02 MPOX Minhaj 508

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National Center for Emerging and Zoonotic Infectiou s Diseases 
2022/2023 Mpox Outbreak: Situational Awareness and Updates 
ACIP Meeting October 25, 2023 Faisal Syed Minhaj, PharmD, MPH, DABAT Epidemiologist 
Poxvirus and Rabies Branch Division of High Consequence Pathogens and Patholog y 
United States Mpox Case Counts May 2022–Sept 28, 202 3 
https://www.cdc.gov/poxvirus/mpox/response/2022/mpx -trends.html /uni004D/uni0061/uni0079/uni002D/uni0032/uni0033
/uni004A/uni0075/uni006E/uni002D/uni0036
/uni004A/uni0075/uni006E/uni002D/uni0032/uni0030
/uni004A/uni0075/uni006C/uni002D/uni0034
/uni004A/uni0075
/uni006C/uni002D/uni0031/uni0038/uni0041/uni0075/uni0067/uni002D/uni0031
/uni0041/uni0075
/uni0067/uni002D/uni0031/uni0035/uni0041/uni0075
/uni0067/uni002D/uni0032/uni0039/uni0053/uni0065
/uni0070/uni002D/uni0031/uni0032/uni0053/uni0065
/uni0070/uni002D/uni0032/uni0036/uni004F/uni0063/uni0074/uni002D/uni0031/uni0030
/uni004F/uni0063/uni0074
/uni002D/uni0032/uni0034/uni004E/uni006F/uni0076/uni002D
/uni0037/uni004E/uni006F/uni0076/uni002D/uni0032/uni0031
/uni0044/uni0065
/uni0063/uni002D/uni0035/uni0044/uni0065/uni0063
/uni002D/uni0031/uni0039/uni004A/uni0061/uni006E/uni002D/uni0032
/uni004A/uni0061/uni006E/uni002D/uni0031/uni0036
/uni004A/uni0061/uni006E/uni002D/uni0033/uni0030
/uni0046/uni0065/uni0062/uni002D/uni0031/uni0033
/uni0046/uni0065/uni0062/uni002D/uni0032/uni0037
/uni004D/uni0061/uni0072
/uni002D/uni0031/uni0033/uni004D/uni0061/uni0072
/uni002D/uni0032/uni0037/uni0041/uni0070/uni0072/uni002D/uni0031/uni0030
/uni0041/uni0070/uni0072/uni002D/uni0032/uni0034
/uni004D/uni0061/uni0079/uni002D/uni0038
/uni004D/uni0061/uni0079/uni002D/uni0032/uni0032
/uni004A/uni0075/uni006E/uni002D/uni0035
/uni004A/uni0075/uni006E/uni002D/uni0031/uni0039
/uni004A/uni0075/uni006C/uni002D/uni0033
/uni004A/uni0075/uni006C/uni002D/uni0031/uni0037/uni004A/uni0075/uni006C/uni002D/uni0033/uni0031/uni0041/uni0075
/uni0067/uni002D/uni0031/uni0034/uni0041/uni0075/uni0067/uni002D
/uni0032/uni0038/uni0053/uni0065
/uni0070/uni002D/uni0031/uni0031/uni0053/uni0065/uni0070/uni002D/uni0032/uni0035/uni0030/uni0031/uni0030/uni0030 /uni0032/uni0030/uni0030 /uni0033/uni0030/uni0030 /uni0034/uni0030/uni0030 /uni0035/uni0030/uni0030 /uni0036/uni0030/uni0030 /uni0037/uni0030/uni0030 /uni0043/uni0061/uni0073/uni0065/uni0020/uni0020/uni0043/uni006F/uni0075/uni006E/uni0074/uni0037/uni002D/uni0064/uni0061/uni0079/uni0020/uni0041/uni0076/uni0065/uni0072/uni0061/uni0067/uni0065 
/uni0032/uni0030/uni0032/uni0032 /uni0032/uni0030/uni0032/uni0033 
Subject to reporting irregularities Subject to reporting irregularities N = 30,681 
United States Mpox Case Counts Jan 1–Sept 28, 2023 
https://www.cdc.gov/poxvirus/mpox/response/2022/mpx -trends.html 
N = 785 
Subject to reporting irregularities 7-day average of daily cases reported 
United States Mpox Case Counts Jan 1–Sept 28, 2023 
https://www.cdc.gov/poxvirus/mpox/response/2022/mpx -trends.html 
Subject to reporting irregularities 5–7
N = 785 
7-day average of daily cases reported 
X7-day daily average case range 
United States Mpox Case Counts Jan 1–Sept 28, 2023 
https://www.cdc.gov/poxvirus/mpox/response/2022/mpx -trends.html 
Subject to reporting irregularities 5–7 1–3
N = 785 
7-day average of daily cases reported 
X7-day daily average case range 
United States Mpox Case Counts Jan 1–Sept 28, 2023 
https://www.cdc.gov/poxvirus/mpox/response/2022/mpx -trends.html 
Subject to reporting irregularities 5–7 2–5 1–3
N = 785 
7-day average of daily cases reported 
X7-day daily average case range 
United States Mpox Case Counts Jan 1–Sept 28, 2023 
https://www.cdc.gov/poxvirus/mpox/response/2022/mpx -trends.html 
Subject to reporting irregularities 5–7 2–5 1–3 1–4
N = 785 
7-day average of daily cases reported 
X
7-day daily average case range 
Cases Following Vaccination 
Reported since the outbreak started, including clusters 
Generally, most have had mild illness 
–Few requiring hospitalization 
–Many did not need any treatment 
–Low number of lesions 
Hazra A. Lancet Infect Dis . 2023 Sep 4:S1473-3099(23)00492-9. 

Mpox Reinfection 
Potential reinfection cases have been published in the literature, but only a few with convincing evidence of true reinfection 
CDC is aware of <10 cases of probable reinfection 
Probable reinfection cases seem to be milder than initial infection 
Hazra A. Lancet Infect Dis . 2023 Sep 4:S1473-3099(23)00492-9. 

CDC Continues to Consult on Severe Mpox Cases and 
Deaths 
https://www.cdc.gov/mmwr/volumes/71/wr/mm7144e1.htmCDC’s mpox clinical consult service continues to consult on  2-6 new cases 
monthly over the last 6 months 
Repeat consultations are more frequent, and include seve re cases with 
infections ongoing for months 
54 people have died from mpox in the United States since  May 2022, with 2 
just this September 
Black persons, people living with HIV (mostly advanced HIV  [AIDS]), and people 
experiencing homelessness are disproportionately affected
Mpox Cases Reported to CDC by Age and Gender May 17, 2022–Sept 28, 2023 
https://www.cdc.gov/poxvirus/mpox/response/2022/dem ographics.html Data were available for /uni200999.4% 
of cases reported to CDC 
Mpox Cases Reported to CDC by Race and Ethnicity May 17, 2022–Jun 14, 2023 
57     1095   9233 10965  4739  1748   686     297    159      61       57       43       90      108    105     82        21 Count within columns 
https://www.cdc.gov/poxvirus/mpox/response/2022/dem ographics.html Subject to reporting irregularities 
Data were available for /uni200994.5% 
of cases reported to CDC 

Mpox Cases Globally Apr–Sept 2023 
15 

https://worldhealthorg.shinyapps.io/mpx_global/ 
First and Second Doses of JYNNEOS Vaccine /uni0041d/uni006Dinistra/g415ons/uni2212/uni0055nited States/uni002C /uni004Da/uni0079 /uni0032/uni0030/uni0032/uni0032/uni2212Se/uni0070t /uni0032/uni0030/uni0032/uni0033 
Overall vaccine coverage* 
1-dose: 38.8% and 2-dose: 24.3% 
*Coverage is the estimated proportion who have recei ved vaccination divided by the population recommend ed to receive the vaccine,which is estimated 
using 2021 data for MSM with HIV pre-exposure proph ylaxis (PrEP) indications and 2020 data for HIV pre valence among MSM from CDC AtlasPlus . These 
estimates are increased by 25% to account for addit ional vaccine eligible people not captured by these  data sources totaling approximately 2 million peop le.
Shift in Vaccine Administration Sites From Public Health Clinics to Medical Centers 
•Public health providers administered 40% of all vaccines through Mar 2023 
•Medical care providers administered an increasing proportion of vaccines since the start of the outbreak 
•Pharmacies consistently provided 3-4% of all vaccines 
Public Health 
Provider or 
Clinic Medical 
Center 
Provider Commercial 
Vaccination 
Service 
Provider Pharmacy Other Percentage of Doses Administered 
Categories of Medical Providers Administering Vaccin es 
From 2022 to 2023, there were statistically significant increases in vaccines provided by •Primary care offices 
•Federally qualifying health centers (FQHC) 
•Other health centers 
Primary 
Care Hospital FQHC Health 
Center -
Other Health 
Center -
STD/HIV Percentage of Doses Administered 
Modeling 
Estimating Averted Cases from Vaccination and Behavioral Adaptation in DC 
https://www.medrxiv.org/content/10.1101/2023.02.10. 23285772v1.full.pdf 
Lines and shaded regions reflect median and interqu artile range from 120 simulations 
Estimated prevalent infections over time with no vaccination or behavioral adaptation. 
Estimating Averted Cases from Vaccination and Behavioral Adaptation in DC 
https://www.medrxiv.org/content/10.1101/2023.02.10. 23285772v1.full.pdf 
Lines and shaded regions reflect median and interqu artile range from 120 simulations 
Behavioral adaptation alone would have had early impact on the curve and flattened it 
Estimating Averted Cases from Vaccination and Behavioral Adaptation in DC 
https://www.medrxiv.org/content/10.1101/2023.02.10. 23285772v1.full.pdf Lines and shaded regions reflect median and interqu artile range from 120 simulations 
Behavioral adaptation alone would have had early impact on the curve and flattened it 
Vaccination alone would have had a later impact, but would have ended the outbreak within 1 year
Estimating Averted Cases from Vaccination and Behavioral Adaptation in DC 
https://www.medrxiv.org/content/10.1101/2023.02.10. 23285772v1.full.pdf Lines and shaded regions reflect median and interqu artile range from 120 simulations 
Behavioral adaptation alone would have had early impact on the curve and flattened it 
Vaccination alone would have had a later impact, but would have ended the outbreak within 1 year
Combined, behavioral adaptation and vaccination averted 80% of cases 1 year into the outbreak 
Risk for Recurrent Mpox Outbreak Lasting >3 Months, by Immunity Level — United States, 2023 
Pollock ED. MMWR MorbMortal WklyRep 2023;72:568–573 .% Risk of 
Recurrence 
% Population at increased mpox risk with partial or  full immunity Risk of recurrence increases linearly as the percent of the high-risk population with full or partial protection decreases
Cumulative Monkeypox virus I nfections Relative to 
2022, by Immunity Level — United States, 2023 
Pollock ED. MMWR MorbMortal WklyRep 2023;72:568–573 .Cumulative 
monkeypox 
virus infections, 
relative to 2022 
% Population at increased mpox risk with partial or  full immunity 
Cumulative Monkeypox virus I nfections Relative to 
2022, by Immunity Level — United States, 2023 
Pollock ED. MMWR MorbMortal WklyRep 2023;72:568–573 .>50% is needed to 
significantly decrease 
the risk of large 
outbreaks Cumulative 
monkeypox 
virus infections, 
relative to 2022 
% Population at increased mpox risk with partial or  full immunity 
Vaccine: Effectiveness and Safety Updates 
Vaccine effectiveness of JYNNEOS against mpox ranges  from 36%–75% 
for 1-dose vaccination and 66%–89% for 2-dose vaccination 
Cases Controls Adjusted* VE (95% CI) 
1-dose JYNNEOS 
Epic Cosmos case-control study 146 1000 36% (22–47) 
Multi-jurisdictional case-control study 58 237 75% (61–84) 
New York State case-control study 10 23 68% (25–86) 
.
2-dose JYNNEOS 
Epic Cosmos case-control study 25 335 66% (47–78) 
Multi-jurisdictional case-control study 14 122 86% (74–89) 
New York State case-control study 2 19 89% (44–98) 
Vaccine Effectiveness (%) 0 20 40 60 80 100 
Vaccine effectiveness of JYNNEOS against mpox ranges  from 36%–75% 
for 1-dose vaccination and 66%–89% for 2-dose vaccination 
Cases Controls Adjusted* VE (95% CI) 
1-dose JYNNEOS 
Epic Cosmos case-control study 146 1000 36% (22–47) 
Multi-jurisdictional case-control study 58 237 75% (61–84) 
New York State case-control study 10 23 68% (25–86) 
.
2-dose JYNNEOS 
Epic Cosmos case-control study 25 335 66% (47–78) 
Multi-jurisdictional case-control study 14 122 86% (74–89) 
New York State case-control study 2 19 89% (44–98) 
Vaccine Effectiveness (%) 0 20 40 60 80 100 
Vaccine effectiveness of JYNNEOS against mpox ranges  from 36%–75% 
for 1-dose vaccination and 66%–89% for 2-dose vaccination 
Cases Controls Adjusted* VE (95% CI) 
1-dose JYNNEOS 
Epic Cosmos case-control study 146 1000 36% (22–47) 
Multi-jurisdictional case-control study 58 237 75% (61–84) 
New York State case-control study 10 23 68% (25–86) 
.
2-dose JYNNEOS 
Epic Cosmos case-control study 25 335 66% (47–78) 
Multi-jurisdictional case-control study 14 122 86% (74–89) 
New York State case-control study 2 19 89% (44–98) 
Vaccine Effectiveness (%) 0 20 40 60 80 100 
Multi-jurisdictional Case-Control Study: Methods 
–Population: Men who have sex with men; ages 18-49; 12 U.S. juri sdictions 
–Time Period: August 19, 2022, to September 27, 2023 
–Methods: 
–Cases identified from jurisdictions’ probable and confirm ed mpox case lists 
–Controls identified from healthcare settings providing HIV P rEP or sexually 
transmitted infection (STI) clinics 
–Demographics, immunocompromised status, exposure hi story, and 
vaccination history collected using electronic surv eys 
–Vaccination status confirmed by state immunization registries 
–Analysis: 
–VE estimated using conditional logistic regression 
–Adjusted for age, race/ethnicity, immunocompromising conditions 
–Stratified by route of administration and immunocompromised statu s 
Both partial and full vaccination with JYNNEOS showed 
effectiveness against mpox, regardless of administr ation 
route 
*Adjusted for age, race/ethnicity, immunocompromise d status, reported close contact with a 
confirmed/suspected mpox case in 3 weeks prior to i ndex event 
Both partial and full vaccination with JYNNEOS showed 
effectiveness against mpox, regardless of administr ation 
route 
*Adjusted for age, race/ethnicity, immunocompromise d status, reported close contact with a 
confirmed/suspected mpox case in 3 weeks prior to i ndex event 
VE trended higher for immunocompetent participants 
compared to self-reported immunocompromised 
participants 
*Adjusted for age, race/ethnicity, immunocompromise d status, reported close contact with a 
confirmed/suspected mpox case in 3 weeks prior to i ndex event 
 Confidence interval remains very wide 
 More work is needed to understand VE in objectively confirmed immunocompromised people 
JYNNEOS Vaccine Safety Monitoring 
CDC vaccine safety monitoring is ongoing using two surveillance systems: 
–Vaccine Adverse Event Reporting System (VAERS) 
–Vaccine Safety Datalink (VSD) 
V-safe data collection for mpox vaccines was availa ble from 
November 2022 through March 21, 2023 
JYNNEOS Vaccine Safety Findings Summary 
90% of VAERS reports were submitted in 2022 
The adverse events most commonly reported to VAERS h ave been injection 
site symptoms (redness, swelling, pain, itching) 
Myocarditis and pericarditis are adverse events of specia l interest 
–Observed rates are consistent with expected backgroun d rates 
JYNNEOS Vaccine Safety Conclusions 
VAERS and VSD data do not suggest an increased risk f or myocarditis or 
pericarditis following JYNNEOS, but the possibility of a small risk cannot be 
excluded 
The frequencies of local and systemic reactions reported  to v-safe after 
mpox vaccine were similar to those reported in clinical trials
No new or unexpected safety concerns have been ident ified 
Summary 
Mpox cases and deaths continue to be reported domest ically and globally 
Need to improve our overall vaccine coverage; <25% of t he eligible 
population is fully vaccinated with 2 doses 
Modeling suggests that without vaccination, transmission o f mpox will 
continue with sporadic outbreaks 
No new safety signals from VAERS or VSD 
VE appears stable for immunocompetent people 
Acknowledgements 
Sarah Guagliardo 
Agam Rao 
Rosalind Carter 
Andrea McCollum 
Ian Kracalik 
Allie Tuttle 
Jonathan Duffy 
Eunice Kimunai 
Katrina Byrd Victoria Shelus 
Christine Hughes 
Christina Hutson 
Ian Spicknall 
Patrick Clay 
Emily Pollock 
For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY:  1-888-232-6348    www.cdc.gov The findings and conclusions in this report are tho se of the authors and do not necessarily represent the 
official position of the Centers for Disease Contro l and Prevention. 
National Center for Emerging and Zoonotic Infectiou s Diseases 
Division of High-Consequence Pathogens and Patholog y Questions?