Epidemiology and control of monkeypox outbreak in Houston,Texas

Background:In the 2022-2023 global outbreak,the United States and state of Texas recorded a total of 31,277 and 3,085 confirmed monkeypox(Mpox)cases respectively as of November 2023.This study aims to investigate the demographic characteristics and risk factors of Mpox outbreak in Houston and document the epidemiologic control measures implemented with their outcomes.Methods:Houston Health Department received reports of suspected Mpox cases via electronic case reports and laboratory reports from healthcare providers within Houston.These were then investigated and reclassified as either positive or negative using DNA polymerase chain reaction tests.All the reported cases received between May 2022 and January 2023 were included in this study using convenient sampling methods.Descriptive statistics using frequency distribution was used to analyze the sociodemographic,clinical features and travel history of the cases.A two-sided Chi-squared test was used to determine association between Mpox test results and risk factors with significant level set at P<0.05.Other infection control measures such as community engagement,health education,tracking and contact tracing,vaccination,referrals and laboratory sample logistics support were implemented by the health department.Results:Out of the total of 1,625 suspected persons investigated for Mpox,724(44.6%)tested positive.Among the 724 confirmed cases,male was 700(96.7%),females 20(2.8%),transgender male 1(0.1%),transgender female 3(0.4%).Age groups 30-39 years constituted 43.6%,18-29 years 27.4%,40-49 years 18.2%,50-59 years was 8%.Race distribution of positive cases was Whites 43.4%,African American 38.7%,Asian 1.4%.Risk factors with P<0.05 included male gender,age groups 30-39 years and 40-49 years,travel history to Mpox endemic areas,recent sexual contact with known or suspected Mpox cases,human immunodeficiency virus seropositivity.Identifying as gay and bisexual were also statistically significant risk factors for Mpox infection.Conclusion:The timely implementation of primary and secondary prevention measures targeted at the most at-risk populations was very effective at curtailing the spread of Mpox infection within the city of Houston.

Epidemiology of Mpox Outbreaks and Implications for Surveillance in Imo State, Nigeria

Mpox disease is caused by a double-stranded DNA virus, genus Orthopoxvirus of the family Poxviridae. The incubation period is usually 6 to 13 days but can range from 5 to 21 days while symptoms and signs may persist for 2 to 5 weeks. Although, the clinical features are usually less severe when compared to the deadly smallpox, the disease can be fatal with case fatality rate between 1% and 10%. In Imo State, Nigeria, there has been a changing epidemiology of the disease in the last 6 years and the frequency and geographic distribution of cases have progressively increased. This study aims to conduct a review of the disease epidemiology between 2017 and 2023 and implications for surveillance in Imo State. Surveillance data from the Surveillance Outbreak Response and Management System (SORMAS) was extracted between January 2017 and December 2023 across the 27 Local Government Areas (LGAs) of Imo State. A line list of 231 suspected cases was downloaded into an excel template and analyzed using SPSS® version 20 software. Analysis was done using descriptive statistics and associations were tested using Fischer’s exact at 0.05 level of significance. Of the 231 suspected cases, 57.1% (132) were males, 42.9% (99) were females and the modal age group was between the ages of 0 - 4 (32.5%). Eight (8) LGAs (districts) accounted for 71% (n = 164) of all the suspected cases. 21.2% (49) were confirmed positive, 27 males (55.1%) and 22 females (44.9%) (p > 0.05). Modal age group was 20 - 24 (22.4%, n = 11), 18% (9) were children under 14 years, p > 0.05. Case fatality rate was 8% (n = 4). There was no significant association between mortality and age group. Five (5) LGAs accounted for about 60% (29) of all confirmed cases. These LGAs contribute only 20% to the total population in the State. Only 5.6% and 4% of suspected and confirmed cases, respectively, had knowledge of contact with an infectious source. The study described the epidemiology of Mpox outbreaks between 2017 and 2023 and the findings have significant implications on detection and outbreak response activities.

Mpox and related poxviruses:A literature review of evolution,pathophysiology,and clinical manifestations

The recently re-emerged mpox(monkeypox)virus that causes mpox disease is a member of genus Orthopoxvirus and has unprecedentedly spread worldwide.Numerous studies have contributed to our understanding of its evolution,pathophysiology,and clinical manifestations.The current outbreak of the mpox virus depicts its novel route of transmission as a new variant.However,the exact reason for its transition from an epidemic to a pandemic remains unclear.Furthermore,other poxviruses such as vaccinia virus,variola virus,and cowpox virus,also belong to the same genus,Orthopoxvirus.In the present review,our objective was to summarize the evidence on evolution,pathophysiology,and clinical manifestations of mpox virus and its related poxviruses.The present review would aid in a better understanding of the current circulating mpox virus and its differences from other poxviruses.In addition,the shared genetic factors contributing to virulence in these Orthopoxvirus highlight their evolutionary connections and genetic similarities.While they exhibit differences in virulence,studying these genetic relationships is crucial for understanding their biology,pathogenicity,and the development of effective vaccines and antiviral therapeutics to curb mpox disease.

Knowledge and awareness of human mpox infection among healthcare workers:A cross-sectional study in southwestern Nigeria

Objective:To identify the knowledge and awareness level of human mpox viral infection among healthcare workers in southwestern Nigeria.Methods:A cross-sectional study was conducted in Ekiti State,southwest Nigeria among 316 healthcare workers that were selected through a systematic random sampling.Data were collected with the aid of a semi-structured,self-administered questionnaire.The Chi-square test and binary logistic regression were used to find the association between the independent and dependent variables.The significance level was set at P-value<0.05.Results:Two hundred and twenty-two(70.3%)of the respondents were aged≤40 years,mean age(36±9)years,189(59.8%)were female,306(96.8%)were Christians,and 203(64.2%)were married.Three hundred and fourteen(99.4%)of the respondents were aware of mpox infection.Main sources of information about mpox were medical education(44.0%),radio/television(32.0%)and newspaper(21.0%).However,among those aware of the disease,209(67.0%)demonstrated poor knowledge levels.Longer than 5 years’experience of medical practice was the only significant predictor of higher knowledge level of the disease(OR 1.76,95%CI 1.01-3.06;P=0.046).Conclusions:Despite the high awareness level of mpox infection among healthcare workers,there still exists a huge knowledge gap.It is recommended that targeted intervention could be directed towards continuous medical education and simulation exercises on re-emerging infectious diseases like mpox to improve the knowledge of the healthcare workers.

Weighing in on monkeypox against the criteria of public health emergency

The monkeypox,a viral zoonotic disease usually found in forest areas of Central and Western Africa,has spread worldwide through new modes of transmission little understood.The WHO on 23 July 2022,declared the virus a Public Health Emergency of International Concern(PHEIC).The declaration has stirred criticism from leading scientists that the criteria for PHEIC as defined by International Health Regulation have not been met and it is non-transparent and contradictory.This paper reviews the criteria of PHEIC and weighs the rationales behind the declaration to increase the clarity of the WHO's decision,justifications,and legitimacy in the ongoing outbreak.

Severe Monkeypox Infection in a Patient with AIDS: An Illustrative Case Report

The Monkeypox (Mpox) virus (MPXV) is endemic in Africa, and cases outside West and Central Africa were previously considered rare. However, around May 2022, outbreaks of multiple cases were reported worldwide including the USA thus presenting a new public health emergency. We present a case report of MPXV infection in a 49-year-old gay male with AIDS who was admitted for management of severe perianal cellulitis. Three days into hospitalization, he developed pustules over the genitals and scattered lesions over the face, trunk and extremities. PCR testing from a pustule was positive for MPXV. He was initiated on tecovirimat as well as antiretroviral therapy. There was a worsening of his rash over the first three days of therapy, followed by a gradual but complete resolution of all the skin lesions. The perianal and gluteal lesions were the most persistent and took more than two months to resolve. A primary contact source of infection was never identified. The differential diagnoses for cutaneous lesions of MPXV infection are also discussed.

Differences in the US Mpox Outbreaks of 2003 and 2022: A Review

Objectives: This research aims to focus on the differences in mpox outbreaks that occurred in 2003 and 2022 in the United States. Methods: We searched the following databases Medline, Google Scholar, Gayle Power Search, PubMed, and Springerlink using the following search terms “mpox virus”, “MPX”, “mpox in the US”, “US mpox virus 2003”, “US mpox virus 2022”, “US mpox outbreak 2003” and US mpox outbreak 2022”. The only articles selected were those written between 2003 and 2022. Results: Findings showed more Mpox research was conducted during the first US Mpox outbreak in 2003 compared to the US Mpox outbreak in 2022. Findings also indicated that the mpox outbreak of 2003 consisted of more animal-to-human transmissions acquired from sick prairie dogs compared to more human-to-human from an infected international traveler from Nigeria to the US. Conclusion: Major differences in the mpox outbreaks in the US include the number, location of lesions, and transmission type. We recommend further research to increase awareness of the human-to-human transmission of mpox via sexual contact to assist healthcare professionals and public health leaders in providing prevention and wellness in US communities.

Monkeypox outbreak: a novel threat after COVID-19?

Dear Editor,Monkeypox is a zoonosis caused by monkeypox virus (MPXV)infection first reported in Central and West Africa[1]. The first outbreak of monkeypox outside of Africa was reported in2003[2].Afterthat,Israel,theUnitedKingdom(UK),Singapore, and other countries have reported monkeypox cases among travelers back from Nigeria since 2018[3].

Introduction of monkeypox virus in Benin,2022

Dear Editor,Monkeypox is an infectious disease that is endemic in a dozen of African countries.Some imported cases have been also reported outside of Africa in the past[1].Since early May 2022,monkeypox infections including human-to-human transmission,were reported in a multi-country outbreak in non-endemic countries and declared Public Health Emergency of International Concern(PHEIC)by the World Health Organization(WHO)in July 2022[2].As of 20 September 2022,a total of at least 62,798 human cases of monkeypox with 20 deaths have been confirmed in 115 countries in five WHO regions[3].

Emergency department approach to monkeypox

BACKGROUND:Monkeypox(mpox) is a viral infection that is primarily endemic to countries in Africa,but large outbreaks outside of Africa have been historically rare.In June 2022,mpox began to spread across Europe and North America,causing the World Health Organization(WHO) to declare mpox a public health emergency of international concern.This article aims to review clinical presentation,diagnosis,and prevention and treatment strategies on mpox,providing the basic knowledge for prevention and control for emergency providers.METHODS:We conducted a review of the literature using PubMed and SCOPUS databases from their beginnings to the end of July 2023.The inclusion criteria were studies on adult patients focusing on emerging infections that described an approach to a public health emergency of international concern,systematic reviews,clinical guidelines,and retrospective studies.Studies that were not published in English were excluded.RESULTS:We included 50 studies in this review.The initial symptoms of mpox are non-specific:fever,malaise,myalgias,and sore throat.Rash,a common presentation of mpox,usually occurs 2–4 weeks after the prodrome,but the presence of lymphadenopathy may distinguish mpox from other infections from the Poxviridae family.Life-threatening complications such as pneumonia,sepsis,encephalitis,myocarditis,and death can occur.There are documented co-occurrences of human immunodeficiency virus(HIV) and other sexually transmitted infections that can worsen morbidity.CONCLUSION:The initial presentation of mpox is non-specific.The preferred treatment included tecovirimat in patients with severe illness or at high risk of developing severe disease and vaccination with two doses of JYNNEOS.However,careful history and physical examination can raise the clinicians’ suspicion and point toward a prompt diagnosis.There are diff erent modalities to prevent and treat mpox infection.

Review of the prevalence,diagnostics,and containment measures of the current mpox outbreak

Monkeypox(mpox),is a disease from the Poxviridae family that can cause several serious medical issues.This mini-review sought to analyze the existing literature regarding the current mpox outbreak with a focus on the prevalence,diagnostics,and containment measures.Mpox cases have been reported to World Health Organization(WHO)from 85 Member States in all six WHO regions during the period of January 1,2022,through August 3,2022.Standardized or optimized guidelines for the clinical care of patients with mpox are limited,particularly in low-resource settings.In an effort to achieve guidance and meet standards,special attention should be paid to this outbreak in order to eradicate such a rare infectious disease by analyzing prevention and control measures.Patient outcomes may also be poor,and their illnesses may last for a long time.The spectrum of clinical symptoms,including complications and sequelae,as well as aspects of the illness may be indicators of sickness severity and complications;therefore,its clinical presentation must be better understood to improve containment measures.In addition,it is important to create and evaluate a standard of care that takes a variety of parameters into account,including antiviral,immune therapies,and clinical metrics that are particular to mpox.The global emergence of mpox has presented new challenges for public health and has called for further investigation into its epidemiological profile across international contexts.

An unfolding monkeypox outbreak in Europe and beyond

Dear Editor,Monkeypox is a zoonotic disease caused by the monkeypox virus(MPXV),a double-stranded DNA virus in the genus Orthopoxvirus,family Poxviridae.MPXV is known to be transmitted between animals such as rats and squirrels,but animal-to-human and human-to-human transmission has been known in Africa since 1970.Transmission is linked to direct contact with body fluids,skin lesions,and patient items as well as respiratory droplets in case of prolonged face-to-face contact[1].Until recently,only a few cases were associated with travel to endemic countries or contact with infected animals imported from endemic countries.

Monkeypox presenting as a chancre-like rash:A case report

BACKGROUND Since May 2022,outbreaks of monkeypox have occurred in many countries around the world,and several cases have been reported in China.CASE SUMMARY A 38-year-old man presented with a small,painless,shallow ulcer on the coronary groove for 8 d.One day after the rash appeared,the patient developed inguinal lymphadenopathy with fever.The patient had a history of male-male sexual activity and denied a recent history of travel abroad.Monkeypox virus was detected by quantitative polymerase chain reaction from the rash site and throat swab.Based on the epidemiological history,clinical manifestations and nucleic acid test results,the patient was diagnosed with monkeypox.CONCLUSION Monkeypox is an emerging infectious disease in China.Monkeypox presenting as a chancre-like rash is easily misdiagnosed.Diagnosis can be made based on exposure history,clinical manifestations and nucleic acid test results.

Monkeypox outbreak in the age of COVID‑19:a new global health emergency

Dear Editor,The World Health Organization recently declared monkeypox as a global emergency after reporting more than 57,000 new cases worldwide[1].Monkeypox is an orthopoxvirus similar in nature to the Variola virus,which is a causative agent for smallpox[2].Monkeypox virus presents as a unique challenge for global health and should be regarded with grave concern as the vast majority of cases are occurring in countries where the disease is not considered endemic.Furthermore,the spread of this pathogen is occurring concomitantly as the world is still engaged in a battle with the coronavirus disease 2019(COVID-19)pandemic,which has caused substantial damage to global healthcare infrastructure.If monkeypox continues its rapid spread,hospitals could be quickly overwhelmed by both COVID-19 and monkeypox cases.Now more than ever,early symptom recognition and use of all available treatments to contain monkeypox outbreaks are vital.Early precautions including early recognition of symptoms by physicians,use of currently available treatments,and promoting precautionary measures in at-risk populations may be vital in preventing hospital burden and further physician burnout.

Inequity in the global distribution of monkeypox vaccines

Monkeypox(mpox)has been a public health emergency of international concern that emerged in mid-2022 and has spread to 110 countries.The clinical findings of the disease vary according to the seriousness of the cases.Although its case fatality risk has not been high,a significant percentage of patients require hospitalization.In this context,local initiatives were taken to extend the limited supply of vaccines against the disease;however,such measures have not been sufficient to contain the spread of cases and ensure an equitable distribution of health resources.As a result,endemic regions of low-income countries continue to have insufficient access to mpox vaccination.Despite this and considering the global scope of the disease,there is still little discussion in the literature about the difficulties in achieving adequate vaccination coverage rates for the target population of interest.In this article,we briefly discussed general aspects of the disease,including its surveillance,the current global context of challenges for mpox vaccination,and issues on global allocation of health resources as well as proposed related recommendations.

Monkeypox in humans:Transmission,pathophysiology,diagnosis,treatment,prevention,and all recent updates

The Centers for Disease Control and Prevention(CDC)is monitoring an epidemic of monkeypox infection in the United States.The outbreak is now global and more than 6900 cases have already been reported.There are 83 confirmed cases among children and adolescents,as shown in the report published on November 3,2022,in the USA.However,monkeypox in pediatric patients is still infrequent(<0.3%of total cases).Among cases in the United States,16 cases were in children<5 years,12 in the age group 5-12 years,and 55 cases in adolescents 13-17 years old.In the adolescent age group,89%were male.For children<12 years of age,close physical contact with an adult household with monkeypox was the primary exposure,but for adolescents,male-to-male sexual contact was found more frequently.The CDC advised United States healthcare providers to remain vigilant for patients with a rash resembling monkeypox,even if there is no history of travel to a country with high risk.This article summarizes the history and epidemiology of monkeypox with a specific emphasis on clinical features and management in pediatric patients.

Near obstructing painful anorectal mass and facial rash in a man with monkeypox: A case report

BACKGROUND Monkeypox(MPX)is a zoonotic infection that is endemic in Western and Central Africa along the Congo River basin.It has a high case fatality rate especially in younger age groups.It belongs to the virus family orthopoxvirus like smallpox.It is transmitted from wild animals to humans but human to human transmission has been established.It is often a self-limited infection in endemic regions.Recently,attention has been given to MPX with the spread of infection to Europe and the United States of America(USA).There is currently sporadic infection of MPX in the USA especially amongst men who have sex with men(MSM).It is a serious life-threatening infection in human immunodeficiency virus/acquired immunodeficiency syndrome co-infected individuals especially those who are treatment naïve with severe immunosuppression.CASE SUMMARY We report a 38-year old man who presented with rectal pain,and anal,torso,and facial rash.Abdominal computed tomography scan showed a near obstructive rectal mass with peri-anal fistula.MPX was positive.He was started on tecovirimat(TPOXX)and HAART therapy.Additional treatment provided included vaccinia immunoglobulin following his clinical deterioration.CONCLUSION This case highlights a rare presentation of MPX with peri-anal fistula and near obstructive rectal mass,and the significance of MPX as a differential diagnosis in proctitis in MSM in addition to other sexually transmitted infection like gonorrhea and chlamydia.

云南省首例女性感染猴痘病例的发现与调查处置

目的对云南省昆明市1例女性感染猴痘病例进行调查处置,为全国预防控制猴痘疫情,特别是女性感染猴痘疫情的早期发现和调查处置提供科学依据。方法按照《猴痘诊疗指南(2022版)》对病例进行诊断,依据《猴痘防控方案(2023版)》开展流行病学调查分析和处置,采集相关标本开展实验室检测。结果经流行病学调查,患者发病前与新婚丈夫发生过1次性行为,其丈夫向其隐瞒男男同性恋史及男男性行为史;该女子及其丈夫实验室检测结果为“猴痘病毒核酸阳性”;该女子及其丈夫均出现典型出疹等临床症状。结论结合流行病学调查、临床症状表现及实验室检测结果,及既往云南省猴痘疫情材料,确认该女子为云南省首例女性感染猴痘病例,可疑暴露为早于其发病的男性配偶。

七例猴痘临床特征分析

对上海市浦东新区人民医院2023年7~12月收治的7例猴痘患者临床症状及实验室检查等资料进行分析。7例患者皮疹部位和咽拭子标本猴痘病毒核酸检测阳性。7例猴痘患者均为MSM人群,年龄26~41岁;发病前21天内均有男男性行为史;6例患者首发部位为阴阜或生殖器区域,1例患者首发部位为口周及肛周;6例出现发热;6例伴有其他性传播疾病;病例发现方式均为主动就诊。

HIV阳性与HIV阴性猴痘患者临床特征分析

目的分析人HIV阳性与HIV阴性猴痘患者的临床和影像特征,为临床诊疗提供参考。方法回顾性分析2023年6月1日至11月30日首都医科大学附属北京佑安医院收治住院的36例确诊猴痘患者的临床和影像资料,按照是否合并HIV感染分为HIV阳性组和HIV阴性组。观察比较两组人群临床和影像特征。结果36例猴痘患者均为男性且为男男性行为者(men who have sex with men,MSM),平均年龄(31.5±6.4)岁;HIV阳性组28例,HIV阴性组8例。主要表现为皮疹、发热、淋巴结肿大。皮疹的首发部位(24例,66.7%)和最主要的分布部位(30例,83.3%)均为生殖器和肛门,以丘疹和脓疱疹为主。合并其他性传播性疾病14例(38.9%,14/36);合并细菌感染21例(58.3%,21/36),主要为皮肤软组织感染和肛周感染。影像检查结果异常者均为HIV阳性组患者。4例(11.1%,4/36)肺炎CT表现以磨玻璃影、实变、多发结节为主;2例并发肠梗阻,影像表现以胃肠道扩张为主,2例直肠炎表现为直肠壁增厚,肠腔狭窄。两组患者的流行病学资料、临床特征、皮疹分布及性质和实验室检查结果比较差异均无统计学意义(P>0.05)。结论36例猴痘患者以青壮年MSM人群为主,且多为HIV感染者;生殖器和肛周是皮疹首发和最多发部位,溃疡样皮疹仅见于HIV感染者;轻症患者预后良好,重症患者可合并细菌性感染、肠梗阻和直肠炎。并发肺炎者CT主要表现为实变和磨玻璃影,并可见两肺多发、随机分布的实性结节。