Multi-country monkeypox outbreak in non-endemic nations

Outbreak at look                 

Since 13 Could 2022, instances of monkeypox have been reported to WHO from 12 Member States that aren’t endemic for monkeypox virus, throughout three WHO areas. Epidemiological investigations are ongoing, nonetheless, reported instances so far don’t have any established journey hyperlinks to endemic areas. Based mostly on at the moment obtainable data, instances have primarily however not solely been recognized amongst males who’ve intercourse with males (MSM) looking for care in major care and sexual well being clinics.

The target of this Illness Outbreak Information is to lift consciousness, inform readiness and response efforts, and supply technical steerage for quick really helpful actions.

The scenario is evolving and WHO expects there will probably be extra instances of monkeypox recognized as surveillance expands in non-endemic nations. Fast actions give attention to informing those that could also be most in danger for monkeypox an infection with correct data, with a purpose to cease additional unfold. Present obtainable proof means that those that are most in danger are those that have had shut bodily contact with somebody with monkeypox, whereas they’re symptomatic. WHO can also be working to supply steerage to guard frontline well being care suppliers and different well being employees who could also be in danger corresponding to cleaners. WHO will probably be offering extra technical suggestions within the coming days. 

Description of the outbreak

As of 21 Could, 13:00, 92 laboratory confirmed instances, and 28 suspected instances of monkeypox with investigations ongoing, have been reported to WHO from 12 Member States that aren’t endemic for monkeypox virus, throughout three WHO areas (Desk 1, Determine 1). No related deaths have been reported to this point.

Desk 1. Circumstances of monkeypox in non-endemic nations reported to WHO between 13 to 21 Could 2022 as at 13:00

Determine 1. Geographical distribution of confirmed and suspected instances of monkeypox in non-endemic between 13 to 21 Could 2022, as at 13:00.

Reported instances so far don’t have any established journey hyperlinks to an endemic space. Based mostly on at the moment obtainable data, instances have primarily however not solely been recognized amongst males who’ve intercourse with males (MSM) looking for care in major care and sexual well being clinics.

Thus far, all instances whose samples have been confirmed by PCR have been recognized as being contaminated with the West African clade. Genome sequence from a swab pattern from a confirmed case in Portugal, indicated a detailed match of the monkeypox virus inflicting the present outbreak, to exported instances from Nigeria to the UK, Israel and Singapore in 2018 and 2019.

The identification of confirmed and suspected instances of monkeypox with no direct journey hyperlinks to an endemic space represents a extremely uncommon occasion. Surveillance to this point in non-endemic areas has been restricted, however is now increasing.  WHO expects that extra instances in non-endemic areas will probably be reported. Accessible data means that human-to-human transmission is going on amongst individuals in shut bodily contact with instances who’re symptomatic.

Along with this new outbreak, WHO continues to obtain updates on the standing of ongoing experiences of monkeypox instances by means of established surveillance mechanisms (Built-in Illness Surveillance and Response) for instances in endemic nations [1], as summarized in desk 2.

[1] Monkeypox endemic nations are: Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Ghana (recognized in animals solely), Ivory Coast, Liberia, Nigeria, the Republic of the Congo, Sierra Leone, and South Sudan.

Desk 2. Circumstances of monkeypox in endemic nations between 15 December 2021 to 1 Could 2022

For extra data please consult with WHO AFRO Weekly Bulletin on Outbreaks and Different Emergencies.

Epidemiology of the illness

Monkeypox is a viral zoonosis (a virus transmitted to people from animals) with signs similar to these seen previously in smallpox sufferers, though it’s clinically much less extreme. It’s brought on by the monkeypox virus which belongs to the orthopoxvirus genus of the Poxviridae household. There are two clades of monkeypox virus: the West African clade and the Congo Basin (Central African) clade. The identify monkeypox originates from the preliminary discovery of the virus in monkeys in a Danish laboratory in 1958. The primary human case was recognized in a toddler within the Democratic Republic of the Congo in 1970.

Monkeypox virus is transmitted from one individual to a different by shut contact with lesions, physique fluids, respiratory droplets and contaminated supplies corresponding to bedding. The incubation interval of monkeypox is normally from 6 to 13 days however can vary from 5 to 21 days.

Numerous animal species have been recognized as prone to the monkeypox virus. Uncertainty stays on the pure historical past of the monkeypox virus and additional research are wanted to establish the precise reservoir(s) and the way virus circulation is maintained in nature. Consuming inadequately cooked meat and different animal merchandise of contaminated animals is a doable threat issue.

Monkeypox is normally self-limiting however could also be extreme in some people, corresponding to kids, pregnant girls or individuals with immune suppression resulting from different well being situations. Human infections with the West African clade seem to trigger much less extreme illness in comparison with the Congo Basin clade, with a case fatality fee of three.6% in comparison with 10.6% for the Congo Basin clade.

  • Additional public well being investigations are ongoing in non-endemic nations which have recognized instances, together with in depth case discovering and speak to tracing, laboratory investigation, medical administration and isolation supplied with supportive care.
  • Genomic sequencing, the place obtainable, have been undertaken to find out the monkeypox virus clade(s) on this outbreak
  • Vaccination for monkeypox, the place obtainable, is being deployed to handle shut contacts, corresponding to well being employees. WHO is convening consultants to debate suggestions on vaccination.

WHO has developed surveillance case definitions for the present monkeypox outbreak in non-endemic nations.

(case definitions will probably be up to date as needed)

Suspected case:

An individual of any age presenting in a monkeypox non-endemic nation[2] with an unexplained acute rash


A number of of the next indicators or signs, since 15 March 2022:

  • Headache
  • Acute onset of fever (>38.5oC),
  • Lymphadenopathy (swollen lymph nodes)
  • Myalgia (muscle and physique aches)
  • Again ache
  • Asthenia (profound weak spot)


for which the next widespread causes of acute rash don’t clarify the medical image: varicella zoster, herpes zoster, measles, Zika, dengue, chikungunya, herpes simplex, bacterial pores and skin infections, disseminated gonococcus an infection, major or secondary syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, molluscum contagiosum, allergic response (e.g., to vegetation); and some other domestically related widespread causes of papular or vesicular rash.

N.B. It’s not needed to acquire unfavourable laboratory outcomes for listed widespread causes of rash sickness with a purpose to classify a case as suspected. 

[2] Monkeypox endemic nations are: Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Ghana (recognized in animals solely), Côte d’Ivoire, Liberia, Nigeria, the Republic of the Congo, and Sierra Leone. Benin and South Sudan have documented importations previously. International locations at the moment reporting instances of the West African clade are Cameroon and Nigeria. With this case definition, all nations besides these 4 ought to report new instances of monkeypox as half of the present multi-country outbreak.

Possible case:

 An individual assembly the case definition for a suspected case


A number of of the next:

  • has an epidemiological hyperlink (face-to-face publicity, together with well being employees with out eye and respiratory safety); direct bodily contact with pores and skin or pores and skin lesions, together with sexual contact; or contact with contaminated supplies corresponding to clothes, bedding or utensils to a possible or confirmed case of monkeypox within the 21 days earlier than symptom onset
  • reported journey historical past to a monkeypox endemic nation1 within the 21 days earlier than symptom onset
  • has had a number of or nameless sexual companions within the 21 days earlier than symptom onset
  • has a constructive results of an orthopoxvirus serological assay, within the absence of smallpox vaccination or different identified publicity to orthopoxviruses
  • is hospitalized as a result of sickness

Confirmed case:

A case assembly the definition of both a suspected or possible case and is laboratory confirmed for monkeypox virus by detection of distinctive sequences of viral DNA both by real-time polymerase chain response (PCR) and/or sequencing.

Discarded case:

A suspected or possible case for which laboratory testing by PCR and/or sequencing is unfavourable for monkeypox virus.

Identification of further instances and additional onward unfold within the nations at the moment reporting instances and different Member States is probably going. Any affected person with suspected monkeypox must be investigated and if confirmed, remoted till their lesions have crusted, the scab has fallen off and a contemporary layer of pores and skin has shaped beneath.

International locations must be on the alert for indicators associated to sufferers presenting with an atypical rash that progresses in sequential levels – macules, papules, vesicles, pustules, scabs, on the similar stage of growth over all affected areas of the physique – that could be related to fever, enlarged lymph nodes, again ache, and muscle aches. These people might current to numerous group and healthcare settings together with however not restricted to major care, fever clinics, sexual well being providers, infectious illness models, obstetrics and gynecology, urology, emergency departments and dermatology clinics. Growing consciousness amongst doubtlessly affected communities, in addition to well being care suppliers and laboratory employees, is crucial for figuring out and stopping additional secondary instances and efficient administration of the present outbreak.

Concerns regarding surveillance and reporting


The important thing aims of surveillance and case investigation for monkeypox within the present context are to quickly establish instances, clusters, and the sources of an infection as quickly as doable with a purpose to present optimum medical care, isolate instances to forestall additional transmission, establish and handle contacts and tailor efficient management and prevention strategies based mostly on mostly recognized routes of transmission.

In non-endemic nations, one case is taken into account an outbreak. Due to the general public well being dangers related to a single case of monkeypox, clinicians ought to report suspected instances instantly to nationwide or native public well being authorities no matter whether or not they’re additionally exploring different potential diagnoses. Circumstances must be reported instantly, in line with the case definitions above or nationally tailor-made case definitions. Possible and confirmed instances must be reported instantly to WHO by means of IHR Nationwide Focal Factors (NFPs) below the Worldwide Well being Rules (IHR 2005).

International locations must be on the alert for indicators associated to sufferers presenting with uncommon rash, vesicular or pustular lesions or lymphadenopathy, typically related to fever, in a spread of group and well being care settings, together with however not restricted to major care, fever clinics, sexual well being providers, infectious illness models, obstetrics and gynecology, and dermatology clinics. Surveillance for rash-like sickness must be intensified and steerage supplied for assortment of pores and skin samples for confirmatory testing.


Case experiences ought to embody at a minimal the next data: date of report; reporting location; identify, age, intercourse and residence of the case; date of onset of first signs; current journey historical past; current publicity to a possible or confirmed case; relationship and nature of contact with possible or confirmed instances (the place related); current historical past of a number of or nameless sexual companions; smallpox vaccination standing; presence of rash; presence of different medical indicators or signs as per case definition; date of affirmation (the place performed); methodology of affirmation (the place performed); genomic characterization (if obtainable); different related medical or laboratory findings, significantly to exclude widespread causes of rash as per the case definition; whether or not hospitalized; date of hospitalization (the place performed); and final result at time of reporting.

A worldwide case reporting kind is below growth.

Concerns associated to case investigation

Throughout human monkeypox outbreaks, shut bodily contact with contaminated individuals is essentially the most important threat issue for monkeypox virus an infection. If monkeypox is suspected, the investigation ought to encompass (i) medical examination of the affected person utilizing acceptable an infection prevention and management (IPC) measures, (ii) questioning the affected person about doable sources of an infection and the presence of comparable illness within the affected person’s group and contacts, and (iii) protected assortment and dispatch of specimens for monkeypox laboratory examination. The minimal knowledge to be captured are included above below ‘Reporting’. Publicity investigation ought to cowl the interval between 5 and 21 days previous to symptom onset. Any affected person with suspected monkeypox must be remoted in the course of the presumed and identified infectious intervals, that’s in the course of the prodromal and rash levels of the sickness, respectively. Laboratory affirmation of suspect instances is vital however shouldn’t delay implementation of public well being actions. Suspected presence of comparable illness within the affected person’s group or amongst contacts must be additional investigated (often known as “backwards contact tracing”).

Retrospective instances discovered by energetic search might now not have the medical signs of monkeypox (they’ve recovered from acute sickness) however might exhibit scarring and different sequelae. It is very important gather epidemiological data from retrospective instances along with energetic ones. Retrospective instances can’t be laboratory confirmed; nonetheless, serum from retrospective instances might be collected and examined for anti-orthopoxvirus antibodies to assist of their case classification.

Samples taken from individuals with suspected monkeypox or animals with suspected monkeypox virus an infection, must be safely dealt with by skilled employees working in suitably outfitted laboratories. Nationwide and worldwide laws on transport of infectious substances must be strictly adopted in the course of the pattern packing and transportation to the testing laboratories. Cautious planning is required to think about nationwide laboratory testing capability. Scientific laboratories must be knowledgeable upfront of samples to be submitted from individuals with suspected or confirmed monkeypox, in order that they will minimise threat to laboratory employees and, the place acceptable, safely carry out laboratory checks which can be important for medical care.

Concerns associated to contact tracing

Contact tracing is a key public well being measure to manage the unfold of infectious illness pathogens corresponding to monkeypox virus. It permits for the interruption of transmission and can even assist individuals at a better threat of creating extreme illness to extra rapidly establish their publicity, in order that their well being standing might be monitored, they usually can search medical care quicker in the event that they turn out to be symptomatic. Within the present context, as quickly as a suspected case is recognized, contact identification and speak to tracing must be initiated. Case sufferers must be interviewed to elicit the names and speak to data of all such individuals. Contacts must be notified inside 24 hours of identification.

Definition of a contact

A contact is outlined as an individual who, within the interval starting with the onset of the supply case’s first signs, and ending when all scabs have fallen off, has had a number of of the next exposures with a possible or confirmed case of monkeypox:

  • face-to-face publicity (together with well being care employees with out acceptable PPE)
  • direct bodily contact, together with sexual contact
  • contact with contaminated supplies corresponding to clothes or bedding

Contact identification

Circumstances might be prompted to establish contacts throughout quite a few contexts, together with family, office, college/nursery, sexual contacts, healthcare, homes of worship, transportation, sports activities, social gatherings, and some other recalled interactions. Attendance lists, passenger manifests, and so on. might be additional used to establish contacts.

Contact monitoring

Contacts must be monitored no less than day by day for the onset of indicators/signs for a interval of 21 days from the final contact with a affected person or their contaminated supplies in the course of the infectious interval. Indicators/signs of concern embody headache, fever, chills, sore throat, malaise, fatigue, rash, and lymphadenopathy. Contacts ought to monitor their temperatures twice day by day. Asymptomatic contacts shouldn’t donate blood, cells, tissue, organs, breast milk, or semen whereas they’re below symptom surveillance. Asymptomatic contacts can proceed routine day by day actions corresponding to going to work and attending college (i.e., no quarantine is important), however ought to stay near residence at some stage in surveillance. It could, nonetheless, be prudent to exclude pre-school kids from daycare, nursery, or different group settings.

Choices for monitoring by public well being authorities are depending on obtainable assets. Contacts might be monitored passively, actively, or straight.

  • In passive monitoring, recognized contacts are supplied with data on the indicators/signs to observe, permitted actions, and tips on how to contact the general public well being division if indicators/signs develop.
  • Energetic monitoring is when public well being officers are liable for checking no less than as soon as a day to see if an individual below monitoring has self-reported indicators/signs.
  • Direct monitoring is a variation of energetic monitoring that entails no less than day by day both bodily visiting or visually inspecting by way of video for indicators of sickness.

A contact who develops preliminary indicators/signs aside from rash must be remoted and intently watched for indicators of rash for the subsequent seven days. If no rash develops, the contact can return to temperature monitoring for the rest of the 21 days. If the contact develops a rash, they have to be remoted and evaluated as a suspected case, and a specimen must be collected for laboratory evaluation to check for monkeypox.

Monitoring uncovered well being employees and caregivers

Any well being employee or family member who has cared for an individual with possible or confirmed monkeypox must be alert to the event of signs that would counsel monkeypox an infection, particularly throughout the 21-day interval after the final date of care. Well being employees ought to notify an infection management, occupational well being, and public well being authorities to be guided a couple of medical analysis.

Well being employees who’ve unprotected exposures (i.e., not carrying acceptable PPE) to sufferers with monkeypox or probably contaminated supplies don’t have to be excluded from work obligation if asymptomatic, however ought to bear energetic surveillance for signs, which incorporates measurement of temperature no less than twice day by day for 21 days following the publicity. Previous to reporting for work every day, the well being employee must be interviewed concerning proof of any related indicators/signs as above.

Healthcare employees who’ve cared for or in any other case been in direct or oblique contact with monkeypox sufferers whereas adhering to really helpful IPC measures might bear self-monitoring or energetic monitoring as decided by native public well being authorities.

Publish-exposure vaccination (ideally inside 4 days of publicity) could also be thought-about by some nations for increased threat contacts corresponding to well being employees Together with laboratory personnel.

Journey-related contact tracing

Public well being officers ought to work with journey operators and public well being counterparts in different areas to evaluate potential dangers and to contact passengers and others who might have had contact with an infectious affected person whereas in transit.

Concerns associated to threat communication and group engagement

Two-way communication on monkeypox associated dangers and engagement of at-risk and affected communities on prevention, detection and care, is crucial for stopping additional unfold of monkeypox and controlling the present outbreak.

This contains offering public well being recommendation by means of the channels that concentrate on audiences use on how the illness transmits, its signs, preventive measures and what to do in case of suspect or confirmed an infection. This must be mixed with focusing on group engagement to the inhabitants teams who’re most in danger, working intently with well being care suppliers, together with sexual well being clinics, and civil society organizations.

Threat communication must be knowledgeable by insights from social listening detecting public sentiment and will well timed handle doable rumours and misinformation. Well being data and recommendation must be supplied avoiding any type of stigmatization of sure teams corresponding to males who’ve intercourse with males (MSM).

Key messages embody the beneath:

  • Prevention – Somebody who has direct contact with an contaminated individual, together with sexual contact can get monkeypox. Steps for self-protection embody avoiding pores and skin to pores and skin or head to head contact with anybody who has signs, practising safer intercourse, holding arms clear with water and cleaning soap or alcohol-based hand rub, and sustaining respiratory etiquette.
  • Detection and care – If individuals develop a rash, accompanied by fever or a sense of discomfort or sickness, they need to contact their well being care supplier and get examined for monkeypox. If somebody is suspected or confirmed as having monkeypox, they need to isolate till the scabs have fallen off and abstain from intercourse, together with oral intercourse. Throughout this era, sufferers can get supportive therapy to ease monkeypox signs. Anybody caring for an individual sick with monkeypox ought to use acceptable private protecting measures, together with carrying a masks, and cleansing objects, & surfaces which were touched.
  • Reporting – Any rash-like sickness throughout journey or upon return must be instantly reported to a well being skilled, together with details about all current journey, sexual historical past and smallpox immunization historical past. Residents and travellers to monkeypox-endemic nations ought to keep away from contact with sick mammals corresponding to rodents, marsupials, non-human primates (useless or alive) that would harbour monkeypox virus and will chorus from consuming or dealing with wild recreation (bush meat).

Concerns associated to massive gatherings

Considerations have been raised by the media with regard to the amplification of the unfold of monkeypox virus within the context of enormous gatherings. Massive gatherings might signify a conducive setting for the transmission of monkeypox virus as they entail shut, extended and frequent interactions amongst individuals, which in flip can expose attendees to contact with lesions, physique fluids, respiratory droplets and contaminated supplies.

Whereas the precise mechanisms of transmission of the current monkeypox outbreak are nonetheless being investigated, they usually probably differ from these of SARS-CoV-2, it is very important remind that the overall precautionary measures really helpful towards COVID-19 are additionally anticipated to largely shield from monkeypox virus transmission.

As well as, any individual assembly the suspected, possible and confirmed case definition detailed above ought to chorus from shut contact with some other particular person and shouldn’t attend massive gatherings.

WHO is intently monitoring the present monkeypox outbreak. Whereas no particular measures are required presently with regard to holding, suspending or cancelling a mass gathering in areas the place monkeypox instances have been detected, data might be shared with potential attendees of mass gatherings for them to make an knowledgeable choice.

Concerns associated to medical administration and an infection prevention and management in well being care settings

Well being employees caring for sufferers with suspected or confirmed monkeypox ought to implement customary, contact and droplet precautions. These precautions are relevant in any well being facility together with outpatient providers and hospitals. Commonplace precautions embody strict adherence handy hygiene, acceptable dealing with of contaminated medical tools, laundry, waste and cleansing and disinfection of environmental surfaces.

Immediate isolation of suspected or confirmed instances in a single room with sufficient air flow, devoted toilet and employees is really helpful. Cohort (confirmed with confirmed, suspected with suspected) might be applied if single rooms are usually not obtainable, guaranteeing minimal of 1-meter distance between sufferers. Beneficial private protecting tools (PPE) contains gloves, robe, medical masks and eye safety – goggles or face defend. The affected person also needs to be instructed to put on a medical masks once they come into shut contact (below 1m) with well being employees or different sufferers, if they will tolerate it. Moreover, a bandage, sheet or robe can be utilized to cowl lesions with a purpose to decrease potential contact with lesions. PPE must be disposed of previous to leaving the isolation space the place the affected person is admitted.

Ought to aerosol producing procedures (AGPs) (i.e. aspiration or open suctioning of respiratory tract specimens, bronchoscopy, intubation, cardiopulmonary resuscitation), be required for any motive and can’t be delayed, then as a matter of normal follow, a respirator (FFP2 or EN licensed equal or US NIOSH-certified N95) should be utilized by well being care employees as an alternative of a medical masks.

Isolation and transmission-based precautions must be continued till decision of signs (together with the decision of any rash and scabs which have fallen off and healed).

Deployment of pharmaceutical countermeasures together with particular antivirals (i.e. tecovirimat, which is accredited for monkeypox, however not but extensively obtainable) might be thought-about below investigational or compassionate use protocols, significantly for many who have extreme signs or who could also be susceptible to poor outcomes (corresponding to these with immune suppression). There’s a vaccine lately accredited for monkeypox which isn’t but extensively obtainable. Some nations might maintain smallpox vaccine merchandise which might be thought-about to be used in line with nationwide steerage. Any request for vaccine merchandise might doubtlessly be obtainable in restricted portions by means of nationwide authorities, relying on the nation. International locations might need to contemplate well timed vaccination of shut contacts as post-exposure prophylaxis or for sure teams of well being care employees for pre-exposure vaccination.

Based mostly on obtainable data presently, WHO doesn’t advocate that Member States undertake any worldwide travel-related measure for each, incoming and outgoing travellers.

WHO will probably be offering interim technical steerage within the coming days.

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