Six individuals who tested positive for monkeypox – two in New York City, two in Chicago, and one in Nevada and one in Maryland – have kicked the bucket, health departments have affirmed.
The New York City Department of Health and Mental Hygiene said it was “profoundly disheartened by the two announced passing, and our hearts go out to the people’s friends and family and community.”
Monkeypox
Key facts
1. Monkeypox is caused by monkeypox virus, a member of the Orthopoxvirus genus in the family Poxviridae.
2. Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. Severe cases can occur. In recent times, the case fatality ratio has been around 3–6%.
3. Monkeypox is transmitted to humans through close contact with an infected person or animal, or with material contaminated with the virus.
4. Monkeypox virus is transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding.
5. Monkeypox is a viral zoonotic disease that occurs primarily in tropical rainforest areas of central and west Africa and is occasionally exported to other regions.
6. Monkeypox typically presents clinically with fever, rash and swollen lymph nodes and may lead to a range of medical complications.
Introduction
- Monkeypox is a viral zoonosis (a virus transmitted to humans from animals) with symptoms similar to those seen in the past in smallpox patients, although it is clinically less severe.
- With the eradication of smallpox in 1980 and subsequent cessation of smallpox vaccination, monkeypox has emerged as the most important orthopoxvirus for public health.
- Monkeypox primarily occurs in central and west Africa, often in proximity to tropical rainforests.
The pathogen
- Monkeypox virus is an enveloped double-stranded DNA virus that belongs to the Orthopoxvirus genus of the Poxviridae family.
- There are two distinct genetic clades of the monkeypox virus: the central African (Congo Basin) clade and the west African clade.
Natural host of virus
- Various animal species have been identified as susceptible to monkeypox virus. This includes rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates and other species.
Outbreaks
- Human monkeypox was first distinguished in quite a while in 1970 in the Democratic Republic of the Congo in a 9-month-old boy in a district where smallpox had been wiped out in 1968.
- From that point forward, most cases have been accounted for from rustic, rainforest locales of the Congo Bowl, especially in the Majority rule Republic of the Congo and human cases have progressively been accounted for from across focal and west Africa.
- Since 1970, human cases of monkeypox have been reported in 11 African countries: Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Cote d’Ivoire, Liberia, Nigeria, the Republic of the Congo, Sierra Leone and South Sudan.
- Since 2017, Nigeria has experienced a large outbreak, with over 500 suspected cases and over 200 confirmed cases and a case fatality ratio of approximately 3%. Cases continue to be reported until today.
- Monkeypox is a disease of global public health importance as it not only affects countries in west and central Africa, but the rest of the world.
- In 2003, the first monkeypox outbreak outside of Africa was in the United States of America and was linked to contact with infected pet prairie dogs.
- Monkeypox has also been reported in travelers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, to Singapore in May 2019, and to the United States of America in July and November 2021.
Transmission
- Animal-to-human (zoonotic) transmission can occur from direct contact with the blood, bodily fluids, or cutaneous or mucosal lesions of infected animals.
- The natural reservoir of monkeypox has not yet been identified, though evidence of monkeypox virus infection has been found in many animals including rope squirrels, tree squirrels, Gambian pouched rats, dormice, different species of monkeys and others in Africa.
- Eating inadequately cooked meat and other animal products of infected animals is a possible risk factor.
- Human-to-human transmission can result from close contact with respiratory secretions, skin lesions of an infected person or recently contaminated objects.
- Transmission via droplet respiratory particles usually requires prolonged face-to-face contact, which puts health workers, household members and other close contacts of active cases at greater risk.
- Transmission can also occur via the placenta from mother to fetus (which can lead to congenital monkeypox) or during close contact during and after birth.
- While close physical contact is a well-known risk factor for transmission, it is unclear at this time if monkeypox can be transmitted specifically through sexual transmission routes. Studies are needed to better understand this risk.
Signs and symptoms
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. Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks
The infection can be divided into two periods:
- The invasion period (lasts between 0–5 days) characterized by fever, intense headache, lymphadenopathy (swelling of the lymph nodes), back pain, myalgia (muscle aches) and intense asthenia (lack of energy)
- The skin eruption usually begins within 1–3 days of appearance of fever. The rash tends to be more concentrated on the face and extremities rather than on the trunk. It affects the face (in 95% of cases), and palms of the hands and soles of the feet (in 75% of cases). Also affected are oral mucous membranes (in 70% of cases), genitalia (30%), and conjunctivae (20%), as well as the cornea.
Diagnosis
- The clinical differential diagnosis that must be considered includes other rash illnesses, such as chickenpox, measles, bacterial skin infections, scabies, syphilis, and medication-associated allergies. Lymphadenopathy during the prodromal stage of illness can be a clinical feature to distinguish monkeypox from chickenpox or smallpox.
- Polymerase chain reaction (PCR) is the preferred laboratory test given its accuracy and sensitivity. For this, optimal diagnostic samples for monkeypox are from skin lesions – the roof or fluid from vesicles and pustules, and dry crusts. Where feasible, biopsy is an option.
Therapeutics of monkeypox
- Clinical care for monkeypox should be fully optimized to alleviate symptoms, manage complications and prevent long-term sequelae. Patients should be offered fluids and food to maintain adequate nutritional status.
Vaccination
- Vaccination against smallpox was demonstrated through several observational studies to be about 85% effective in preventing monkeypox. Thus, prior smallpox vaccination may result in milder illness.
Prevention
- Raising awareness of risk factors and educating people about the measures they can take to reduce exposure to the virus is the main prevention strategy for monkeypox.
Reducing the risk of human-to-human transmission
- Surveillance and rapid identification of new cases is critical for outbreak containment. During human monkeypox outbreaks, close contact with infected persons is the most significant risk factor for monkeypox virus infection.
Reducing the risk of zoonotic transmission
- Over time, most human infections have resulted from a primary, animal-to-human transmission. Unprotected contact with wild animals, especially those that are sick or dead, including their meat, blood and other parts must be avoided.
Preventing through restrictions on animal trade
- Some countries have put in place regulations restricting importation of rodents and non-human primates. Captive animals that are potentially infected with monkeypox should be isolated from other animals and placed into immediate quarantine.
Frequently asked question
1. What is Lymphadenopathy?
- Lymphadenopathy is a distinctive feature of monkeypox compared to other diseases that may initially appear similar (chickenpox, measles, smallpox)
2. How monkeypox relates to smallpox?
- The clinical presentation of monkeypox resembles that of smallpox, a related orthopoxvirus infection which has been eradicated. Smallpox was more easily transmitted and more often fatal as about 30% of patients died. It has been 40 or more years since all countries ceased routine smallpox vaccination with vaccinia-based vaccines
3. What is Natural host of monkeypox virus?
- Various animal species have been identified as susceptible to monkeypox virus. This includes rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates and other species. Uncertainty remains on the natural history of monkeypox virus and further studies are needed to identify the exact reservoir(s) and how virus circulation is maintained in nature.
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