Thread by @mugecevik

As the monkeypox virus (MPX) outbreak continues, a lot of data emerging in real-time & being rapidly disseminated (as well as misinformation). I complied the unfolding scientific data (with direct links to papers and threads) on what we (don’t) know so far. #IDTwitter 🧵(1/n)

First, MPXV is not a novel virus. It is a viral zoonosis first discovered in 1958, with the first human infection reported in 1970. It is classified as a high priority pathogen by WHO, cases mostly identified in central & western Africa until now. (2/n) (who.int/news-room/fact…\)

Confirmed and suspected cases of #MonkeyPox now reached 145 among 13 countries with 20 cases in the UK. The main concern is that there are non-travel associated cases in Europe, meaning there is likely unnoticed community transmission. (3/n)

https://twitter.com/MOUGK/status/1527055553876348928?s=20&t=iwlFRW76yTCpfhhLW--CIQ

The first case detected was in London on 7 May related to travel from Nigeria, followed by additional cases across England & is the first outbreak of community transmission in Europe. The global reach of transmission for this outbreak is beyond that previously experienced. (4/n)

The precise drivers & ongoing global risk is not entirely well defined. However, we have now learned a few things, which provide crucial answers. Normally, MXP doesn’t spread efficiently h2h. So, one of the concerns was whether this a new & more transmissible strain of MPX. (5/n)

Full genome sequence of a MPX case in Belgium shows that the protein coding sequence appears identical to that of a sequence from 2018 from the UK (linked to Nigeria). This preliminary data argue against evolutionary adaptation. (6/n)

https://twitter.com/borges__vitor/status/1527436883093078029?s=20&t=yuKXQDSCcS6AAfnjNaR3tQ

But sequencing is ongoing - although these are closely related to 2018 MXP we can’t completely rule out a mutation conferring enhanced transmissibility. Sequencing to greater depth will improve quality of the consensus genomes. See A Rambaut et al. (cont)
virological.org/t/discussion-o…

If MXP didn’t suddenly become better at infecting people and our previous knowledge in regard to its transmission dynamics remain the same, why are we seeing a lot of cases all of a sudden? There are some clues in the epidemiological data gathered so far. (7/n)

~65% of cases are identified in 4 countries - UK (20), Portugal (34), Spain (53) & Canada (22), and clusters of cases include many men who have sex with men (MSM). This has raised Qs about a new route of transmission, but prolonged close contact is how MXP normally spreads. (8/n)

MPX primarily presents as a vesicular-pustular illness (skin lesions), preceded by fever, headache, muscle aches and fatigue. MXP is transmissible from the time when skin lesions appear, throughout the entire course of illness [i.e. all lesions have healed]. (9/n)

While we still need to estimate the incubation period of the current outbreak, from the historical evidence, MXP has a long-ish incubation period. So, cases we are seeing at the moment relates to an event or events that happened a few weeks ago.  (10/n)

https://twitter.com/adamjkucharski/status/1527494313080303617?s=20&t=H0mWnqxwSVZ6Ga9OLejhhA

Throughout the covid19 pandemic, my main research focused on transmission dynamics. And network dynamics are the most important factor that define how a virus spreads. Network related factors include network size, density of connections, & link to high-risk activities. (11/n)

Sexual networks can allow linkage of seemingly isolated outbreaks. For instance, Spanish researchers are investigating a linkage to sauna as a common exposure setting, which fits within close contact definition. (12/n) (theolivepress.es/spain-news/202…\)

Larger, more densely connected networks, closer to the core, can be associated with steep rises in incidence. For instance, introduction to MSM networks and connection to recent event(s) in Western Europe may explain the current outbreak. (13/n)

https://twitter.com/angie_rasmussen/status/1527620962044153856?s=20&t=wJVfjYt1G280dhe3BVB2xA

This is not very surprising as historical data suggest that MXP tends to spread very well within households with 9% secondary attack rate in unvaccinated populations. So, this does not only relate to sexual networks, close and prolonged contact is definitely an issue. (14/n)

Majority of the cases were not admitted to hospital & no deaths so far. This is reassuring and fits with historical data as the current outbreak is caused by the MXP West Africa clade, which has a CFR of 1- 3.6% (who.int/emergencies/di…\) (15/n)

This is the biggest outbreak outside of Africa, and there will be more cases to come. The concern is not necessarily a global pandemic like what we’ve seen w/ coronaviruses or influenza. But a growing & large MXP epidemic is a concern especially if PH measures are delayed. (16/n)

Especially given the apparent symptoms of MXP and transmission mostly after symptoms suggest that isolation + contact tracing can be very effective to control MPX. With the help from smallpox ring vaccination, I hope that it very much can be contained. (17/n)

However, the biggest challenge in my opinion is the delayed identification of cases, which may have profound implications not only on communities, but on healthcare workers, from risk of exposure or prolonged isolation, adding strains on healthcare systems during outbreaks.(18/n)

For instance, the case in Belgium was initially only tested for HSV & Syphilis. Upon international alerts was then tested for MXP. This is also due limited published literature on MXP due to the challenges faced by colleagues in global South (19/n)

https://twitter.com/boghuma/status/1416569112856350735?s=12&t=A34tU9lKyrKcbQ41lcG_kw

So, the most important thing is to inform our communities & healthcare workers about the clinical presentation, incubation period, so that people can be diagnosed at an earlier possibility, isolated and contacts are protected. This is the range of skin lesions. (20/n)

In conclusion, #monkeypox is not really a rare disease & is a PH concern. According to prelim evidence there is no indication that current outbreak is due to a new MXP variant & epi data suggest that it’s been introduced to MSM networks, likely sometime in late-April. (21/n)

We have observed MXP outbreaks in many countries mainly in Africa, this is the first time that we are observing wide transmission in Europe. MXP remains an under-recognized and underreported emerging disease. Good clinical management can limit disease severity or death. (22/n)

We are in an unknown territory as individuals who have prior smallpox vaccination do have some degree of protection against monkeypox, but we don’t really know the degree of protection it provides to individuals who had vaccination 50, 60 years prior. (23/n)

For further reading, I will link some useful threads here in addition to the ones in my thread.
 
1- This thread by @JohnRossMD covers some clinical information from incubation period to clinical presentation. (24/n)
 

https://twitter.com/JohnRossMD/status/1527045028417241088?s=20&t=ZbI3rWB59yu1UiuSj3dfUA

2- In this article & thread @edyong209 brilliantly covers the current MXP situation in detail with quotes from colleagues managing the current outbreak

https://twitter.com/edyong209/status/1527356834260013058?s=20&t=tpzwQE3rmE4oJT_g7aAyGA

(25/n)

3- This is the Monkeypox contact tracing guidance by @UKHSA: classification of contacts and advice for vaccination and follow up. This guidance provides principles for risk assessment and follow up of contacts of confirmed monkeypox cases (26/n)
assets.publishing.service.gov.uk/government/upl…

4- This thread by @tuliodna brings together 10 important papers if you want to learn more about MXP. (27/n)

https://twitter.com/tuliodna/status/1527167408980492289?s=12&t=A34tU9lKyrKcbQ41lcG_kw

I will update this thread as more data become available. But please remember that it doesn’t mean monkeypox is a gay disease and stigma has no place in outbreak response. A great article by @Boghuma et al.

https://twitter.com/Boghuma/status/1527403801233215506