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Clade I Mpox Outbreak:
Situational UpdateCenters for Disease Control and Prevention
Agam Rao, MD
CAPT, U.S. Public Health Service
Chief Medical Officer, Poxvirus and Rabies Branch
ACIP meeting
Oct 24, 2024
2Clade I MPXV:
Countries
known for
decades to be
endemicDemocratic Republic of the Congo (DRC), Central
African Republic, Republic of Congo, Cameroon,
Gabon
•Exposure to infected wildlife
•Person -to-person spread
-Skin-to-skin contact (including intimate or sexual contact)
-Direct contact with respiratory secretions (e.g., via kissing)
-Direct contact with contaminated objects (e.g., shared towels, bedding)Monkeypox virus (MPXV) Transmission
Clade I Outbreak in DRC, 2023 -present
•Reason for concern
▪High number of suspect cases
▪Laboratory confirmed cases identified in
provinces previously without cases
•At least two concurrent outbreaks
▪Clade Ia (e.g., Equateur Provence in western
DRC): Mortality rate historically reported as
1.4-11%; however, NIH trial in DRC indicates
routine supportive care led to mortality rate
of ~1.7%*
▪Clade Ib (e.g., Sud Kivu in eastern DRC): Seems
to cause less severe disease than clade Ia;
mortality rate <1% in DRC
*https://www.nih.gov/news -events/news -releases/antiviral -tecovirimat -safe-
did-not-improve -clade -i-mpox -resolution -democratic -republic -congohttps://www.who.int/emergencies/disease -outbreak -
news/item/2024 -DON522
•Clade Ia: multifactorial
-From animals to people: high proportion of cases in children
-Human -to-human spread in households: both adults and children
-Sexual contact, regardless of sexual orientation and gender identity: adults
•Clade Ib: Sexual contact comprises large proportionHow Clade I Mpox is Spreading in DRC*
*Based on what is known at this time
Cases Outside of DRC
•Clade Ia: Only detected in
endemic countries (Central
African Republic and Republic of
the Congo)
•Clade Ib:
▪Associated with sustained
spread: Burundi, Uganda,
Rwanda
▪Not associated with sustained
spread: Kenya, Thailand, Sweden,
India, Germany
https://wwwnc.cdc.gov/travel/notices/level2/mpox -drc-neighboring -countriesList of countries with sustained spread maintained here:
https://www.cdc.gov/mpox/vaccines/index.html https://emergency.cdc.han/2024/han00513.asp
•Primarily via sex (e.g., transactional sex) while visiting countries with sustained
transmission
•Secondary spread
-Limited (if any) in several non -endemic countries (e.g., Thailand, Sweden, India)
-Uncertain at this time in some countries but believed to be associated with close
household contactHow Clade I Mpox is Spreading to Non -
Endemic Countries*
*Based on what is known at this time
Laboratory Confirmed Clade I Mpox
Cases During 2024 (As of 13 October)
*Only ~20% of suspected cases are laboratory confirmed; total DRC population = >110 million people
†Many are cases among children; no deaths
§Death in an individual with underlying health conditions and may not be due to mpox
https://worldhealthorg.shinyapps.io/mpx_global/#24_Data_by_countryCountry Total casesCase
fatality
ratio (%)Cases in
2024Deaths
in 2024Cases in the
past six
weeks1Deaths
in the
past six
weeks1Clades
detected in
countryDate of last
reported
case
The Democratic
Republic of the Congo8,207* 0% 6,962 25 1914 0 Clades Ia and Ib 13-Oct-24
Central African Republic 104 2% 57 1 10 0 Clade Ia 29-Sep-24
Republic of Congo 48 4% 22 0 1 0 Clade Ia 29-Sep-24
Burundi 1,169 0% 1,169 0† 841 0 Clade Ib 13-Oct-24
Uganda 91 0% 91 0 76 0 Clade Ib 13-Oct-24
Kenya 13 8% 13 1§ 9 1 Clade Ib 13-Oct-24
Rwanda 6 0% 6 0 2 0 Clade Ib 15-Sep-24
9Clade I Mpox Cases and the United States
No Clade I Cases in the United States*
*Active surveillance conducted via clade -specific testing of high proportion of MPXV positive specimens, including those tested in commercial laboratories
•Pre-travel counseling about risk reduction strategies
-Avoid close contact with people sick with signs and symptoms of mpox, including
skin or genital lesions
-Avoid contact with contaminated materials used by people who are sick (e.g.,
clothing, bedding)
•Vaccination, irrespective of sexual orientation and gender identity, for
travelers to certain countries* who anticipate any of the following during
travel
-Sex with a new partner
-Sex at a commercial sex venue (such as a sex club or bathhouse)
-Sex in exchange for money, goods, or other trade
-Sex in association with a large public event (such as a rave, party, or festival)Risk Considered Low for U.S. Travelers
*List of countries maintained here: https://www.cdc.gov/mpox/outbreaks/2023/index.html https://emergency.cdc.gov/han/2024/han00516.asp
•Even in extreme scenario (e.g., household secondary attack risk of 30%,
double the previously considered worse case scenario)†
-Most simulated outbreaks were small (66% had ≤ 5 cases and 73% had ≤10 cases)
-Most simulated outbreaks had minimal spread between households (72%
affected ≤ 3 households)
•Modeling suggests that even with extremely high secondary attack risk,
household clusters (including cases in children) would most likely involve 10
or fewer MPXV clade I cases, with limited spread between households
•Based on what we know today and current characteristics of viral spread,
do not expect children to be heavily impacted if clade I diagnosed
domestically §Risk Considered Low for General U.S.
Population*
*https://www.cdc.gov/cfa -qualitative -assessments/php/data -research/mpox -risk-assessment/index.html
† https://www.cdc.gov/cfa -modeling -and-forecasting/mpox -transmission -technical -brief/index.html and unpublished data
§ https://www.cdc.gov/mpox/php/data -research/clade -i-mpox -in-children -in-africa -and-potential -impacts -on-children -in-the-
united -states.html
13What CDC and Other U.S. Government
Partners are Doing
•Providing technical assistance and funding to DRC’s Ministry of Health
• Working with USAID, WHO, International Organization for Migration,
African Field Epidemiology Network, and other partner teams on the
ground to help manage outbreaks
•Collaborating with public health officials in several countries bordering DRC
to assess needs and provide support for outbreak preparedness
•Donating 1 million doses of JYNNEOS vaccine and $500 million for supportInternationally
•Increasing capacity to rapidly detect, contain, and manage clade I cases
should they occur domestically
•Increasing capacity to detect cases of clade I and clade II mpox through
existing surveillance systems, including wastewater testing in communities
across the United States and in select airports
•Coordinating with state, tribal, local, and territorial public health
departments to provide clinical, diagnostic, and other guidance
•Raising awareness: Regular communications and updatesDomestically
* https://www.cdc.gov/nwss/wastewater -surveillance/mpox -data.html
•High number of suspected clade I mpox cases in DRC; ~20% are laboratory -
confirmed
•Travel -associated spread of clade Ib to some countries
-Cases milder than those associated with clade Ia
-Predominantly associated with sex (e.g., transactional sex) with subsequent
spread to others (e.g., children) likely via household contact
•Risk to U.S. travelers low but counseling and vaccination should be provided
to travelers
•Impact to persons in the United States (including children) expected to be
low Summary*
*Conclusions are based on investigations and other data available to CDC at the time this presentation was given;
findings and CDC guidance may change over time
17ACIP
•Reforming
-Dr. Bonnie Maldonado, Workgroup chair
-Dr. Faisal Minhaj: Workgroup lead
•Workgroup charge
-Review NIH study about use of JYNNEOS in persons 12 -17 years of age
-Consider bringing to an ACIP vote, use of JYNNEOS in persons 12 -17 years of age
at risk for mpox during mpox outbreaks (including the global clade IIb outbreak)
•Anticipating presentations (including Terms of Reference) during February
2025 ACIP meeting
•Planning publication of ACIP recommendations for persons 12 years of age
and older in one consolidated MMWRWorkgroup
The findings and conclusions in this report are those of the authors and do not
necessarily represent the official position of the Centers for Disease Control and
PreventionThank you
19
[email protected]