Monkeypox disease 2024

Introduction

Monkeypox is a zoonotic viral disease that first gained attention in the 1950s when it was discovered in laboratory monkeys, hence the name. The disease is caused by the monkeypox virus, which belongs to the Orthopoxvirus genus, the same genus as the virus that causes smallpox. Monkeypox is primarily found in Central and West Africa, particularly in regions close to tropical rainforests, where humans come into contact with infected animals.

Initially, monkeypox was considered a rare and geographically confined illness, mostly affecting individuals who had direct contact with wild animals, such as rodents or primates. However, over time, human-to-human transmission has been documented, leading to occasional outbreaks. The disease presents with symptoms similar to those of smallpox, including fever, headache, muscle aches, and a distinctive rash that evolves into pustules and scabs.

Despite being less severe than smallpox, monkeypox can still cause significant illness and, in some cases, death. The disease has gained increased attention due to recent outbreaks outside of Africa, raising concerns about its potential to spread more widely. While no specific treatment for monkeypox exists, vaccination against smallpox has been found to offer some protection. Public health measures focus on containment, surveillance, and prevention, especially in regions where the virus is endemic or has been introduced.

Key facts.

Here are some key facts about monkeypox:

1. Cause:

Monkeypox is caused by the monkeypox virus, which belongs to the Orthopoxvirus genus, the same group of viruses that includes smallpox and cowpox.

2. First Identified:

The disease was first identified in 1958 in laboratory monkeys, but the first human case was recorded in 1970 in the Democratic Republic of the Congo.

3. Geographical Distribution:

Monkeypox is primarily found in Central and West Africa, particularly in rural and remote areas near tropical rainforests. However, outbreaks have also been reported in other parts of the world, including North America, Europe, and Asia.

4. Transmission:

Animal to Human: The virus can spread to humans from animals through direct contact with the blood, bodily fluids, or skin/mucosal lesions of infected animals. Rodents are considered the most likely natural reservoir of the virus.
Human to Human: Transmission occurs through respiratory droplets during close, prolonged face-to-face contact, direct contact with body fluids or lesion material, and indirect contact through contaminated objects like bedding.

5. Symptoms:

Symptoms include fever, headache, muscle aches, back pain, swollen lymph nodes, chills, exhaustion, and a characteristic rash that goes through several stages (macules, papules, vesicles, pustules, scabs).
The incubation period is typically 6 to 13 days, but it can range from 5 to 21 days.

6. Severity:

While monkeypox is less severe than smallpox, it can still cause serious illness. The case fatality rate varies between 1% and 10%, depending on the strain and the health of the infected person.

7. Prevention:

Vaccination: The smallpox vaccine is about 85% effective in preventing monkeypox.
Avoiding Contact: Reducing contact with potentially infected animals and practicing good hygiene are key preventive measures.
Isolation: Infected individuals should be isolated to prevent the spread of the virus.

8. Treatment:

There is no specific treatment for monkeypox, but supportive care and treatment of symptoms can help. Antivirals developed for smallpox may also be used.

9. Recent Outbreaks:

There have been recent outbreaks in non-endemic countries, raising global awareness and concern about the disease’s potential to spread beyond traditional endemic regions.

10. Public Health Response:

Rapid identification, isolation of cases, contact tracing, and vaccination campaigns are crucial in controlling outbreaks and preventing the spread of monkeypox.

Transmission

Monkeypox is transmitted through both animal-to-human and human-to-human contact. Understanding the modes of transmission is crucial for preventing and controlling the spread of the virus.

1. Animal-to-Human Transmission

Direct Contact: The virus can be transmitted to humans through direct contact with the blood, bodily fluids, or skin/mucosal lesions of infected animals. This includes handling animals, consuming undercooked meat, or coming into contact with the animal’s environment.
Animal Reservoirs: While the exact animal reservoir of the monkeypox virus is unknown, evidence suggests that certain rodents, such as squirrels and Gambian pouched rats, as well as non-human primates, may be carriers.
Hunting and Consumption: In regions where monkeypox is endemic, hunting, handling, and consumption of bushmeat (wild animals) are common ways through which humans come into contact with the virus.

2. Human-to-Human Transmission

Respiratory Droplets: Human-to-human transmission occurs primarily through large respiratory droplets. These droplets typically do not travel more than a few feet, so prolonged face-to-face contact is usually required for transmission.
Direct Contact: Transmission can occur through direct contact with the body fluids, lesions, or scabs of an infected person. This includes touching the skin lesions, handling contaminated materials, or coming into contact with mucosal surfaces (e.g., eyes, mouth).
Contaminated Objects: The virus can also spread through indirect contact with contaminated objects, such as clothing, bedding, or towels used by an infected person.
Sexual Contact: Though not traditionally classified as a sexually transmitted infection (STI), the close physical contact involved in sexual activities can facilitate transmission, particularly through skin-to-skin contact with lesions.

3. Vertical Transmission

Mother to Fetus: In rare cases, the virus can be transmitted from a pregnant woman to her fetus through the placenta, which is known as congenital monkeypox. Newborns can also be infected during or after birth through close contact.

4. Risk Factors for Transmission

Close Contact: Individuals who live with or care for someone infected with monkeypox are at higher risk due to the close contact involved.
Healthcare Workers: Without proper protective equipment, healthcare workers treating monkeypox patients are at risk of contracting the virus.
Travel: Travel to regions where monkeypox is endemic increases the risk of exposure to the virus.

5. Prevention of Transmission

Isolation: Infected individuals should be isolated to prevent the spread of the virus to others.
Protective Measures: Use of personal protective equipment (PPE) by healthcare workers and those caring for infected persons is essential.
Hygiene: Frequent hand washing and disinfection of surfaces can help reduce the risk of transmission.
Vaccination: Vaccination with the smallpox vaccine has been shown to provide some protection against monkeypox, and it is recommended for those at high risk of exposure.

Understanding these transmission pathways is vital for controlling outbreaks and protecting both individuals and communities from the spread of monkeypox.

Signs and Symptoms of disease.

Monkeypox symptoms typically appear within 5 to 21 days after exposure to the virus. The illness can be divided into two phases:

1. Invasion Phase (0-5 days)

Fever: Usually the first symptom, often high and sudden.
Headache: Intense and persistent.
Muscle Aches (Myalgia): Commonly felt throughout the body.
Back Pain: Lower back pain is particularly common.
Swollen Lymph Nodes (Lymphadenopathy): A distinguishing feature from smallpox, which usually does not cause lymph node swelling.
Chills: Often accompanying the fever.
Exhaustion: Severe fatigue and lack of energy.

2. Eruptive Phase (1-3 days after the fever)

Rash: Begins typically on the face and spreads to other parts of the body, including the palms of the hands, soles of the feet, and mucous membranes (mouth, genitals, etc.). The rash goes through several stages:
1. Macules: Flat, discolored spots on the skin.
2. Papules: Raised, solid bumps.
3. Vesicles: Fluid-filled blisters.
4. Pustules: Pus-filled lesions.
5. Scabs: The lesions eventually crust over and fall off.

Other Symptoms

Sore Throat, Cough: Respiratory symptoms can occur if the mucous membranes of the throat or lungs are involved.
Conjunctivitis: If the eyes are affected, leading to redness and irritation.
Pain: Lesions can be painful, particularly if they occur in sensitive areas.

The disease typically lasts 2 to 4 weeks. While most individuals recover fully, some may experience complications, especially if they are immunocompromised or have underlying health conditions.

Diagnosis of this disease

Diagnosing monkeypox involves a combination of clinical evaluation, patient history, and laboratory testing. Given that monkeypox shares symptoms with other diseases, particularly smallpox, accurate diagnosis is essential to distinguish it from other illnesses.

1. Clinical Evaluation

Symptom Assessment: The diagnosis begins with evaluating the patient’s symptoms. Key symptoms include fever, headache, muscle aches, back pain, swollen lymph nodes, and a characteristic rash that progresses from macules to papules, vesicles, pustules, and scabs.
Lymphadenopathy: Swollen lymph nodes are a distinguishing feature that helps differentiate monkeypox from smallpox.

2. Patient History

Exposure History: A detailed history of potential exposure is critical. This includes recent travel to areas where monkeypox is endemic, contact with animals (especially wild or exotic animals), and any known contact with individuals who have been diagnosed with or are suspected of having monkeypox.
Outbreak Context: In the context of an outbreak, the likelihood of monkeypox increases if the patient has been in contact with confirmed cases or areas of known transmission.

3. Laboratory Testing

Specimen Collection: Samples are typically collected from skin lesions, such as vesicles, pustules, or scabs. Throat swabs, blood, or other bodily fluids may also be tested.
Polymerase Chain Reaction (PCR): PCR is the preferred laboratory test for diagnosing monkeypox because it is highly sensitive and specific. It can detect the presence of the monkeypox virus DNA in samples taken from lesions or other body fluids.
Electron Microscopy: This method can be used to visualize the virus particles in lesion samples. It helps in identifying the Orthopoxvirus genus but is less commonly used due to the availability of more specific tests.
Serology: Blood tests can be used to detect antibodies against the monkeypox virus. However, because of cross-reactivity with other Orthopoxviruses (like smallpox), serology is not always conclusive.
Virus Isolation: The virus can be isolated from clinical specimens through cell culture. This method, while definitive, is time-consuming and requires specialized laboratory facilities.

4. Differential Diagnosis

Smallpox: Although eradicated, smallpox has symptoms similar to monkeypox. Differentiation is crucial and is primarily done through laboratory testing.
Chickenpox (Varicella): The rash of chickenpox might be confused with monkeypox, but chickenpox lesions are usually more superficial and are all at different stages of development.
Measles, Bacterial Skin Infections, Scabies, Syphilis, and Allergic Reactions: These conditions can also cause rashes or lesions that may be mistaken for monkeypox. The presence of systemic symptoms like fever and lymphadenopathy, along with the specific progression of the monkeypox rash, helps distinguish it from these conditions.

5. Advanced Diagnostic Techniques

Next-Generation Sequencing (NGS): In research and specialized labs, NGS can be used to sequence the virus’s genome, providing detailed information about the virus strain and aiding in epidemiological studies.

6. Public Health Considerations

Reporting: Monkeypox is a notifiable disease in many countries. Confirmed cases should be reported to public health authorities to help with outbreak control and contact tracing.
Contact Tracing: Identifying and monitoring contacts of confirmed cases is crucial to prevent further spread.

Accurate diagnosis of monkeypox is essential for patient management, outbreak control, and the prevention of transmission to others.

Prevention methods?

Preventing the spread of monkeypox involves a combination of strategies, including personal protective measures, vaccination, and public health interventions. Here are key prevention methods:

1. Vaccination

Smallpox Vaccine: The smallpox vaccine provides about 85% protection against monkeypox due to the similarity between the two viruses. Vaccination is recommended for those at high risk, such as healthcare workers, laboratory personnel, and individuals who have been exposed to monkeypox.
Post-Exposure Vaccination: Vaccination within four days of exposure to the monkeypox virus can prevent the onset of the disease. If given between four and 14 days after exposure, it may reduce the severity of symptoms.

2. Avoiding Contact with Infected Animals

Wild Animals: Avoid contact with wild animals, especially rodents, primates, and other animals that may carry the virus. This is particularly important in regions where monkeypox is endemic.
Sick or Dead Animals: Avoid handling sick or dead animals. If contact is necessary, use protective gloves and other protective equipment.
Bushmeat: Refrain from hunting, handling, or consuming bushmeat (wild game) from areas where monkeypox is known to occur.

3. Personal Protective Measures

Hand Hygiene: Regular handwashing with soap and water is essential, especially after contact with potentially infected animals or humans. If soap and water are not available, alcohol-based hand sanitizers can be used.
Protective Clothing: Wear protective clothing, such as gloves, masks, and gowns, when caring for someone with monkeypox or handling animals that could be infected.
Avoid Close Contact: Limit close physical contact with individuals who have monkeypox. This includes avoiding skin-to-skin contact with rashes or lesions.

4. Infection Control in Healthcare Settings

Isolation of Patients: Infected individuals should be isolated in a separate room to prevent the spread of the virus to others. Healthcare workers should use standard precautions, including the use of personal protective equipment (PPE).
Disinfection: Surfaces, bedding, and clothing used by infected individuals should be properly disinfected using standard disinfectants to prevent environmental contamination.
Waste Management: Proper disposal of medical waste and materials contaminated with the virus is critical to prevent further spread.

5. Public Health Measures

Surveillance and Contact Tracing: Monitoring and tracking cases, along with identifying and isolating contacts of infected individuals, are vital for controlling outbreaks.
Public Awareness and Education: Educating the public about monkeypox, its transmission, and prevention strategies can reduce the risk of spread. This includes disseminating information through media, community outreach, and health education programs.
Travel Precautions: Travelers to areas where monkeypox is endemic should take precautions, including avoiding contact with wild animals and practicing good hygiene.

6. Avoiding Contaminated Materials

Contaminated Objects: Avoid sharing bedding, towels, clothing, and other items with someone who is infected. Ensure that any items that have come into contact with an infected person are washed and disinfected properly.
Healthcare and Laboratory Safety: Healthcare workers and laboratory personnel should adhere to biosafety protocols when handling specimens or caring for patients with monkeypox.

7. Food Safety

Cook Meat Thoroughly: Ensure that all meat, particularly wild game, is cooked thoroughly before consumption. Proper cooking kills the virus and reduces the risk of transmission.

8. Community Measures During Outbreaks

Quarantine: In the event of an outbreak, quarantine measures may be necessary for those exposed to the virus to prevent further spread.
Vaccination Campaigns: During outbreaks, targeted vaccination campaigns may be implemented to control the spread of the virus.

By following these prevention strategies, the spread of monkeypox can be significantly reduced, protecting both individuals and communities.

Treatment options?

Treatment for monkeypox primarily focuses on relieving symptoms, managing complications, and preventing long-term effects. Although there is no specific antiviral treatment specifically approved for monkeypox, certain medications developed for related viruses, as well as supportive care, can be effective. Here are the main treatment options:

1. Supportive Care

Symptom Management: This includes treating fever, pain, and discomfort with antipyretics (fever reducers) like acetaminophen or ibuprofen, and using oral rehydration solutions to prevent dehydration.
Skin Care: Keeping the skin lesions clean and dry helps to prevent secondary bacterial infections. In some cases, topical antiseptics or antibiotics may be applied to prevent infection.
Fluid Replacement: Patients with severe monkeypox may become dehydrated, so fluid replacement through oral or intravenous (IV) hydration is often necessary.
Nutritional Support: Ensuring adequate nutrition is important, especially for patients who are unable to eat due to oral or throat lesions.

2. Antiviral Treatments

Tecovirimat (TPOXX): Tecovirimat is an antiviral medication that has been approved by the FDA for the treatment of smallpox and is also effective against monkeypox. It works by inhibiting the virus’s ability to spread within the body. Tecovirimat is considered the primary antiviral treatment for severe cases of monkeypox.
Cidofovir (Vistide): Originally developed for cytomegalovirus (CMV) infections, cidofovir has been used experimentally to treat monkeypox. It works by inhibiting viral DNA replication. Due to its potential nephrotoxicity, it is generally reserved for severe cases or when other treatments are not available.
Brincidofovir (Tembexa): A derivative of cidofovir, brincidofovir is another antiviral that has been used in the treatment of monkeypox. It has a similar mechanism of action but with potentially fewer side effects.
Vaccinia Immune Globulin (VIG): VIG can be used in cases where complications arise from the smallpox vaccination, or when treating severe monkeypox cases, especially in immunocompromised individuals.

3. Management of Complications

Bacterial Infections: Secondary bacterial infections of the skin lesions can occur and may require treatment with antibiotics.
Respiratory Support: For patients with severe respiratory symptoms, such as those who develop pneumonia, respiratory support including supplemental oxygen or mechanical ventilation may be necessary.
Eye Care: If the eyes are affected, careful management is necessary to prevent complications like corneal scarring. This may include the use of antiviral eye drops or other supportive measures.

4. Isolation and Infection Control

Isolation: Infected individuals should be isolated to prevent the spread of the virus to others. This also helps in managing the patient’s condition in a controlled environment.
Infection Control: Proper hygiene and disinfection practices are crucial to prevent the spread of the virus, especially in healthcare settings.

5. Monitoring and Follow-up

Ongoing Monitoring: Patients with monkeypox should be monitored for the development of complications, particularly if they have underlying health conditions or are immunocompromised.
Follow-up Care: After recovery, follow-up care may be necessary to monitor for any long-term effects, such as scarring or other complications.

6. Experimental Therapies

New Antivirals: Research is ongoing to develop and test new antiviral drugs that could be effective against monkeypox. Clinical trials may provide access to these experimental treatments.

7. Vaccination as Post-Exposure Prophylaxis

Post-Exposure Vaccination: In some cases, vaccination with the smallpox vaccine after exposure to monkeypox can help reduce the severity of the disease if given within four days of exposure. If administered later, it may still reduce the severity of symptoms.

8. Treatment in Special Populations

Immunocompromised Patients: These patients may require more aggressive treatment, including the use of antivirals like tecovirimat and close monitoring for complications.
Pregnant Women: Special consideration is needed due to the risk of transmission to the fetus. The benefits and risks of antiviral treatment must be carefully weighed.

By combining these treatment approaches, healthcare providers can effectively manage monkeypox and reduce the risk of severe illness and complications.

Who is at risk?

Certain groups of people are at a higher risk of contracting monkeypox or experiencing more severe outcomes from the disease. Understanding these risk factors helps in implementing targeted prevention and control measures.

1. People in Endemic Regions

Geographical Risk: Individuals living in or traveling to Central and West Africa, particularly rural and forested areas, are at higher risk of exposure to the monkeypox virus. These regions are where the virus is endemic, and contact with wild animals or consumption of bushmeat is more common.

2. Individuals with Close Contact with Infected Persons

Household Contacts: Family members or others living in close quarters with someone infected with monkeypox are at increased risk, especially through direct contact with lesions, body fluids, or contaminated materials like bedding.
Sexual Contacts: Monkeypox can be transmitted through intimate physical contact, including sexual contact. Therefore, partners of infected individuals are at higher risk.

3. Healthcare Workers

Occupational Exposure: Healthcare providers, including doctors, nurses, and laboratory technicians, who care for monkeypox patients or handle specimens, are at risk due to close and frequent exposure. Proper use of personal protective equipment (PPE) is crucial to reduce this risk.

4. Immunocompromised Individuals

Higher Severity Risk: People with weakened immune systems, such as those with HIV/AIDS, cancer patients undergoing chemotherapy, organ transplant recipients, or individuals on immunosuppressive drugs, are at higher risk for severe illness if they contract monkeypox.
Increased Susceptibility: Due to their compromised immune systems, these individuals may have a reduced ability to fight off the infection, leading to more severe symptoms and complications.

5. Pregnant Women

Vertical Transmission Risk: Pregnant women are at risk of transmitting the virus to the fetus through the placenta, which can lead to congenital monkeypox. Infected pregnant women may also experience more severe disease.

6. Children

Severity in Young Children: Children, particularly those under the age of 8, may experience more severe symptoms and a higher risk of complications compared to adults. Their developing immune systems may not respond as effectively to the infection.

7. Individuals with Eczema or Other Skin Conditions

Increased Vulnerability: People with pre-existing skin conditions like eczema or atopic dermatitis are at greater risk for severe skin lesions and secondary bacterial infections if they contract monkeypox.

8. Animal Handlers and Laboratory Workers

Zoonotic Transmission: People who handle animals, particularly in regions where monkeypox is endemic, are at risk of zoonotic transmission. This includes hunters, farmers, and individuals involved in wildlife research or veterinary work.
Laboratory Exposure: Laboratory workers who handle the monkeypox virus or specimens from infected animals or humans are at risk if proper biosafety protocols are not followed.

9. Travelers to Affected Areas

Exposure Risk: Travelers to areas with reported monkeypox cases, especially those who engage in activities that increase contact with wildlife or local populations, may be at risk of contracting the virus.

10. Individuals in Outbreak Settings

High-Risk Environments: During an outbreak, anyone in close contact with infected individuals, contaminated environments, or healthcare settings where monkeypox cases are being treated is at elevated risk.

11. Unvaccinated Individuals

Lack of Immunity: People who have not been vaccinated against smallpox, particularly younger individuals who were not part of the routine smallpox vaccination programs, may be more susceptible to monkeypox. The smallpox vaccine provides some cross-protection against monkeypox.

Summary

Those at higher risk of contracting monkeypox include people living in endemic regions, those with close contact with infected individuals, healthcare workers, immunocompromised individuals, pregnant women, children, people with skin conditions, animal handlers, laboratory workers, and unvaccinated individuals. These groups should take particular care to follow preventive measures to reduce their risk of infection.