Cases of monkeypox with no direct link to travel to Central or West Africa or to people returning from such trips have been reported in Europe and around the world since early May 2022. Since then, the outbreak has spread to a growing number of countries, and the disease is being closely monitored in both France and Europe.

On Saturday, July 23, the WHO Director-General announced that he was declaring this outbreak a Public Health Emergency of International Concern (PHEIC). This is the organization’s highest alert level, intended to trigger a series of actions by member states.

In France, orthopoxvirus infections are subject to ongoing surveillance through the mandatory reporting system. Given the ongoing outbreak, surveillance of these infections has been strengthened by Santé publique France, and information, prevention, and alert messages have been sent to healthcare professionals and the populations most at risk.

Update on the Situation in France

As of August 9, 2022, at 12:00 p.m., 2,601 confirmed cases had been reported in France. Cases were most frequently reported in Île-de-France (885 cases, or 47% of cases for which the region of residence is known), Occitanie (230 cases, or 12%), and Auvergne-Rhône-Alpes (192 cases, or 10%).

The distribution of cases by region of residence (when known) is shown in Figure 1 for cases residing in France. The distribution by region of reporting, when known, is shown in Figure 2.
The region of residence is unknown for 699 cases, and 10 cases reside abroad.

Figure 1. Confirmed cases of monkeypox (n=1,892 cases) by region of residence, France, May–August 2022 (data as of 08/09/2022 – 12:00 p.m.)

Figure 2. Confirmed cases of monkeypox (n=2,600 cases) by region of reporting, France, May–August 2022 (data as of 08/09/2022 – 12:00 PM)

The distribution of cases by date of symptom onset (when known) is shown in Figure 3. The date of symptom onset for these cases ranges from May 7, 2022, to August 4, 2022. They were diagnosed a median of 6 days (ranging from 0 to 36 days) after symptom onset; consequently, and given reporting delays, data from the past few weeks have not been consolidated.

The reports received do not always mention the date of symptom onset or the date of diagnosis. As an alternative to this information, the distribution of cases by date of reporting is shown in Figure 4.

Figure 3. Confirmed cases of monkeypox (n=1,766 cases) by week of symptom onset, France, May–August 2022 (data as of 08/09/2022 – 12:00 PM). Data from the last few weeks (in gray) are not fully consolidated.

Figure 4. Confirmed cases of monkeypox (n=2,600 cases) by week of reporting, France, May–August 2022 (data as of 08/09/2022 – 12:00 PM). Data for the last week (in gray) are not fully consolidated. Data for the last few weeks (in gray) are not fully consolidated.

The dip in reporting observed in week 28 (July 11–17) can be explained by the public holiday (July 14).
All cases recorded to date are adult males, except for 23 adult females and 2 children (under 15 years of age). Adult cases have a median age of 36 years; 25% of adult cases are under 30 years old and 25% are between 43 and 77 years old.
Among the cases investigated, 75% presented with a genito-anal rash, 70% with a rash on another part of the body, 76% with fever, and 72% with lymphadenopathy.

Fifty-one cases (3%) were hospitalized due to their Monkeypox virus infection, including 43 (2.7%) for complications related to this diagnosis. In France, no deaths have been reported to date.
The median time to testing by date of symptom onset has been decreasing since the start of the outbreak (Table 1).

Table 1. Median time to testing in days (n=1,519 cases) by date of symptom onset, France, May–August 2022 (data as of 08/09/2022 – 12:00 PM)

*DDS: Date of symptom onset. Data from the last few weeks (in gray) are not fully consolidated.

Among the cases investigated, 74 are immunocompromised (5.1% of responding cases); 385 are HIV-positive (25% of cases aware of their HIV status). Among non-HIV-positive cases, 701 are on pre-exposure prophylaxis or “PrEP”** (representing 64% of non-HIV-positive cases who answered the question).

To date, in France, 95% of cases for which sexual orientation is reported have occurred among men who have sex with men (MSM).

Among cases for which information is available, 71% report having had at least 2 sexual partners in the 3 weeks prior to the onset of symptoms.

Most of the cases surveyed report being unable to identify the person who infected them; 24% are secondary cases, meaning they report having been in contact with a monkeypox case within the three weeks prior to the onset of symptoms.

The next update to this report will be on Friday, August 12.

**PrEP is a preventive treatment for HIV intended for people who are HIV-negative but at high risk of infection.

Starting Thursday, August 11, surveillance protocols will change; only cases involving women, children, and severe cases will be investigated. Consequently, information on symptoms and case profiles will no longer be updated in the next report.

Information and Prevention Initiatives

Given what has been observed in Europe regarding the disease, targeted communication was quickly implemented for MSM. The website sexosafe.fr, dedicated to the sexual health of MSM, is regularly updated with a summary of current knowledge on the subject and prevention measures. Messages reminding people of the symptoms and what to do if symptoms appear were shared through a digital campaign. Since June 17, the digital campaign has generated nearly 622,565 clicks on banners and over 491,314 visits to the Sexosafe website.
This initiative was supplemented by a poster campaign in social gathering places, with nearly 1,350 display locations. In recent weeks, it has also included the broadcast of spots on community radio stations. At the same time, posters, flyers, and advice sheets have been distributed through community organizations, Regional Health Agencies (ARS), and Sexosafe teams on the ground, during Pride parades, and in MSM social spaces. To date, 2,842 posters and 94,400 flyers have been ordered.

A digital campaign on preventive vaccination began on July 25, and tools for field use will also be made available in the coming days, following the publication of the Haute Autorité de Santé’s advisory on July 7.

Prevention efforts are continuously adapted to the evolving situation and the current state of knowledge.

• Access the documents

To facilitate access to information for vulnerable people in precarious situations, a visual tool, translated into 6 languages and developed with professionals working with these individuals, is available on Santé Publique France.

The MOBCO Newsletter No. 7, developed in collaboration with frontline workers, compiles a series of questions and answers on the topic of monkeypox. It is intended for professionals and volunteers working with people in precarious situations.

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Monkeypox Info Service: A Helpline to Answer Questions About Monkeypox

Since Wednesday, July 13, a hotline has been available to answer questions about monkeypox. Funded by Santé publique France and operated by SIS Association, the “Monkeypox Info Service” hotline is available daily from 8 a.m. to 11 p.m. at the toll-free number 0 801 90 80 69 (free calls and services; anonymous and confidential). This service is responsible for supporting prevention messages and protective measures, providing information on symptoms, treatments, and vaccination, and offering advice and referrals to care services.

Since the hotline opened, 5,007 calls have been handled by the Monkeypox Info Service (median age: 39 years).

• 1,328 calls were handled in week 31 (compared to 1,647 the previous week)

• 58% of calls came from the Île-de-France region (and mostly from Paris)

• As in previous weeks, the 25–39 age group remains the largest among callers, but there has been an increase in the proportion of people over 55 (19% of calls vs. 16% the previous week) and those under 25 (9% vs. 7%)

• An emerging trend of calls from healthcare professionals seeking assistance to obtain information and better guide their patients diagnosed with monkeypox (2% of calls in week 31)

• In order of importance, conversations continue to focus primarily on prevention measures (66% of conversations), particularly access to vaccination and the difficulties callers face in securing an appointment, followed by psychological and relationship issues (22% of conversations), and symptoms (21%)

Preventive Vaccination Against Monkeypox

In response to the spread of the Monkeypox virus, the High Authority for Health, following a referral from the Directorate General for Health, recommended in its opinion dated July 7, 2022, that preventive vaccination be offered to groups most at risk of exposure to the virus.
Regarding the rollout of the vaccination, 54,585 doses of the third-generation vaccine had been delivered by the Agency to the regions as of August 9, 2022.

Since July 11, 2022, in addition to individuals who have had high-risk contact with an infected person, individuals meeting the criteria established by the HAS may schedule an appointment to be vaccinated throughout the country:

• Men who have sex with men and report having multiple sexual partners.

• Transgender individuals reporting multiple sexual partners.

• Sex workers.

• Professionals working in venues where sexual services are provided.

Vaccination may also be considered on a case-by-case basis for healthcare professionals who care for infected individuals.

To learn more about vaccination and access to vaccination sites:

• https://www.sante.fr/monkeypox

• https://www.sexosafe.fr/Variole-du-singe

• https://vaccination-info-service.fr/Les-maladies-et-leurs-vaccins/Variole-du-singe-Monkeypox

• https://www.iledefrance.ars.sante.fr/variole-du-singe-conseils-et-prise-en-charge-en-ile-de-france