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Clinical features and management of human monkeypox: a retrospective observational study in the UK

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High Alder, Susan Gould, Paul Hine, Luke Blagdon Snell, Waison Wong, Catherine F Houlihan, Jane Osborne, Tommy Rampling, Mike Beadsworth, Christopher Duncan, Jake Dunning, Tom Fletcher, Ewan Hunter, Mike Jacobs, Saye Khoo, William Newsholme, David Porter, Robert Porter, Libuse Ratcliffe, Mathias Schmidt & 4 more Malcolm G. Semple, Anne Tunbridge, Tom Wingfield, Nicholas Price

Original languageEnglish
Pages (from-to)1153-1162
Number of pages10
JournalThe Lancet infectious diseases
Volume22
Issue number8
DOIs
PublishedAug 2022

Bibliographical note

Funding Information: The authors gratefully acknowledge all of the patients for their consent to publish this clinical experience, the clinical and support staff in the High Consequence Infectious Diseases (Airborne) Network isolation units, regional ambulance services, UK Health Security Agency, Public Health Wales, the Rare and Imported Pathogens Laboratory, and NHS England specialist commissioning services for their support in managing these complex cases. CJAD is funded by a Wellcome Clinical Research Career Development Fellowship (211153/Z/18/Z). TW is supported by grants from the Wellcome Trust, UK (209075/Z/17/Z), Medical Research Council (MRC; MR/V028618/1), and Joint Global Health Trials, UK (MR/V004832/1). Consent to publication was provided under the framework of the ISARIC study, which is supported by grants from: the National Institute for Health Research (NIHR; award CO-CIN-01), MRC (grant MC_PC_19059), the NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool (in partnership with the UK Health Security Agency, Liverpool School of Tropical Medicine, and the University of Oxford [NIHR award 200907]), Wellcome Trust and Department for International Development (DID; 215091/Z/18/Z), the Bill and Melinda Gates Foundation (OPP1209135), and Liverpool Experimental Cancer Medicine Centre (grant reference C18616/A25153). Funding Information: The authors gratefully acknowledge all of the patients for their consent to publish this clinical experience, the clinical and support staff in the High Consequence Infectious Diseases (Airborne) Network isolation units, regional ambulance services, UK Health Security Agency, Public Health Wales, the Rare and Imported Pathogens Laboratory, and NHS England specialist commissioning services for their support in managing these complex cases. CJAD is funded by a Wellcome Clinical Research Career Development Fellowship (211153/Z/18/Z). TW is supported by grants from the Wellcome Trust, UK (209075/Z/17/Z), Medical Research Council (MRC; MR/V028618/1), and Joint Global Health Trials, UK (MR/V004832/1). Consent to publication was provided under the framework of the ISARIC study, which is supported by grants from: the National Institute for Health Research (NIHR; award CO-CIN-01), MRC (grant MC_PC_19059), the NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool (in partnership with the UK Health Security Agency, Liverpool School of Tropical Medicine, and the University of Oxford [NIHR award 200907]), Wellcome Trust and Department for International Development (DID; 215091/Z/18/Z), the Bill and Melinda Gates Foundation (OPP1209135), and Liverpool Experimental Cancer Medicine Centre (grant reference C18616/A25153). Publisher Copyright: © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license

King's Authors

Abstract

Background: Cases of human monkeypox are rarely seen outside of west and central Africa. There are few data regarding viral kinetics or the duration of viral shedding and no licensed treatments. Two oral drugs, brincidofovir and tecovirimat, have been approved for treatment of smallpox and have demonstrated efficacy against monkeypox in animals. Our aim was to describe the longitudinal clinical course of monkeypox in a high-income setting, coupled with viral dynamics, and any adverse events related to novel antiviral therapies. Methods: In this retrospective observational study, we report the clinical features, longitudinal virological findings, and response to off-label antivirals in seven patients with monkeypox who were diagnosed in the UK between 2018 and 2021, identified through retrospective case-note review. This study included all patients who were managed in dedicated high consequence infectious diseases (HCID) centres in Liverpool, London, and Newcastle, coordinated via a national HCID network. Findings: We reviewed all cases since the inception of the HCID (airborne) network between Aug 15, 2018, and Sept 10, 2021, identifying seven patients. Of the seven patients, four were men and three were women. Three acquired monkeypox in the UK: one patient was a health-care worker who acquired the virus nosocomially, and one patient who acquired the virus abroad transmitted it to an adult and child within their household cluster. Notable disease features included viraemia, prolonged monkeypox virus DNA detection in upper respiratory tract swabs, reactive low mood, and one patient had a monkeypox virus PCR-positive deep tissue abscess. Five patients spent more than 3 weeks (range 22–39 days) in isolation due to prolonged PCR positivity. Three patients were treated with brincidofovir (200 mg once a week orally), all of whom developed elevated liver enzymes resulting in cessation of therapy. One patient was treated with tecovirimat (600 mg twice daily for 2 weeks orally), experienced no adverse effects, and had a shorter duration of viral shedding and illness (10 days hospitalisation) compared with the other six patients. One patient experienced a mild relapse 6 weeks after hospital discharge. Interpretation: Human monkeypox poses unique challenges, even to well resourced health-care systems with HCID networks. Prolonged upper respiratory tract viral DNA shedding after skin lesion resolution challenged current infection prevention and control guidance. There is an urgent need for prospective studies of antivirals for this disease. Funding: None.

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