SMALLPOX & MPOX

Keeping up to date: Things to know in practice currently:

23rd October: Three unrelated cases of clade I mpox have been confirmed in California, USA. NOT travel related.

10th September: The fifth meeting of the WHO International Health Regulations (2005) Emergency Committee regarding the upsurge of mpox cases in 2024 met on 4 September. The Committee advised that the mpox situation in Africa no longer represents a PHEIC which was initially declared in August 2024. The lifting of this emergency declaration does not mean the threat is over... in fact there's still a lot of investment in vaccines happening - check this out: US government signs $56 million deal for smallpox/mpox vaccine (ACAM2000).

16th July 2025: June JCVI minutes say:

The Committee noted that outbreak cases of Clade Ib mpox were still be identified in the Democratic Republic of Congo and several neighbouring countries in Central and Eastern Africa. Advice had been requested from the travel sub-committee on vaccination of travellers to affected regions. The Committee agreed with the travel sub-committee’s advice that individuals travelling to areas with ongoing community transmission of Clade Ib mpox, who also meet criteria for being at high risk of exposure to mpox, should be vaccinated. The high-risk criteria include travellers (regardless of gender identity, sex or sexual orientation) who:

• Have a sexual partner who is at high risk of mpox;

• Are a sex worker

• Volunteer at sex-on-premises venues and have contact with contaminated materials without using personal protective equipment;

• Engage in sex tourism;

• Or anticipate experiencing any of the above scenarios.

• The general risk to travellers was considered to be low as close contact with communities where there would be transmission of mpox would not be usual.

• The Green Book currently recommends occupational vaccination for UK workers deployed to an area with an ongoing mpox outbreak. Vaccination of sex workers was already included in outbreak response planning outlined in the Green Book and may be deployed should an outbreak in the UK be identified.

• 2nd July 2025: Public facing leaflets updated

• 26th June 2025: Trial of Jynneos mpox vaccine begins in infants, toddlers, pregnant women

• 25th June 2025: Vaccine update has landed with an Mpox and MenB special - LOADS of useful resources. If you are working in sexual health have a good browse.

• 13th June: A letter has arrived! Introduction of new routine mpox and 4CMenB for gonorrhoea vaccination programmes letter. This letter provides the information required to implement the expanded pre-exposure mpox and new 4CMenB for gonorrhoea vaccination programmes primarily targeting GBMSM in sexual health services. There will be a rolling start from 1 August 2025, with all providers offering vaccinations by 1 September 2025.

• 6th June 2025: Sierra Leone battles intense mpox activity as Ethiopia reports first death. As of May, the number of lab-confirmed cases (17,845) has nearly reached the total reported for all of 2024. Test positivity is as high as 100% in seven of the country’s districts. Ethiopia confirmed its first mpox cases in late May, and last week the total rose sharply, to 40 cases, 17 of them confirmed. The death was an infant and linked with clade 1b.

• 29th May 2025: Ethiopia confirms first mpox cases

• 26th May: Malawi battles mpox as cases of the infectious disease surge in Africa

• 21st May 2025: Important news, particularly for sexual health services with regards to routine mpox and gonorrhoea vaccination programmes. Individuals should be identified through sexual health services, using markers of high risk of infection, including a recent history of multiple sexual partners or recent bacterial sexually transmitted infection. Full details on the eligible cohorts for each programme will be made available in the mpox and (?new) gonorrhoea chapters of the Green Book (look out for that new chapter!). At the same appointment, patients will also be offered vaccinations for HPV, and hepatitis A and B. The bulletin says that providers can begin to start vaccinating eligible people from 1 August 2025 once they have contracts in place, staff are trained, and vaccines are in stock (available via ImmForm). And that all providers must be vaccinating by no later than 1 September 2025.

• 30th April 2025: Sierra Leone launches mpox vaccination drive as cases soar. Health authorities confirm 763 cases of the virus, including 177 recorded in a two-day period last week

• 28th April 2025: Mpox outbreak continues to meet the WHO criteria of a public health emergency of international concern.

• 9th April 2025: Switzerland confirms clade 1b mpox. At least 15 countries in Asia, Europe, and North America have now confirmed clade 1b detections, almost all travel related. However, earlier this week the UK Health Security Agency said it has recorded a clade 1b case in a patient with no history of travel to outbreak areas and no contact with any known case-patients.

• 7th April 2025: A debut in the world of mpox vaccination! Vaccination against mpox: information for healthcare practitioners published. This new guidance document is for health practitioners implementing the mpox vaccination programme to protect against MPVX.

• Much needed given that this also happened this week: UK reports clade 1b mpox case with no travel history or links to earlier cases.

• 1st April 2025: FDA approves freeze-dried version of Jynneos mpox vaccine. The freeze-dried vaccines are easier to store and transport and have a longer shelf life than the frozen liquid version, which was approved in 2019.

• 31st March 2025: Can Repurposed Smallpox Vaccine Prove Effective for Mpox?

• 19th March 2025: Clade Ia and Ib mpox will no longer be classified as high consequence infectious diseases (HCID) following a review of available evidence by the Advisory Committee on Dangerous Pathogens. This decision has been taken because the evidence related to this clade no longer meets the criteria for an HCID, which includes having a high mortality rate and a lack of available interventions.

• On the same day this article appeared which highlighted that Jynneos/Imnavex mpox vaccine is 84% effective in people without HIV and 35% effective with HIV (one dose of the vaccine was 58% effective against mpox infection overall). That's quite a disparity! eeeek, perhaps we should be considering extra doses in those living with HIV?

• 10th March 2025: Brazil reports its first clade 1b mpox case

• 3rd March 2025: New mutant mpox strain discovered in the DRC. A new variant of mpox that may be better adapted to spread between people has been identified in the Democratic Republic of Congo. The new strain is a mutation of Clade 1a mpox – an older variant that has been known to cause more severe disease than Clade 2, which caused a global outbreak in 2022, or Clade 1b

• 27th Feb 2025: WHO extends mpox emergency as more transmissible clade 1a variant identified in DRC eeeeeek.....

• 20th Feb 2025: Scientists warn of increased mpox transmission

• 19th Feb 2025: Smallpox and mpox Green Book chapter updated: Amendment to post-exposure recommended use to include those previously primed with a live smallpox vaccine (in addition to those who have had one dose of MVA-BN) vaccine.

• 14th Feb 2025: UAE reports first case of clade 1b mpox. Linked to Uganda travel again.

• 12th Feb 2025: Article: Clade 1b mpox outbreak in DR Congo linked to sex workers. New research on the epidemiologic and genomic evolution of the clade 1b mpox outbreak in the DRC suggests 83% of cases were linked to sex work. During the study period, seven deaths from mpox were noted among hospitalised patients, and three healthcare workers contracted the disease. Four of the seven deaths occurred in young adults, ages 20 to 30 years. Also of note, 14 patients were pregnant women, among whom 8 reported miscarriages after contracting mpox.

In related news, New York has had their first case of confirmed clade 1b. This is the fourth clade 1b case confirmed in the United States.

7th Feb 2025: A timely reminder to anyone doing courses that things can change very quickly in the world of immunisation. Today A LOT of mpox guidance has been updated - of course this is just 2 days after delivering a course all about it. I've had some post-course emails to send today! Check everything out if relevant to you. The things that have been either added or updated are:

• Smallpox (MVA) vaccination against monkeypox checklist and consent form

• Mpox (monkeypox) contacts vaccination resources: Information on the smallpox vaccination used to protect those who have had contact with an mpox case against the monkeypox virus (MPXV).

• Mpox (monkeypox) vaccination resources: Information and leaflets to give to the patients and some more patient info specifically on ID technique

• I also came across this article from the 30th Jan which has some interesting discussion points about the ongoing outbreaks in Africa, the change in transmission routes, and the susceptibility of children to the more deadly clade 1b.

• 4th Feb 2025: 9th 1b case reported in the UK with a travel history to Uganda.

• 3rd Feb 2025: NHS opens new mpox vaccination sites across England.

• 1st Feb 2025: Article: Trump’s dismantling of USAid raises risk of mpox global emergency, experts warn

• 31st Jan 2025: An 8th UK case of 1b with a travel history to Uganda - no known link to any previous UK cases.

• 27th Jan 2025: A 7th UK case with a history to Uganda.

• 20th Jan 2025: Another UK case of mpox clade 1b. On 20 January 2025, the UK Health Security Agency reported one new case of clade Ib mpox in a returned traveller who recently visited Uganda. This is the sixth confirmed clade Ib mpox case in England since October 2024 and has no known links to previous UK cases.

• 9th Jan 2025: China reports mpox clade 1b cluster - article.

• 6th Jan 2025: France identifies first case of Clade 1b - article

• 24th Dec 2024: Updates to the smallpox and mpox Green Book chapter: Updated epidemiology following clade I cases in UK and clarification of advice in the event of a failed intradermal administration.

• 30th Nov 2024: A fifth case of Mpox Clade 1b has been found in the UK. This one is following travel to Uganda and is unrelated to the previous four UK cases. Fortunately, despite the higher death rate with Clade 1b, all of the first four cases are recovered now. It's well worth being prepared for any further cases. In development is a new trial to assess the vaccine in pregnant women and infants. This is reassuring.

• 19th Nov 2024: First case of mpox clade 1b in the USA.

• 7th Nov 2024: ANOTHER (household contact) case of mpox bringing the total UK cases to 4.

• 4th Nov 2024: Two more cases of Mpox Clade 1b in the UK. They are household contacts of the first case, which is not a surprise really.

• 30th October: The UKHSA has detected a single confirmed human case of Clade Ib mpox in the UK. A recent visitor to a known infected area of Africa. This is not great news :-( Germany also reported their first case on the 22nd October.

• 29th October: First Children Vaccinated in New Clinical Study Seeking to Expand the Indication for Bavarian Nordic’s Mpox Vaccine

• 14th October: The PGD template (formally named the smallpox PGD) for mpox (formally named monkeypox) has been updated. If you work in a clinical area make sure you have also seen this guidance on preparation for any cases.

• 20th September: This news item from NaTHNaC has some useful info in it for the occupational healthers out there who crossover with travel health. Check out the 'returning workers scheme'.

• 16th September: As Mpox continues to escalate in Africa, significant changes to the Green Book chapter on Mpox and Smallpox have been made to account for the current PHEIC situation. Worth a read! A new vaccine has achieved WHO pre-qualification (thanks for sharing this news Laura). And vaccines are being sent to Africa, but still not enough.

• 23rd August 2024 National PGD template updated for Smallpox vaccine

• 22nd August 2024 Thailand's first case of the Clade 1 strain of Mpox

• 14th August 2024: Arrrrgggghhhhhhhh my predictions are coming true :-( WHO Director-General declares mpox outbreak a public health emergency of international concern. Travellers to the following countries should be made aware of the risk of disease: DRC, Republic of Congo, Central African Republic, Burundi, Rwanda, Uganda, Kenya, Cameroon, Gabon, Angola, South Sudan, Tanzania and Zambia. I guess we will await any potential vaccine recommendations in due course. Anecdotally, I have heard about lots of private clinics getting inundated with requests for the vaccine, which is not available yet privately as far as I know.

• JULY 2024 Watch this space... we may not be in the clear just yet....20 new mpox cases and 3 deaths in South Africa in the last two months. And over in DRC in the last 4 weeks 130 children have been affected by a new more deadly strain of Mpox ("clade 1b") which kills 10% of it's victims. DRC has reported over 29,000 cases and 1,100 fatalities of Mpox since Jan 2023. Most of them children. This has pandemic potential. Keep an eye on this one!

• JUNE 2024 A new mpox strain spreading in DRC in New Scientist, and this article in the Guardian also talks about it.

• JUNE 2024 Since May 2022 117 countries reported over 97 thousand cases of Mpox and 186 deaths

• NOV 2023 New JCVI advice here about the Mpox vaccine programme

• MAY 2022 Mpox cases broke out globally. Globally, between January 2022 and 31 March 2024, there were 95,226 confirmed cases of Mpox, and 185 confirmed deaths. In Europe, there were 27,179 confirmed cases and 10 deaths.

• SEPT 2022 A vaccine programme (using good old Smallpox vaccine) was rolled out targeting those most at risk and this ended in July 2023. The NHS Mpox outbreak vaccination programme is currently only available in London and Greater Manchester for men who are gay, bisexual or have sex with other men, and who have multiple partners, participate in group sex or attend sex-on-premises venues. Some staff who work in specialist roles, such as caring for patients with Mpox, or staff who work at sex-on-premises venues are also eligible.

1980 SMALLPOX ERADICATED WORLDWIDE!!!!! Well done vaccines!!!! ALL the pictures on this page are of horrid Smallpox. PHEW, glad we shifted that one!!!!

Other useful links and further reading:

Guidance: De-isolation and discharge of mpox-infected patients: interim guidance

Interim guidance to support NHS Trusts in managing the de-isolation and discharge of mpox-infected patients.

Guidance: Mpox: reducing risk of transmission at vaccination clinics. Advice to help lower the chance of passing mpox infection to others during post-exposure vaccination clinics.

Mpox: guidance. Information and advice for healthcare professionals and the general public and Intradermal mpox (monkeypox) vaccination for eligible patients

Mpox: background information: The epidemiology, symptoms, diagnosis and management of monkeypox virus infections.

Article: Researchers report mpox DNA, live virus on surfaces and in air from patients' rooms. A study conducted in UK hospitals found mpox virus clade 1b DNA in 73% of surface samples and 7% of air samples from infected patients' rooms, as well as live virus in 19% of surface samples that underwent viral isolation.

Bits and bobs to casually drop into conversation

According to the Vaccine Knowledge Project, did you know....

• Mpox virus was originally found in captive monkeys in Denmark in 1958, before being found in humans in 1970 in the equatorial province of the Democratic Republic of Congo (DRC), Central Africa.

• Mpox is similar to smallpox – a disease we haven’t seen since 1977 because of the success of the smallpox vaccination programme; because of these similarities, the smallpox vaccine, can also protect against Mpox. Lucky it was still in existence because look what happened in May 2022!

• Just FYI in case you are trying to figure out someone's vaccine history from records the vaccine is sold under two trade names, Imvanex in the UK and Jynneos in the US.

• Vaccination can be offered up to 14 days after exposure to the mpox virus (ideally no longer than 4 days for the best chances of intercepting it) to reduce the symptoms of the disease for those who do not already have symptoms.