Epidemiologic features of the June 2022 monkeypox outbreak in Spain

By Neha MathurReviewed by Danielle Ellis, B.Sc.Jul 14 2022

In a recent study published in the Emerging Infectious Diseases, researchers described epidemiologic features of monkeypox cases reported in Spain and the intervention measures taken to control the outbreak.

Background

Spain was among the most affected nations worldwide by a multi-country monkeypox outbreak in June 2022. There were chains of viral transmission without links to disease-endemic countries in Spain, and the majority of these cases were among men who had sex with men (MSM).

The study

In the present study, researchers described the epidemiologic features of monkeypox cases reported to the National Surveillance Network in Spain between May 17 and July 4, 2022. They also obtained relevant information about the same from bilateral consultations with the Spanish Autonomous Regions and subsequent measures taken to respond to the alert notification initiated by the United Kingdom (UK).

By July 4, 2022, 16/19 Autonomous Regions in Spain reported 1,256 monkeypox cases, 61.1% of which occurred in the Region of Madrid. Most cases occurred in men compared to women (1242 vs. 14), and the average age of patients was 37 years. An epidemic plot showed a trend towards an increase in cases between May and June 2022; however, a dip observed in late June most likely was due to a delay in reporting. The researchers found a date of symptom onset for 89.5% of cases.

Based on information from 45 patients who self-reported an exposure date (four to 22 patients/region), the team observed an average incubation period of the monkeypox virus between seven to 9.6 days. The commonly reported symptoms of monkeypox were fever, rash, asthenia, and lymphadenopathy. A total of 216 patients had localized lymphadenopathy, of which 191 had general symptoms. Of all the patients, 530 had a rash, and based on information from 427 patients, the average number of days from symptom onset to developing a rash was less than one day. Although there were no deaths, 30/530 patients were admitted to a hospital on average for two days, and 33 patients suffered from infection-related complications, including oral ulcers and secondary bacterial infections in 11 and 15 patients, respectively.

Of 440, 62 patients had traveled to countries that had reported monkeypox cases, and 101 had close contact with other confirmed or probable patients. A prolonged contact during sex was the most probable cause of transmission in 332/387, i.e., 85.8% of the patients, 290 were MSM; six reported heterosexual contacts, 31 cases had close contact but not related to sex, and the information for the rest was pending. Before symptom onset, 163 patients had attended a mass gathering, and 101 attended Pride Month events across Spain. Regarding female patients, seven had sex with men, two had contact within family, and information for the rest was unavailable. Sequencing of patient samples identified the West African clade of monkeypox virus as the causative agent for the cases.

The Ministry of Health in Spain followed the national protocol for early detection and case management within three days of detection of suspected cases. They assessed and reported the situation to update official situation records regularly. In collaboration with relevant scientific societies, they also released an atlas encompassing differential diagnoses for monkeypox skin lesions. Further, the Ministry involved Boards of nongovernmental organizations for the engagement of the lesbian, gay, bisexual, and transgender (LGBTQ) community. They publically released key health messages based on previous safe sex campaigns adhering to the World Health Organization (WHO) and European Centre for Disease Prevention and Control guidelines.

More importantly, the National Board for Vaccines proposed vaccinating close contacts. Based on information from 12 regions, they vaccinated over 80 contacts, including healthcare workers (HCWs) who struggled with faulty personal protective equipment. As vaccine availability shall increase, it is under consideration to use them as preexposure prophylaxis for high-risk groups and HCWs.

Conclusions

Monkeypox is not exclusive to MSM who have close physical contact during sexual encounters. In fact, transmission risk is high even for other population groups. The current study, thus, highlights the significance of timely reporting and early detection of monkeypox cases. It is equally crucial to monitor the dynamics of the outbreak to continue tailoring counter-measures. Further, engaging communities and effective communication are crucial to disseminating information to the general and at-risk populations. However, the framework for intervention measures should be such that it does not stigmatize the LGBTQ community.