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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 47-52

Global health emergency of monkeypox after COVID-19: A narrative review


Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India

Date of Submission27-Aug-2022
Date of Decision12-Sep-2022
Date of Acceptance08-Oct-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Prachi Jain
Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jssrp.jssrp_11_22

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  Abstract 


Global hit by coronavirus is followed by another public health emergency known as monkeypox (MPX) that is a rare disease and yet has presented with sudden and wide geographic distribution. The guidelines have been released by the concerned authorities for prevention and management; however, strict measures need to be enforced so that these guidelines can be followed. Surveillance, intervention, close monitoring of the situation, and collaborative international efforts as per the guidelines can optimally aid in achieving the goal of curbing the infection spread. This article presents the current situation update of MPX infection globally and discusses the symptoms, management, and preventive measures to be followed for MPX infection.

Keywords: Monkeypox, Orthopoxvirus, zoonosis


How to cite this article:
Jain P, Rathee M, Shetye AG, Divakar S R, Singh S, Tomar SS. Global health emergency of monkeypox after COVID-19: A narrative review. J Surg Spec Rural Pract 2022;3:47-52

How to cite this URL:
Jain P, Rathee M, Shetye AG, Divakar S R, Singh S, Tomar SS. Global health emergency of monkeypox after COVID-19: A narrative review. J Surg Spec Rural Pract [serial online] 2022 [cited 2023 Feb 2];3:47-52. Available from: http://www.jssrp.org/text.asp?2022/3/3/47/364427




  Introduction Top


Severe global hit by COVID-19 infection has so far unstabilized the global economic status. We have still not recovered from the repercussion of this pandemic and the world has been virusified by another zoonotic infection named monkeypox (MPX). Since the first discovery was in colonies of monkeys in 1958, hence the disease was known as "Monkeypox".[1] MPX is known to share the same family as smallpox, i.e., Poxviridae family; however, it is clinically less severe than smallpox.[1],[2],[3] Hence, vaccination against smallpox also confers protection to some extent against other poxviruses indirectly. However, the vaccination against smallpox was ceased in 1980 postcertification of smallpox eradication, and this cleared the way for MPX virus.[4] The Democratic Republic of Congo, earlier known as Equateur province of Zair, is known to report the first case of MPX in a 9-year-old boy in 1970 as confirmed by the World Health Organization (WHO).[3] The rainforests of Central and West Africa have been the major areas to be affected by MPX virus for decades. Hence, the two genetic clades of MPX virus were referred to as Central African Clade and West African Clade.[3]

Recently, unexpected and sudden increase in the cases of MPX particularly in nonendemic countries and in patients with no epidemiological link has been observed. Owing to the increasing number of cases of MPX, the WHO declared MPX as Global Public Health Emergency of International Concern on July 23, 2022.[5] The first country to announce quarantine for 3 weeks for persons infected with MPX was Belgium.

Thorough knowledge about MPX among the primary health-care providers is essential for prevention, control, and treatment of MPX outbreak. Through this article, the authors intend to present the current situation update of MPX infection globally and to discuss the symptoms, management, and preventive measures to be followed for MPX infection as adequate understanding of the disease will aid the health-care providers and family physicians in timely detection and identification of the suspected or confirmed cases and management of patients with MPX.


  Epidemiology Top


Although Africa was the major country affected by MPX virus, sporadic cases outside Africa have been witnessed over the past few decades. As of September 9, 2022, there were 57,527 confirmed cases of MPX in total 103 countries with 57,016 cases in countries (96) with no history of MPX, whereas the remaining 511 cases were reported in countries (7) with a history of MPX.[6] The maximum number of cases has been reported in the United States (US) with 21893 cases, followed by Spain with 6749 cases. The least number of cases with only one person being infected as yet has been reported in Barbados, Bermuda, Curacao, Egypt, El Salvador, Guadeloupe, Hong Kong, Indonesia, Iran, Martinique, New Caledonia, Paraguay, Russia, and Turkey.[6]

The first case that reported in India was a 35-year-old male who had a travel history from Middle East to Kerala on July 15, 2022.[7] Four cases of MPX were reported in WHO South-East Asia Region as of July 24, 2022, among which three were from India and one from Thailand.[8] All three cases were confirmed in Kerala. After the first case, the second case was reported from Kannur district of Kerala on July 18, 2022, where a 31-year-old male was positive with MPX infection.[8] The third case was confirmed on July 22, 2022, where a 35-year-old male with a travel history from UAE to Malappuram district of Kerala tested positive.[8] The fourth case of India was confirmed on July 25, 2022, by the Government of National Capital Territory of Delhi from West District including a 34-year-old male with no travelling history taking the total toll of MPX in India to four. As of July 25, 2022, apart from the confirmed cases, there was one suspected case of a 40-year-old male form Kamareddy district of Telangana with a travel history from Kuwait.

Unlike before, the unusual feature of the outbreak this time is the human-to-human transmission, particularly in males with a history of intimate physical contact with another male. As of July 21, 2022, majority of the confirmed cases were reported in males (99%), among which 79% of males belong to 25–45 years of age.[9] The detailed epidemiology of MPX infection[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] is summarized in [Table 1].
Table 1: Epidemiology of monkeypox virus

Click here to view



  Causative Agent Top


The MPX virus is a double-stranded DNA virus.[23] The natural reservoir of this virus is unknown. However, African rodents and nonhuman primates such as monkeys may harbor the virus and infect people. The difference between two clades of MPX[23] is demonstrated in [Table 2]. The virus has an incubation period ranging between 7 and 14 days with 21 days as upper limit.[24]
Table 2: Difference between two monkeypox clades

Click here to view



  Evaluation Top


Thorough history of the patient including recent travel history to affected countries and contact with the infected individuals must be taken into consideration. The virus has a high transmission rate and thus any contact with the infected person via respiratory droplets and/or cutaneous means including contact with body fluids, infectious rash, and intimate physical contact can trigger the spread of the virus.[25] It can be transmitted indirectly via contaminated clothing of an infected person. A secondary attack rate of 9.3% has been estimated in individuals who have not received vaccination for smallpox. Animal-to-human transmission has also been witnessed via scratching or biting by the infected animals or by eating products from infected animals.[25],[26] During the 2003 outbreak of MPX in US, case definition criteria were established by the Centers for Disease Control and Prevention (CDC). However, the specificity of these criteria decreases with the increasing exposure of the population as well as increasing prevalence of similar illness. Laboratory investigations including isolation via viral culture or PCR have been recommended. The Ministry of Health and Family Welfare, India (MOHFW), has categorized the cases of MPX into suspected case, probable case, and confirmed case.[25] The characteristics of all three are described in [Table 3].
Table 3: Difference between suspected, probable, and confirmed cases of monkeypox as categorized by the Ministry of Health and Family Welfare[25]

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The three phases of MPX infection include incubation phase, prodromal phase, and eruptive phase. The first symptom is usually fever that occurs in the prodromal stages (0–5 days). It is often accompanied by other symptoms including chills, excessive sweating, throbbing headache, backache, aching muscles, profound weakness, pharyngitis, sore throat, dyspnea, and cough (with or without sputum).[25],[26] Fever is followed by lymphadenopathy that can be unilateral or bilateral and that appears within 2–3 days. The commonly involved lymph nodes include periauricular, axillary, cervical, or inguinal lymph nodes.[25]

In the eruptive stage, majority of infected people develop a rash within 1–10 days after the onset of fever. The rash has a centrifugal distribution with face as the first area for the appearance of this rash followed by rest of the body areas. The distribution of rashes according to the body parts as given by MOHFW[25] is mentioned in [Table 4]. The rash clinically presents as painful, well-circumscribed, deep-seated rash with umbilication. It persists for 2–4 weeks after which the pain subsides and the lesion becomes itchy.[25]
Table 4: Distribution of rashes on the body parts in Monkeypox infection as per the Ministry of Health and Family Welfare

Click here to view


In some cases, the infected person may also present with atypical signs and symptoms including lesion in only genital, perineal, or perianal area with no other area involved. There can be anal pain and bleeding with complete absence of any lesion. The lesion may appear before fever and there may be presence of a single or few lesions.

The symptoms of MPX are although similar to smallpox, however, the most reliable clinical sign differentiating MPX from smallpox and chickenpox is enlarged lymph nodes, especially the submental, submandibular, cervical, and inguinal nodes.[27]

To increase the awareness among the masses about MPX, MOHFW, India, has posted about the common symptoms of MPX, complications after MPX infection, high-risk population affected by MPX and transmission mode of the virus on social media platform including Twitter.[28] The posts are presented in [Figure 1], [Figure 2], [Figure 3], [Figure 4].[28]
Figure 1: Common symptoms of monkeypox

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Figure 2: Complications of monkeypox

Click here to view
Figure 3: High risk population for monkeypox

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Figure 4: Transmission route of monkeypox

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  Treatment Top


The specific medication or vaccination for MPX infection has not been developed as yet. Until now, symptomatic treatment to relieve the symptoms has been provided to the patients. The infection is self-limited and resolves within 2–4 weeks in majority of cases. In addition, preventive measures must be taken to prevent the spread. As it has high human-to-human transmission rate, the patient must follow all the protocols for self-isolation until cured.[25] If exposed to the virus accidently, regular monitoring for 21 days is essential to assess the temperature and symptoms.[25]

Ankara vaccine, a modified vaccine obtained from live non-replicating virus has been recommended post-exposure of MPX virus. Two shots of the vaccine are given at the interval of 4 weeks. This vaccine has the advantage of not posing a risk of local or disseminated spread. Although a live vaccine, it can be administered even in patients with compromised immunity as it has been documented to stimulate antibody production in these patients as well. Another vaccine named Jynnoos on similar grounds as Ankara vaccine was approved by US Food and Drug Administration in September 2019.[29]

Recently, the European Medicines Agency has approved an antiviral drug named tecovirimat for Orthopoxvirus-associated infections, including MPX.[30] However, reliable data on its safety and efficacy are yet to be explored. The symptomatic treatment includes rehydration therapy via oral fluids or even intravenous fluids in severe dehydration. Nutrition support is provided by ensuring adequate nutritious diet by the patient. Antihistaminics can be provided to relieve itching, antiemetics for nausea, and paracetamol for headache and malaise.

The prognosis varies with the status of the infected person in terms of age, nutritional status, and systemic condition. Preventive measures to prevent the spread of the virus are highly essential and thus any contact with the infected person's body fluids, respiratory droplets, and broken skin must be avoided. The CDC has laid down protocols regarding vaccination against MPX infection as follows:

  • Within 4 days of exposure: Onset of disease can be prevented
  • Within 14 days: The severity of disease can be reduced.



  Discussion Top


The worldwide hit by COVID-19 appears to be ending for majority of locations. However, another viral zoonosis referred as "monkeypox" has emerged. As rightly said

"Precaution and Preparation through Education is less costly than learning through tragedy"

The outbreak can be controlled by enhanced awareness and attention. The aim is to stop the spread of the virus as much as possible. Although declared a global public health emergency, the virus spread is still in its first phase. Isolation of cases for the prevention of further transmission is must along with identification of the probable contacts with the infected persons to manage these suspected cases timely.[3],[25] If suspected, further investigation to rule out infection must be carried out. Furthermore, protection of the health-care workers in line with the strategies followed during COVID time is must. The standard infection control protocols must be reinforced and followed.

The personal protective equipment, hand hygiene, and biomedical waste management guidelines must be followed. If the exposed person is asymptomatic but has a travel history from affected countries, observation for 21 days for the development of symptoms must be done.[31] Furthermore, family-based education need to be given related to hygiene and isolation of patients.

The WHO has already been working to raise awareness among the people and in establishing guidelines for investigation, clinical management, and prevention and control of infection. Strengthening of the surveillance by state and local authorities for contact tracing of susceptible and probable cases is critical at this stage to curtail further spread. Until now, the surveillance in nonendemic regions was limited; however, efforts are being made to expand it now. The MOHFW, India, has released comprehensive guidelines for the management of MPX disease that include the measures to be taken to prepare the public and management of suspected and confirmed cases.[25] The guidelines have been circulated to all District Surveillance Units and hospitals on June 1, 2022, and July 15, 2022.[25] In addition, since the health-care workers are at high risk, safety practices must be implemented.


  Prevention of Monkeypox in Health-care Setting Top


Health-care personnel if exposed in the health-care setting must be monitored regularly and postexposure management must be initiated. Patients admitted in the hospital must be isolated completely and visits to these patients must be limited to include only those necessary for patient's well-being.[32] To minimize the risk of transmission, visitors at high risk must not be allowed to visit the infected patients. Discontinuation of isolation of infected patients must be done only after all lesions have crusted. Thorough cleaning with only EPA-registered hospital-grade disinfectants must be used for disinfection procedure of the hospital setup.[32] All the wastes from the infected person must be segregated based on whether they have epidemiological link or not. If epidemiological link is present, the waste must be categorized as Category A infectious substance and in absence of epidemiological link, patient's waste can be categorized as Regulated Medical Waste.[32]


  Conclusion Top


The current pattern of emergence of MPX reflects a new transmission pattern, which needs to be evaluated and preventive steps to stop the spread and preparation in advance in case of worsening of the situation must be done. As we are still in the preliminary stages of the viral spread, guidelines must be established worldwide and followed with implementation of strict regulations by the authorities to curtail the spread as early as possible. Health emergency preparedness is a team sport and the mistakes done during the early days of COVID-19 infection must not be repeated and public health attention in this regard is must.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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