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“Many of these global reports of monkeypox cases are occurring within sexual networks. However, healthcare providers should be alert to any rash that has features typical of monkeypox. We’re asking the public to contact their healthcare provider if they have a new rash and are concerned about monkeypox,” said Inger Damon, MD, PhD, a poxvirus expert with more than 20 years’ experience and Director of CDC’s Division of High-Consequence Pathogens and Pathology, where the agency’s poxvirus research is based. What people should do: People who may have symptoms of monkeypox, particularly men who report sex with other men, and those who have close contact with them, should be aware of any unusual rashes or lesions and contact their healthcare provider for a risk assessment.” (US CDC, May 18, 2022)

“While one vaccine (MVA-BN) and one specific treatment (tecovirimat) were approved for monkeypox, in 2019 and 2022 respectively, these countermeasures are not yet widely available, and populations worldwide under the age of 40 or 50 years no longer benefit from the protection afforded by prior smallpox vaccination programmes”.  
https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON383 And, so, WHO recognizes that the original smallpox vaccine is protective.

The UK had an outbreak at almost exactly the same time last year. People were also monitored within the United States. Why don’t they require smallpox vaccination for travel to Nigeria, where it is found, instead of setting up conditions where many people may need to be vaccinated? Are the African outbreaks seasonal? Why did it re-emerge in Nigeria in 2017, after 40 years with no cases? Was the first case a man who had sex with men (MSM) in Nigeria and then brought it to other men having sex with men in Europe? Are they HIV immunocompromised? Is this from May holiday (sexual) tourism? This is apparently how HIV initially spread to Haiti – sexual tourism. MSM (men who have sex with men) is a health hazard, spreading hepatitis B, too. [MSM (mainstream media) is also a health hazard.] Now everyone is vaccinated for hepatitis B due to sloppy medical workers and MSM. Is monkey pox the new MSM plague? And/or is it being intentionally spread? Biblical and other ethical prohibitions against MSM were likely initially, in part, because of health considerations. Obviously banning MSM wouldn’t help, but individuals should be aware of the risks of nontraditional lifestyles.

“On 13 May 2022, WHO was notified of two laboratory confirmed cases and one probable case of monkeypox, from the same household, in the United Kingdom. On 15 May, four additional laboratory confirmed cases have been reported amongst Sexual Health Services attendees presenting with a vesicular rash illness and in gay, bisexual, and other men who have sex with men (GBMSM).” (WHO May 18, 2022)

“CDC and Health Partners Responding to Monkeypox Case in the U.S.
Case identified after monkeypox clusters in several other countries
Media Statement
For Immediate Release: Wednesday, May 18, 2022

Scientists at the Centers for Disease Control and Prevention (CDC) are collaborating with the Massachusetts Department of Public Health to investigate a case of monkeypox in a Massachusetts resident who had recently traveled to Canada by private transportation.

Testing in Massachusetts found orthopox virus infection Tuesday night, and CDC labs confirmed as monkeypox this afternoon.

CDC is also tracking multiple clusters of monkeypox that have been reported within the past two weeks in several countries that don’t normally report monkeypox, including Portugal, Spain, and the United Kingdom. It’s not clear how people in those clusters were exposed to monkeypox but cases include individuals who self-identify as men who have sex with men.

CDC is urging healthcare providers in the U.S. to be alert for patients who have rash illnesses consistent with monkeypox, regardless of whether they have travel or specific risk factors for monkeypox.

Anyone, regardless of sexual orientation, can spread monkeypox through contact with body fluids, monkeypox sores, or shared items (such as clothing and bedding) that have been contaminated with fluids or sores of a person with monkeypox. Monkeypox virus can also spread between people through respiratory droplets typically in a close setting, such as the same household or a healthcare setting. Common household disinfectants can kill the monkeypox virus.

“Many of these global reports of monkeypox cases are occurring within sexual networks.  However, healthcare providers should be alert to any rash that has features typical of monkeypox. We’re asking the public to contact their healthcare provider if they have a new rash and are concerned about monkeypox,” said Inger Damon, MD, PhD, a poxvirus expert with more than 20 years’ experience and Director of CDC’s Division of High-Consequence Pathogens and Pathology, where the agency’s poxvirus research is based.

What people should do:
* People who may have symptoms of monkeypox, particularly men who report sex with other men, and those who have close contact with them, should be aware of any unusual rashes or lesions and contact their healthcare provider for a risk assessment.

What healthcare providers should do:
* If healthcare providers identify patients with a rash that looks like monkeypox, consider monkeypox, regardless of whether the patient has a travel history to central or west African countries.
* Do not limit concerns to men who report having sex with other men. Those who have any sort of close personal contact with people with monkeypox could potentially also be at risk for the disease.
* Some patients have had genital lesions and the rash may be hard to distinguish from syphilis, herpes simplex virus (HSV) infection, chancroid, varicella zoster, and other more common infections.
* Isolate any patients suspected of having monkeypox in a negative pressure room, and ensure staff understand the importance of wearing appropriate personal protective equipment (PPE) and that they wear it each time they are near suspected cases.
* Consult the state health department or CDC’s monkeypox call center through the CDC Emergency Operations Center (770-488-7100) as soon as monkeypox is suspected.

Monkeypox is a rare but potentially serious viral illness that typically begins with flu-like illness and swelling of the lymph nodes and progresses to a widespread rash on the face and body. Monkeypox reemerged in Nigeria in 2017 after more than 40 years with no reported cases. Since then, there have been more than 450 reported cases in Nigeria and at least eight known exported cases internationally.” https://www.cdc.gov/media/releases/2022/s0518-monkeypox-case.html

UKHSA May 18, 2022:
“Two more cases of monkeypox identified by UKHSA
The UK Health Security Agency (UKHSA) has detected 2 additional cases of monkeypox, one in London and one in the South East of England. The latest cases bring the total number of monkeypox cases confirmed in England since 6 May to 9, with recent cases predominantly in gay, bisexual or men who have sex with men (MSM). The 2 latest cases have no travel links to a country where monkeypox is endemic, so it is possible they acquired the infection through community transmission. The virus spreads through close contact and UKHSA is advising individuals, particularly those who are gay, bisexual or MSM, to be alert to any unusual rashes or lesions on any part of their body, especially their genitalia, and to contact a sexual health service if they have concerns. Monkeypox has not previously been described as a sexually transmitted infection, though it can be passed on by direct contact during sex. It can also be passed on through other close contact with a person who has monkeypox or contact with clothing or linens used by a person who has monkeypox… Initial symptoms of monkeypox include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion. A rash can develop, often beginning on the face, then spreading to other parts of the body including the genitals. The rash changes and goes through different stages, and can look like chickenpox or syphilis, before finally forming a scab, which later falls off.” https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-updates There are images at the original but some even look like acne.

“Monkeypox – United Kingdom of Great Britain and Northern Ireland
18 May 2022

Situation at a glance

On 13 May 2022, WHO was notified of two laboratory confirmed cases and one probable case of monkeypox, from the same household, in the United Kingdom. On 15 May, four additional laboratory confirmed cases have been reported amongst Sexual Health Services attendees presenting with a vesicular rash illness and in gay, bisexual, and other men who have sex with men (GBMSM). 

As response measures, an incident team has been established to coordinate contact tracing efforts. 

In contrast to sporadic cases with travel links to endemic countries (see Disease outbreak news on Monkeypox in the United Kingdom published on 16 May 2022), no source of infection has been confirmed yet. Based on currently available information, infection seems to have been locally acquired in the United Kingdom. The extent of local transmission is unclear at this stage and there is the possibility of identification of further cases. 

Description of the cases

On 13 May 2022, the United Kingdom notified WHO of two laboratory confirmed cases and one probable case of monkeypox to WHO. All three cases belong to the same family. 

The probable case is epidemiologically linked to the two confirmed cases and has fully recovered. The first case identified (index case) developed a rash on 5 May and was admitted to hospital in London, the United Kingdom on 6 May. On 9 May, the case was transferred to a specialist infectious disease centre for ongoing care. Monkeypox was confirmed on 12 May. Another confirmed case developed a vesicular rash on 30 April, confirmed to have monkeypox on 13 May, and is in a stable condition. 

The West African clade of monkeypox was identified in the two confirmed cases using reverse transcriptase polymerase chain reaction (RT PCR) on vesicle swabs on 12 May and 13 May. 

On 15 May, WHO was notified of four additional laboratory confirmed cases, all identified among GBMSM attending Sexual Health Services and presenting with a vesicular rash. All four were confirmed to have the West African clade of the monkeypox virus.

Epidemiology of the disease

Monkeypox is a sylvatic zoonosis with incidental human infections that usually occur in forested parts of Central and West Africa. It is caused by the monkeypox virus which belongs to the orthopoxvirus family. Monkeypox can be transmitted by droplet exposure via exhaled large droplets and by contact with infected skin lesions or contaminated materials. The incubation period of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days.  The disease is often self-limiting with symptoms usually resolving spontaneously within 14 to 21 days. Symptoms can be mild or severe, and lesions can be very itchy or painful. The animal reservoir remains unknown, although is likely to be among rodents. Contact with live and dead animals through hunting and consumption of wild game or bush meat are known risk factors.

There are two clades of monkeypox virus: the West African clade and Congo Basin (Central African) clade. Although the West African clade of monkeypox virus infection sometimes leads to severe illness in some individuals, disease is usually self-limiting. The case fatality ratio for the West African clade has been documented to be around 1%, whereas for the Congo Basin clade, it may be as high as 10%. Children are also at higher risk, and monkeypox during pregnancy may lead to complications, congenital monkeypox or stillbirth.

Milder cases of monkeypox may go undetected and represent a risk of person-to-person transmission. There is likely to be little immunity to the infection in those travelling or otherwise exposed, as endemic disease is normally geographically limited to parts of West and Central Africa. Historically, vaccination against smallpox was shown to be protective against monkeypox.

While one vaccine (MVA-BN) and one specific treatment (tecovirimat) were approved for monkeypox, in 2019 and 2022 respectively, these countermeasures are not yet widely available, and populations worldwide under the age of 40 or 50 years no longer benefit from the protection afforded by prior smallpox vaccination programmes.  

Public health response

Health authorities in the United Kingdom have established an incident management team to coordinate the extensive contact tracing which is currently underway in health care settings and the community for those who have had contact with the confirmed cases. Contacts are being assessed based on their level of exposure and followed up through active or passive surveillance for 21 days from the date of last exposure to a case. Vaccination is being offered to higher risk contacts.

A detailed backwards contact tracing investigation is also being carried out to determine the likely route of acquisition and establish whether there are any further chains of transmission within the United Kingdom for all cases. Sexual contacts and venues visited (for example saunas, bars and clubs) are actively being investigated for the four GBMSM cases.

WHO risk assessment

No source of infection has yet been confirmed for either the family or GBMSM clusters. Based on currently available information, infection seems to have been locally acquired in the United Kingdom. The extent of local transmission is unclear at this stage and there is the possibility of identification of further cases. However, once monkeypox was suspected, authorities in the United Kingdom promptly initiated appropriate public health measures, including isolation of the cases and extensive forward and backward contact tracing to enable source identification.

In the United Kingdom, there have been eight previous cases of monkeypox reported: all importations were related to a travel history to or from Nigeria. In 2021, there were also two separate human monkeypox cases imported from Nigeria reported by the United States of America. During an outbreak of monkeypox in humans in 2003 in the United States of America, exposure was traced to contact with pet prairie dogs that had been co-housed with monkeypoxvirus-infected small mammals imported from Ghana.

WHO advice

Intensive public health measures should continue in the United Kingdom. In addition to the ongoing forward and backward contact tracing and source tracing, case searching, and local rash-illness surveillance should be strengthened in the GBMSM and wider community, as well as in primary and secondary health care settings. Any patient with suspected monkeypox should be investigated and isolated with supportive care during the presumed and known infectious periods, that is, during the prodromal and rash stages of the illness, respectively. Timely contact tracing, surveillance measures and raising awareness among health care providers, including sexual health and dermatology clinics, are essential for preventing further secondary cases and effective management of the current outbreak. Additionally, deployment of pharmaceutical countermeasures under investigational protocols can be considered.

Health workers and other care givers caring for patients with suspected or confirmed monkeypox should implement standard, contact and droplet infection control precautions. Samples taken from people with suspected monkeypox or animals with suspected monkeypox virus infection should be safely handled by trained staff working in suitably equipped laboratories. 

Any illness during travel or upon return from an endemic area should be reported to a health professional, including information about all recent travel and immunization history.

Residents and travellers to endemic countries should avoid contact with sick animals (dead or alive) that could harbour monkeypox virus (rodents, marsupials, primates) and should refrain from eating or handling wild game (bush meat). The importance of hand hygiene by using soap and water or alcohol-based sanitizer should be emphasized.

International travel or trade: WHO does not recommend any restriction for travel to and trade with the United Kingdom based on available information at this time.
WHO continue to closely monitor as the situation is evolving rapidly.
https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON383

Monkeypox – United Kingdom of Great Britain and Northern Ireland
16 May 2022
Situation at a glance
On 7 May 2022, WHO was informed of a confirmed case of monkeypox in an individual who travelled from the United Kingdom to Nigeria and subsequently returned to the United Kingdom. 

The case developed a rash on 29 April 2022 and arrived in the United Kingdom on 4 May, departing Nigeria on 3 May. Monkeypox was suspected and the case was immediately isolated. Monkeypox was suspected and the case was immediately isolated. As of 11 May, extensive contact tracing has been undertaken to identify exposed contacts in healthcare settings, the community and the international flight. These individuals are being followed up for 21 days from the date of last exposure with the case. None has reported compatible symptoms so far.

Since the case was immediately isolated and contact tracing was performed, the risk of onward transmission related to this case in the United Kingdom is minimal. However, as the source of infection in Nigeria is not known, there remains a risk of ongoing transmission in this country.

Description of the case

On 7 May 2022, the National IHR Focal Point for the United Kingdom notified WHO of a confirmed case of monkeypox in an individual who travelled from United Kingdom to Nigeria from late April to early May 2022 and stayed in Lagos and Delta States in Nigeria. The case developed a rash on 29 April and arrived in the United Kingdom on 4 May, departing Nigeria on 3 May.  On the same day (4 May), the case presented to hospital. Based on the travel history and rash illness, monkeypox was suspected at an early stage and the case was isolated immediately.  Appropriate use of personal protective equipment was ensured during hospitalization. Monkeypox (West African clade) was laboratory confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) on a vesicular swab on 6 May by the United Kingdom Health Security Agency (UKHSA) Rare and Imported Pathogens Laboratory. 

Epidemiology of the disease

Monkeypox is a sylvatic zoonosis with incidental human infections that usually occur sporadically in forested parts of Central and West Africa. It is caused by the monkeypox virus which belongs to the orthopoxvirus family. Monkeypox can be transmitted by contact and droplet exposure via exhaled large droplets. The incubation period of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days.  The disease is often self-limiting with symptoms usually resolving spontaneously within 14 to 21 days. Symptoms can be mild or severe, and lesions can be very itchy or painful. The animal reservoir remains unknown, although is likely to be among rodents. Contact with live and dead animals through hunting and consumption of wild game or bush meat are known risk factors.

There are two clades of monkeypox virus, the West African clade and Congo Basin (Central African) clade. Although the West African clade of monkeypox virus infection sometimes leads to severe illness in some individuals, disease is usually self-limiting. The case fatality ratio for the West African clade has been documented to be around 1%, whereas for the Congo Basin clade, it may be as high as 10%. Children are also at higher risk, and monkeypox during pregnancy may lead to complications, congenital monkeypox or stillbirth.

Milder cases of monkeypox may go undetected and represent a risk of person-to-person transmission. There is likely to be little immunity to the infection in those travelling and exposed as endemic disease is geographically limited to parts of West and Central Africa. While a vaccine has been approved for prevention of monkeypox, and traditional smallpox vaccine also provides protection, these vaccines are not widely available and populations worldwide under the age of 40 or 50 years no longer benefit from the protection afforded by prior smallpox vaccination programmes.  

Public health response
• Health authorities in the United Kingdom have set up an incident management team to coordinate identification and management of contacts.

• As of 11 May, extensive contact tracing has identified exposed contacts in the community, the healthcare setting and on the international flight. None has reported compatible symptoms so far.

• All identified contacts have been assessed and classified based on their exposure to the case and are being followed up accordingly through either active or passive surveillance for 21 days after their last exposure to the case. Post-exposure prophylaxis with vaccination is being offered to the higher risk contacts.

• Nigerian authorities were informed about this case and travel history in Nigeria on 7 May. The case did not report contact with anyone with a rash illness or known monkeypox in Nigeria. Details of travel and contacts within Nigeria have been shared with authorities in Nigeria for follow up as necessary.

WHO risk assessment
In the United Kingdom, there have been seven cases of monkeypox previously reported; all importations were related to a travel history to or from Nigeria. In 2021, there were also two separate human monkeypox cases imported from Nigeria reported by the United States of America.

Since September 2017, Nigeria has continued to report cases of monkeypox. From September 2017 to 30 April 2022, a total of 558 suspected cases have been reported from 32 states in the country. Of these, 241 were confirmed cases, and among these there were eight deaths recorded (Case Fatality Ratio: 3.3%). From 1 January to 30 April 2022, 46 suspected cases have been reported of which 15 were confirmed from seven states – Adamawa (three cases), Lagos (three cases), Cross River (two cases), Federal Capital Territory (FCT) (two cases), Kano (two cases), Delta (two cases) and Imo (one case). No death has been recorded in 2022.

In the present case, the source of infection is currently unknown and the risk of further transmission in Nigeria cannot be excluded. Once monkeypox was suspected in the United Kingdom, authorities promptly initiated appropriate public health measures, including isolation of the case and contact tracing. The risk of potential onward spread related to this case in the United Kingdom is therefore minimal. As the source of infection in Nigeria is not known, there remains a risk of further transmission in Nigeria.

Importations of monkeypox from an endemic country to another country has been documented on eight previous occasions. In this instance, the confirmed case has a history of travel from Delta state in Nigeria, where monkeypox is endemic.

WHO advice
Any illness during travel or upon return from an endemic area should be reported to a health professional, including information about all recent travel and immunization history. Residents and travelers to endemic countries should avoid contact with sick animals (dead or alive) that could harbour monkeypox virus (rodents, marsupials, primates) and should refrain from eating or handling wild game (bush meat). The importance of hand hygiene using soap and water, or alcohol-based sanitizer should be emphasized. While a vaccine and specific treatment have recently been approved for monkeypox, in 2019 and 2022 respectively, these countermeasures are not yet widely available.

A patient with monkeypox should be isolated and provided with supportive care during the presumed and known infectious periods, that is during the prodromal (early signs) and rash stages of the illness, respectively. Timely contact tracing, surveillance measures and raising awareness of imported emerging diseases among health care providers are essential for preventing further secondary cases and effective management of monkeypox outbreaks.

Health workers caring for patients with suspected or confirmed monkeypox should implement standard, contact and droplet infection control precautions. This includes all workers such as cleaners and laundry personnel who may be exposed to the patient care setting, bedding, towels, or personal belongings. Samples taken from people with suspected monkeypox or animals with suspected monkeypox virus infection should be handled by trained staff working in suitably equipped laboratories.

International travel and trade: WHO does not recommend any restriction for travel to and trade with Nigeria or the United Kingdom based on available information at this time https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON381