smallpox has also been licensed for the treatment of monkeypox.
The clinical presentation of monkeypox resembles that of smallpox, a related orthopoxvirus infection which was declared eradicated worldwide in 1980. Monkeypox is less contagious than smallpox and causes less severe illness.
Monkeypox typically presents clinically with fever, rash and swollen lymph nodes and may lead to a range of medical complications….
Outbreaks
Human monkeypox was first identified in humans in 1970 in the Democratic Republic of the Congo in a 9-month-old boy in a region where smallpox had been eliminated in 1968. Since then, most cases have been reported from rural, rainforest regions of the Congo Basin, particularly in the Democratic Republic of the Congo and human cases have increasingly been reported from across central and west Africa.
Since 1970, human cases of monkeypox have been reported in 11 African countries: Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Cote d’Ivoire, Liberia, Nigeria, the Republic of the Congo, Sierra Leone and South Sudan. The true burden of monkeypox is not known. For example, in 1996–97, an outbreak was reported in the Democratic Republic of the Congo with a lower case fatality ratio and a higher attack rate than usual. A concurrent outbreak of chickenpox (caused by the varicella virus, which is not an orthopoxvirus) and monkeypox was found, which could explain real or apparent changes in transmission dynamics in this case. Since 2017, Nigeria has experienced a large outbreak, with over 500 suspected cases and over 200 confirmed cases and a case fatality ratio of approximately 3%. Cases continue to be reported until today.
Monkeypox is a disease of global public health importance as it not only affects countries in west and central Africa, but the rest of the world. In 2003, the first monkeypox outbreak outside of Africa was in the United States of America and was linked to contact with infected pet prairie dogs. These pets had been housed with Gambian pouched rats and dormice that had been imported into the country from Ghana. This outbreak led to over 70 cases of monkeypox in the U.S. Monkeypox has also been reported in travelers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, to Singapore in May 2019, and to the United States of America in July and November 2021. In May 2022, multiple cases of monkeypox were identified in several non-endemic countries. Studies are currently underway to further understand the epidemiology, sources of infection, and transmission patterns.
