more likely to have fever ≥ 38.3°C (P = 0.70); fever lasting ≥ 7 days (P = 0.63); cervical lymphadenopathy (P = 1.00); hospitalization > 48 hours (P = 0.42); rash comprised of > 100 lesions (P = 0.32). · Prior smallpox vaccination (n = 7; median age = 39 years [range 33–47 years]) was not associated with fever (temperature ≥ 38.3°C) (P = 0.62); fever lasting ≥ 7 days (P = 1.00); intensive care (P = 1.00); cervical lymphadenopathy (P = 0.67); or hospitalization > 48 hours (P = 1.00); rash comprised of > 100 lesions (P = 1.00). Multi-Jurisdictional Monkeypox Outbreak 2022 – What We Know So Far 7 · On bivariate analysis, hospitalization > 48 hours was associated with fever ≥ 38.3°C (risk ratio [RR] undefined, P = 0.02); rash comprised of > 100 lesions (RR = 3.7; 95% confidence interval [CI] = 1.5–9.0; P = 0.03); adenopathy (RR undefined; P = 0.03); nausea and vomiting (RR = 6.4; 95% CI = 1.6–25.5; P < 0.01); oral lesions (RR = 4.3; 95% CI = 1.6–11.8; P = 0.01). · On multivariate analysis, nausea and/or vomiting was associated with hospitalization > 48 hours (OR = 15.8; 95% CI = 2.3–106.2; P = 0.005). · In a systematic review of the epidemiology of human monkeypox:28 · From the 1970’s to 1999, 47 deaths were reported; all (100%) occurred in children under 10 years of age in Africa (45 in the DRC and 2 in Gabon). The exact causes of death were not reported. · Between 2000 and 2019, 18 deaths were reported (1 in Cameroon, 3 in the Central African Republic, 1 in the DRC, 9 in Nigeria, 4 in the Republic of the Congo); 6 (37.5%) out of 16 with age information occurred in children < 10 years of age. No deaths were reported among the 51 cases in non-endemic areas and the author also noted that the mean age of the seven deaths among the 122 confirmed or probable cases in the 2017 Nigerian outbreak was 27 years. Transmission Incubation Period · The incubation period for monkeypox is usually 6–13 days (ranges = 5–21 days).33 Period of Communicability · The infectious period of monkeypox generally starts with the onset of rash until all scabs have fallen off and new skin has grown in, although transmission of monkeypox virus may take place during the prodromal period.3,4,27 · In a retrospective study of seven monkeypox acquired via travel to Nigeria (n = 4) as well as locally (n = 2 household members) and nosocomially (n = 1) in the UK between 2018 and 2021, the authors reported prolonged viremia (viral DNA remained detectable by polymerase chain reaction up to 29 days from rash onset) and upper respiratory tract viral shedding after crusting of all cutaneous lesions (viral DNA remained detectable by polymerase chain reaction up to 41 days from rash onset).30 · More studies are required to inform if person-to-person transmission can take place in asymptomatic monkeypox. Multi-Jurisdictional Monkeypox Outbreak 2022 – What We Know So Far 8 Routes of Transmission · While various animal species have been identified as susceptible to monkeypox virus, the exact reservoir(s) has yet to be determined. Uncertainty remains on the natural history of the monkeypox virus and further studies are needed to identify the exact reservoir(s) and how virus circulation is maintained in nature. Humans can be infected with monkeypox virus from eating inadequately cooked meat and other animal products of infected animals.1 · Unlike Central African monkeypox virus for which person-to-person spread is well documented, West African monkeypox virus is associated with limited person-to-person spread27 (see Secondary Attack Rates below) and may take the following routes:3,4,26 · Respiratory tract secretions during direct and prolonged face-to-face contact (duration of contact not reported). Also, laboratory workers are at risk of acquiring monkeypox from spillage or aerosolization of virus-containing specimens when appropriate biosafety procedures are not followed. · Spillage or aerosolization of virus-containing specimens by laboratory workers · Contact of non-intact skin or mucous membranes with body fluids of an infected person (including from mother to infant after birth), open rash lesions or scabs, or objects (e.g., bedding or clothing) contaminated with the virus. · Transplacental transmission from mother to fetus. · In the 2017 Nigeria monkeypox outbreak, Ogoina et al. described >100 skin lesions associated with monkeypox ulceration affecting the genitalia of two monkeypox patients co-infected with HIV, postulating the potential for monkeypox transmission via close physical contact or genital secretions. However, the authors noted that the role of genital secretions in monkeypox transmission has not been established.31 Secondary Attack Rates · Person-to-person transmission of monkeypox seem to take place more efficient for the Central African clade. · In a systematic review by Bunge et al., the overall secondary attack rates (SARs) of monkeypox range from 0% to 10.2%, including:28 · Among household members: · 0% (0/20 contacts) in Cameroon where both Western and Central African clades have been detected. · 7.5% (3/40 contacts); median of 50% (range = 50%–100%; contacts of 16 households) in the DRC where primarily Central African clade circulates. · Contacts of unspecified nature in areas where