We need to prepare for monkeypox – now confirmed in 21 countries


Traditionally, monkeypox infection was rare in the United States (US). However, recent reports indicate an unusual outbreak of monkeypox in a number of countries. Efforts must be made to limit the spread of this virus in order to prevent another pandemic. A proactive approach to medical management will not only help stop the outbreak but also help determine its spread.

Opinion article: A new global outbreak of monkeypox. Image Credit: cometa geo / Shutterstock

The monkeypox virus is a member of the same family of viruses as smallpox. It is a double-stranded DNA virus that was first discovered in monkeys during the 1950s. This virus infects a wide range of hosts, including rodents. The smallpox eradication campaign exposed the human outbreak. The Congo Basin clade is more virulent compared to the West African clade, a milder species. The latter has been implicated in most monkeypox outbreaks.

The outbreak currently includes Australia, Austria, Belgium, Canada, the Czech Republic, Denmark, England, Finland, France, Germany, Israel, Italy, the Netherlands, Portugal, Scotland, Slovenia, Spain, Sweden, Switzerland, the United Arab Emirates and the United States, which have reported any confirmed cases of monkeypox. This virus is spreading in a pattern unlike previous outbreaks outside Africa.

Outbreaks of monkeypox have been identified in 11 African countries during the past few years; The majority occurred in the Democratic Republic of the Congo. This increase in the number of cases is attributed to the erosion of the population’s immunity to smallpox. Children formed a large group among the asymptomatic individuals in Africa with monkeypox.

Monkeypox virus was first discovered on other continents only after 2003. This viral spread can occur through direct contact, respiratory droplets, or venting. The incubation period is 5-21 days, after which symptoms begin along with the risk of transmission. Evidence of human-to-human transmission is scarce; Hence reports of small, isolated outbreaks in the past in humans.

Air transmission, however, has been predicted by the Centers for Disease Control and Prevention (CDC) — which has also recommended airborne infection control measures. Infection control protocols emphasize the use of N95 masks and personal protective equipment for healthcare professionals and the general population when visiting public places.

Complications associated with monkeypox are – central nervous system (CNS) involvement and airway dysfunction due to lymphadenitis. The mortality rate can be between 1-10%, which is lower in areas with advanced medical care facilities.

Significant outbreak of monkeypox

The most notable outbreak of the disease was that in the United States in 2003, which extended from the import of African rats to prairie dogs and then to humans. Of the fourteen documented cases, three became seriously ill while there were no deaths. There is a possible relationship between all human cases and infected animals. In response, preventive applications of the smallpox vaccine have been recommended.

The past two decades have seen a significant influx of monkeypox through international travelers exposed to the virus in endemic countries. The United States recorded two travel-related cases in 2021, but without secondary spread.

Diagnosis of monkeypox

During the current outbreak, any episode of fever and new rash should be suspected as monkeypox, especially in patients with lymphadenopathy.

Usually the rash appears in the mouth first, and then spreads to the face and extremities – with a centrifugal distribution. A polymerase chain reaction (PCR) test of skin lesions or fluids is confirmation of this infection.

Monkey pox treatment

The standard of care for monkeypox has not yet been established. Smallpox antivirals, for example – cidofovir, brincidofovir, and teicofirim, can be an effective method. Brincidofovir and tecovirimat are FDA-approved drugs for smallpox. These agents should be reserved for the management of severe monkeypox cases and for the treatment of immunocompromised individuals.

Prevent monkeypox

Smallpox vaccines have shown effectiveness In the prevention of monkeypox and as a post-exposure precaution. Therefore, the US Food and Drug Administration (FDA) suggested that the new generation smallpox vaccine – JYNNEOS (Northern Bavarian), can be used to prevent monkeypox. Besides, using the ACAM2000 vaccine – the older generation of smallpox vaccine – is also an option.

Experience from previous outbreaks indicates that vaccination of close contacts of an infected person can help reduce the transmission of monkeypox. In addition, preventive vaccines given immediately after a potential exposure can significantly weaken and even abort it. Vaccine vaccine immunoglobulin may be used as an alternative post-exposure precaution in individuals who have contraindications to the smallpox vaccine.

current outbreak

Dozens of monkeypox cases have been reported in Europe, the United Kingdom and North America – all outside endemic areas. During the current outbreak, most of these countries have documented person-to-person transmission in unrelated groups that cannot be traced back to endemic country travels. Thus, undiscovered transmission chains are now visible.

In addition, a significant proportion of cases have been identified in homosexual males. This virus, however, is not only sexually transmitted; It can also infect other humans after skin-to-skin contact or when exposed to respiratory droplets from an infected person.

Detecting the epidemiology of monkeypox that led to the current outbreak remains a challenge and may have global significance in explaining the emergence of new pathogens. A deeper understanding of the cause of this outbreak, which has spread geographically further than previous monkeypox outbreaks in humans, is urgently needed. Results like this may prevent similar microbial outbreaks in the future.

Genetic analyzes do not identify viral mutations as a cause of increased transmissibility. Many random speculations have been made in this regard, for example – it has spread through human gatherings and social networks. Case investigations and case-control studies can help understand the emergence of the broader monkeypox virus in the current scenario.

Meanwhile, viral containment protocols should be implemented, which may include – case detection, isolation, contact tracing, preventive measures and vaccination in contacts, and vaccination after exposure. Healthcare professionals, especially those who work in primary care, are most exposed to monkeypox and have the greatest chances of identifying new cases.

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