WHAT WE KNOW ABOUT THE LATEST MONKEY POX OUTBREAK
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Updated 12th August 2022
This article is continuously updated.
The recent outbreak of monkeypox all over the world has taken the scientific community by surprise. Although there were frequent outbreaks of monkeypox in the past, they were limited to specific areas. The recent outbreak, however, has involved multiple countries and seems to be spreading globally.
This has brought out a general state of panic among the general public, more so because of various other outbreaks of different diseases happening at an increasing pace.
So, what is monkeypox? Does it pose any life-threatening danger?
Monkeypox is a viral infection. It is transmitted to humans from animals. The symptoms of monkeypox were very similar to those of another viral infection known as smallpox. Smallpox has been eradicated globally since 1980. (1)
However, with the eradication of smallpox, monkeypox infections have raised significantly. Usually, monkeypox infections primarily occur in Central and West African rainforests. Lately, it has been seen even in urban areas. (2)
Monkeypox is caused due to the monkeypox virus. The virus has either of two distinct family lines or clades. They are (3)
- Central African (Congo Basin) clade
- West African clade.
The Congo Basin clade is believed to be more transmissible and the one causing severe impact among the two. (3)
Monkeypox is transmitted to humans from animals. (4) Some of the animals which are susceptible to monkeypox are (5)
- Rope squirrels
- Tree squirrels
- Gambian pouched rats
- Non-human primates and other species.
However, more evidence is still required to pinpoint the exact reservoir of the virus.
Monkeypox in humans was first identified in 1970 in the Democratic Republic of the Congo. This was in a 9-year-old boy. (3, 5) This region in particular had smallpox eliminated in 1968.
Most of the cases until today have been reported from rainforest areas of rural regions of the Congo basin in the Democratic Republic of the Congo. However, cases of monkeypox have increasingly been reported from across Central and West Africa.
11 African countries have a documented history of monkeypox. These countries are (5)
- the Central African Republic
- the Democratic Republic of the Congo
- Cote d’Ivoire
- the Republic of the Congo
- Sierra Leone
- South Sudan.
However, with travel and tourism, many cases have been reported in countries other than the ones belonging to Africa. Almost all cases had a travel history to Africa.
The World Health Organization (WHO) and its partners are still working to understand better the extent and cause of an outbreak of monkeypox.
The recent outbreaks reported across 11 countries so far are atypical, as they are occurring in non-endemic countries. Usually, cases have a history of contact or travel to the areas where monkeypox is prevalent in animal species. (5)
As of now, there are about 80 confirmed cases, according to the WHO. 50 are still under investigation. (6)
The WHO has asked member nations to increase surveillance in this regard. (6)
Monthly updates on the latest monkeypox outbreak
Monkeypox is not a new disease; there have been multiple outbreaks in the past. However, recently the outbreak has involved multiple countries, and the disease has spread globally.
This article provides monthly updates on the latest monkeypox outbreak and highlights what to do if you suspect you have monkeypox.
- Monkeypox infection was identified in a British resident who had been to Nigeria, which is considered an endemic region for the disease. He developed a rash on the 29th of April, arrived in the United Kingdom on May 4th, and was diagnosed with monkeypox on May 6th. (1,2)
- On the 12th of May, further cases were identified in the UK in those who had not been to the endemic region. (3)
- Further cases of monkeypox infection were identified on May 18th in Portugal, Spain, the United States, and Canada. (4,5)
- A genomic analysis of the virus in Portugal revealed that the virus is related to the monkeypox cases in Nigeria in 2018 and 2019. (6)
- The United States ordered 13 million smallpox vaccines from Bavarian Nordic. (7)
- The United Kingdom Health Security Agency (UKHSA) reported that the majority of cases are prevalent in bisexual and gay communities and urged these communities to be alert. (8)
- On May 20, Belgium became the first country to impose mandatory isolation for people infected with monkeypox for 21 days. The United Kingdom advised people to self-isolate if identified, but it was not mandatory. (9)
- Some countries, such as Canada, Montreal, and Quebec, have started vaccinating people with a high risk of exposure. (10)
- CDC issued a health advisory on May 20, asking clinicians to be vigilant toward the characteristic rash of monkeypox. (11)
- For the prevention of monkeypox, restrictions were placed on the animal trade, and it was advised that animals with potential infection be isolated, and those with contact be quarantined and observed for symptoms of monkeypox for 30 days.
- On June 25, WHO declared that the outbreak was not a global health emergency. (12)
- The CDC updated and expanded its case definition to encourage testing for monkeypox infection to take early steps to protect contacts. It also alerted healthcare providers about the issue of disease courses differing from the past outbreaks in central and western Africa. Also, community cases increased with infection seen among those without international travel. (11)
- Scientific development of a CORE protocol for the universal standardized treatment of monkeypox was planned, and a structure was developed for conducting the study. A randomized, placebo-controlled trial for the drug Tecovirimat was planned. The study population would be outpatients and inpatients; children, pregnant women, and immunosuppressed patients. The time to resolution of lesions was considered the endpoint variable. The study design was conducted under the WHO.(13)
- From January 1st through July 22nd, 2022, 16,016 laboratory-confirmed cases of monkeypox and five deaths have been reported to WHO from 75 countries/territories/areas in all six WHO regions. 319 cases were reported among healthcare workers. 98% of cases with reported sexual orientation were gay or bisexual, and 41% of cases with reported HIV status were HIV positive.(14)
- On the 23rd of July, WHO declared the monkeypox outbreak a Public Health Emergency of International Concern. (14)
- Outside the endemic region, the first death due to monkeypox infection was reported in Brazil, followed by Spain.
- The following vaccines were discussed for the prevention of monkeypox infection: ACAM2000, Jynneos, APSV: Aventis Pasteur smallpox vaccine, IMVANEX, Imvamune, LC16m8, and smallpox vaccine (dried and frozen liquid formulation). However, further study is required for the clinical safety and characterization of the immunity. (13)
- For contacts of cases, post-exposure prophylaxis (PEP) with the vaccine is advised, ideally within four days of the first exposure (and up to 14 days in the absence of symptoms). (14)
- Pre-exposure vaccination is recommended for health workers at high risk of exposure, laboratory personnel working with orthopoxviruses, clinical laboratory personnel performing diagnostic testing for monkeypox, outbreak response team members, and other individuals involved who may be at risk in this outbreak, such as people with multiple sex partners. (14)
- On 28th June, WHO published guidance to provide public health advice for gatherings during the current monkeypox outbreak. (14)
If you suspect that you had close contact with someone diagnosed with monkeypox, you need to monitor yourself for the clinical signs and symptoms of the infection for at least 21 days after your exposure. You need to limit your contact with other people as much as possible. If there is any contact after the exposure, you need to inform them that you have been exposed to monkeypox infection. (15)
While monitoring yourself, if you develop the characteristic symptoms of monkeypox, such as rash, fever, and lymphadenopathy, you need to immediately contact your healthcare provider and ask for support regarding further testing and care. You need to isolate yourself till you get the test reports. Additionally, you need to clean your hands regularly.
If your test comes out to be positive, isolation is required, and your healthcare provider will advise you regarding isolation at the healthcare center or at home. They would also advise you on the care required.
During your isolation, you need to follow certain instructions, such as:
- Using a separate bathroom or cleaning it after use.
- Clean the surfaces you frequently touch with soap and water or disinfectant.
- Do not share towels, utensils, or any other things that you touch as much as possible.
- Do laundry on your own.
- Isolate in a well-ventilated room.
- Encourage other household members to wash their hands frequently.
- Using medical masks when you are in close contact with others. Also, encourage others to use masks. Try to maintain a physical distance of at least 1 meter.
Monkeypox is usually a self-limited disease with symptoms lasting from 2 to 4 weeks. Severe cases are more commonly seen among children. Various factors like the extent of virus exposure, patient health status and nature of complications play a major role in deciding the outcome. (2, 3, 4, 5)
The incubation period (interval from infection to onset of symptoms) of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days. (2, 3, 4, 5)
On the first five days of infection, you are more likely to suffer from (5)
- intense headache
- lymphadenopathy (swelling of the lymph nodes)
- back pain
- myalgia (muscle aches)
- lack of energy.
- skin manifestations in the form of rash can be seen all over the body.
Lymphadenopathy or swollen lymph node is a distinctive feature of monkeypox compared to other diseases that may initially appear similar like chickenpox, measles and smallpox. (3, 5)
The skin eruption usually begins within 1-3 days of the appearance of fever. The rash tends to be more concentrated on the face and extremities rather than on the trunk. In the majority of the cases face is mostly affected followed by the palms and soles. Other areas include oral mucous membranes, genitalia and conjunctivae which is the white portion of your eye. (2, 3, 5)
The rashes can be of varying shapes and sizes and thus can be confused with other diseases with a similar presentation like chickenpox. (5)
Monkeypox has been found to spread from animals to humans. This type of transmission is known as zoonotic transmission. Zoonotic transmission can occur from direct contact with the blood, bodily fluids, and skin lesions of infected animals. (4, 5)
Similarly, eating inadequately cooked meat and other animal products of infected animals is also a possible risk factor. (4, 5)
After a human is infected, he can transmit it to other humans. Human-to-human transmission can happen due to (1, 2, 3, 4, 5)
- close contact with respiratory secretions and droplets of an infected person
- direct contact with the skin lesions of an infected person
- direct contact with recently contaminated objects.
- Transmission can also occur via the placenta from mother to foetus or during close contact during and after birth.
According to WHO, the risk of transmission from physical contact and sexual contact still requires much more study and the study is underway. (5)
Monkeypox is diagnosed both clinically and with the help of lab tests.
Clinically monkeypox can resemble other rash illnesses, such as chickenpox, measles, bacterial skin infections, scabies, syphilis, and medication-associated allergies. Monkeypox, however, presents with lymphadenopathy during the early days of infection. This can help differentiate it from other diseases of similar nature. (3, 5)
The confirmation of monkeypox on the other hand is done by various laboratory tests. The WHO has suggested health workers gather a sample and send it for appropriate testing. (5)
Polymerase Chain reaction or PCR is one such reliable test. PCR testing allows for the identification of the monkeypox virus in the sample. The sample is usually taken from lesions rather than blood as the first one is more accurate. (3, 5)
One thing to consider is false-positive results, particularly in elder people who were vaccinated with the smallpox vaccine and health workers particularly lab personnel who have received some form of vaccination. (3, 5)
According to The WHO, for correct interpretation of results, the sample along with the following patient information must be clearly provided: (5)
- date of onset of fever
- date of onset of rash
- date of specimen collection
- current status of the individual (stage of rash)
- age of the patient
It is therefore best to seek medical attention if you have any suspicious rash.
According to the Centres for Disease Control and Prevention(CDC), as of now, there is no proven, safe treatment for monkey poxvirus infection. (3)
Clinical care for monkeypox is being done symptomatically and can vastly differ from one person to another.
Doctors and health care providers are working to alleviate symptoms, manage complications and prevent long-term sequelae. (3, 5)
The CDC has also approved the use of the smallpox vaccine, vaccinia immunoglobulin and antivirals to treat the monkeypox virus. (3)
An antiviral agent known as tecovirimat that was developed for smallpox was licensed by the European Medical Association (EMA) for monkeypox in 2022 for use within the European Union only. (5, 7)
Monkeypox has claimed the lives of people who had the illness. The case fatality ratio of monkeypox has historically ranged from 0 to 11 % in the general population meaning that among 100 people suffering from monkeypox, a maximum of 11 people can die from it. (5, 8)
As of now, the WHO has not officially published any monkeypox related deaths in relation to the latest 2022 outbreak.
The outcome of the disease can depend on factors such as weak immunity, underlying g diseases and complications arising from monkeypox itself. (2, 3, 5)
Several complications can come along with monkeypox. Some of them are (2,5)
- Secondary infections
- Encephalitis which is an infection of brain tissue
- Infection of the cornea, that can lead to loss of vision.
The transmission of monkeypox can be prevented by following the following methods: (3, 5)
- Avoiding contact with animals that could carry the virus, especially in the endemic regions
- Avoiding contact with any materials, such as bedding, that has been in contact with a sick animal or person
- Isolating infected patients from others who could be at risk for infection.
- Practice good hand hygiene after contact with infected animals or humans. For example, washing your hands with soap and water or using an alcohol-based hand sanitiser.
- Using personal protective equipment (PPE) when caring for patients.
- Avoiding food containing animal parts from the endemic regions
- Introducing stricter regulations on animal trade and handling of wild animals
Vaccination against smallpox has been found to be effective in preventing monkeypox. Thus, previous smallpox vaccination can result in milder illness. (5)
At present, the CDC recommends laboratory personnel dealing with monkeypox and military personnel get vaccinated with a type of smallpox vaccine. (9)
However, the CDC and the Advisory Committee on Immunization Practices (ACIP) are currently evaluating the smallpox vaccines to use for monkeypox prevention. (9)
The recent identification of monkeypox cases in 2022 has been a little bit worrisome. The previous outbreaks of monkeypox had some form of contact with the endemic areas. This latest outbreak on the other hand has no direct links to travel to those areas.
Further investigations are underway to determine the likely source of infection. Active measures and surveillance programs have been called into play and health professionals are being asked to report and investigate suspected cases.
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- Breman, J G et al. "Human monkeypox, 1970-79." Bulletin of the World Health Organization vol. 58,2 (1980): 165-82.
- Moore M, Zahra F. Monkeypox. [Updated 2022 Feb 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574519/
- "About Monkeypox." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 23 Nov. 2021, https://www.cdc.gov/poxvirus/monkeypox/about.html
- "Transmission of Monkey Pox." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 23 Nov. 2021, https://www.cdc.gov/poxvirus/monkeypox/transmission.html
- "Monkeypox." World Health Organization, World Health Organization, https://www.who.int/news-room/fact-sheets/detail/monkeypox
- "Who Working Closely with Countries Responding to Monkeypox." World Health Organization, https://www.who.int/news/item/20-05-2022-who-working-closely-with-countries-responding-to-monkeypox
- EMA. "TECOVIRIMAT SIGA." European Medicines Agency, 1 Feb. 2022, https://www.ema.europa.eu/en/medicines/human/EPAR/tecovirimat-siga
- Sklenovská, Nikola, and Marc Van Ranst. "Emergence of Monkeypox as the Most Important Orthopoxvirus Infection in Humans." Frontiers in public health vol. 6 241. 4 Sep. 2018, doi:10.3389/fpubh.2018.00241
- “Monkeypox and Smallpox Vaccine Guidance.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 23 Nov. 2021, https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html
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