The UK Health Security Agency (UKHSA) has announced a further four cases of monkeypox in the UK, three in London and one in the North East of England that is believed linked with the London cases.

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However, there are no known connections between the latest cases and either the first case reported on 7 May or the two additional cases, both from the same household, announced at the weekend.

These latest cases mean that there are currently seven confirmed monkeypox cases in the UK, diagnosed between 6–15 May.

The four most recently detected cases all appear to have been infected in London and the UKHSA is investigating possible links between them. All four self-identify as gay, bisexual or other men who have sex with men, it said. As of Monday 16 May, it had uncovered common contacts for two of the four latest cases.  

Monkeypox is a viral infection usually associated with travel to West Africa, and the first reported case had a history of travel to Nigeria, where it is believed the disease was contracted.

Prior to this outbreak there have been a few other small clusters of cases in the UK. In 2018, monkeypox was reported in two individuals who had contracted it abroad and a healthcare worker treating one of the cases. A confirmed case in 2019 was believed to have been contracted on a visit to Nigeria, and last summer a patient who had been working in Nigeria developed symptoms 2 days after arrival in the UK and passed the disease to two household contacts.

Tests have revealed that the four recently detected individuals have the West African clade of the virus. However, the UKHSA said in its announcement: ‘There is no link to travel to a country where monkeypox is endemic, and exactly where and how they acquired their infections remains under urgent investigation, including whether they have further links to each other.’

Monkeypox is usually a self-limiting illness and the West African clade is milder compared with the Central African clade. The incubation period is usually from 6–13 days. Symptoms typically start with fever, headache, muscle and backaches, swollen lymph nodes, chills, and exhaustion. A rash may follow, often beginning on the face before spreading to other parts of the body, particularly the hands and feet and including the genitals. The rash may be itchy or painful and goes through various stages that can look like chicken pox or syphilis, before finally scabbing and falling off within 14–21 days. Most of those affected recover within a few weeks.

Not all of the cases so far have required medical care, but those who have needed hospital treatment are all in specialist infectious disease units at the Royal Free Hospital, Royal Victoria Infirmary in Newcastle upon Tyne, and Guys’ and St Thomas’ Hospital in London.

Close contact spread

‘The name “Monkeypox” is a misnomer,’ according to Dr Michael Skinner, reader in virology at Imperial College London, who explained: ‘It’s primarily a disease (mostly sub-clinical) of small African animals including rodents. Like humans, monkeys sometimes acquire infection from the small animals.’

The disease is caused by a poxvirus, and Dr Skinner said that sporadic cases in the UK are likely to be imported by travel but generally requires close contact to spread. ‘Depending on the stage of infection, close range respiratory or droplet transmission can probably occur. Direct contact with lesions will probably transmit the virus, which might enter by the mouth. When the lesions have healed, the scabs (which might carry infectious virus) can be shed as dust, which could be inhaled.’

The UKHSA said that monkeypox does not spread easily between people, so the risk to the general population is low. However, since the most recent cases are within the communities of gay, bisexual, and other men who have sex with men, the Agency is advising these groups to be alert to any unusual rashes or lesions on any part of their body, especially their genitalia, and to contact a sexual health service if they have concerns. They are asked to make contact with clinics ahead of their visit and assured of confidentiality.

The Agency also asked clinicians to be alert to individuals presenting with rashes without a clear alternative diagnosis, and to contact specialist services for advice.

‘Due to the recent increase in cases and uncertainties around where some of these individuals acquired their infection, we are working closely with NHS partners to identify if there may have been more cases in recent weeks, as well as international partners to understand if similar rises have been seen in other countries.’

Dr Susan Hopkins, the UKHSA’s chief medical adviser, said: ‘This is rare and unusual. UKHSA is rapidly investigating the source of these infections because the evidence suggests that there may be transmission of the monkeypox virus in the community, spread by close contact. We are particularly urging men who are gay and bisexual to be aware of any unusual rashes or lesions and to contact a sexual health service without delay.’

She added: ‘We are contacting any potential close contacts of the cases to provide health information and advice.’

Jimmy Whitworth, professor of international public health at the London School of Hygiene & Tropical Medicine, said: ‘This outbreak of monkeypox is unprecedented in the UK and has provoked urgent public health action. There is a need to engage with the at-risk community of gay and bisexual men to ensure they know about the presence of this infection and report any sign and symptoms to health facilities.

‘Cases need to be identified, isolated, and treated, either in hospital or at home, depending on severity and circumstances. Close contacts need to be identified and monitored for signs of infection. Monkeypox is not very transmissible and with these measures the outbreak can be quickly brought under control.’ 

He added that the disease can spread both through close personal contact and via items such as bedding or shared utensils. Treatment is generally supportive as there are no specific drugs available, and although it can cause serious illness, most people recover fully within a few weeks.

This article was originally publised on Medscape, part of the Medscape Professional Network.

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