A global outbreak of monkeypox in non-endemic countries was reported just over a period of two months. This outbreak led to more than 16,000 cases, over two-thirds of which were reported in the European region. Since a significant number of cases have been reported from 75 countries, on 23 July 2022, the World Health Organisation (WHO) Director General declared monkeypox a public health emergency of international concern. This represents the highest level of alert under the International Health Regulations.
This article contains excerpts from the WHO’s fact sheets and press release published on 24 July 2022, to clarify details about the current outbreak and to clear up the associated misconceptions.
What is monkeypox?
Monkeypox is a virus that belongs to the genus orthopoxvirus, and causes a disease with symptoms similar but less severe to smallpox virus. Smallpox, which had a long history, was eradicated in 1980. However, monkeypox continued to survive in the countries of Central and West Africa.
It is usually a self-limiting disease, which simply means that it resolves spontaneously. The symptoms may last for about two to four weeks. Monkeypox is transmitted through close contact with an infected person or animal, or even with contact of material contaminated with the virus. Lesions, body fluids, respiratory droplets, and contaminated beddings can transmit the virus from person to person.
Symptoms of monkeypox
The incubation period of monkeypox, ie., the duration between exposure to the virus and appearance of symptoms, ranges from five to 21 days.
The febrile stage of illness usually lasts one to three days, with symptoms including fever, intense headache, lymphadenopathy (swelling of the lymph nodes), back pain, myalgia (muscle ache), and an intense asthenia (lack of energy).
The febrile stage is followed by the skin eruption stage, lasting for two to four weeks. Lesions evolve from macules (lesions with a flat base) to papules (raised, firm, painful lesions) to vesicles (filled with clear fluid) to pustules (filled with pus), followed by scabs or crusts. The rash tends to be more concentrated on the face and extremities, rather than on the trunk.
Severe cases are not so common, but can occur among children and are related to the extent of virus exposure and the health status of the patient. Underlying immune deficient conditions such as cancers and long-term illnesses can lead to severe illness.
High-risk persons
At the inception of the current outbreak, these symptoms were being frequently noted by a general practitioner in Lisbon, Portugal, who also conducts a sexual health clinic in the city. He noted several patients presenting with ulcers at the beginning of May and tested them for sexually transmitted infections, which returned negative. This triggered the identification of the first cases of monkeypox and researchers were able to connect the dots to a significant outbreak of the disease. It is important to distinguish monkeypox from other illnesses such as chickenpox, measles, bacterial skin infections, scabies, syphilis, and medication-related allergies.
Although most of the cases identified have been among men who have sex with men (MSM), it is vital to stress that it is not a disease that is exclusively affecting MSM, and should not be stigmatised. However, it is important to note that MSM are at higher risk of contracting the disease because of the social and sexual networks, which facilitates the faster spread.
According to the WHO Director General: “This is an outbreak that can be stopped with the right strategies in the right groups. It’s therefore essential that all countries work closely with MSM communities, to design and deliver effective information and services, and to adopt measures that protect the health, human rights, and dignity of affected communities.”
Monkeypox cases are also being detected in women and children. Hence, clinicians must be alert to the possibility of the disease in their assessment of any patient.
Diagnosis
Detection of viral DNA by polymerase chain reaction (PCR) is the preferred laboratory test for monkeypox. The best diagnostic specimens are directly from the rash – skin, fluid, or crusts, or biopsy where feasible. Antigen and antibody detection methods may not be useful, as they do not distinguish between other orthopoxviruses.
Treatment of Monkeypox
Since it is a self-limiting disease, only supportive care is required, depending on the symptoms. At present, various compounds that may be effective against monkeypox infection are being developed and tested.
Vaccination against smallpox with a first generation vaccinia-virus-based smallpox vaccine was shown to be 85% effective in preventing monkeypox, as it offers some cross-protection. Hence, the individuals who were vaccinated against smallpox in childhood may have some remaining protection against the disease. Populations have become more susceptible to monkeypox as a result of the termination of routine smallpox vaccination.
Prevention and control
Prevention and control of the spread of monkeypox relies on raising awareness in communities and educating healthcare workers to prevent infection and stop transmission. It should be emphasised that monkeypox is not as contagious as Covid-19, and hence prevention and control is practically more feasible than with the Covid-19 pandemic.
The following steps should be followed in prevention of spread:
- Most human monkeypox infections result from a primary animal-to-human transmission. Hence, contact with sick or dead animals should be avoided. All foods containing animal meat or parts need to be properly cooked before eating
- Avoid close contacts with infected people or contaminated materials
- Gloves and other personal protective clothing and equipment should be worn while taking care of the sick, whether in a health facility or at home