2022 mpox outbreak

The 2022 mpox outbreak refers to a significant outbreak of mpox, formerly known as monkeypox, in the United States and in other countries beginning in May 2022. Mpox is a virus closely related to smallpox that was first observed in monkeys in 1958 and in humans in 1970. The virus causes a variety of symptoms such as fever, chills, headache, backache, and swollen lymph nodes. It is most notable for a widespread rash, which can occur all over the body and results in scabbing. The origin of mpox is unknown, but it can be harbored in African rodents and primates, and then passed on to humans.

Prior to 2022, the virus was associated with West and Central Africa, especially the Congo Basin. Starting in May 2022, however, mpox began to spread across the globe with a prevalence of confirmed cases in Europe and North America. This was the first time in history that this virus was reported in such high numbers outside West and Central African countries. Many, but not all, of reported mpox cases were found in men who have sex with men. In response, the United States and European Union (EU) developed plans to vaccinate, treat, and prevent the spread of the disease.

Background

Mpox is caused by the monkeypox virus, which is a member of the Orthopoxvirus genus, which also includes the smallpox, vaccinia, and cowpox viruses. All Orthopoxviruses can be transmitted to humans, but cowpox has not been observed being passed from human to human. In 1980 the World Health Organization (WHO) officially declared the eradication of smallpox worldwide. Although in the same genus, each virus is transmitted slightly differently. Smallpox and vaccinia are mostly respiratory but can sometimes be passed by contact with infectious skin, lesions, or scabs. After first being passed from animals such as African rodents and primates to humans, mpox spreads from human to human through respiratory secretions or through direct contact with infectious skin lesions like scabs.

Mpox was first discovered in 1958 when two outbreaks of a pox-like disease were observed in research monkeys. The origins of the disease are unknown, but African rodents and non-human primates may carry the virus and infect people. The first human case of mpox occurred in 1970. In 2003 mpox arrived in the United States and was linked to contact with pet prairie dogs. This was the first mpox outbreak outside Africa and led to more than seventy cases of mpox in the United States. Isolated cases have been reported since 2018 in countries such as Israel and within the United Kingdom. These cases were linked to travel from Nigeria.

People who are infected with mpox first experience a fever along with symptoms such as swollen lymph nodes, headache, backache, exhaustion, chills, vomiting, severe abdominal pain, and respiratory symptoms such as a sore throat, nasal congestion, and coughing. These symptoms are accompanied by a widespread rash that may be located on or near the genitals or anus, and in other areas like the hands, feet, chest, face, or mouth. The rash goes through several stages, including scabbing, before healing. It may appear like pimples or blisters and can be painful or itchy. These symptoms usually start within three weeks of exposure to the virus. After the onset of flu-like symptoms, those infected with mpox generally develop a rash within one to four days.

Mpox can be spread from human to human from the time that symptoms start until the rash has completely healed, all scabs have fallen off, and a fresh layer of skin has formed. The duration of mpox is usually two to four weeks. The Centers for Disease Control and Prevention (CDC) recommends that anyone with a new or an unexplained rash or symptoms take measures to prevent the spread of mpox. The virus can be spread in several ways. In addition to having sex with an infected person, mpox can be spread through direct contact with a person’s rash, scabs, or bodily fluid. It can also be spread from prolonged face to face contact, such as kissing, and by touching items, such as clothing, that have previously touched a person’s rash or bodily fluids.

Patients who develop any symptoms should see a physician as soon as possible. It is recommended that patients wear a mask when being examined by a doctor. To stop the spread of mpox, the CDC recommends that those who have or suspect that they may have mpox isolate at home until all scabs have healed and new skin is formed. The agency also recommends that patients refrain from sharing anything they have touched with others. The disease can be spread to animals, so the CDC advises staying away from pets and livestock. In addition, the CDC recommends notifying close contacts as soon as possible so they can isolate if they have symptoms and consider getting vaccinated. Even after exposure to mpox, vaccination can lessen the symptoms of the virus or even prevent it entirely, especially if it is done as soon as possible.

At the time of the 2022 outbreak, no treatments existed that were specifically geared for the monkeypox virus, but because the virus is genetically similar to smallpox, several smallpox drugs and vaccines can be used to treat and prevent the virus. Tecovirimat (TPOXX) is an antiviral drug that can be used in patients who are likely to get severely ill from mpox, such as patients with weakened immune systems.

Impact

Starting in May 2022, cases of mpox spread across the globe. Most confirmed cases were reported from people with travel history in Europe and North America. The virus is not endemic to these regions, meaning it is not generally found in the population in these areas. Mpox is endemic to West and Central Africa, however. The 2022 outbreak was the first time in history that this virus was reported in such high numbers concurrently in non-endemic and endemic countries. The majority, but not all, of reported mpox cases were found in men who have sex with men. By July, the WHO identified the outbreak as a public health emergency of international concern.

As a result of the outbreak, the WHO began collaborating with health authorities in affected countries to prevent further spread of the disease. WHO issued guidance to help countries with surveillance, laboratory work, clinical care, and infection prevention and control. The organization also issued guidance in risk communication and community engagement to help inform at-risk communities and the public about mpox and how to avoid contracting it. By September 13, 2022, WHO reported more than 58,000 mpox cases worldwide and twenty-two deaths. Some of the hardest hit countries included Brazil, with 6,033 cases and two deaths; Canada, with 1,321 cases; Colombia, with 938 cases; France, with 3,785 cases; Germany, with 3,547 cases; The Netherlands, with 1,195 cases; Peru, with 1,937 cases; Spain, with 6,947 cases and two deaths; the UK and Northern Ireland, with 3,552 cases; and the United States, with 21,504 cases.

In August Europe became a global mpox hotspot, and some nations were better equipped to fight the virus than others. According to the New York Times, nations began competing for limited vaccine supplies, and some people began crossing borders to receive the vaccine in what is known as “vaccine tourism.” Spain became the epicenter of the epidemic in Europe, and until mid-August, the country had access to only about five thousand mpox vaccine, leaving many vulnerable people waiting. The country received seven thousand more doses from Belgium. In contrast, France, which at the time had fewer than half as many confirmed cases as Spain, had already vaccinated 27,000 people. Only one small pharmaceutical company, Bavarian Nordic, was approved to make mpox vaccines, which caused the shortages in Europe. The company faced production limitations and competing orders. Bavarian Nordic’s drug was known as Imvanex in Europe but was also distributed in Canada under the name Imvamune and in the United States under the name JYNNEOS. Two doses are required to be fully vaccinated.

In the United States, the Biden-Harris administration announced a vaccine strategy on June 28, 2022. The first phase aimed to rapidly deploy vaccines in the most affected communities to help stop the spread of the disease. The administration also announced a broader public health response including scaling up and decentralizing testing, and amping up provider education and community engagement about mpox across the country. It also explained that the country had dealt with mpox outbreaks multiple times over the last twenty years. In the memo, the United States committed to allocating 296,000 doses in a span of weeks, starting in late June. The administration also committed to the availability of 1.6 million doses over a span of months. To make testing easier, the CDC increased testing capacity to seventy-eight sites in forty-eight states, according to the White House. That enabled health officials to conduct nearly ten thousand tests per week across the nation at that time.

The White House also launched a campaign to distribute the JYNNEOS vaccine to individuals at high risk of exposure. The vaccine, which was approved by the Food and Drug Administration (FDA) for the prevention of mpox, is also approved for the prevention of smallpox. The initial goal was to allocate 56,000 vaccine doses, prioritizing at-risk populations. By December 2022 over a million doses of the vaccine had been administered in the United States. While at that point the ACAM2000 vaccine had only been approved for vaccination against smallpox, the vaccine was cleared to be used against mpox under the FDA’s Expanded Access Investigational New Drug (IND) mechanism, which required informed consent along with additional requirements. ACAM2000 had possible side effects, including inflammation of the heart muscle. In studies, this condition was experienced by one out of every 175 individuals who received the vaccine. Other serious possible side effects included swelling of the brain or spinal cord, problems with the vaccination site becoming infected, and accidental infection of the eye. On August 22, 2022, The United States Administration for Strategic Preparedness and Response (ASPR) made fifty thousand patient courses of the smallpox drug TPOXX (one hundred thousand bottles) available, though at that point the drug had not yet been approved by the FDA for the treatment of mpox.

In addition to domestic efforts, the White House announced its commitment to combating mpox globally, including in countries where it had been endemic such as Nigeria and the Democratic Republic of the Congo. The Biden-Harris Administration offered help to endemic and non-endemic countries in combating their outbreaks and explored options to further support the international response. The administration also announced that it had begun developing key mpox research and evidence priorities to help energize the United States and global scientific community around mpox research.

In November 2022 the WHO, responding to criticism that the term "monkeypox" had racist undertones and stigmatized patients, recommended referring to the disease by a new name—mpox. By early December there had been roughly 82,500 cases reported worldwide, including nearly 30,000 in the US. Modern medical care kept death rates low in non-endemic countries; for example, the US reported only twenty deaths from the disease by that point. Despite ongoing, low-level spread in some communities, global transmission rates dropped significantly by the end of 2022. Daily new cases in the US fell from four hundred per day in August to approximately twelve per day in December. Health experts cited a number of factors, namely a successful vaccination effort and behavioral and lifestyle changes in some vulnerable populations, as a major reason for the drop in cases. By 2023, the WHO stated that the mpox outbreak that began in 2022 was no longer a public health emergency of international concern.

Bibliography

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