Introduction
Monkeypox (mpox) infection is caused by the monkeypox virus, a virus in the orthopoxvirus genus of poxviruses. Historically, cases of mpox have been associated with travel to, or exposure from, endemic areas of Africa. Beginning in May 2022, cases of mpox began occurring outside of endemic areas with evidence of local human-to-human transmission in areas where mpox transmission had not been previously seen.1
As of May 9, 2023, globally there have been 104 countries, territories, or areas reporting monkeypox cases that have not historically reported mpox prior to the 2022 outbreak.2 Prior to the current outbreak, most mpox infections were transmitted to humans through infected animals or animal products with limited human-to-human transmission. The mpox outbreak that began in 2022 has involved human-to-human transmission via close intimate contact (including sexual contact) with symptomatic individuals.
The first outbreak-related mpox case in the United States was identified on May 17, 2023, and cases have since been identified in all 50 states.3,4 A majority of cases have occurred in men, and cases in which the sex of sexual partners was known, a majority have been among men who have sex with men.4
Mpox – Mississippi
The Mississippi State Department of Health (MSDH) identified its first reported case of monkeypox (mpox) in July 2022. Over the next seven months, an additional 108 cases were reported to MSDH with the last case being reported in February 2023. Between August 28 and September 24, 2022, 45% (n=49) of the mpox cases were identified from laboratory reporting. (Figure 1)
The cases were geographically distributed across the state with the majority (52%) of the cases reported from Public Health District 5 which includes Hinds, Rankin, and Madison counties. The cases ranged in age from 17 to 57 years and had a median age of 31 years. (Figure 2) Of the 109 reported mpox cases, 92% (n=100) of the cases identified as male. Gender was unknown for four cases. (Figure 3) Ninety-five out of the 109 cases provided their sexual preference during their interview. Of those who provided a response, 81% (n=73) identified as men who have sex with other men. Eighty-four percent of the mpox cases were identified in Black or African American individuals while 12% of the cases were identified in White individuals. Race was unknown for two cases. (Figure 4)
A positive HIV status was identified in 64% (n=70) of the mpox cases. (Figure 5) Acute coinfections were also noted in 19 (17%) of the mpox cases. The coinfections included syphilis, gonorrhea, chlamydia, herpes, and trichomonas.
During the mpox case investigation interviews, MSDH asked the cases about specific symptoms they were experiencing. Of the 16 symptoms, fever was the most commonly reported symptom (n=100, 92%) with pruritis (n=70, 64%) and malaise (n=68, 62%) also being frequently reported. (Table 1)
In an effort to limit transmission, MSDH inquired about the mpox cases’ contacts during the case investigation interviews. Eighty-four contacts were identified during the interview process. Of the 84 contacts, 63 (75%) were identified as a high-risk contact and six (7%) were identified as an intermediate risk contact.5 The exposure risk was unknown for one contact. Post-exposure prophylaxis (PEP) was offered to 65 high- or intermediate-risk contacts, with 35 contacts being vaccinated. Of those vaccinated, 31 were high-risk contacts and four intermediate-risk contacts.
Mitigation and Response
In response to the increasing cases of mpox in the United States, the Centers for Disease Control and Prevention (CDC) and the Administration for Strategic Preparedness and Response (ASPR) worked to make vaccines and treatment for mpox available through the Strategic National Stockpile (SNS). The Jynneos vaccine is indicated for prevention of smallpox and mpox. It is a 2-dose series that is authorized to be given subcutaneously. During the outbreak, the FDA issued an emergency-use authorization (EUA) for intradermal use in order to provide vaccine to more individuals with the limited doses available in the SNS.
Tecovirimat (TPOXX) for treatment of mpox was made available through a CDC expanded access Investigational New Drug (EA-IND) protocol following FDA regulations. Allocations of both Jynneos and TPOXX were provided to states and jurisdictions based on mpox case burden and using a CDC determination of the number of at-risk individuals.
In Mississippi, MSDH provided Jynneos vaccine intradermally at 9 health department locations across the state. Screening for eligibility was accomplished via call-in to a call center to limit the need for in-person assessment of risk for mpox. The MSDH Office of Immunizations and Office of STD/HIV also worked with community STD/HIV and Ryan White physicians, nurse practitioners, and physician assistants to increase access to Jynneos vaccine across the state.
During the mpox outbreak, MSDH provided support for testing and treatment for mpox in addition to direct patient care for patients presenting to local health departments. Testing for mpox was provided in the Mississippi Public Health lab on request for symptomatic patients with suspected mpox. In addition, the MSDH Pharmacy and Office of Epidemiology created an online request form for TPOXX. This form allowed physicians, nurse practitioners, and physician assistants caring for patients with mpox to request TPOXX for eligible patients; once a patient was approved, the medication was shipped directly to the patient’s home.
In the fall of 2022, MSDH worked with a variety of community partners to provide vaccine and education and certain Pride events across the state. MSDH is currently working on a media campaign to improve awareness of mpox and information regarding preventive action to limit risk in high-risk individuals. Jynneos vaccine remains available at 9 health department clinics across the state, and physicians, nurse practitioners, and physician assistants with patients who have symptoms consistent with mpox can request testing through a number of reference labs or the Mississippi Public Health lab.