Mpox (formerly Monkeypox) Global Outbreak

• According to WHO, “This [was] the first time that cases and sustained chains of transmission [were] reported in countries without direct or immediate epidemiological links to areas of West or Central Africa.”
• With the exception of those regions, the majority of cases (86.2%) occurred among men who have sex with men, including gay and bisexual men.
• Overall, the severity of mpox is quite low. While extremely painful, most cases were managed without hospitalization and only 65 deaths were reported up to Dec. 16.
• Anyone can catch mpox, although the majority of cases in the 2022 outbreak were linked to sexual transmission.
• It is uncertain whether mpox can be eradicated in non-endemic countries, although some researchers think it is likely to become endemic in more places.

As of Dec. 16, 2022,  82,762 global cases had occurred in 110 countries across all six of WHO’s regions. The highest number of cases were found in the U.S. (29,687 cases and 20 deaths), followed by Brazil (10,252 cases and 14 deaths), Spain (7,416 cases and three deaths), France (4,110 cases and no deaths), Colombia (3,908 cases and no deaths) and the United Kingdom (3,730 cases and no deaths). These six countries, together with Germany, Peru, Mexico and Canada, represented 85.9% of cases reported. The transmission rate had slowed dramatically after the U.S. summer months in most places; for example, Germany only increased by four cases between mid-November and mid-December 2022.

Overall, the new cases had decreased by 45.6%% between Dec. 5 and Dec. 11, compared to the previous week. According to WHO, as of Dec. 11, 2022, 12 countries reported an increase in their cases. In the week prior to that date, the highest increase reported was from Mexico. There were 73 countries that had not reported any cases in the 21 days prior to Dec. 11 in the same time period, the Region of the Americas had 93.4% of the cases and the European Region had 5.6% of the cases.

Given the high rate of mpox within the U.S., the Biden administration declared monkeypox/mpox a public health emergency on Aug. 4. This allowed Health and Human Services (HHS) to access funds and hire new staff.

As of Dec. 16, mpox had been found in every state across the U.S. New cases had fallen to an average of five per day (Dec. 14), down from the peak of 627 on Aug. 1. The highest overall number was in California (5,622) with New York state (4,184) ranking second.

The first U.S. death was confirmed in California on Sept. 12. The death of a man in Ohio was announced on Sept. 29. After that point, an additional 18 deaths were recorded in the U.S.

A disproportionate number of people in the U.S. who contracted mpox were Black and Hispanic men. As of Dec. 4, 55% of cases were Black or African-American and 14% were Hispanic or Latino, compared to 21% white. By comparison, 59.3% of people in the U.S. are white (non-Hispanic), 13.6% are Black and 18.9% are Latino.

Like HIV in the 1980s, the majority of cases in this outbreak to date were among men who have sex with men (including gay and bisexual men) and their close associates. The term MSM was used to capture this as not all individuals engaging in same-gender sexual encounters identify as gay or bisexual.

Nonetheless, this association resulted in a form of “gay panic” and an opportunity for those opposed to LGBTIA+ rights to seize on the disease as a moral failure.

WHO has analyzed and traced a number of the cases. They have reported (as of Dec. 16):

• “96.8% of cases with available data are male, the median age is 34 years.
• Males between 18-44 years old continue to be disproportionately affected by this outbreak as they account for 79.7% of cases.
• Among cases with known data on sexual orientation, 86.1% identified as MSM. Of those identified as MSM, 5.3% were identified as bisexual men. For women, the available data shows that 87% are heterosexual.
• Among those with known HIV status, 51.6% were HIV-positive. Note that information on HIV status is not available for the majority of cases, and for those for which it is available, it is likely to be skewed towards those reporting positive HIV results.
• 942 cases were reported to be health workers. However, most were infected in the community and further investigation is ongoing to determine whether the remaining infection was due to occupational exposure.
• Of all reported types of transmission, a sexual encounter was reported most commonly, with 70.5of all reported transmission events. [This was a decrease from earlier in the outbreak when the rate was over 90%.]
• Of all settings in which cases were likely exposed, the most common was in party settings with sexual contacts, 59.1% of all likely exposure categories.”

According to a WHO analysis, 571 cases were found in children under 18 (1.2%), and of these, 148 were children ages 0-4 (0.3%). As of Dec. 16, there had been over 696 cases of Mpox detected in children and youth under 20 across the U.S. This includes: 20 children aged 0 to 5, nine aged 6 to 10, 11 aged 11 to 15 and 636 cases in people aged 16 to 20.

According to the CDC, while mpox can be spread through sexual contact, it is not the only mode of transmission. Anyone can get mpox if they have close personal contact with someone who has symptoms of mpox. Household transmission such as shared towels, clothing and bed linens is seen as the primary cause for cases in children. Despite this, homophobic opponents of equal rights are pointing to infections in children and CDC Director Rachelle Walensky’s describing children as “risk-adjacent” as proof of pedophilia, even though mpox is not considered to be a sexually transmitted disease (STD) (and even if it was an STD, household transmission is possible through activities of daily living).

Due to increasing criticism of the name “monkeypox” to describe the virus, especially within the U.S., actions were taken to rename the virus.

According to the New York Times, “Public health researchers say the term evokes racist stereotypes, reinforces offensive tropes about Africa and abets stigmatization that can prevent people from seeking care.”

The WHO held an open process to rename the disease the virus causes. It agreed upon mpox. Both names were to be for a year to alleviate concerns of changing the name in the midst of an outbreak.

The variants have been reclassified as Clade I (previously The Congo Basin variant) and Clade II (previously West African variant). There were two sub-clades (or sub-variants) Clade IIa and Clade IIb. It is Clade IIb that primarily circulated.

Two meetings of the International Health Regulation Emergency Committee (IHR Emergency Committee) were held – one in June and one in July – to determine whether WHO should declare mpox a public health emergency of international concern (PHEIC). In June, the IHR Emergency Committee felt there was not enough evidence to make such a declaration and in July, the committee could not reach a consensus. As a result, Dr. Tedros Adhanom Ghebreyesus, Director-General of the WHO, made the decision to break the deadlock and declared mpox as a PHEIC. This has also been done for several diseases, the most recent in January 2020 for COVID-19.

CNBC states, “The rare designation means the WHO now views the outbreak as a significant enough threat to global health that a coordinated international response is needed to prevent the virus from spreading further and potentially escalating into a pandemic. Although the declaration does not impose requirements on national governments, it serves as an urgent call for action. The WHO can only issue guidance and recommendations to its member states, not mandates. Member states are required to report events that pose a threat to global health.