Monkeypox cases under investigation in Canada as outbreak spreads in Europe, U.S.

UPDATE: On Thursday, Montreal public health officials announced that 17 cases of suspected monkeypox are now under investigation in the region, including 15 cases on the island of Montreal, one on the South Shore and another on the North Shore.

Health officials in Quebec are investigating more than a dozen cases of suspected monkeypox in Canada, after U.S. and European health officials confirmed rising cases of the rare infectious disease — suggesting a wider outbreak may be happening globally.

Radio-Canada reported Wednesday that Montreal public health officials are investigating at least 13 cases flagged by doctors in the city, following diagnoses made in three clinics specializing in sexually transmitted and blood-borne infections. Laboratory confirmation of the cases is in progress and an announcement is expected in the coming days.

Quebec's Ministry of Health and Social Services said in a statement to CBC News late Wednesday they were notified of a person with a confirmed case of monkeypox who travelled to the province. While the ministry said it cannot confirm any additional cases yet, it is investigating reports of about 10 people with genital lesions that may be associated with the disease.

The U.S. confirmed its first case of monkeypox in a man who recently travelled to Canada, after European health officials confirmed more than two dozen cases of the rare infectious disease this week.

Man in U.S. case travelled to Canada 

The Massachusetts Department of Public Health confirmed a single case of monkeypox infection on Wednesday in an adult man who had been to Canada and returned to the state — but did not specifically say which province the man had travelled to. STAT News reported Wednesday that the man had travelled to Quebec.

The Public Health Agency of Canada (PHAC) said in a statement to CBC News Wednesday that there were no cases of monkeypox reported to the agency yet.

"PHAC is aware of and closely monitoring the current situation concerning the reporting of monkeypox cases in Europe. No cases have been reported to PHAC at this time," a spokesperson said in an email.

"PHAC has alerted provincial and territorial public health authorities and laboratory partners across Canada to be alert for and investigate any potential cases. As the situation evolves we will continue to keep Canadians informed."

The agency said it was also "collaborating closely" with international partners, including the World Health Organization (WHO), the U.S. Centers for Disease Control (CDC) and Prevention and the U.K. Health Security Agency (UKHSA), on the investigation.

Britain reported its first case of monkeypox on May 7 and has found nine in total since then, while Portuguese health officials confirmed five cases Wednesday and Spain is investigating more than 20 possible infections.

"This, once again, highlights the threat of viruses like this," said Dr. Maria Van Kerkhove, an infectious diseases epidemiologist and technical lead on COVID-19 and emerging diseases with the WHO, during a press conference this week.

"We really need to better understand the extent of monkeypox in endemic countries, like in DRC and in Nigeria, Central African Republic and others, to really understand how much is circulating and the risk that it poses for people who are living there — as well as the risk of exportation."

U.K. cases may suggest community transmission

It's unusual to see monkeypox in Europe and North America, but there are thousands of cases on an annual basis throughout West and Central Africa, WHO officials said this week.

The earliest known case in the U.K. was linked to travel in Nigeria, according to the U.K. Health Security Agency. But the two latest infections there, reported on Wednesday, were not tied to either travel or to other previously confirmed cases.

"So it is possible they acquired the infection through community transmission," the agency said.

Angela Rasmussen, a virologist and researcher with the University of Saskatchewan's Vaccine and Infectious Disease Organization (VIDO), said the spread of cases in Europe and North America was surprising compared to previous outbreaks of monkeypox.

"It does seem to be spreading, at least from the information that we have so far, through human-to-human contact," she told CBC News.

"Which means that it's either that it's a more transmissible variant of monkeypox than any that we've seen before between humans, or there are behaviours that are associated with increased transmission."

Possible sexual transmission

Dr. Robert Pilarski, a family physician who treated several recent suspected monkeypox patients at Clinique Médicale La Licorne in Montreal, said so far, cases appear to be tied to close contact, and are impacting members of the city's LGBT community.

"What's going to be most important is people who do have the infection — who have had contact with the person who was diagnosed or had symptoms — should isolate themselves and stop spreading the disease to others," he said.

The UKHSA said four of the cases detected in Britain self-identified as gay, bisexual or other men who have sex with men, and has urged men who are gay and bisexual to be aware of any unusual rashes or lesions and to immediately contact a sexual health service.

Pilarski, however, is concerned about targeting certain groups. "I don't think the disease is going to be serious enough, or have serious consequences, to put more stigma on the community — I hope not," he said.

The virus is known to spread through surface transmission or close contact, but has not previously been characterized as a sexually transmitted infection, though it can be passed on through direct contact during sex.

"We didn't think that Ebola virus was sexually transmitted and, of course, it was found in semen. Same thing with Zika virus," said Dr. Isaac Bogoch, an infectious diseases physician at Toronto General Hospital.

"The question is, is this sexually transmitted? The answer is unknown. But of course we do know it's transmitted by people who are in close proximity to each other. So it's not surprising that it might be amplified among sexual networks of people."

The virus is known to spread through a variety of ways — including respiratory droplets, open sores, contact with bodily fluids or by touching contaminated clothes or bedding.

Monkeypox was first identified in the 1950s, when two outbreaks occurred in colonies of monkeys used for research purposes, with the first human case reported in 1970, in the Democratic Republic of the Congo.

The illness is often likened to a milder form of smallpox, a disease that has been eradicated globally through widespread vaccination against the smallpox virus.

Smallpox vaccine effective

The smallpox vaccine is largely effective against monkeypox as well, but routine immunization programs ended in Canada in the early 1970s — leaving Canadians under 50 vulnerable to infection.

"There certainly are generations of people that have not received a smallpox vaccine and would have no protection against monkeypox infection if they were exposed," Bogoch said.

Symptoms of a monkeypox infection can include fever, headache, swollen lymph nodes, chills and exhaustion, along with lesions across the body.

There is no proven treatment, and infections can be deadly for up to one in 10 people who become infected, depending on the strain. Pilarski stressed people typically heal from monkeypox, despite the lack of approved treatments.

A vaccine developed against smallpox has been approved for monkeypox, and several antivirals also appear to be somewhat effective.

"It is possible that even though the supplies of that vaccine are somewhat limited from country to country, a ring vaccination strategy could be used to prevent people who have been exposed from becoming infected," said Rasmussen.

"There is also a drug that also can be used to treat pox virus infections. So it's not as though we don't have any tools whatsoever to contain this outbreak."