New York continues mpox vaccine and health awareness campaign

5 May 2024. Related: mpox (monkeypox).

Simon Collins, HIV i-Base

On 3 May 2024, an update about mpox in New York City reported low but increasing cases over the last seven months. [1]

Most of the 256 cases since October (188/256, 73%), have been in people who were either not vaccinated or had only received one dose.

Mpox vaccination continues to be recommended and is available throughout the city.
People at risk of mpox are recommended to have both doses of the vaccine, even if the initial dose was several years ago.
Information was included about the outbreaks of Clade I mpox in the Democratic Republic of Congo. All cases in NYC have been with Clade II.

The full update is included below.

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In the UK, only 19 cases of mpox have been reported this year, although this might not include mild cases. [2]

Although UKHSA originally planned to discontinue routine access to the mpox vaccine, it is still available from sexual health clinics in the UK. This might only be from large sexual clinics and might be something you need to specifically ask for.

A recent review in the US MMWR for 23 May reported less than 1of people with both shots of the vaccines reported mpox infection and that durability of vaccine protection appears to be significant. [3]

The highest risk of severe mpox is in people with significantly reduced immunity, especially in people with advanced HIV infection who are usually undiagnosed and not on ART. As is clear from the US, this risk is likely to be higher in people who are marginalised or disconnected from routine care.

Severe immunosuppression also reduces the efficacy of most vaccines, likely including for mpox. Effective ART however will usually increase the CD4 count to higher levels that then generate vaccine protection.

Reference

NYC Health Department. 2024 Health Advisory #12: Updates on Mpox in New York City. (3 May 2024).
https://www.nyc.gov/assets/doh/downloads/pdf/han/advisory/2024/han-advisory-12-mpox.pdf
UKSHA. Notifiable diseases: last 52 weeks.
https://www.gov.uk/government/publications/notifiable-diseases-last-52-weeks
Guagliardo SA et al. Monkeypox Virus Infections After 2 Preexposure Doses of JYNNEOS Vaccine — United States, May 2022–May 2024. MMWR Morb Mortal Wkly Rep 2024;73:460–466.
http://dx.doi.org/10.15585/mmwr.mm7320a3.

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

2024 Health Advisory #12: Updates on Mpox in New York City

Mpox continues to circulate in New York City (NYC), with a substantial increase in reported cases since October 2023.
An outbreak of the more severe Clade I monkeypox virus (MPXV) in the Democratic Republic of the Congo poses risk for the introduction of Clade I into the U.S.
Consult with the NYC Department of Health and Mental Hygiene about testing if a patient is suspected of having Clade I MPXV. Treatment and vaccination strategies for Clade I are similar to those for Clade II.
Individuals with potential risk of exposure to mpox should be fully vaccinated. Continue to encourage and offer vaccination or refer to vaccination sites.
Commercialization of the JYNNEOS vaccine is underway. Begin to identify processes and funds to purchase vaccine on the commercial market.

Mpox continues to circulate in New York City (NYC). Overall, the number of cases is low compared to the 2022 outbreak, but there have been increases in cases since October 2023. This, along with the large outbreak of the more severe Clade I monkeypox virus (MPXV) in the Democratic Republic of the Congo, highlight the need for ongoing vigilance, especially approaching the summer when increased transmission may occur.

The U.S. continues to see only Clade II cases. Reported case numbers in NYC were relatively low for most of 2023, ranging from two to 20 cases per month between January and September. Since October, there has been an increase to an average of 36 cases per month, with a peak case count of 51 cases in January 2024. Of the 256 cases from October 2023 through April 15, 2024:

73% (188) were not vaccinated or had received only one dose.
94% were among men who have sex with men.
Most were Black or Hispanic and between the ages of 25-44.
Most were mild; ten (3.9%) people were hospitalised.

Clade I outbreak in the Democratic Republic of the Congo

There is an outbreak of concern of Clade I MPXV in the Democratic Republic of the Congo. There have been no reported cases of Clade I in the U.S. and no evidence of transmission outside of endemic countries of Central Africa.

However, it is possible that Clade I could be introduced into the U.S. by a traveler to the Democratic Republic of the Congo or other endemic countries, or with epidemiological links to those regions. Clade I appears to be more transmissible and cause more severe disease. Isolation vaccination (JYNNEOS, ACAM2000), and treatment (e.g., tecovirimat, brincidofovir, vaccinia immune globulin intravenous) strategies used for Clade II infections are expected to be effective for Clade I infections.

Vaccination update

People with potential risk of exposure to mpox should receive two doses of the JYNNEOS vaccine to be fully vaccinated. It is estimated that only one in four people recommended to receive the vaccine in the U.S. are fully vaccinated. Increasing vaccine uptake is essential to preventing infections and severe disease.

On April 1, 2024, the JYNNEOS vaccine began transition to the commercial market, though no- cost federal supplies are available until early summer 2024. JYNNEOS vaccine will be made available through the Vaccines for Children (VFC) Program (for eligible adolescents), likely within a few months of commercialization.

Recommendations for health providers

1. Testing

Given mild signs and symptoms reported by most cases since the 2022 outbreak, maintain a low threshold for mpox testing to reduce the potential for missed cases. Testing should be provided to any individual who requests it and has a sore or skin lesion that can be swabbed.
Refer to the GOALS Framework for Sexual History Taking in Primary Care to assess testing needs and facilitate the patient-provider relationship by normalizing discussions about sexual health and behavior as a routine part of health care.
Submit mpox specimens to a commercial or facility-based laboratory that has been approved to conduct mpox testing by New York State. If testing is not feasible, call the NYC Department of Health and Mental Hygiene (Health Department) Provider Access Line at 866-692-3641 to arrange for testing, following the NYC Public Health Laboratory specimen collection guidelines.
Be alert to the possibility of Clade I MPXV and need for specimen collection for people with symptoms and a history of travel or epidemiological links to a region of endemicity, including the Democratic Republic of the Congo, within 21 days of symptom onset.
If Clade I MPXV is suspected, call the Provider Access Line at 866-692-3641 for immediate consultation and to arrange for testing by the Centers for Disease Control and Prevention (CDC) (currently, only CDC can test for Clade I).

2. Vaccination

Continue to encourage vaccination for individuals for whom it is recommended and especially those with a higher risk of mpox complications (e.g., people with advanced HIV or other severe immunocompromise).
Advise those who have not yet received a second vaccine dose to do so as soon as possible, regardless of how much time has passed since their first dose.
Start to identify processes and funds for ordering JYNNEOS on the commercial market.
Order no-cost vaccine by emailing poxvax@health.nyc.gov. The NYC Health Department anticipates being able to fulfill requests until early summer 2024.
If you do not offer vaccination, refer to vaccinefinder.nyc.gov to find a vaccination site.3) Patient care
Determine clinical management based on an individual’s clinical status (e.g., vaccination history, underlying health conditions), severity of illness, and risk factors, regardless of MPXV clade.
Share guidance on symptom relief (e.g., over-the-counter medication, cooling lotions and jelly, sitz baths) and how to prevent transmission.
For immediate consultation regarding hospitalized people with or who are at risk for severe manifestations, call the CDC Clinical Escalations team at 770-488-7100.
Offer treatment (e.g., tecovirimat [TPOXX], brincidofovir) in accordance with CDC guidance, including CDC’s Guidance for Tecovirimat Use. TPOXX can only be accessed through the Study of Tecovirimat for Mpox (STOMP) clinical trial (mild to moderate illness), or the Expanded Access-Investigational New Drug (EA-IND) protocol if someone has severe illness or does not want to participate in STOMP. STOMP has a remote enrollment option that enables people to continue to receive care from their regular provider. Refer to instructions for prescribing TPOXX for local delivery through Pharmex Pharmacy.
Although the risk of occupational transmission of MPXV remains low, ensure health care staff who may be caring for people with suspected or confirmed infections are trained on infection prevention control, including appropriate personal protective equipment.Thank you for your continued support in protecting the sexual health of New Yorkers.