About Monkeypox Outbreak : All You Need To Know

On 23 July 2022 World Health Organization (WHO) has declared Monkeypox as global health emergency quoting the report released from second meeting of International Health Regulation (IHR). This declaration was based considering the views of committee members, advisors and reports of multi-country outbreak. In response different countries has alerted their respective health authorities to get prepared for yet another public health challenge. Since India recently has reported increasing new cases and death event of Monkeypox victim, Nepal is also at risk of this disease outbreak if not able to take effective action early on. As an initiative, WHO representative has recently handed PCR test kits required for Monkeypox diagnosis to National Public Health Laboratory (NPHL) Nepal. This effort officially initiated in-house capacity development for disease surveillance, case identification and containment activities which should be strengthen enough to sustain and take control over future outbreak.

Brief History Of Monkypox Outbreak

Caused by Orthopoxvirus, monkeypox - supposed to be shy on human has reported its first case against human on 1970 from Democratic Republic of Congo. Firstly identified in 1958 from laboratory Monkey, Monkeypox has two distinct genotypes - Congo Basin and West African. The First outbreak was noticed in these two geographic regions only with animal to human transmission as primary source of infection and human to human transfer as the disease further spread. Outside Africa, Monkeypox was reported in United States by 2003 in dogs which rapidly infected people of midwestern states such as Wisconsin, Indiana, Illinois, Kansas, Missouri and Ohio. With extensive diagnostic, isolation and treatment facility, US was able to contain the virus within a month of spread. After a long gap of 15 years, United Kingdom reported four cases of Monkeypox on human beings by 2018 from people who moved to UK from Nigeria. With rapid public health responses, UK also contained the virus. Similarly, such small incidents were being identified and subsided in various other countries like US, Israel, Singapore and Benin within 2018 to 2021. 

Unfortunately on recent outbreak started from UK, world has miserably failed to contain the spread of virus and it is taking its toll globally and spreading further. First cases of west African strain was identified on 6 May 2022, followed by six more such events within a week. As per High Consequences Infectious Disease (HCID) network, total of 1735 cases were already reported by mid July, most of which are centered around London. Virus has made its way throughout the Europe, America and our close neighbor India as well. 

Clinical Progression of Monkeypox Infection

• For initial 10 - 12 days, there is an incubation period 
• Prodromal symptoms of headache, fever, malaise, weakness etc. 
• Lymphadenopathy: Localized or general swelling of lymph nodes is the distinguishing clinical presentation of monkeypox from other infections
• Rashes develop very soon which further progress to well formed lesion. Initial macular rashes develops to papules, vesicles and pustules. Monekypox lesion are well circumscribed, deep and umblicated (a dot like pattern is noted on the top). 
• Lesions generally confined to facial, anorectal and genital regions, 
• Generally 2 - 4 weeks of infection, the pustules get crusted and scabbed over and the illness resolves. 

Monkeypox has distinct clinical features from viruses of similar kind Chickenpox and Smallpox. Chickenpox is much more contagious, rashes appeared in a wave fashion and get subsided by  two weeks. Smallpox mimics monkeypox to maximum degree but thankfully timely development of vaccine has eradicated it by 1980 already. 

Is Monkeypox More Prominent in LGBTQ community ? 

Recent report from WHO has suggested that 98 % of the monkeypox cases  outside Africa are reported in gay men. This fact has spread a message of LGBTQ community being targeted disease population which can be misleading and help disease to spread further. In fact, spread of disease is dependent on people's behavior, basic health practice and hygiene not the sexual orientation. Monkeypox can be transmitted by close personal contact which includes - direct skin to skin contact, contact with body fluids, touching infected objects used by victims such as towel, beddings and clothes; respiratory contact also helps in easy transmission of disease. Also infected mother transmit the disease to fetus as monkeypox virus can cross placental barrier. It implies that any kind of close physical intimacy is attributable to disease spread. Reason behind predominance of reports from gay and bisexual community may be their confined communication and intimacy among their own community and poor health / hygiene practice. In fact, LGBTQ is highly susceptible to other infections also where disease  transmission is directly linked with sexual contact.

Is Monkeypox  changing its disease pattern ? 

Recently on 1st of August 2022, India has reported its first death case of monkeypox. A 22 years young male was tested positive on 19 July in UAE, but he travelled to India and later developed fever and swelling  and admitted to hospital at Kerala state. Though patient was having lymphadenopathy and fever, there were no lesions noticed throughout stay. Patient's overall health status quickly deteriorated and succumbed to death. As per the autopsy report, cause of death was unconfirmed and other justifiable underlying medical illness were absent, cause of death was attributed to monkeypox.  Though World Health Organization (WHO) has officially labeled the disease as moderate public health risk, reported case fatality are  in increasingly trend. Comparing the classical clinical presentation with the recent deaths reported from India, Brazil and Spain, all death events seems to be unanticipated. Here, Clinical presentation of monkeypox are more or less similar but susceptibility of the victims to other various infections increased significantly after getting infected with monkeypox. This phenomenon is further augmented by underlying chronic illness. Since there are no new reported mutated variants, disease pattern of virus is still unchanged. 

Treatment and Prevention

• Medicines: As per the Food and Drug Administration (FDA), there are no approved treatment specific for monkeypox virus. However, treatment of smallpox and cytomegalovirus also works for Monekypox as well. A drug candidate named "Tecovirimat" has shown some promising results from animal studies but scant is known about it's effectiveness in human; further clinical trials are under the way. Other potential treatment candidates include VIGIV, cidofovir, Brincidofovir, for which also extensive effectiveness data is yet to come. 

• Vaccination: Pre-exposure prophylaxis in the form of vaccination is the currently available most effective way of disease prevention. For various reasons, Center for Disease Control and Prevention (CDC) has suggested only high risk personnel such as laboratory workers be get vaccinated against Orthopoxviruses which is effective against Smallpox as well as Monkeypox. Routine immunization for all health workers is not a current recommendation. The two FDA licensed vaccine candidates are JYNNEOS and ACAM2000. The former is to be taken in two dosage 28 days apart and later one in single dose. 

• Public Health Measures: Active surveillance, investigation and contact tracing is mandatory to prevent human to human transmission by rapidly identifying, isolation and treatment of infected individuals and halt the speed of new transmission. Along with these measures since transmission of monkeypox is somewhat similar to COVID-19 (not in intensity), common public health measures are also similar. Routine healthy practice includes avoiding unnecessary public gathering, wearing mask in public places, washing hands frequently, avoiding unhealthy sexual behaviors and avoiding pregnancy by suspected women. 

Is There A Chance of Monkeypox Pandemic ?

Considering all the reported information about the natural history of disease, Monkeypox can affect human life significantly by becoming a major public health concern for a particular point of time at its worst but resulting into pandemic is far beyond from its ability. There are many attributable factors needed to create pandemic such as rate of disease spread, mode of disease transmission, incubation period of disease, clinical severity, effectiveness of available treatment options and preparedness of health facility in different countries. Monkeypox stands with feeble strength in all these aspects. Firstly, transmission potential of Monkeypox is far more slower and weaker than any other pandemic we have witnessed (like smallpox, COVID-19 etc); in order to transmit disease, relatively longer close physical contact is needed which itself limits rapid spread of disease. Also clinical severity of the disease is very less since there is no systemic involvement of the virus, which makes death due to Monkeypox virus alone extremely unlikely. Also, if we suffice the availability of smallpox vaccine before the disease take over and make use of all the strengthened (and already sensitized) healthcare system and augment it little further, existing healthcare facility can easily withstand burden of this disease. 

Monkeypox will be a big burden only if respected health authority of the countries fail to implement common public health guideline suggested by experts. 

Thank You !!!

References: 

1. https://www.nepalitimes.com/banner/big-story-of-small-pox-in-nepal/

2. https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html#:~:text=Persons%20with%20monkeypox%20will%20develop,lymphadenopathy%20(swollen%20lymph%20nodes).

3. https://www.bbc.com/news/world-asia-india-62344928

4. https://www.bmj.com/content/378/bmj-2022-072410

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157091/#:~:text=Between%20September%202017%20and%2031,region%20of%20Nigeria%20%5B16%5D.

6. India reports Asia's first monkeypox-related death; exact cause unconfirmed | The Times of Israel

7. https://www.who.int/southeastasia/news/detail/24-07-2022-enhance-surveillance--public-health-measures-for-monkeypox--who