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On Thursday in Los Angeles County, California, health officials confirmed the death of a man who was recently diagnosed with monkeypox. This brings the number of deaths with confirmed monkeypox infection to two in the United States. On August 30, Harris County, Texas reported the first such death in the US in a severely debilitated individual. Dr. John Hellerstedt of the Texas Department of Health said at the time that the case was being investigated to determine what role infection played in his death.
Like Hellerstedt, chief medical officer of the Los Angeles County Department of Public Health, Dr. Rita Singhal, was cautious about attributing the cause of death to the monkeypox virus until an autopsy was performed and her role in his death could not be determined.
Singhal said of the death: “We are at the beginning of the investigation and we do not have any further details at this time. We will share details as they become available, while maintaining confidentiality and privacy.”
California, which has 4,346 monkeypox cases to date, has the highest number of infections of any state in the country, including 14 cases among those 19 and younger. In total, more than 22,000 cases have been reported in the US since May, of which 89 confirmed or suspected cases are among children or adolescents. Florida leads in this category with 27 children’s cases.
The global case the number for non-endemic regions during the 2022 monkeypox outbreak reached more than 64,000, affecting more than 100 countries and territories. While international cases have been on a downward trend since mid-August, the drop has been steepest across Europe, down 70 percent on average over seven days per month. However, cases seem to have leveled off recently.
By comparison, the seven-day average of U.S. cases fell by just 35 percent, settling at about 500 cases a day. Meanwhile, Latin America, where the number of cases has risen above 10,000 confirmed cases, is seeing continued growth in the seven-day average. In particular, with almost 6,000 confirmed infections, Brazil remains the epicenter of South America. In addition to confirmed cases, more than 5,900 suspected cases indicate a significant underestimation of such infections.
Including the two deaths in the US, global monkeypox deaths in non-endemic countries remain low at 16. But if endemic countries are added to the tally, the global number of cases rises to more than 68,000 and the number of deaths jumps significantly. Most of these deaths occurred in the Democratic Republic of the Congo (DRC).
In their September 8, 2022, weekly updates on the monkeypox outbreak in of the African UnionThe African Centers for Disease Control and Prevention said there were 695 additional cases last week (37 confirmed and 658 suspected) from the DRC, Egypt and Nigeria. This represents a 50 percent increase from the previous update on August 31st. Last week’s 17 new monkeypox deaths in Africa occurred in the DRC.
However, the monkeypox epidemic continues in endemic areas. As of January 2022, the cumulative number of cases among African Union member states has reached 4,244 (520 confirmed and 3,724 suspected) and 124 deaths. Most of these cases (2,938) and deaths (110) occurred in the DRC, where the more deadly Clade I monkeypox virus is endemic. The fatality ratio (CFR) there reaches 3.7 percent.
Meanwhile, the number of cases in Nigeria rose by 71 percent from the previous week, with 136 new cases. A total of 981 cases and six deaths have been reported from 34 states and the Federal Capital Territory since the New Year. Egypt reported its first case of monkeypox last week. It follows that without ending the monkeypox pandemic everywhere, it will continue to threaten every other country. Indeed, the more dangerous clade from Central Africa may appear in different regions.
In light of the issues surrounding the death of a man infected with the virus in California, a public health press conference in Los Angeles was notable for its continued emphasis on the LGBTQ+ community. Los Angeles County has documented more than 1,700 infections, the most of any county in the state. Singhal explained that 95 percent of them were among men and 95 percent identified as LGBTQ+.
As the Jynneos smallpox vaccine shortage has eased somewhat, Los Angeles County health officials are expanding eligibility criteria, although priority continues to be given to immunocompromised individuals, such as people with HIV.
Singhal said the sooner vaccines are given after exposure, the greater the potential benefit against developing more severe disease. However, they administered the vaccine to individuals two weeks after exposure. Supportive care and monitoring is also recommended when someone develops monkeypox.
As of last week, Los Angeles County has received 57,000 vials of Jynneos, which equates to 113,000 doses. Almost 43,000 vials and almost 61,700 doses were administered. Of these, 51,000 (84 percent) received the first dose and 10,000 (16 percent) received the second dose. However, only one third of those who should receive the second dose received them. Singhal strongly urged those who have not received the complete series to do so.
It also noted that TPOXX (tecovirimat), an antiviral drug approved in 2018 for use against smallpox, was used mostly in the outpatient setting for patients with painful lesions in sensitive areas. A quarter of the 311 patients for whom they had data were immunocompromised and half were HIV positive. These treatments were administered to patients who developed overt monkeypox disease. In addition, they asked people with monkeypox to isolate themselves at home, cover their rashes and avoid close contact and sharing with others and pets.
The presented guidance is consistent with the recommendations of the US Centers for Disease Control and Prevention (CDC) based on their recent the study on US monkeypox infections among nearly 2,000 persons in eight US jurisdictions. They highlighted the fact that there was a high prevalence of HIV and other sexually transmitted infections (STIs) among those infected with monkeypox.
They wrote: “Among 1,969 people with monkeypox between May 17 and July 22, 2022, HIV prevalence was 38 percent, and 41 percent had been diagnosed with one or more other reportable STDs in the previous year.” The CDC also noted that patients with HIV had a higher rate of hospitalization (8 percent versus 3 percent).
This is consistent with the current prevalence of confirmed monkeypox infection among men who have sex with men (MSM) and sex workers, specifically among those with recent access to HIV and sexual health services. The CDC wrote that their findings suggest “that the reported cases of monkeypox are occurring among persons with recent access to HIV and sexual health services. Referral bias may partially explain these findings, as persons with signs and symptoms of M.pox who have established contact with HIV or sexual health providers may be more likely to seek care, and those providers may be more likely to recognize and test for M.pox virus. Signs and symptoms of monkeypox may have led persons with HIV infection who were not in HIV care to re-engage in care.”
With 1.6 million gay and bisexual men in the U.S. who are HIV positive or on medication to reduce their HIV risk, they are undoubtedly the group most at risk from the monkeypox virus. Resources need to be directed to this community to stop the spread of the infection. However, the failure to recognize the intertwining of multiple social networks in these communities means that the monkeypox virus can spread undetected to a wider extent.
There are also at least 7 million immunocompromised people in the U.S., including people with cancer, stem cell transplants, and organ transplants, affecting all ages. Children and pregnant women are an important group with a higher risk of complications if they unknowingly contract monkeypox. Yet there is no comprehensive and well-thought-out public health initiative to eradicate the virus, let alone offer appropriate guidelines based on evolving evidence during a pandemic to protect the entire population.
Original systematics review on the availability, scope and quality of recommendations for the clinical management of monkeypox published in July v BMJ (previously British Medical Journal) found a “lack” of high-quality guidelines to assist frontline caregivers.
Many sources cited were of low quality, with no documentation or explicit references to evidence supporting their recommendations. Guidelines for therapy and post-exposure prophylaxis were often conflicting. The authors wrote: “We observe[d] the tendency to rapidly produce guidelines in response to outbreaks that never return but are still available in the public domain. Failure to recall outdated guidelines when new evidence emerges poses a risk to patient care.”
As seen on https://www.wsws.org/en/articles/2022/09/13/dnpz-s13.html