Monkeypox: What Experts Know and What is Still Unknown
Monkeypox is a virus transmitted from animals to humans, making it a viral zoonotic disease. Monkeypox symptoms are similar to smallpox, but they are not severe. This virus is a very crucial orthopoxvirus for public health. It mainly occurs in west and Central Africa, close to tropical rainforests, however, it is now alarmingly rising in urban areas.
Monkeypox in India
On 24 July 2022, World Health Organisation (WHO) reported that 4 cases of monkeypox virus were found in South-East Asia. Of these, the number of monkeypox cases in India was three. These cases are found in Indian nationals returning from the Middle East. Currently, the risk of monkeypox is moderate, but it has the potential to spread further internationally. Even now, the virus has many unknowns. Preparing ourselves to remain alert and roll out an intense response to stop monkeypox from spreading further is essential.
An enveloped double-stranded DNA virus, the monkeypox virus has two distinct genetic clades: the West African clade and the central African clade / Congo Basin clade. The central African clade has been more transmissible and has led to more severe diseases, and Cameroon is the only nation that has both clades of this disease.
Monkeypox virus’ natural host
Several animal species are susceptible to the host monkeypox virus. The list includes:
- rope squirrels
- tree squirrels
- Gambian pouched rats
- non-human primates
In 1970, monkeypox, in humans, was first identified in a boy of 9 months of age in the Democratic Republic of the Congo. The first monkeypox outbreak beyond African borders was in 2003 in the USA, and it was found to have happened due to contact with pet prairie dogs. With this outbreak, more than 70 cases were reported in the U.S.
This virus was found in travellers coming from Nigeria to Israel (2018), the United Kingdom (2018, 2019, 2021, and 2022), Singapore (2019), and the USA (2021). In May 2022, several cases of this virus showed up in various non-endemic countries. There is little clarity about monkeypox’s epidemiology, the infection sources, and transmission patterns.
Zoonotic or animal-to-human transmission could happen with direct contact with an infected animal’s bodily fluids, blood, or cutaneous or mucosal lesions. It has not been possible to identify monkeypox’s natural reservoir, but it is considered most probably to be rodents. Risk factors include the consumption of meat that is inadequately cooked and consumption of other animal products that come from infected animals. People residing close to forested regions could have indirect or low-level exposure to infected animals.
In the case of human-to-human transmission, it could be passed on via close contact with respiratory secretions, an infected individual’s skin lesions, or objects that have been recently contaminated. Prolonged face-to-face contact through respiratory droplet particles also results in infection transmission, putting the lives of household members, health workers, and those in close contact with an infected person at high risk. The longest transmission chain documented for any community has gone up from 6 persons to 9 successive persons. It shows a fall in immunity for the public because of the cessation of smallpox vaccination.
Infection can be carried from mother to fetus via the placenta (can result in congenital monkeypox) or with close contact at the time of birth or later. It is unclear if this virus is transmittable via sexual transmission routes, and further study needs to be conducted.
Symptoms and signs of monkeypox
This virus has an incubation period of normally 6-13 days and can even range from 5-21 days.
It has two periods of infection:
- The invasion period of 0 to 5 days of intense headache, fever, swollen lymph nodes (distinctive feature in monkeypox), pain in the back, muscle aches, and energy loss.
- The skin eruption appears from 1 to 3 days after the fever starts. They are mainly concentrated on the extremities and face rather than the trunk. Also, the oral mucous membranes, genitalia, conjunctivae, and cornea can get affected. People can get just a few lesions or thousands of them. When the case is severe, the lesions can coalesce until the skin sloughs off in large sections.
The rash progresses in these stages:
- Lesions have a flat base
- Slightly raised lesions that are firm
- Clear fluid-filled lesions
- Yellowish fluid-filled lesions
- Crusts that become dry and fall away
Usually, this virus is self-limited, and its symptoms persist between 2 – 4 weeks. Severe cases are found primarily in children. While vaccination against smallpox proved protective in the past, people aged between 40 and 50 years (based on the country) could be more prone to this virus because of the cessation of smallpox vaccination across the world after the disease got eradicated.
Swollen lymph nodes (lymphadenopathy) at the prodromal stage could be treated as one clinical feature for distinguishing this virus from smallpox or chickenpox. When a case is suspected of being monkeypox, sample specimens must be packaged and forwarded following the international and national requirements specified for this purpose. The test of preference for this virus is PCR (polymerase chain reaction) due to its sensitivity and accuracy. Samples must be taken from skin lesions and should not be blood samples.
Antibody and antigen detection methods are not confirmatory for monkeypox and are not recommended. It is also possible to get a false positive result from a remote or recent vaccination with a vaccinia-based vaccine.
Information that must accompany the specimen for the test for better interpretation of test results is:
a) date of fever onset
b) date of rash onset
c) specimen collection date
d) individual’s current status (stage of rash)
e) individual’s age
Treating monkeypox clinically
During clinical care, patients are given food and fluids that will maintain their nutritional status at an adequate level. During monkeypox treatment, follow their specified treatment if secondary bacterial infections occur. The antiviral agent, tecovirimat, developed for smallpox, was licensed in 2022 by the EMA (European Medicines Agency) for this monkeypox virus based on data collected from human and animal studies.
The smallpox vaccine is 85% effective in the prevention of monkeypox. If infected, those who have taken the smallpox vaccine earlier will have a mild bout of monkeypox. Currently, original smallpox vaccines are not available to the general public and are made available to health workers and laboratory personnel in some places. A newer vaccine based on modified attenuated vaccinia virus (Ankara strain) was approved in 2019 for preventing monkeypox. This two-dose vaccine has limited availability.
Currently, prevention can be done by creating awareness regarding the risk factors. Also, people must be informed about what measures can be taken to reduce exposure to the virus.
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Monkeypox is a zoonotic viral infection causing this illness, and it can transmit from human-human and animal-human. Little is known about how it is transmitted or its natural reservoir/hosts, so it is essential to be aware of the risk and take steps to minimize the exposure.
Can monkeypox spread from humans to animals?
No cases of monkeypox-affected humans infecting animals have been reported, but this risk cannot be ruled out as a potential one.
How can I protect myself against monkeypox?
- Limit close contact with animals/ persons with confirmed/suspected infection.
- Regularly disinfect and clean environments with possible contamination from someone’s infections.
- Remain informed about monkeypox in your area
- Maintain open conversations with people regarding symptoms you, or they might have.
Will monkeypox become a large outbreak?
There are chances to control possible outbreaks by closely working with groups and communities that face more significant risks. Everyone must come together to prevent the spread by being aware of the risks and acting to lower the risks.
Does monkeypox infect children?
Yes, if they come in close contact with someone with symptoms.
What risks are there of getting monkeypox when pregnant?
According to the current information, monkeypox can prove dangerous for the fetus during pregnancy.