Policy Note

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Public Health Weekly Report 2022; 15(39): 2666-2677

Published online September 29, 2022

https://doi.org/10.56786/PHWR.2022.15.39.2666

© The Korea Disease Control and Prevention Agency

Hyungmin Lee, Tel: +82-43-719-9100, E-mail: sea2sky@korea.kr

This article has been translated from the Public Health Weekly Report (PHWR) Volume 15, Number 34, 2022.

Received: August 17, 2022; Revised: August 19, 2022; Accepted: August 22, 2022

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Monkeypox is an endemic disease mainly occurring in some countries in Central and West Africa, but unusual outbreaks have been observed since May 2022 in many countries across Europe and North America. From January 1 to August 11, 2022, a total of 32,760 confirmed cases (12 deaths) were reported in 91 countries and the World Health Organization declared a public health emergency of international concern on July 23, as the cumulative number of confirmed cases is rapidly increasing and there are concerns about the disease spreading globally. The Korea Disease Control and Prevention Agency has been closely monitoring the status of overseas cases and conducting risk assessment to prepare a response system for possible domestic outbreaks before the first case in the Republic of Korea was reported. The first expert advisory meeting was held on May 23, followed by a domestic risk assessment on May 24, consultation with the Infectious Disease Crisis Management Expert Committee on May 30, and a Risk Assessment Meeting on May 31; a crisis alert level of ‘interest’ was issued and the monkeypox countermeasure team commenced operation. In addition, on June 8, a legal basis for responding to infectious diseases was prepared by revising the notification that designated it as Class 2 legal infectious disease and quarantinable infectious disease. Preemptive management through the announcement of an emerging infectious disease syndrome was initiated prior to the revision of the notification to prepare countermeasures for the infectious disease, including reporting suspected cases, assigning diagnostic criteria, designating of institutions for treatment, conducting epidemiological investigations, and instituting quarantine measures. Further, pre-training was performed on response guidelines for local governments, related departments, and medical institutions. For early detection of monkeypox and prevention of its spread in regional communities, information brochures were distributed for healthcare professionals and travelers from affected countries in order to raise awareness of suspected symptoms and prevention measures while strengthening quarantine measures for incoming travelers and encouraging medical institutions to report any potential cases as a part of domestic monitoring. Following the report of the first domestic patient on June 22, the crisis alert was raised to ‘caution’ and the Committee was upgraded to a Central Quarantine Countermeasure Headquarters. As of June 27, ‘Regional Quarantine Countermeasure Teams’ were installed in cities and provinces across the country to cooperate with the central government. Among the cases reported until August 8, 18 were identified as potential cases and were tested; to date, there are no additional cases exclude one confirmed case. This report aims to provide reference information for facing emerging infectious diseases by introducing the process of establishing a domestic response system and reporting the actual response outcome for an emerging infectious disease that had never occurred in the Republic of Korea.

Keywords Monkeypox, Risk assessment, Crisis alert, Establishment emerging infectious disease of response system

Key messages

① What is known previously?

Monkeypox is an acute zoonotic disease caused by monkeypox virus infection. It is mainly transmitted through close contact with symptomatic persons and mainly occurs in rural tropical rain forests in Central and West Africa.

② What new information is presented?

Since May 2022, cases of monkey pox have been spreading in many countries, mainly in Europe and North America, with no travel history and no connection to endemic areas. Reports show that morbidity is higher, but severity and fatality are lower, compared to the monkeypox cases reported from African endemic regions. In addition, clinical patterns are different from those shown in existing endemic cases (occurring only in a specific area, not in the distal region, first in the anus and genital area, the number of rash lesions is small, etc.) such that prodromal symptoms such as fever, headache, and chills may or may not appear after the rash. Also, there have been reports of cases of anorectitis accompanied by severe pain, bleeding, and tenesmus.

③ What are implications?

Monkeypox is an infectious disease with no prior history in South Korea; therefore, available information is limited. As such, introducing the process of establishing a surveillance response system as well as measuring actual response outcomes has allowed information to be used in establishing a response system for an emerging infectious disease, which could be valuable in practice in future actual responses.

Monkeypox is an acute, zoonotic disease caused by the monkeypox virus infection. After its discovery in laboratory-bred monkeys in 1958, the first human infection was identified in the Democratic Republic of the Congo in 1970 [1,2]. It remained an endemic disease that mainly occurred in the rural rainforests of Central and West Africa, until a case of monkeypox infection was identified in the United Kingdom on May 7, 2022, followed by reports of unusual outbreaks in many countries across Europe and North America in which the infected patients show no history of traveling to affected countries nor any epidemiologic association [3,4]. This disease is becoming an international issue, as the number of patients in non-endemic countries is increasing rapidly and as the affected geographic area is expanding.

The British Health and Safety Agency conducted an investigation after seven cases occurred between May 7 and 16 and announced on June 1 that the community transmission of monkeypox had already begun in the UK [4,5]. Starting with the first emergency meeting regarding monkeypox on May 20, the World Health Organization (WHO) conducted a risk assessment and distributed guidelines while urging countries around the world to be prepared and vigilant for potential cases and disease spread. Nevertheless, the disease continued to spread, and the WHO Director-General declared a public health emergency of international concern (PHEIC) on July 23 in accordance with the International Health Regulations (IHR) and issued an interim recommendation [5-9]. In addition, the U.S. Centers for Disease Control and Prevention issued a warning message to the medical community and the public after the first case of monkeypox was confirmed in Massachusetts on May 18 and distributed guidelines for infection prevention and management while instituting a national response including operating information call centers. Despite these efforts, due to the recent rapid increase in the number of cases, the 5th disease-related US public health emergency since 2001 was declared on August 4 [10,11].

Korea Disease Control and Prevention Agency (KDCA) has been closely monitoring these overseas circumstances since May 2022 and has established a response system to preemptively respond to monkeypox in preparation for the first reported case in the country. In this report, we introduce the monkeypox response system in the Republic of Korea along with the initial outcome of the response.

1. Establishing a Response System for Monkeypox

Monkeypox is spreading in non-endemic countries this year with a higher morbidity rate than that of previous outbreaks; however, the exact route of infection for community transmission has not yet been fully elucidated [7]. However, the majority of the confirmed patients are men (99%) with a mean age of 36 years old; many cases are being reported among groups of men who are homosexuals, are bisexuals, or have had sexual intercourse with other men [4,7,8,11]. The main route of infection is close contact with a symptomatic person, and sexual contact is the most common among all reported routes of infection [1,4,7]. The current monkeypox outbreak and spread is different from previously known outbreak in terms of rash pattern and clinical symptoms- it either lacks or has an unnoticeable prodromal stage with initial rash appearing inside the oral cavity, anus and genital area without spreading to the trunk or the limbs, often with fewer than 5 lesions. New clinical symptoms such as anorectitis and pain and genitourinary system-related complications have also been reported [12-16]. Although the incubation period (5 to 21 days) is long, the initial stage of infection may manifest no or nonspecific symptoms, so early detection of suspected patients is important to prevent community transmission [6,13-15]. Furthermore, control of pets and wild animals is also necessary given the nature of the zoonotic disease. The 2003 outbreak of monkeypox in the United States was a case in which a family member was infected from a pet prairie dog [17,18]. A recently published paper in France reported that a dog who shared a bed with two confirmed human cases was diagnosed with monkeypox, stating that infection from humans cannot be ruled out because the dog’s viral gene sequence also matched that of the owner [18]. It is necessary to monitor this phenomenon and institute control policies for pets and wild animals in order to prevent the monkeypox virus from evolving and mutating across interspecies barrier to become an endemic disease. The KDCA prepared a response system in preparation for an outbreak of domestic cases based on the information gathered from overseas cases and the nature of the disease.

Starting with the first expert advisory meeting on May 23, 2022, domestic risk assessment was conducted on May 24, followed by a consultation with the Infectious Disease Crisis Management Expert Committee on May 30, and Risk Assessment Meeting on May 31, after which the crisis alert level of ‘interest’ was issued. The Monkeypox Countermeasure Team included relevant organizations including local governments, the Ministry of Agriculture, Food and Rural Affairs, the Ministry of Health and Welfare, the Ministry of Environment and the Fire Department. Under the cooperation of these organizations, information brochures were created and distributed to guide prompt transport of potential and confirmed patients, pre-designate of hospital beds for treatment in isolation, establish of control plans for pets and wild animals, and create treatment guidelines for veterinarians. Seventeen municipalities and the countermeasure team held weekly meetings to monitor the response plan and to prepare the response system.

Although monkeypox was designated as a Class 2 infectious disease requiring isolation of hospitalized patients, the initial response followed the management criteria for Class 1 infectious diseases given the fact that this emerging infectious disease has no prior history in the Republic of Korea and the number of cases rapidly increased. Five response systems as follows:

1) Establishment of reporting and diagnostic test system

After announcing monkeypox as a novel infectious disease syndrome on May 31, a legal basis was prepared by revising a notification that designated it as a Class 2 legal infectious disease and a quarantined infectious disease in order to prepare the basis for response to preemptively monitor and manage suspected patients through reports, epidemiological investigations, and quarantine measures. Following the designation as a legal infectious disease on June 8, 2022, medical institutions were required to report potential cases according to the specified diagnostic and reporting criteria, while health authorities were given the responsibility to manage the reported potential cases. Since the characteristic clinical symptom of monkeypox is ‘rash’, it is critical to differentiate this symptom from rashes with other etiologies [1,11]. Reflecting the research results showing that the symptoms of ‘rash’ in patients of monkeypox prevalent in Europe and the US this year are different from those previously reported, healthcare professionals were encouraged to report cases by giving them a diagnostic flowchart explaining differential diagnosis according to ‘rash’ symptoms [1,6,13-16].

The diagnosis and test method developed in 2016 was being used by the KDCA for testing, but in order to prepare for an increase in the demand for future testing, education and quality assessment of laboratory tests were conducted so that monkeypox diagnostic tests can also be performed at municipal and provincial health and environment research institutes. Diagnostic test guidelines were established and distributed so that researchers across the 17 local governments (Health Environment Research Institute) nationwide could also conduct diagnostic testing starting on July 11.

2) Measures to prevent domestic cases

Quarantine measures were strictly enforced for entry into the country and travel history was required when treating overseas travelers at hospitals. First, strict quarantine measures included designating 27 countries with monkeypox cases as controlled areas and requiring a health condition survey at quarantine phase for travelers coming from these regions. For five countries with frequent cases (UK, Spain, Germany, Portugal, and France), monitoring was strengthened by lowering the criteria for fever from 37.5 to 37.3 degrees Celsius. With the cooperation of the Ministry of Foreign Affairs, the precautionary measures for monkeypox were provided to outbound travelers who have arrived in the affected country via SMS. Upon return, travelers were informed to voluntarily report suspected symptoms through SMS to encourage self-reporting during the quarantine stage. Considering the long incubation period of monkeypox, travelers were encouraged through notices and SMS to voluntarily report if symptoms developed. Also, when travelers from the above countries with frequent cases visited medical institutions, International Traveler Information System synched with Drug Utilization Review is used for early diagnosis and treatment to provide inbound traveler information to medical institutions. Active response to prevent the influx of overseas monkeypox cases was initiated by encouraging the report of suspected symptoms by medical institutions and inbound travelers while strictly monitoring all stages of entry into the country.

3) Preparation and education of response guidelines and information systems

On May 27, a case definition of monkeypox in Republic of Korea was prepared to monitor and respond to potential and confirmed patients. Based on this definition, an information brochure for healthcare professionals was prepared and first distributed on May 29, with details on disease overview, differential diagnosis among similar rash diseases, precautions for treating and reporting suspected patients, and a report template. On June 16, ‘Monkeypox Response Guideline Edition 1’ was distributed for educating local governments by providing more detailed information on reporting of suspected patients, diagnostic testing criteria, epidemiological investigation of suspected patients, management of confirmed and close-contact patients, and treatment systems. Subsequently, on June 17, ‘Monkeypox Information Brochure Edition 1–2’ for healthcare professionals was distributed to revise the case definition, introduce differential diagnostic method, provide rash photographs, and outline diagnostic guide using a flowchart based on the latest research. Even without epidemiological associations, potential were assigned diagnostic testing if monkeypox was suspected as a result of consultation from infectious disease, proctology, urology, and dermatology departments. On July 6, ‘Monkeypox Response Guideline Edition 2’ was updated based on the latest research and the current response status was distributed. In the second edition, information regarding case definition and changes in classification criteria, close-contact investigations and management guidelines, and responding to suspected cases was updated. In addition to overall response guidelines, ‘Monkeypox Treatment Guidelines for Healthcare Professionals’ was distributed over three rounds in order to provide the information necessary for the treatment of monkeypox.

In order to increase the practical application and usability of the prepared response guidelines and latest guides, the KDCA conducted two scenario-based trainings on June 28 and July 15 to verify and supplement response guidelines and to enhance actual response capabilities. In addition, on June 28 and 29, education was provided for healthcare professionals in the high-risk geographic area for monkeypox, and information was shared on the treatment methods and reporting suspected monkeypox cases, clinical symptoms, and actual cases of confirmed patients. In August, an educational video for healthcare professionals based on domestic and overseas confirmed cases and the latest response guidelines was produced and distributed through the Infectious Disease Newsletter and the KDCA website. By providing healthcare professionals with the latest clinical information related to monkeypox, early detection of suspected patients with nonspecific suspected symptoms during treatment is prioritized.

An information system was built to manage and integrate the basic personal information, epidemiological investigation results, diagnostic test results, and close contacts of reported suspected cases. Since July 7, it has been in use with the added function of case investigation entry. Through this newly prepared information system, public health centers, cities/provinces, regional disease response centers, and the KDCA can simultaneously view the same information; periodic statistical analysis of information will be used to evaluate and supplement operation of the monitoring system.

4) Vaccination promotion system and securing vaccines and treatments

Subjects were vaccinated after being classified based on exposure to the monkeypox virus (before versus after exposure) using the second-generation vaccine that was already available domestically while working to introduce a third-generation vaccine for emergency use. Vaccination prior to exposure to the monkeypox virus was provided for high-risk groups such as healthcare professionals working in close proximity to treatment beds, members of diagnostic laboratories and epidemiologists. Post-exposure vaccinations will be provided for those who consent as necessary through epidemiological investigation of factors such as the level of contact with confirmed cases. Post-exposure vaccinations are effective in preventing an infection when administered within 4 days of exposure, while vaccination within 14 days has been reported to be effective in symptom relief. Second generation vaccinations are provided by the National Medical Center while third-generation vaccines are provided by the 17 designated public health centers. Adverse event surveillance will be conducted on Day 3 and 7, and national compensation will be provided based on causalities in the case of adverse events [19].

Vaccines and treatments for monkeypox were introduced in South Korea and 504 doses of the antiviral drug, Tecovirimat, were introduced on July 8. The doses will be supplied to hospitals in 17 municipalities for use and the purchases of additional doses will be reviewed considering future cases. Also, the process of introducing the third-generation vaccine (JINNEOSTM; Bavarian Nordic, Copenhagen, Denmark) was expedited and the contract for purchasing 10,000 doses from an overseas manufacturer was signed on July 20, which were introduced on August 11.

5) Information disclosure and crisis communication

First, the protocol for information disclosure was established so that personal information that could specify suspected and confirmed patients, such as residential area, and gender, as well as the details not directly related to the prevention and response to infectious diseases were to remain confidential. Social stigma and discrimination against confirmed patients form a critical aspect of crisis communication of infectious diseases, as they discourage voluntary reports from individuals with suspected symptoms, leading to avoidance of testing and ultimately resulting in the increase in the number of undetected cases quietly spreading throughout a community. Furthermore, a vital quarantine measure is encouraging public cooperation. Through sharing occurrence and government response trends along with quarantine measures, public anxiety is mitigated, which in turn encourages voluntary reporting and improves. As such, active communication was provided through the preparation and distribution of various types of contents on monkeypox, including Q&A, card news, and briefings.

2. Monitoring Suspected Monkeypox Cases and Responding to Confirmed Cases

1) Outcome of monitoring suspected cases

Among the cases reported between June 21 and August 8, 2022, 18 cases were classified as potential cases and tested. So far, there are no additional domestic occurrences aside from one confirmed case. The 18 potential cases were identified through quarantine stations (1 case, 5.6%) and local communities (17 cases, 94.4%), whereas the reporter/reporting method was an individual calling the 1339 hotline (6 cases, 33.3%) or a medical institution (12 cases, 66.7%) reporting to the local public health center. By gender, there were 10 male cases (55.6%) and eight female cases (44.4%). By age, seven cases (38.9%) were in their 20s, six cases (33.3%) were in their 30s, three cases (16.7%) were in their 40s, and two cases (11.1%) were children (three years old and five years old). Initial clinical symptoms were skin lesions that looked like rash in all of the cases (18, 100.0%), with 10 cases (55.6%) also showing lymphadenopathy or fever. By nationality, 12 cases (66.7%) were Korean nationals while six subjects (33.3%) were foreigners. Among 12 potential cases who received differential diagnoses, the confirmed diagnosis was chickenpox in three subjects, syphilis in one case, Sweet syndrome in one case, coronavirus disease 2019 (COVID-19) in one case, HIV infection in two cases, and herpes virus II infection in one case. Underlying diseases included psoriasis, allergies, cellulitis, HIV infection, neuropathy, panic disorder, herpes zoster, rhinitis, and atopic dermatitis.

Upon inspection of the epidemiological association 21 days before symptom onset, 13 out of 18 patients had travel history to an affected country, one had contact with a confirmed case, five had sexual contact, and four had animal contact. Although there was no epidemiological relationship in three cases, they were reported as potential cases as a result of treatment by a specialist in the department of infectious diseases.

2) Response to confirmed cases

(1) Management of confirmed patients

As of August 8, one confirmed case was reported in Republic of Korea [20]. The confirmed patient was a 34-year-old Korean male who had visited Germany from June 1 to June 21 before entering the country and lived with same-sex acquaintances for a part of his stay. The individual reported a headache and neck lymph node pain since June 18 prior to re-entering Korea but was not aware of any skin lesions upon entry. After receiving the news that an acquaintance was classified as a close contact with monkeypox virus and received a diagnostic test after quarantine at an airport, he directly inquired about the suspected symptoms at the KDCA (1339). The monkeypox response team who received the call classified the individual as a suspected case and forwarded the case to an epidemiologist at the National Incheon Airport Quarantine Center, who immediately transferred the individual to the isolation facility at the airport for further testing. At the time of investigation, the patient's body temperature was 37℃ and the patient complained of systemic symptoms including sore throat, cough, headache, itching, asthenia, and fatigue. During the process of case investigation, various types of skin lesions such as scab lesions on the lips, one genital skin ulcer, blurred skin spots on the trunk and arms, and small blisters on the palms, were identified [21].

Although the clinical symptoms were atypical, this individual was classified as a potential case given the high epidemiological association; the patient was placed in an isolation ward at a designated hospital. Eight samples were collected from the upper respiratory tract; blood and skin lesions and laboratory tests were requested to the High Risk Pathogen Analysis Division of the KDCA. On June 22, real-time polymerase chain reaction (PCR) test results showed monkeypox-specific genes in the skin lesion smears collected from the upper respiratory tract (nasopharyngeal and oropharyngeal smears) and the scrotum. The patient had fever, chills, and sore throat for 3 days after the date of hospitalization; upon the recovery of fever, systemic rash starting from the trunk spreading to the limbs appeared accompanied by itching. During the isolated hospitalization period, symptomatic treatment was provided for fever, sore throat, and itching. The patient was released from isolation as the healthcare professionals determined that the patient was no longer infectious; all skin lesions had recovered based on the clinical symptoms and laboratory test results as of July 7. The patient was in good health at the time of discharge. The route of infection was presumed to be due to close contact with a confirmed individual, as an acquaintance that he stayed with in Germany was a confirmed case [20].

(2) Management of close contacts

Upon receiving reports, the likelihood of the potential case having monkeypox disease was determined to be high. In response, a central epidemiological investigation on-site response team was formed, and a close-contact management plan was prepared for identifying the movement of the confirmed patient and securing a list of close contacts in cooperation with the quarantine station, center, and local governments. Upon identifying a positive case as a result of the diagnostic test conducted in the morning of June 22, an on-site response team was dispatched to hold an on-site response meeting with related organizations including healthcare professionals while immediately starting the tracing of close contacts of confirmed cases to prevent spread among communities in addition to in-depth epidemiological investigations on confirmed cases. The investigation of close-contacts was completed on the same day as identifying the confirmed case and a total of 49 close contacts were identified from the same flight. Among them, eight passengers within one row of the confirmed case were classified as medium-risk contacts while 39 passengers within three rows of the patient along with the two flight attendants who provided inflight services to the patient were classified as low-risk contacts. The movement of the confirmed case was identified using CCTV and it was confirmed that there were no additional close contacts as a result of tracing close contacts at the airport based on the statements provided by the confirmed case.

In accordance with the response guidelines, medium-risk contacts were classified as subject to 21-day active surveillance and monkeypox vaccination while low-risk contacts were placed under passive surveillance for 21 days. The list of close contacts and the tracing method were provided to local governments, with accompanying instructions to identify medium-risk contacts who wished to be vaccinated after exposure and submit daily reports on close contacts tracing. In addition, close contacts were informed over telephone of their initial exposure to the confirmed case as well as the corresponding surveillance period and the method of tracing. There were a few close contacts who could not be reached via telephone or were lost to follow-up; they were eventually contacted with the assistance of the police department. Vaccinations were not provided as none of the medium-risk contacts wished to be vaccinated after exposure. For the six close contacts who left the country during the surveillance period, they were informed to comply with in-flight quarantine measures and to take immediate action if symptoms arose during the surveillance period. Through such close management depending on the level of exposure to the confirmed patient, no additional confirmed cases were identified during the incubation period and follow-up was terminated on July 11 as there were no confirmed cases of transmission to other communities.

(3) Follow-up

Following the first confirmed case on June 22, a risk assessment meeting was held, and the crisis alert was upgraded to ‘caution’, while the response team was upgraded to a Central Quarantine Countermeasure Headquarters. An immediate response team was configured consisting of a central-expert-regional epidemiological investigation team. In accordance with the IHRs of the WHO, information on the confirmed cases of monkeypox and measures to be taken was provided to the WHO Western Pacific Regional Office and Germany, the country of departure for the confirmed case. Subsequently, there were six individuals who left the country during the surveillance period, prompting a discussion on who should be notified of monkeypox and the scope of information to be shared in accordance with the IHRs to prepare a notification plan for those who leave the country during the surveillance period. For monkeypox, notifications will be made in cases of confirmed patients and when high-risk contacts leave the country during the surveillance period; information will be shared with the country of departure, country of citizenship, and departure and contact information of the high-risk contacts. On June 27, a ‘Regional Quarantine Countermeasure Team’ was installed in each municipality nationwide to reenforce the cooperation between the central and the local governments.

Reports on suspected monkeypox patients are continuously being received under the cooperation of local governments and medical institutions along with active surveillance by the KDCA. It is necessary to compile these outcomes of response to identify major clinical symptoms and infection routes; this information can be used in differentially diagnosing monkeypox from other diseases that exhibit similar rash symptoms. Based on overseas cases, the cases of monkeypox causing outbreaks this year are reported to show clinical symptoms different from the cases observed in endemic regions [12-16]. As there had been no prior cases of monkeypox in South Korea to date, available information is limited, thus necessitating analysis of overseas research results and domestic response outcomes. Based on the results presented here, suspected patients in communities will be detected early without any response delay and surveillance systems will be continuously supplemented through changes in effective case definition so that resources are not misallocated amid the current COVID-19 situation.

As there have been no domestic monkeypox cases to date, it is difficult to acutely identify the scale of outbreaks and their potential for spreading among communities as available information is limited. In addition, reports of mutations, unresolved questions on other transmission routes that have not been identified clearly, and clinical patterns that are different from existing reports create anxiety among the public [6,13-15,22]. However, the major route of transmission known to date is close contact with a symptomatic case; although there have been reports of asymptomatic cases, most are not infectious, have slow transmission rates compared to respiratory infectious diseases, and have lower fatality rates than cases from Africa [1,6,7,12,13,15]. Based on reports analyzing confirmed cases, the UK has revised the guidelines so that confirmed patients of the West African clade who have no history of traveling to an endemic country are excluded from the high-risk group and are allowed to self-isolate and receive outpatient treatment [12]. By sharing the latest research results on clinical symptoms and transmission routes, excessive anxiety is discouraged while maintaining an adequate level of alertness to comply with prevention measures and quarantine measures; response guidelines are also being revised based on the latest evidence [13].

Taken together, these results suggests that response preparation and continuous monitoring are key to preventing infectious diseases and blocking transmission to communities. Quarantine authorities must prepare a system by disseminating the latest results on transmission routes, major symptoms, and prevention methods to the public in a timely manner to allow for advance prevention, early detection, early treatment of suspected symptoms. Also, in the case of confirmed cases, tracing of close contacts must be conducted as soon as possible during the incubation period. Medical institutions must monitor the latest clinical information on monkeypox, comply with the standard infection control measures when treating those with suspected symptoms, and actively conduct tests and report results. The public should follow the basic infection prevention measures notified by the quarantine authorities instead of creating excessive anxiety and contact the quarantine authorities in the event of a suspected symptom. With such a timely response system and surveillance response, the first confirmed patient in South Korea was detected early and spread was controlled. The experience with the monkeypox response system performed to date has reminded us of the importance of constant monitoring and preparing response plans for infectious diseases originating overseas.

The KDCA is promptly revising the guidelines on response and surveillance systems so that they could be implemented in real-life by taking into consideration domestic and international studies, incidence rates, and guidelines on monkeypox in addition to various circumstances such as COVID-19. In the future, continuous updates will be made so that these guidelines can reflect the latest overseas knowledge and the domestic situations on quarantine to be useful in the field.

We would like to express our gratitude to the Monkeypox Central Disease Control Headquarters1), KDCA, Disease Response Centers in the metropolitan area, Gyeongbuk area, Gyeongnam area, Honam area, Chungcheong area, the Incheon International Airport Quarantine Center, Regional Monkeypox Quarantine Countermeasure Team, and local governments (17 municipalities nationwide), Ministry of Agriculture, Food and Rural Affairs, Ministry of Health and Welfare, Ministry of Environment, National Fire Agency, and the Institute of Health and Environment for their assistance in establishing the monkeypox response system and early response systems, as well as the healthcare professionals who actively contributed by reporting cases.

Monkeypox Central Disease Control Headquarters, Korea Disease Control and Prevention Agency

Crisis Management Team (TongRyoung Jung, Wookgyo Lee, Jeonghwan Shin, Gukseong Jeong, Hyelim Lee, Hyeyoung Kim, Seungwook Jung, Dasol Kim, Yeoran Yun, Isu Choi)

Crisis Control Team (Cha Won Kang, Jung Youl Lee, Jung-eun Lee, Misuk An, Ik Hyun Ahn, Jung In Ham, Jungwoo Kim)

Press Public Relations Team (Jaeyoung Ko, Seonggyu Kim, Yuhseog Choi, Jangho Park, Seungho Cha, Soyeon Kim)

International Affairs Team (Yujin Jeong, Shinye Lee, Sunghee Lee)

Overseas Immigration Control Team (Joosim Kim, Jinuk Park, Jaewoo Kwon, Seungho Kim)

Medical Response Support Team (Woncho Bae, Yoonsuk Jang, Sujeong Hwang, Soyeon Kim, Anna Lee)

Medical Stockpile Support Team (Oksoo Kim, Yunseock Jang, Eunyoung Yang, Hyunjung Ahn)

Patient Control Team (Minjoung Shin, Yoo-Yeon Kim, Jungyeon Kim, Hee Sook Kim, Jongmu Kim, Soonjong Bae, Seok Kyoung Choi)

Epidemiological Investigation Control Team (Haekyung Shin, Siik Ryu, Chaemin Chun, Hwami Kim, Jeongmi Kang)

Epidemiological Investigation Team (Sang-Eun Lee, Young-Man Kim, Hye Young Lee, Yeong-Jun Song, JIS-Hyeon Lim, Ju-Hee Lee)

Crisis Analysis Team (Sangwoo Tak, Hyeyoung Lee, Jiyoung Oh, Chungman Chae, Soohyun Kim, Minjei Lee, YuJin Mun)

Diagnostics Management Team (Gab Jung Kim, Jae Sun Park, Ok Kyu Park, Minjoon Kim, Hyun Jeong Lee, Deok Bum Park, Hyun Yeong Kim)

Diagnostics Team (Gi-eun Rhie, Hwajung Yi, Junyoung Kim, Eunkyung Shin, Jin-Won Kim, Myung-Min Choi, Chi-Hwan Choi, Minji Lee, Hwachul Shin, Jungsun Park)

Immunization Team (Geun-Yong Kwon, Seunghyun Lewis Kwon, Jin Hee Park, Jeeyeon Shin, Hyuna Bae, Seonhwa Ban, Heeyoun Park)

Vaccine Supply Team (Joonku Park, Juhong Kim, Kueyoung Lee)

Conceptualization: SYL, YJP. Investigation: SYL. Supervision: HL. Writing–original draft: SYL. Writing–review & editing: YJP, HL.

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    Available from: https://www.who.int/publications/m/item/multi-country-outbreak-of-monkeypox--external-situation-report--1---6-july-2022. cited 2022 Jul 18
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    Available from: https://www.ecdc.europa.eu/en/publications-data/monkeypox-multi-country-outbreak-first-update. cited 2022 Jul 8
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Article

Policy Note

Public Health Weekly Report 2022; 15(39): 2666-2677

Published online September 29, 2022 https://doi.org/10.56786/PHWR.2022.15.39.2666

Copyright © The Korea Disease Control and Prevention Agency.

Received: August 17, 2022; Revised: August 19, 2022; Accepted: August 22, 2022

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Monkeypox is an endemic disease mainly occurring in some countries in Central and West Africa, but unusual outbreaks have been observed since May 2022 in many countries across Europe and North America. From January 1 to August 11, 2022, a total of 32,760 confirmed cases (12 deaths) were reported in 91 countries and the World Health Organization declared a public health emergency of international concern on July 23, as the cumulative number of confirmed cases is rapidly increasing and there are concerns about the disease spreading globally. The Korea Disease Control and Prevention Agency has been closely monitoring the status of overseas cases and conducting risk assessment to prepare a response system for possible domestic outbreaks before the first case in the Republic of Korea was reported. The first expert advisory meeting was held on May 23, followed by a domestic risk assessment on May 24, consultation with the Infectious Disease Crisis Management Expert Committee on May 30, and a Risk Assessment Meeting on May 31; a crisis alert level of ‘interest’ was issued and the monkeypox countermeasure team commenced operation. In addition, on June 8, a legal basis for responding to infectious diseases was prepared by revising the notification that designated it as Class 2 legal infectious disease and quarantinable infectious disease. Preemptive management through the announcement of an emerging infectious disease syndrome was initiated prior to the revision of the notification to prepare countermeasures for the infectious disease, including reporting suspected cases, assigning diagnostic criteria, designating of institutions for treatment, conducting epidemiological investigations, and instituting quarantine measures. Further, pre-training was performed on response guidelines for local governments, related departments, and medical institutions. For early detection of monkeypox and prevention of its spread in regional communities, information brochures were distributed for healthcare professionals and travelers from affected countries in order to raise awareness of suspected symptoms and prevention measures while strengthening quarantine measures for incoming travelers and encouraging medical institutions to report any potential cases as a part of domestic monitoring. Following the report of the first domestic patient on June 22, the crisis alert was raised to ‘caution’ and the Committee was upgraded to a Central Quarantine Countermeasure Headquarters. As of June 27, ‘Regional Quarantine Countermeasure Teams’ were installed in cities and provinces across the country to cooperate with the central government. Among the cases reported until August 8, 18 were identified as potential cases and were tested; to date, there are no additional cases exclude one confirmed case. This report aims to provide reference information for facing emerging infectious diseases by introducing the process of establishing a domestic response system and reporting the actual response outcome for an emerging infectious disease that had never occurred in the Republic of Korea.

Keywords: Monkeypox, Risk assessment, Crisis alert, Establishment emerging infectious disease of response system

INTRODUCTION

Key messages

① What is known previously?

Monkeypox is an acute zoonotic disease caused by monkeypox virus infection. It is mainly transmitted through close contact with symptomatic persons and mainly occurs in rural tropical rain forests in Central and West Africa.

② What new information is presented?

Since May 2022, cases of monkey pox have been spreading in many countries, mainly in Europe and North America, with no travel history and no connection to endemic areas. Reports show that morbidity is higher, but severity and fatality are lower, compared to the monkeypox cases reported from African endemic regions. In addition, clinical patterns are different from those shown in existing endemic cases (occurring only in a specific area, not in the distal region, first in the anus and genital area, the number of rash lesions is small, etc.) such that prodromal symptoms such as fever, headache, and chills may or may not appear after the rash. Also, there have been reports of cases of anorectitis accompanied by severe pain, bleeding, and tenesmus.

③ What are implications?

Monkeypox is an infectious disease with no prior history in South Korea; therefore, available information is limited. As such, introducing the process of establishing a surveillance response system as well as measuring actual response outcomes has allowed information to be used in establishing a response system for an emerging infectious disease, which could be valuable in practice in future actual responses.

Monkeypox is an acute, zoonotic disease caused by the monkeypox virus infection. After its discovery in laboratory-bred monkeys in 1958, the first human infection was identified in the Democratic Republic of the Congo in 1970 [1,2]. It remained an endemic disease that mainly occurred in the rural rainforests of Central and West Africa, until a case of monkeypox infection was identified in the United Kingdom on May 7, 2022, followed by reports of unusual outbreaks in many countries across Europe and North America in which the infected patients show no history of traveling to affected countries nor any epidemiologic association [3,4]. This disease is becoming an international issue, as the number of patients in non-endemic countries is increasing rapidly and as the affected geographic area is expanding.

The British Health and Safety Agency conducted an investigation after seven cases occurred between May 7 and 16 and announced on June 1 that the community transmission of monkeypox had already begun in the UK [4,5]. Starting with the first emergency meeting regarding monkeypox on May 20, the World Health Organization (WHO) conducted a risk assessment and distributed guidelines while urging countries around the world to be prepared and vigilant for potential cases and disease spread. Nevertheless, the disease continued to spread, and the WHO Director-General declared a public health emergency of international concern (PHEIC) on July 23 in accordance with the International Health Regulations (IHR) and issued an interim recommendation [5-9]. In addition, the U.S. Centers for Disease Control and Prevention issued a warning message to the medical community and the public after the first case of monkeypox was confirmed in Massachusetts on May 18 and distributed guidelines for infection prevention and management while instituting a national response including operating information call centers. Despite these efforts, due to the recent rapid increase in the number of cases, the 5th disease-related US public health emergency since 2001 was declared on August 4 [10,11].

Korea Disease Control and Prevention Agency (KDCA) has been closely monitoring these overseas circumstances since May 2022 and has established a response system to preemptively respond to monkeypox in preparation for the first reported case in the country. In this report, we introduce the monkeypox response system in the Republic of Korea along with the initial outcome of the response.

RESULTS

1. Establishing a Response System for Monkeypox

Monkeypox is spreading in non-endemic countries this year with a higher morbidity rate than that of previous outbreaks; however, the exact route of infection for community transmission has not yet been fully elucidated [7]. However, the majority of the confirmed patients are men (99%) with a mean age of 36 years old; many cases are being reported among groups of men who are homosexuals, are bisexuals, or have had sexual intercourse with other men [4,7,8,11]. The main route of infection is close contact with a symptomatic person, and sexual contact is the most common among all reported routes of infection [1,4,7]. The current monkeypox outbreak and spread is different from previously known outbreak in terms of rash pattern and clinical symptoms- it either lacks or has an unnoticeable prodromal stage with initial rash appearing inside the oral cavity, anus and genital area without spreading to the trunk or the limbs, often with fewer than 5 lesions. New clinical symptoms such as anorectitis and pain and genitourinary system-related complications have also been reported [12-16]. Although the incubation period (5 to 21 days) is long, the initial stage of infection may manifest no or nonspecific symptoms, so early detection of suspected patients is important to prevent community transmission [6,13-15]. Furthermore, control of pets and wild animals is also necessary given the nature of the zoonotic disease. The 2003 outbreak of monkeypox in the United States was a case in which a family member was infected from a pet prairie dog [17,18]. A recently published paper in France reported that a dog who shared a bed with two confirmed human cases was diagnosed with monkeypox, stating that infection from humans cannot be ruled out because the dog’s viral gene sequence also matched that of the owner [18]. It is necessary to monitor this phenomenon and institute control policies for pets and wild animals in order to prevent the monkeypox virus from evolving and mutating across interspecies barrier to become an endemic disease. The KDCA prepared a response system in preparation for an outbreak of domestic cases based on the information gathered from overseas cases and the nature of the disease.

Starting with the first expert advisory meeting on May 23, 2022, domestic risk assessment was conducted on May 24, followed by a consultation with the Infectious Disease Crisis Management Expert Committee on May 30, and Risk Assessment Meeting on May 31, after which the crisis alert level of ‘interest’ was issued. The Monkeypox Countermeasure Team included relevant organizations including local governments, the Ministry of Agriculture, Food and Rural Affairs, the Ministry of Health and Welfare, the Ministry of Environment and the Fire Department. Under the cooperation of these organizations, information brochures were created and distributed to guide prompt transport of potential and confirmed patients, pre-designate of hospital beds for treatment in isolation, establish of control plans for pets and wild animals, and create treatment guidelines for veterinarians. Seventeen municipalities and the countermeasure team held weekly meetings to monitor the response plan and to prepare the response system.

Although monkeypox was designated as a Class 2 infectious disease requiring isolation of hospitalized patients, the initial response followed the management criteria for Class 1 infectious diseases given the fact that this emerging infectious disease has no prior history in the Republic of Korea and the number of cases rapidly increased. Five response systems as follows:

1) Establishment of reporting and diagnostic test system

After announcing monkeypox as a novel infectious disease syndrome on May 31, a legal basis was prepared by revising a notification that designated it as a Class 2 legal infectious disease and a quarantined infectious disease in order to prepare the basis for response to preemptively monitor and manage suspected patients through reports, epidemiological investigations, and quarantine measures. Following the designation as a legal infectious disease on June 8, 2022, medical institutions were required to report potential cases according to the specified diagnostic and reporting criteria, while health authorities were given the responsibility to manage the reported potential cases. Since the characteristic clinical symptom of monkeypox is ‘rash’, it is critical to differentiate this symptom from rashes with other etiologies [1,11]. Reflecting the research results showing that the symptoms of ‘rash’ in patients of monkeypox prevalent in Europe and the US this year are different from those previously reported, healthcare professionals were encouraged to report cases by giving them a diagnostic flowchart explaining differential diagnosis according to ‘rash’ symptoms [1,6,13-16].

The diagnosis and test method developed in 2016 was being used by the KDCA for testing, but in order to prepare for an increase in the demand for future testing, education and quality assessment of laboratory tests were conducted so that monkeypox diagnostic tests can also be performed at municipal and provincial health and environment research institutes. Diagnostic test guidelines were established and distributed so that researchers across the 17 local governments (Health Environment Research Institute) nationwide could also conduct diagnostic testing starting on July 11.

2) Measures to prevent domestic cases

Quarantine measures were strictly enforced for entry into the country and travel history was required when treating overseas travelers at hospitals. First, strict quarantine measures included designating 27 countries with monkeypox cases as controlled areas and requiring a health condition survey at quarantine phase for travelers coming from these regions. For five countries with frequent cases (UK, Spain, Germany, Portugal, and France), monitoring was strengthened by lowering the criteria for fever from 37.5 to 37.3 degrees Celsius. With the cooperation of the Ministry of Foreign Affairs, the precautionary measures for monkeypox were provided to outbound travelers who have arrived in the affected country via SMS. Upon return, travelers were informed to voluntarily report suspected symptoms through SMS to encourage self-reporting during the quarantine stage. Considering the long incubation period of monkeypox, travelers were encouraged through notices and SMS to voluntarily report if symptoms developed. Also, when travelers from the above countries with frequent cases visited medical institutions, International Traveler Information System synched with Drug Utilization Review is used for early diagnosis and treatment to provide inbound traveler information to medical institutions. Active response to prevent the influx of overseas monkeypox cases was initiated by encouraging the report of suspected symptoms by medical institutions and inbound travelers while strictly monitoring all stages of entry into the country.

3) Preparation and education of response guidelines and information systems

On May 27, a case definition of monkeypox in Republic of Korea was prepared to monitor and respond to potential and confirmed patients. Based on this definition, an information brochure for healthcare professionals was prepared and first distributed on May 29, with details on disease overview, differential diagnosis among similar rash diseases, precautions for treating and reporting suspected patients, and a report template. On June 16, ‘Monkeypox Response Guideline Edition 1’ was distributed for educating local governments by providing more detailed information on reporting of suspected patients, diagnostic testing criteria, epidemiological investigation of suspected patients, management of confirmed and close-contact patients, and treatment systems. Subsequently, on June 17, ‘Monkeypox Information Brochure Edition 1–2’ for healthcare professionals was distributed to revise the case definition, introduce differential diagnostic method, provide rash photographs, and outline diagnostic guide using a flowchart based on the latest research. Even without epidemiological associations, potential were assigned diagnostic testing if monkeypox was suspected as a result of consultation from infectious disease, proctology, urology, and dermatology departments. On July 6, ‘Monkeypox Response Guideline Edition 2’ was updated based on the latest research and the current response status was distributed. In the second edition, information regarding case definition and changes in classification criteria, close-contact investigations and management guidelines, and responding to suspected cases was updated. In addition to overall response guidelines, ‘Monkeypox Treatment Guidelines for Healthcare Professionals’ was distributed over three rounds in order to provide the information necessary for the treatment of monkeypox.

In order to increase the practical application and usability of the prepared response guidelines and latest guides, the KDCA conducted two scenario-based trainings on June 28 and July 15 to verify and supplement response guidelines and to enhance actual response capabilities. In addition, on June 28 and 29, education was provided for healthcare professionals in the high-risk geographic area for monkeypox, and information was shared on the treatment methods and reporting suspected monkeypox cases, clinical symptoms, and actual cases of confirmed patients. In August, an educational video for healthcare professionals based on domestic and overseas confirmed cases and the latest response guidelines was produced and distributed through the Infectious Disease Newsletter and the KDCA website. By providing healthcare professionals with the latest clinical information related to monkeypox, early detection of suspected patients with nonspecific suspected symptoms during treatment is prioritized.

An information system was built to manage and integrate the basic personal information, epidemiological investigation results, diagnostic test results, and close contacts of reported suspected cases. Since July 7, it has been in use with the added function of case investigation entry. Through this newly prepared information system, public health centers, cities/provinces, regional disease response centers, and the KDCA can simultaneously view the same information; periodic statistical analysis of information will be used to evaluate and supplement operation of the monitoring system.

4) Vaccination promotion system and securing vaccines and treatments

Subjects were vaccinated after being classified based on exposure to the monkeypox virus (before versus after exposure) using the second-generation vaccine that was already available domestically while working to introduce a third-generation vaccine for emergency use. Vaccination prior to exposure to the monkeypox virus was provided for high-risk groups such as healthcare professionals working in close proximity to treatment beds, members of diagnostic laboratories and epidemiologists. Post-exposure vaccinations will be provided for those who consent as necessary through epidemiological investigation of factors such as the level of contact with confirmed cases. Post-exposure vaccinations are effective in preventing an infection when administered within 4 days of exposure, while vaccination within 14 days has been reported to be effective in symptom relief. Second generation vaccinations are provided by the National Medical Center while third-generation vaccines are provided by the 17 designated public health centers. Adverse event surveillance will be conducted on Day 3 and 7, and national compensation will be provided based on causalities in the case of adverse events [19].

Vaccines and treatments for monkeypox were introduced in South Korea and 504 doses of the antiviral drug, Tecovirimat, were introduced on July 8. The doses will be supplied to hospitals in 17 municipalities for use and the purchases of additional doses will be reviewed considering future cases. Also, the process of introducing the third-generation vaccine (JINNEOSTM; Bavarian Nordic, Copenhagen, Denmark) was expedited and the contract for purchasing 10,000 doses from an overseas manufacturer was signed on July 20, which were introduced on August 11.

5) Information disclosure and crisis communication

First, the protocol for information disclosure was established so that personal information that could specify suspected and confirmed patients, such as residential area, and gender, as well as the details not directly related to the prevention and response to infectious diseases were to remain confidential. Social stigma and discrimination against confirmed patients form a critical aspect of crisis communication of infectious diseases, as they discourage voluntary reports from individuals with suspected symptoms, leading to avoidance of testing and ultimately resulting in the increase in the number of undetected cases quietly spreading throughout a community. Furthermore, a vital quarantine measure is encouraging public cooperation. Through sharing occurrence and government response trends along with quarantine measures, public anxiety is mitigated, which in turn encourages voluntary reporting and improves. As such, active communication was provided through the preparation and distribution of various types of contents on monkeypox, including Q&A, card news, and briefings.

2. Monitoring Suspected Monkeypox Cases and Responding to Confirmed Cases

1) Outcome of monitoring suspected cases

Among the cases reported between June 21 and August 8, 2022, 18 cases were classified as potential cases and tested. So far, there are no additional domestic occurrences aside from one confirmed case. The 18 potential cases were identified through quarantine stations (1 case, 5.6%) and local communities (17 cases, 94.4%), whereas the reporter/reporting method was an individual calling the 1339 hotline (6 cases, 33.3%) or a medical institution (12 cases, 66.7%) reporting to the local public health center. By gender, there were 10 male cases (55.6%) and eight female cases (44.4%). By age, seven cases (38.9%) were in their 20s, six cases (33.3%) were in their 30s, three cases (16.7%) were in their 40s, and two cases (11.1%) were children (three years old and five years old). Initial clinical symptoms were skin lesions that looked like rash in all of the cases (18, 100.0%), with 10 cases (55.6%) also showing lymphadenopathy or fever. By nationality, 12 cases (66.7%) were Korean nationals while six subjects (33.3%) were foreigners. Among 12 potential cases who received differential diagnoses, the confirmed diagnosis was chickenpox in three subjects, syphilis in one case, Sweet syndrome in one case, coronavirus disease 2019 (COVID-19) in one case, HIV infection in two cases, and herpes virus II infection in one case. Underlying diseases included psoriasis, allergies, cellulitis, HIV infection, neuropathy, panic disorder, herpes zoster, rhinitis, and atopic dermatitis.

Upon inspection of the epidemiological association 21 days before symptom onset, 13 out of 18 patients had travel history to an affected country, one had contact with a confirmed case, five had sexual contact, and four had animal contact. Although there was no epidemiological relationship in three cases, they were reported as potential cases as a result of treatment by a specialist in the department of infectious diseases.

2) Response to confirmed cases

(1) Management of confirmed patients

As of August 8, one confirmed case was reported in Republic of Korea [20]. The confirmed patient was a 34-year-old Korean male who had visited Germany from June 1 to June 21 before entering the country and lived with same-sex acquaintances for a part of his stay. The individual reported a headache and neck lymph node pain since June 18 prior to re-entering Korea but was not aware of any skin lesions upon entry. After receiving the news that an acquaintance was classified as a close contact with monkeypox virus and received a diagnostic test after quarantine at an airport, he directly inquired about the suspected symptoms at the KDCA (1339). The monkeypox response team who received the call classified the individual as a suspected case and forwarded the case to an epidemiologist at the National Incheon Airport Quarantine Center, who immediately transferred the individual to the isolation facility at the airport for further testing. At the time of investigation, the patient's body temperature was 37℃ and the patient complained of systemic symptoms including sore throat, cough, headache, itching, asthenia, and fatigue. During the process of case investigation, various types of skin lesions such as scab lesions on the lips, one genital skin ulcer, blurred skin spots on the trunk and arms, and small blisters on the palms, were identified [21].

Although the clinical symptoms were atypical, this individual was classified as a potential case given the high epidemiological association; the patient was placed in an isolation ward at a designated hospital. Eight samples were collected from the upper respiratory tract; blood and skin lesions and laboratory tests were requested to the High Risk Pathogen Analysis Division of the KDCA. On June 22, real-time polymerase chain reaction (PCR) test results showed monkeypox-specific genes in the skin lesion smears collected from the upper respiratory tract (nasopharyngeal and oropharyngeal smears) and the scrotum. The patient had fever, chills, and sore throat for 3 days after the date of hospitalization; upon the recovery of fever, systemic rash starting from the trunk spreading to the limbs appeared accompanied by itching. During the isolated hospitalization period, symptomatic treatment was provided for fever, sore throat, and itching. The patient was released from isolation as the healthcare professionals determined that the patient was no longer infectious; all skin lesions had recovered based on the clinical symptoms and laboratory test results as of July 7. The patient was in good health at the time of discharge. The route of infection was presumed to be due to close contact with a confirmed individual, as an acquaintance that he stayed with in Germany was a confirmed case [20].

(2) Management of close contacts

Upon receiving reports, the likelihood of the potential case having monkeypox disease was determined to be high. In response, a central epidemiological investigation on-site response team was formed, and a close-contact management plan was prepared for identifying the movement of the confirmed patient and securing a list of close contacts in cooperation with the quarantine station, center, and local governments. Upon identifying a positive case as a result of the diagnostic test conducted in the morning of June 22, an on-site response team was dispatched to hold an on-site response meeting with related organizations including healthcare professionals while immediately starting the tracing of close contacts of confirmed cases to prevent spread among communities in addition to in-depth epidemiological investigations on confirmed cases. The investigation of close-contacts was completed on the same day as identifying the confirmed case and a total of 49 close contacts were identified from the same flight. Among them, eight passengers within one row of the confirmed case were classified as medium-risk contacts while 39 passengers within three rows of the patient along with the two flight attendants who provided inflight services to the patient were classified as low-risk contacts. The movement of the confirmed case was identified using CCTV and it was confirmed that there were no additional close contacts as a result of tracing close contacts at the airport based on the statements provided by the confirmed case.

In accordance with the response guidelines, medium-risk contacts were classified as subject to 21-day active surveillance and monkeypox vaccination while low-risk contacts were placed under passive surveillance for 21 days. The list of close contacts and the tracing method were provided to local governments, with accompanying instructions to identify medium-risk contacts who wished to be vaccinated after exposure and submit daily reports on close contacts tracing. In addition, close contacts were informed over telephone of their initial exposure to the confirmed case as well as the corresponding surveillance period and the method of tracing. There were a few close contacts who could not be reached via telephone or were lost to follow-up; they were eventually contacted with the assistance of the police department. Vaccinations were not provided as none of the medium-risk contacts wished to be vaccinated after exposure. For the six close contacts who left the country during the surveillance period, they were informed to comply with in-flight quarantine measures and to take immediate action if symptoms arose during the surveillance period. Through such close management depending on the level of exposure to the confirmed patient, no additional confirmed cases were identified during the incubation period and follow-up was terminated on July 11 as there were no confirmed cases of transmission to other communities.

(3) Follow-up

Following the first confirmed case on June 22, a risk assessment meeting was held, and the crisis alert was upgraded to ‘caution’, while the response team was upgraded to a Central Quarantine Countermeasure Headquarters. An immediate response team was configured consisting of a central-expert-regional epidemiological investigation team. In accordance with the IHRs of the WHO, information on the confirmed cases of monkeypox and measures to be taken was provided to the WHO Western Pacific Regional Office and Germany, the country of departure for the confirmed case. Subsequently, there were six individuals who left the country during the surveillance period, prompting a discussion on who should be notified of monkeypox and the scope of information to be shared in accordance with the IHRs to prepare a notification plan for those who leave the country during the surveillance period. For monkeypox, notifications will be made in cases of confirmed patients and when high-risk contacts leave the country during the surveillance period; information will be shared with the country of departure, country of citizenship, and departure and contact information of the high-risk contacts. On June 27, a ‘Regional Quarantine Countermeasure Team’ was installed in each municipality nationwide to reenforce the cooperation between the central and the local governments.

Reports on suspected monkeypox patients are continuously being received under the cooperation of local governments and medical institutions along with active surveillance by the KDCA. It is necessary to compile these outcomes of response to identify major clinical symptoms and infection routes; this information can be used in differentially diagnosing monkeypox from other diseases that exhibit similar rash symptoms. Based on overseas cases, the cases of monkeypox causing outbreaks this year are reported to show clinical symptoms different from the cases observed in endemic regions [12-16]. As there had been no prior cases of monkeypox in South Korea to date, available information is limited, thus necessitating analysis of overseas research results and domestic response outcomes. Based on the results presented here, suspected patients in communities will be detected early without any response delay and surveillance systems will be continuously supplemented through changes in effective case definition so that resources are not misallocated amid the current COVID-19 situation.

CONCLUSION

As there have been no domestic monkeypox cases to date, it is difficult to acutely identify the scale of outbreaks and their potential for spreading among communities as available information is limited. In addition, reports of mutations, unresolved questions on other transmission routes that have not been identified clearly, and clinical patterns that are different from existing reports create anxiety among the public [6,13-15,22]. However, the major route of transmission known to date is close contact with a symptomatic case; although there have been reports of asymptomatic cases, most are not infectious, have slow transmission rates compared to respiratory infectious diseases, and have lower fatality rates than cases from Africa [1,6,7,12,13,15]. Based on reports analyzing confirmed cases, the UK has revised the guidelines so that confirmed patients of the West African clade who have no history of traveling to an endemic country are excluded from the high-risk group and are allowed to self-isolate and receive outpatient treatment [12]. By sharing the latest research results on clinical symptoms and transmission routes, excessive anxiety is discouraged while maintaining an adequate level of alertness to comply with prevention measures and quarantine measures; response guidelines are also being revised based on the latest evidence [13].

Taken together, these results suggests that response preparation and continuous monitoring are key to preventing infectious diseases and blocking transmission to communities. Quarantine authorities must prepare a system by disseminating the latest results on transmission routes, major symptoms, and prevention methods to the public in a timely manner to allow for advance prevention, early detection, early treatment of suspected symptoms. Also, in the case of confirmed cases, tracing of close contacts must be conducted as soon as possible during the incubation period. Medical institutions must monitor the latest clinical information on monkeypox, comply with the standard infection control measures when treating those with suspected symptoms, and actively conduct tests and report results. The public should follow the basic infection prevention measures notified by the quarantine authorities instead of creating excessive anxiety and contact the quarantine authorities in the event of a suspected symptom. With such a timely response system and surveillance response, the first confirmed patient in South Korea was detected early and spread was controlled. The experience with the monkeypox response system performed to date has reminded us of the importance of constant monitoring and preparing response plans for infectious diseases originating overseas.

The KDCA is promptly revising the guidelines on response and surveillance systems so that they could be implemented in real-life by taking into consideration domestic and international studies, incidence rates, and guidelines on monkeypox in addition to various circumstances such as COVID-19. In the future, continuous updates will be made so that these guidelines can reflect the latest overseas knowledge and the domestic situations on quarantine to be useful in the field.

Acknowledgments

We would like to express our gratitude to the Monkeypox Central Disease Control Headquarters1), KDCA, Disease Response Centers in the metropolitan area, Gyeongbuk area, Gyeongnam area, Honam area, Chungcheong area, the Incheon International Airport Quarantine Center, Regional Monkeypox Quarantine Countermeasure Team, and local governments (17 municipalities nationwide), Ministry of Agriculture, Food and Rural Affairs, Ministry of Health and Welfare, Ministry of Environment, National Fire Agency, and the Institute of Health and Environment for their assistance in establishing the monkeypox response system and early response systems, as well as the healthcare professionals who actively contributed by reporting cases.

Footnote

Monkeypox Central Disease Control Headquarters, Korea Disease Control and Prevention Agency

Crisis Management Team (TongRyoung Jung, Wookgyo Lee, Jeonghwan Shin, Gukseong Jeong, Hyelim Lee, Hyeyoung Kim, Seungwook Jung, Dasol Kim, Yeoran Yun, Isu Choi)

Crisis Control Team (Cha Won Kang, Jung Youl Lee, Jung-eun Lee, Misuk An, Ik Hyun Ahn, Jung In Ham, Jungwoo Kim)

Press Public Relations Team (Jaeyoung Ko, Seonggyu Kim, Yuhseog Choi, Jangho Park, Seungho Cha, Soyeon Kim)

International Affairs Team (Yujin Jeong, Shinye Lee, Sunghee Lee)

Overseas Immigration Control Team (Joosim Kim, Jinuk Park, Jaewoo Kwon, Seungho Kim)

Medical Response Support Team (Woncho Bae, Yoonsuk Jang, Sujeong Hwang, Soyeon Kim, Anna Lee)

Medical Stockpile Support Team (Oksoo Kim, Yunseock Jang, Eunyoung Yang, Hyunjung Ahn)

Patient Control Team (Minjoung Shin, Yoo-Yeon Kim, Jungyeon Kim, Hee Sook Kim, Jongmu Kim, Soonjong Bae, Seok Kyoung Choi)

Epidemiological Investigation Control Team (Haekyung Shin, Siik Ryu, Chaemin Chun, Hwami Kim, Jeongmi Kang)

Epidemiological Investigation Team (Sang-Eun Lee, Young-Man Kim, Hye Young Lee, Yeong-Jun Song, JIS-Hyeon Lim, Ju-Hee Lee)

Crisis Analysis Team (Sangwoo Tak, Hyeyoung Lee, Jiyoung Oh, Chungman Chae, Soohyun Kim, Minjei Lee, YuJin Mun)

Diagnostics Management Team (Gab Jung Kim, Jae Sun Park, Ok Kyu Park, Minjoon Kim, Hyun Jeong Lee, Deok Bum Park, Hyun Yeong Kim)

Diagnostics Team (Gi-eun Rhie, Hwajung Yi, Junyoung Kim, Eunkyung Shin, Jin-Won Kim, Myung-Min Choi, Chi-Hwan Choi, Minji Lee, Hwachul Shin, Jungsun Park)

Immunization Team (Geun-Yong Kwon, Seunghyun Lewis Kwon, Jin Hee Park, Jeeyeon Shin, Hyuna Bae, Seonhwa Ban, Heeyoun Park)

Vaccine Supply Team (Joonku Park, Juhong Kim, Kueyoung Lee)

Ethics Statement

Not applicable.

Funding Source

None.

Conflict of Interest

The authors have no conflicts of interest to declare.

Author Contributions

Conceptualization: SYL, YJP. Investigation: SYL. Supervision: HL. Writing–original draft: SYL. Writing–review & editing: YJP, HL.

References

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PHWR
Jun 13, 2024 Vol.17 No.23
pp. 991~1020

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PHWR 주간 건강과 질병
PUBLIC HEALTH WEEKLY REPORT
질병관리청 (Korea Disease Control and Prevention Agency)

eISSN 2586-0860
pISSN 2005-811X