• Mpox can be transmitted to humans through physical contact with someone who is infectious, with contaminated materials, or with infected animals.
• Identifying mpox can be difficult as other infections and conditions can look similar. It is important to distinguish mpox from chickenpox, measles, bacterial skin infections, scabies, herpes, syphilis, other sexually transmissible infections, and medication-associated allergies. Someone with mpox may also have another sexually transmissible infection such as herpes. Alternatively, a child with suspected mpox may also have chickenpox. For these reasons, testing is key for people to get treatment as early as possible and prevent further spread.

• Getting an mpox vaccine can help prevent infection. The vaccine should be given within 4 days of contact with someone who has mpox (or within up to 14 days if there are no symptoms). 

  It is recommended for people at high risk to get vaccinated to prevent infection with mpox, especially during an outbreak. This includes:

  • health workers at risk of exposure
  • men who have sex with men
  • people with multiple sex partners
  • sex workers.

  Persons who have mpox should be cared for away from other people.

• Mpox is a zoonosis, a disease that is transmitted from animals to humans, with cases often found close to tropical rainforests where there are animals that carry the virus. Evidence of monkeypox virus infection has been found in animals including squirrels, Gambian pouched rats, dormice, different species of monkeys and others. 

In 2003,  https://www.cdc.gov/poxvirus/mpox/outbreak/us-outbreaks.html - an outbreak of mpox in domesticated prairie dogs  occurred after they shared bedding and caging with a shipment of infected small mammals from West Africa. This led to 47 human cases in six states in the United States. This was the first time that human mpox was reported outside of Africa. Separating animals and people who are infected or have been exposed to mpox can help stop mpox from spreading further.

What We Know About Mpox in Animals

• Monkeypox virus can infect a wide range of mammal species, including monkeys, anteaters, hedgehogs, prairie dogs, squirrels, and shrews.
• We are still learning which species of animals can get infected with Monkeypox virus. While we do not know if reptiles, amphibians, or birds can get mpox, it is unlikely since these animals have not been found to be infected with other orthopoxviruses.
• Not all animals have a rash when they have mpox.
• Infected animals can spread Monkeypox virus to people and other animals, and it is possible that people who are infected can spread Monkeypox virus to animals through close contact.
• Monkeypox virus can be found in the rash caused by mpox (scabs, crusts, fluids) and infected body fluids, including respiratory secretions, and potentially in urine (pee) and feces (poop).

What We Know About Mpox in Pets

• We don’t know for sure if pets like dogs and cats can be infected with Monkeypox virus, but it may be possible.
• People with mpox could possibly spread the virus to pets through close contact, including petting, cuddling, hugging, kissing, licking, sharing sleeping areas, and sharing food.

No pets or other animals were confirmed to have mpox during the global mpox outbreak that began in 2022.

How to Care for Pets if You Have Mpox

• If you have mpox, avoid contact with animals, including pets, domestic animals, and wildlife to prevent spreading the virus.
  • Ask friends or family members who live in a separate home to care for your animals until you fully recover. After you recover,  https://www.cdc.gov/poxvirus/mpox/if-sick/cleaning-disinfecting.html - clean and disinfect your home  before bringing healthy animals back.
• People who are at increased risk for severe mpox should not care for animals that had close contact with a person with mpox. This includes
  • People with weakened immune systems
  • Pregnant people
  • Young children
  • People with a history of atopic dermatitis or eczema

Steps to Take if You Think Your Pet Has Mpox

• Possible symptoms of mpox in pets include rash, lethargy, lack of appetite, coughing, bloating, nasal and/or eye secretions or crust, fever, and/or pox-like skin sores (may initially resemble a pimple or blister first).
• If your pet had close contact with a person with probable or confirmed mpox and they have a new rash or two other symptoms, get your pet tested for mpox.
• Call your veterinarian if you notice an animal appears sick within 21 days after contact with a person with probable or confirmed mpox. A veterinarian can help notify your  http://www.nasphv.org/Documents/StatePublicHealthVeterinariansByState.pdf - state public health veterinarian Separate the sick animal from other pets and animals.
• Limit direct contact between the animal and people for at least 21 days until they are fully recovered or a veterinarian tells you it’s safe.
• Wash your hands often and wear clothing that covers your skin when caring for and cleaning up after sick animals. Wash your clothes after caring for sick animals.
• Disinfect animal bedding, enclosures, food dishes, and any other items in direct contact with infected animals.
• Do not shake soiled laundry and bedding (including disposable rodent bedding).

For information on how to clean and disinfect your home when someone is sick, visit  https://www.cdc.gov/poxvirus/mpox/if-sick/cleaning-disinfecting.html - Cleaning and Disinfecting .

Seeking safety, seeking sustenance

Since a power struggle between the Sudanese Armed Forces (SAF) and the paramilitary Rapid Support Forces (RSF) erupted into civil war on April 15, 2023, the two sides have plunged the country into a devastating crisis.

Some 10 million people are displaced – the highest figure in the world – and famine-like conditions are taking hold across the country.

About 756,000 people are facing “catastrophic levels of hunger” with an additional 25.6 million people facing acute food shortages, according to the Integrated Food Security Phase Classification, the United Nations’ hunger-level scale.

As a result, people are moving, seeking physical safety and enough food to sustain life, and more than 600,000 have ended up in Chad, according to the United Nations High Commissioner for Refugees (UNHCR).

Many are barely surviving, dependent on food aid from the World Food Programme (WFP).

While it isn't getting the attention it deserves, for the better part of a year we've been watching the rapid spread of a new, and arguably more dangerous, Mpox clade (Ib) which was first detected in the DRC in 2023 (see  https://afludiary.blogspot.com/2023/11/who-reports-1st-confirmed-cluster-of.html - WHO Reports 1st Confirmed Cluster Of Sexually Transmitted MPXV Clade 1 in the DRC ).

Meanwhile the milder clade IIb virus - which began its world tour in 2022 - continues to cause sporadic outbreaks around the globe (see  https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON525 - WHO DON Mpox - South Africa ). 

While that hasn't happened yet, the Mpox epidemic in the DRC continues to worsen, and neighboring nations are on heightened alert.  In recent weeks Mpox cases have been reported in Burundi, and given limited surveillance, other cases may be flying under the radar. 

-

The caveat of course is that up until mid-May of 2022, the risk of Mpox Clade II spreading internationally was considered equally low.  The Mpox virus was only belatedly  https://afludiary.blogspot.com/2022/05/cdc-han-00466-monkeypox-virus-infection.html - discovered to be spreading in multiple non-endemic nations , leading to the  https://afludiary.blogspot.com/2022/07/who-director-declares-monkeypox-public.html - declaration of a PHEIC  (Public Health Emergency of International Concern) the following July. 

As we've  https://afludiary.blogspot.com/2022/12/flying-blind-in-viral-storm.html - seen with COVID, H5N1, and other infectious disease reporting  around the globe, surveillance and reporting on Mpox is often limited, or sometimes missing entirely.  The WHO described this situation in their last  https://cdn.who.int/media/docs/default-source/health-emergency-information-risk-assessment/20240628_mpox_external-sitrep_34.pdf - monthly Mpox update #34 :

WHO continues to encourage all countries to ensure that mpox is a notifiable disease and to report mpox cases, including reporting when no cases have been detected (known as ‘zero-reporting’, as outlined in the Standing Recommendations on mpox issued by the WHO Director General).

This report does not highlight non-reporting countries. Therefore, it should be noted that an absence of reported cases from a country may be due to the country not reporting, rather than having no cases. Reporting to WHO has been declining, therefore, the decline in reported cases should be interpreted with caution.

A reminder that an absence of evidence is not necessarily evidence of absence. 

Earlier this week, in  https://afludiary.blogspot.com/2024/07/ecdc-risk-statement-on-mpox-as-cases.html - ECDC Risk Statement On Mpox As Cases Continue to Spread In Africa , we looked at the increasing spread of (both clade I & clade II) Mpox across endemic regions of central Africa (see map above), and feared incursions into neighboring countries. 

In the past few days both Kenya in east Africa, and Côte d'Ivoire in west Africa, have reported cases, raising further concerns that the virus is gaining territory. 

The Central African Republic (CAR) has also  https://www.bbc.com/news/articles/cm52rk2el81o - declared an outbreak  after cases - which are normally reported from more rural regions - have been reported in their capital; Bangui. 

Complicating matters even further, we've seen reports for the better part of a year on a new variant of the virus - dubbed clade Ib - which is spreading in the DRC (see  https://afludiary.blogspot.com/2024/04/preprint-sustained-human-outbreak-of.html - Preprint: Sustained Human Outbreak of a New MPXV Clade I Lineage in Eastern Democratic Republic of the Congo ).

While this new clade has not been confirmed outside of central Africa, it appears to be more easily transmissible and more severe, sparking a number of recent risk assessments.

-

But as our collective immunity from the smallpox vaccine - which was discontinued in the late 1970s - dwindles, there are increased opportunities for pox viruses to make a comeback. 

As they spread from host-to-host, additional evolutionary changes seem likely (see  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9795006/ - Evolution of monkeypox virus from 2017 to 2022: In the light of point mutations ).

In the past month, at least 50 Mpox cases have been reported in four other countries bordering the DRC - countries that have not experienced the virus before.

They include Burundi, Kenya, Rwanda and Uganda. 

Like in the previous Mpox outbreak, the new strain is predominantly affecting men who have sex with men, and those with multiple sex partners like sex workers.

During 2023, a clade I outbreak of mpox disease in the Democratic Republic of Congo (DRC) resulted in 14,626 suspected cases being reported, with 654 associated deaths, making for a case-fatality rate of 4.5%. The outbreak continued into 2024 with an additional 3,576 suspected mpox cases and 265 deaths being reported in the DRC through the first 9 weeks of the year, making for an estimated CFR of 7.4%. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-drcmpox-93 - [91]}

Transmission of the virus in the outbreak appears to be primarily through sexual and close familial contact, with cases occurring in areas without a history of mpox, such as  https://en.wikipedia.org/wiki/South_Kivu - South Kivu  and  https://en.wikipedia.org/wiki/Kinshasa - Kinshasa . An estimated 64% of the cases and 85% of fatalities have occurred in children. The outbreak seems to consist of two separate sub-variants of clade I, with one of the sub-variants having a novel mutation making detection with standard assays unreliable. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-drcmpox-93 - [91] https://en.wikipedia.org/wiki/Mpox#cite_note-94 - [92]}

The outbreak spread to the neighbouring country of the  https://en.wikipedia.org/wiki/Republic_of_Congo - Republic of Congo , with 43 mpox cases being reported in March 2024. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-drcmpox-93 - [91]}  By early August the outbreak spread further into central and southern Africa with cases reported in  https://en.wikipedia.org/wiki/Burundi - Burundi ,  https://en.wikipedia.org/wiki/Rwanda - Rwanda ,  https://en.wikipedia.org/wiki/Uganda - Uganda ,  https://en.wikipedia.org/wiki/Kenya - Kenya , and  https://en.wikipedia.org/wiki/South_Africa - South Africa . ^{https://en.wikipedia.org/wiki/Mpox#cite_note-cohen-68 - [66] https://en.wikipedia.org/wiki/Mpox#cite_note-:1-18 - [16]}

Mpox can be transmitted from one person to another through contact with infectious lesion material or fluid on the skin, in the mouth or on the genitals; this includes touching, close contact and during sex. It may also spread by means of respiratory droplets from talking, coughing or sneezing. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-WHOfact2023-1 - [1] https://en.wikipedia.org/wiki/Mpox#cite_note-CDC_Transmission-34 - [32]}  

During the 2022–2023 outbreak, transmission between people was almost exclusively via sexual contact. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-35 - [33]}

 There is a lower risk of infection from  https://en.wikipedia.org/wiki/Fomite - fomites  (objects which can become infectious after being touched by an infected person) such as clothing or bedding, but precautions should be taken. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-CDC_Transmission-34 - [32]}

The virus then enters the body through broken skin, or mucosal surfaces such as the mouth, respiratory tract, or genitals. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-WHOfact2023-1 - [1]}

The  https://en.wikipedia.org/wiki/Natural_reservoir - natural reservoir  of monkeypox virus is thought to be small mammals in tropical Africa. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-NIH_mpox-33 - [31]}  The virus can be transmitted from animal to human from bites or scratches, or during activities such as hunting, skinning, or cooking infected animals. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-WHOfact2023-1 - [1]}

Although it has been endemic there for decades, in November of 2023 we began to see escalating reports of Mpox activity in the DRC, including the  https://afludiary.blogspot.com/2023/11/who-reports-1st-confirmed-cluster-of.html - first Confirmed Cluster Of Sexually Transmitted MPXV Clade 1 , which led to both the ECDC and CDC issuing risk assessments in December.

https://afludiary.blogspot.com/2023/12/ecdc-risk-assessment-on-transmission.html - ECDC Risk Assessment On Transmission & Spread of Clade I Mpox From The DRC

https://afludiary.blogspot.com/2023/12/cdc-han-advisory-00501-mpox-caused-by-h.html - CDC HAN Advisory #00501: Mpox Caused by H-2-H Transmission with Geographic Spread in the Democratic Republic of the Congo

While the risk to Americans and Europeans from this clade I virus has been  https://afludiary.blogspot.com/2024/07/ecdc-risk-statement-on-mpox-as-cases.html - repeatedly assessed  as `very low', the same was said about the clade II Mpox virus in the spring of 2022, before it began its world tour. 

Since then, the news has only gotten worse; a new clade Ib MPXV was identified last March (see  https://afludiary.blogspot.com/2024/04/preprint-sustained-human-outbreak-of.html - Preprint: Sustained Human Outbreak of a New MPXV Clade I Lineage in Eastern Democratic Republic of the Congo ), and in recent weeks we've seen the spread of clade I from the DRC into neighboring countries (see map above).

Compared to the the clade II Mpox virus, clade I viruses tend to produce more severe illness, and have a significant fatality rate (variously reported between 3%-10%).  While it still appears to be limited to African nations, in our highly mobile 21st century, there are no guarantees how long that will last. 

Situation in DRC

There are several outbreaks happening at the same time in DRC, with cases reported throughout the country, in the capital city of Kinshasa, and in some other large cities. In DRC, different provinces have outbreaks with different features.

In some provinces, patients have acquired infection through contact with infected dead or live wild animals, household transmission, or patient care (transmitted when appropriate PPE wasn’t used or available); a high proportion of cases have been reported in children younger than 15 years of age.

In other provinces, the cases are associated with sexual contact among men who have sex with men and female sex workers and their contacts. These are first reported cases of sexual transmission with clade I mpox.

CDC has been supporting DRC mpox research and response for more than 20 years. CDC and other U.S. government agencies are on the ground in DRC helping partners in the country with disease surveillance, laboratory capacity including testing materials, strengthening workforce capacity, case investigation, case management, infection prevention and control, border health, and risk communication and community engagement. DRC has approved the use of vaccines in-country, so CDC is working with other U.S. government and partners on a plan to get vaccines to them as soon as possible.

Situation in Central and Eastern Africa

The Republic of the Congo (ROC), which borders DRC to the west, declared a clade I mpox outbreak in April 2024. There have also been confirmed clade I cases in Central African Republic (CAR), which borders DRC to the north. Clade I mpox is endemic to ROC and CAR, but the new cases appear to be linked to spread from DRC. In late July 2024, Burundi, Rwanda, and Uganda, which sit on the eastern border of DRC, reported confirmed cases of mpox. Clade I mpox has not been known to be endemic in these countries.

Although contact tracing is ongoing, some cases have links to DRC. Rwanda and Uganda have confirmed these cases are clade I MPXV. In Burundi, clade-specific testing is underway, but cases are presumed to be clade I because of DRC and Rwanda’s shared borders with Burundi. Person-to-person transmission has occurred during this outbreak, including through sexual contact, household contact, and within the healthcare setting. People have also gotten mpox through contact with infected wild animals.

Its perceived mildness, and the availability of vaccines and antivirals, have made it less of a public health concern. But clade I Mpox is viewed as being far more serious, and it remains to be seen https://afludiary.blogspot.com/2023/10/cdc-eid-journal-two-reports-on.html -  how effective our vaccines and antivirals  will be against it. 

Unlike the clade II Mpox virus, which began its world tour in the spring of 2022, clade I & Ib Mpox cause far more severe illness, and carry a significantly higher fatality rate. 

Clade Ib appears to be spreading far more efficiently in the DRC than previous strains, and is disproportionately affecting (and killing) children. In recent weeks clade Ib has been  https://afludiary.blogspot.com/2024/07/ecdc-risk-statement-on-mpox-as-cases.html - detected in three new countries (Rwanda, Uganda and Kenya),  and testing is ongoing in a 4th (Burundi).

Add in the fact that many countries are lax in looking for, or reporting cases (see  https://afludiary.blogspot.com/2024/06/who-multi-country-outbreak-of-mpox.html - WHO statement  below), and it becomes difficult to say with absolute certainty how widespread clade I has become. 

The clade I variant contains predominantly APOBEC3-type mutations, indicating an adaptation of the virus due to intense circulation in humans (8). Person-to-person transmission has been continuous since its detection, and this is the first time that sustained community transmission of the virus has been described in the country (8).

Since the beginning of 2024, as of the last report on 26 July 2024, the Democratic Republic of the Congo Ministry of Health reported 14,479 cases of mpox (2,715 confirmed; 11,764 suspected) and 455 deaths (case fatality rate: 3.1%), affecting 25 of the country's 26 provinces. Children under 15 years of age accounted for 66% of cases and 82% of deaths. Of the confirmed cases, 73% were males (9).

Exactly what that would look like is impossible to say, since the virus continues to evolve.  Past performance has never been a reliable guarantee of future results. 

About the only thing we can say is, the longer we wait to acknowledge a problem, the harder is becomes to effectively deal with it.  

And the warning lights have been flashing with Mpox for quite some time. 

Last week, the Director General of the WHO Dr. Tedros  https://afludiary.blogspot.com/2024/08/who-d-g-will-convene-ihr-emergency.html - announced his intention to convene an emergency IHR meeting  to advise him on whether these recent developments met the criteria for declaring PHEIC. 

Yesterday the  https://africacdc.org/ - African CDC  declared Mpox a regional emergency (see  https://africacdc.org/news-item/africa-cdc-declares-mpox-a-public-health-emergency-of-continental-security-mobilizing-resources-across-the-continent/ - Africa CDC Declares Mpox A Public Health Emergency of Continental Security, Mobilizing Resources Across the Continent ) and today the WHO has followed suit, declaring Mpox a PHEIC for the second time in just over 2 years. 

How is mpox virus transmitted?

The mpox virus is transmitted to humans through close contact with an infected animal or person.

Animal-to-human transmission typically occurs through bites, scratches, or direct contact with the blood, body fluids, or wounds of an infected animal.

Human-to-human transmission can happen through:

• Direct contact with skin lesions, body fluids, or respiratory droplets of an infected person.
• Prolonged face-to-face contact with an infected person.
• Touching contaminated objects, such as bedding or clothing that have been in contact with the infectious material, although this is a rare mode of transmission.

The virus enters the body through broken skin, the respiratory tract, or mucous membranes (which include eyes, nose, and mouth).

Pakistan has confirmed at least one case of the mpox virus, a day after Sweden confirmed an infection with a more easily spread and deadlier variant linked to a recent outbreak in Africa.

Pakistan’s Ministry of Health said in a statement on Friday that the  https://www.aljazeera.com/news/2024/8/14/what-is-mpox-and-why-has-who-declared-it-global-health-emergency - mpox  strain that had caused the confirmed case was not immediately known.

Irshad Roghani, director of public health in the northwestern province of Khyber Pakhtunkhwa, where the 34-year-old patient is being treated, said samples had been sent to Islamabad for genetic sequencing to ascertain which variant of the virus the patient contracted.

Historically, the  https://en.wikipedia.org/wiki/Case_fatality_rate - case fatality rate  (CFR) of past outbreaks was estimated at between 1% and 10%, with clade I considered to be more severe than clade II. ^{https://en.wikipedia.org/wiki/Mpox#cite_note-Death_Rates-23 - https://en.wikipedia.org/wiki/Mpox#cite_note-Gessain_2022-24 - The case fatality rate of the  https://en.wikipedia.org/wiki/2022%E2%80%932023_mpox_outbreak - 2022–2023 global outbreak  caused by clade IIb has been very low, estimated at 0.16%, with the majority of deaths in individuals who were already  https://en.wikipedia.org/wiki/Immunodeficiency - immunocompromised . https://en.wikipedia.org/wiki/Mpox#cite_note-25 - https://en.wikipedia.org/wiki/Mpox#cite_note-:2-26 - Mpox in both humans and animals is caused by infection with the  https://en.wikipedia.org/wiki/Monkeypox_virus - monkeypox virus  – a  https://en.wikipedia.org/wiki/DNA_virus#Double-stranded_DNA_viruses - double-stranded DNA virus  in the genus  https://en.wikipedia.org/wiki/Orthopoxvirus - Orthopoxvirus , family  https://en.wikipedia.org/wiki/Poxviridae - Poxviridae , making it closely related to the  https://en.wikipedia.org/wiki/Variola - smallpox ,  https://en.wikipedia.org/wiki/Cowpox - cowpox , and  https://en.wikipedia.org/wiki/Vaccinia - vaccinia  viruses. The two  https://en.wikipedia.org/wiki/Clade#viruses - subtypes of virus  are clade I and clade II. https://en.wikipedia.org/wiki/Mpox#cite_note-WHOfact2023-1 -  Clade II is further divided into subclades: clade IIa and clade IIb. Cases identified as part of the 2022–2023 global outbreak are caused by clade IIb. https://en.wikipedia.org/wiki/Mpox#cite_note-WHOfact2023-1 -  Clade I is largely limited to the  https://en.wikipedia.org/wiki/Democratic_Republic_of_the_Congo - DRC  and is estimated to cause more severe disease and higher mortality than clades IIa and IIb. https://en.wikipedia.org/wiki/Mpox#cite_note-32 -}

“As a result of the rapid spread of this outbreak in Africa, ECDC has increased the level of risk for the general population in the EU/EEA and travellers to affected areas. Due to the close links between Europe and Africa, we must be prepared for more imported clade I cases,” says Pamela Rendi-Wagner, Director of ECDC.

Much also depends on how thorough, and proactive, individual nations are in detecting cases and in preventing secondary transmission. 

It should be noted that the ECDC can only only present  https://www.ecdc.europa.eu/sites/default/files/documents/ECDCStrategy-2024update2_0.pdf - non-binding recommendations  to member states. What they decide to do with it is something we'll have to wait to see. 

Mpox Spreads to Countries: Will the World Learn from its Mistakes? | Vantage with Palki Sharma

A month ago the  https://afludiary.blogspot.com/2024/08/who-declares-mpox-pheic-public-health.html - WHO declared the Mpox outbreak in Central Africa to constitute a PHEIC  (Public Health Emergency of International Concern) after reports that a recently emerged clade (Ib) of the virus began to spread outside of the DRC (see  https://afludiary.blogspot.com/2024/08/more-african-nations-reporting-mpox.html - More African Nations Reporting Mpox - Africa CDC Mpox Update (Jul 30th) ).