The strain of the virus in the current monkeypox outbreak in nonendemic countries likely diverged from the monkeypox virus that caused a 2018-19 Nigerian outbreak and has far more mutations than would be expected, several that increase transmission.
The study comes from Portugal’s National Institute of Health in Lisbon, which was the first institution to genetically sequence the current strain behind more than 3,000 cases of monkeypox in Europe, North America, and other regions that had never seen the virus until this year.
Researchers found the current strain diverges from the original strain by 50 single nucleotide polymorphisms (SNPs), and several mutations made the virus more transmissible.
The strain belongs to clade 3 of the West African strain of the virus, which is less fatal than the Congo Basin clade. Monkeypox outbreaks from clade 3 are typically reported from western Cameroon to Sierra Leone and usually carry a less than 1% case-fatality rate.
The authors said the outbreak was likely not caused by undetected silent spread, or from an animal-to-human crossover event. Instead, “Current data points for a scenario of more than one introduction from a single origin, with superspreader event(s) (e.g., saunas used for sexual encounters) and travel abroad likely triggering the rapid worldwide dissemination.“
The authors also said the 50 SNPs that diverge from the original strain are far more (roughly sixfold to 12-fold more) than one would expect considering previous estimates of the substitution rate for orthopoxviruses, which typically have 1 to 2 substitutions per site per year.
Modeling study shows potential growth of outbreak
In another study, scientists use modeling to predict what will happen in nonendemic countries if public health measures to curb ongoing outbreaks are not taken.
They predict that, without interventions, the introduction of 3 cases in a country could cause 18 secondary cases, 30 could cause 118 secondary cases, and 300 cases could cause 402 secondary cases.
Contact tracing and surveillance, isolation of symptomatic cases, and ring vaccination would reduce the number of secondary cases by up to 86.1% and the duration of the outbreak by up to 75.7%, the authors conclude.
The authors also said the outbreak is a moderate international concern. Currently, consultants to the World Health Organization are weighing if the outbreak constitutes an international public health emergency during a 2-day meeting.
US, Portugal add more cases
In the United States, the Centers for Disease Control and Prevention said the national total is now 173 in 24 states, an increase of 17 cases since yesterday.
A New York City sexual health clinic offering monkeypox vaccine to men who have sex with men was forced to close because of overwhelming demand. Many men sought the vaccine in the days leading up to Pride celebrations.
Portugal now has 348 monkeypox cases, with 20 new cases in the last 24 hours. Along with Spain and the United Kingdom, Portugal has the most cases in Europe.
In other news, Croatia and Taiwan each reported their first cases of the virus.
Monkeypox outbreak in U.S. is bigger than the CDC reports. Testing is ‘abysmal’
On the surface, the monkeypox outbreak in the U.S. doesn’t look that bad, especially compared with other countries. Since the international epidemic began in May, the U.S. has recorded 201 cases of monkeypox. In contrast, the U.K. has nearly 800 cases. Spain and Germany both have more than 500.
But in the U.S., the official case count is misleading. The outbreak is bigger — perhaps much bigger — than the case count suggests.
For many of the confirmed cases, health officials don’t know how the person caught the virus. Those infected haven’t traveled or come into contact with another infected person. That means the virus is spreading in some communities and cities, cryptically.
“The fact that we can’t reconstruct the transmission chain means that we are likely missing a lot of links in that chain,” Jennifer Nuzzo, an epidemiologist at Brown University, says. “And that means that those infected people haven’t had the opportunity to receive medicines to help them recover faster and not develop severe symptoms.
“But it also means that they’re possibly spreading the virus without knowledge of the fact that they’re infected,” she adds.
In other words: “We have no concept of the scale of the monkeypox outbreak in the U.S.,” says biologist Joseph Osmundson at New York University. ”
Why are so few cases getting detected?
Testing. In many ways, the U.S. has dropped the ball on monkeypox testing.
Across the nation, public health agencies are running too few tests — way too few, Osmundson says. “State officials are denying people testing because they’re using a narrow definition of monkeypox to decide who receives a test. They’re testing in only a very restrictive number of cases.”
Take for instance the man Makofane knows. Eventually, after seeing more than four doctors, the man finally finds an activist who’s trying to expand testing. The activist connects the man with a doctor who orders a test through a private company (that’s working to produce a commercial test.) The result: He’s positive. He has monkeypox.
Makofane says the testing situation right now is so “abysmal” in the U.S. that he launched his own study, called RESPND-MI, to figure out the prevalence of monkeypox in New York City and to help friends share information about monkepox.
The CDC would not divulge to NPR how many tests have been performed across the country, nor will the agency say where community transmission is likely occurring in the U.S. (NPR emailed the agency multiple times about these questions but the press person declined to comment or provide an interview.)
On Thursday, the CDC told the New York Times, it has performed 1,058 monkeypox tests. However, it’s not clear how many of these tests are duplications for the same person. And several sources involved with monkeypox testing doubt the agency has tested that many cases. One source told NPR that, as of last Friday, the CDC had tested about 300 cases. At that time, about 100 of those tests were positive, giving a positivity rate of more than 30%.
When the outbreak first began last month, the CDC quickly helped to set up testing in about 70 state and local labs across the country. Unlike with COVID, the agency already had a test developed and ready to send to labs.
“We should celebrate that prior investment,” Nuzzo says. “That’s what preparedness means.
An ineffective testing system
But as the need for testing grew — and the disease became more common than officials initially predicted — the testing system set up by the CDC stopped functioning well, because it actually deters doctors from ordering a monkeypox test.
Providers have to go out of their way to order a test. They have to receive permission and instructions from local or state labs, Nuzzo says. The process is cumbersome and often time-consuming. Sometimes a doctor has to sit on the phone for hours.
“That’s really the bottleneck that we’re worried about,” she says. “We need to cast a wider net with testing to find infections that we’re missing. And that’s really hard to do if we make it cumbersome and difficult for health care providers to request a test in the course of their busy days.”
Nuzzo says the CDC and local health departments need to remove the barriers to testing. “I also want to make testing easier and more widespread so that all clinicians feel that they can test a patient. Any patient with a suspicious rash.”
And doctors and nurses need to have a better understanding of what monkeypox actually looks like in patients. It’s different from what’s in medical textbooks. It can present like many other diseases, including herpes, syphilis and colon cancer.
“Infections have been largely found in men who have sex with men, who may typically seek care at a sexual health clinic,” Nuzzo explains. “Those providers may be particularly well-educated now about monkeypox and may be more willing to send a specimen out for testing. But we may not be seeing that level of education and willingness to test with other health care providers, who see different kinds of patients. And that means we may be missing infections in different patient groups.”
On Thursday afternoon, the CDC announced they were working to ramp up testing at the main labs that health providers normally use. And the agency is aiming to make testing easier sometime in July.
But Nuzzo says changes to testing need to happen right away. It needs to be easier, right now, for doctors to submit samples to the labs already doing this testing.
“Time is not on our side here,” she says. “Every day we delay, we are missing links in the transmission chain and are allowing this outbreak to grow possibly beyond control.”
And monkeypox, just like COVID, may become a long-term — perhaps even permanent — problem here in the U.S.
Meanwhile, the US Centers for Disease Control and Prevention announced on Tuesday the activation of its Emergency Operations Center (EOC) to respond to the US monkeypox outbreak.
The activation of the EOC “allows the agency to further increase operational support for the response to meet the outbreak’s evolving challenges,” the agency said in a news release.
This facility is currently activated for Covid-19 and is where experts monitor information on other public health emergencies, such as hurricanes, earthquakes and oil spills.
This all feels like a Dejà Vu! The good news thus far is it’s been relatively quite mild. We’re at well over 5000 confirmed cases with only a single death recorded. It’s not unlikely that the actual case count is far higher due to lack of testing too. Now, an important caveat is that near entirety of cases have been within young, sexually active gay or bisexual men, who naturally will be more healthy and resilient. Is that the new AIDS? Sorry, I digress. [Cidrap, CDC, NPR]
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