Monkeypox Outbreak 2022 - Comment
Monkeypox Outbreak 2022
1. Monkeypox outbreak by/ Kholoud Mohamed Family Medicine Resident Under supervision of Dr/ Samar Osama Assistant lecturer at the Family Medicine Department
2. The Causative Agent: Monkeypox is an infectious disease caused by the Monkeypox virus which is a double-stranded DNA, zoonotic virus and a species of the genus Orthopoxvirus in the family Poxviridae. Other human orthopoxviruses include variola, cowpox , and vaccinia viruses.
3. • The virus is found mainly in tropical rainforest regions of Central and West Africa. • The virus is split into Congo Basin and West African clades. • The Central African clade is reported more frequently and more severely than the West African clade . • The case fatality rate for the West African clade is around 3.6 %, whereas for the Central African clade, it may be as high as 10.6 %.
5. 2003 U.S. outbreak: It was the first outbreak of monkeypox outside of Africa. In May 2003, a young child became ill with fever and rash after being bitten by a prairie dog. In total, 71 cases of monkeypox were reported & all cases were traced to Gambian pouched rats imported from Ghana. No deaths were reported. 2003 Midwest monkeypox outbreak
6. 2017 Nigeria outbreak: In 2017, Nigeria has experienced a large outbreak, with over 500 suspected cases and over 200 confirmed cases and a case fatality rate of approximately 3%. 2018 United Kingdom cases: In Sept 2018, the United Kingdom's first case of monkeypox was recorded. The person contracted monkeypox in Nigeria before travelling to the United Kingdom. Till December 2019, 3 cases were recorded, and 2 of them were travelling to the UK from Nigeria. One of them was a medical worker who cared for a case.
7. 2018 Israel case: In October 2018, one case occurred in a man who traveled from Nigeria to Israel. 2019 Singapore case: On May 2019, Singapore reported the first case of monkeypox who travelled from Nigeria. 2021 cases: On 24 May in the UK, three cases of monkeypox from a single household were reported. On 16 July in the US, an American returning from a trip in Nigeria was diagnosed with monkeypox.
8. Countries reporting confirmed human cases of monkeypox 1970 – 2021, WHO
9. 2022 UK outbreak: The index case: In late April 2022, the case was reported of a British resident who travelled to Nigeria. The patient developed symptoms of monkeypox on 29 April while still in Nigeria. On 4 May, the patient flew back to the UK, presented to hospital later the same day. The monkeypox infection was immediately suspected. The patient was hospitalized and isolated.
10. Extensive contact tracing of people who had been in contact with the index case both on the international flight from Nigeria to the United Kingdom and within the country following their arrival was carried out. The potential contacts were advised to remain aware of the symptoms of monkeypox and immediately isolate if any symptom develops within 21 days of the contact event. Monkeypox (West African clade) was laboratory confirmed by polymerase chain reaction (PCR) on a vesicular swab on 6 May by the United Kingdom Health Security Agency (UKHSA).
11. on 12 May, two new cases of monkeypox were confirmed by the UKHSA in London. There was no known link between either of them and the index case or travel to endemic regions. on 17 May, Four additional cases of monkeypox were confirmed by the UKHSA. None of these new cases had any known contact history with the previous three confirmed cases, suggesting wider community transmission of the virus in London. On 20 May, it was reported that another eleven cases had been confirmed in the UK, bringing the total number in the country to 20.
12. Europe, North America and Australia: On May 18 Portugal: 14 confirmed cases 20 suspected cases Spain: 7 confirmed cases 23 suspected cases The USA: confirmed single case Canada: 13 suspected cases
13. On May 19 On May 20 Sweden : the first confirmed case Belgium: the first confirmed case Italy: the first confirmed case France: a suspected case Australia : 2 confirmed cases Germany : first confirmed case
14. On May 20, the World Health Organization held an emergency meeting to discuss the outbreak. The WHO European chief expressed concern that infections could accelerate in Europe as people gather for parties and festivals over the summer. The WHO is expected to provide an update on sequencing of the virus genome from different cases to determine the cause.
15. Cases of monkeypox in non-endemic countries reported to WHO between 13 to 21 May 2022
16. Geographical distribution of confirmed and suspected cases of monkeypox in non-endemic between 13 to 21 May 2022
17. Cases of monkeypox in endemic countries between 15 December 2021 to 1 May 2022
18. Cases of monkeypox in non-endemic countries till 27 May 2022
19. The current situation in Egypt: On May 20, Dr. Hossam Abdel Ghaffar, the spokesman of the Egyptian Ministry of Health and population confirmed that there are no cases of infection or suspected infection with the monkeypox virus so far.
20. Animal Reservoir: • Monkeys •Dormice •Gambian pouched rats •African squirrels Monkeys dormouse Gambian pouched rat African squirrel
21. Mode of Transmission: The virus enters the body through: Broken skin (even if not visible). The mucous membranes (eyes, nose, or mouth). Respiratory tract. Animal-to-human transmission may occur by: Bite or scratch. Bushmeat preparation. Direct contact with body fluids or lesion material. Indirect contact with lesion material, such as contaminated bedding.
22. Human-to-human transmission occurs through: Large respiratory droplets. Direct contact with body fluids or lesion material. Indirect contact with lesion material, such as contaminated clothing or linens. Human-to-human transmission is occurring among people in close physical contact with cases who are symptomatic.
23. Is it a sexually transmitted disease??! Almost all of the case clusters include men aged 20–50, many of whom are gay, bisexual and have sex with men (GBMSM). Although monkeypox isn’t known to be sexually transmitted, sexual activity certainly constitutes close contact. The most likely explanation is that the virus was coincidentally introduced into a GBMSM community, and the virus has continued circulating there.
24. Is the virus genetically mutated??! In Portugal, the first draft genome sequence of the monkeypox virus was obtained from a swab collected on May 4th from skin lesions from a male patient. The draft genome indicates that the 2022 virus belongs to the West African clade and is most closely related to viruses associated with the exportation of monkeypox virus from Nigeria to several countries in 2018 and 2019, namely the United Kingdom, Israel and Singapore.
25. The incubation period: usually 6-13 days but can range from 5-21 days.
26. History taking: Important clues: Recent travel to endemic areas. Interaction with wild animals imported from endemic areas. Providing care to an infected animal or human.
27. Clinical picture: Initial symptoms : Fever. Headache. Myalgia. Fatigue. Lymphadenopathy. (a key differentiating feature of monkeypox from smallpox)
28. Within 1 to 3 days after the fever, the patient develops a rash: • Begins on the face and extremities (including palms and soles). • Centrifugally concentrated. • The total number of lesions may vary from a small amount to thousands. Lesions progress through the following sequential stages before falling off: • Macules • Papules • Vesicles • Pustules • Scabs
29. Monkeypox lesions
30. Differential Diagnosis: Smallpox Chickenpox Disseminated zoster Eczema herpeticum Disseminated herpes simplex Syphilis Scabies Rickettsia Measles Bacterial skin infections Drug-associated eruption
31. Diagnosis: Clinically. Laboratory testing: • Polymerase chain reaction (PCR) testing of samples from skin lesions. • Specimens should be collected from at least 3 lesions and from different sites on the body. • Viral culture • Anti-orthopoxvirus IgM and IgG. WHO-Laboratory testing for the monkeypox virus: Interim guidance is available at: https://www.who.int/publications/i/item/WHO- MPX-laboratory-2022.1
32. Prevention: Avoid contact with animals that could harbor the virus Avoid contact with any materials of a sick animal. Isolate infected patients from others who could be at risk for infection. Practice good hand hygiene after contact with infected animals or humans. Use personal protective equipment (PPE) when caring for patients including gown, gloves and masks.
33. Vaccination: Smallpox vaccine (ACAM2000): • It contains live vaccinia virus, and it was approved by the Food and Drug Administration (FDA) on 31 August 2007. • It is administered by (scarification) using a bifurcated needle. • Following a successful inoculation, a lesion will develop at the site of the vaccination. The virus growing at the site of this inoculation lesion can be spread to other parts of the body or even to other people.
34. The vaccine is not routinely available for public. It is licensed for immunization in people who are at least 18 years old and at high risk for smallpox infection such as laboratorians working with certain orthopoxviruses and military personnel. The smallpox vaccine is thought to be at least 85% effective in preventing monkeypox.
35. JYNNEOS (also known as Imvamune or Imvanex) JYNNEOS is a live, attenuated vaccinia virus, incapable of replicating. On Sept 2019, it was approved by the U.S. Food and Drug Administration (FDA). It is administered as two subcutaneous injections four weeks apart. There is no visible “take” and as a result, no risk of spread to other parts of the body or other people.
36. People who receive JYNNEOS are not considered vaccinated until they receive both doses of the vaccine. It is indicated for preventing smallpox and monkeypox disease in adults 18 years of age and older who are at high risk for smallpox or monkeypox infection. It can be used for patients with weakened immune systems or atopic dermatitis.
37. When to take the vaccine? • Vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox virus. • The vaccine can be given within 4 days from the date of exposure in order to prevent onset of the disease. • If given between 4–14 days after the date of exposure, vaccination may reduce the symptoms of disease, but may not prevent the disease.
38. Monkeypox Disease vs Vaccine Risks. In Central Africa—where people live in remote areas and are medically underserved—showed that the monkeypox disease killed 1–10% of people infected. Complications of the vaccines include eczema vaccinatum, progressive vaccinia resulting in death, contact transmission of vaccine virus, and fetal vaccinia. Between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine
39. Ring Vaccination This would vaccinate the close contacts of people who have been infected with monkeypox to cut off any routes of transmission and contain the spread of monkeypox.
40. Treatment: Supportive care: • Antipyretic. • Treatment of fluid & electrolytes disturbance. • Oxygenation if needed. • Empirical antibiotic therapy if secondary bacterial infection is suspected. • Acyclovir if varicella zoster infection is suspected.
41. Tecovirimat (ST-246): • On 13 July 2018, it was approved the U.S. Food and Drug Administration (FDA) and was approved for medical use in the European Union in January 2022. • Animal Studies have shown that ST-246 is effective in treating orthopoxvirus-induced disease. • Human clinical trials indicated the drug was safe and tolerable with only minor side effects.
42. Brincidofovir & Cidofovir: • Cidofovir was approved for medical use in 1996. • Brincidofovir was approved for medical use in June 2021. Brincidofovir is a prodrug of cidofovir. • Brincidofovir may have an improved safety profile over Cidofovir. • It have proven activity against poxviruses in in vitro and animal studies.
43. Vaccinia Immune Globulin (VIG) • It has no proven benefit in the treatment of smallpox complications. • IVIG can be considered for prophylactic use in an exposed person with severe immunodeficiency in T-cell function for which smallpox vaccination following exposure to monkeypox is contraindicated.
44. Complications: Bacterial superinfection of skin Permanent skin scarring Hyperpigmentation or hypopigmentation Permanent corneal scarring (vision loss) Pneumonia Dehydration Sepsis Encephalitis Death
45. Complications among Pregnant Women With Human Monkeypox: In 2017, Mbala et al. reported the fetal outcomes of 4 pregnant women who were infected by monkeypox virus. Variable Case 1 Case 2 Case 3 Case 4 severity Moderate Severe Mild Moderate Age, y 20 25 29 22 Time of gestation, wk 6 6–7 14 18 Event Miscarriage Miscarriage Live birth Fetal death
46. Pathologic findings for the stillborn fetus from case 4: Diffuse cutaneous maculopapular lesions. Hydrops fetalis Marked hepatomegaly with peritoneal effusion. No congenital malformations or deformities. Postmortem autopsy was consistent with intrauterine fetal demise. Placental hemorrhages on the maternal surface.
47. Monkeypox is usually self-limiting. The condition resolves around 3 to 4 weeks after symptom onset in most cases. Patients are no longer considered infectious after all crusts fall off. The West African clade has a more favorable prognosis with a case fatality rate 3.6% . The Central Basin clade is more lethal, with a case fatality rate of up to 10.6% in unvaccinated children.
48. The role of Family Physicians:
49. Case and Contact Definitions:
50. CASE INVESTIGATIONS: • Once a suspected case is detected, the physician should notify health care authority to start intensified surveillance. CDC case Investigation Form available at: https://www.cdc.gov/poxvirus/monkeypox/pdf/Monkeypox-Exposure- Questionnaire.pdf • Referral to the isolation facility. • The patient should wear a surgical mask& skin lesions should be covered (e.g., long sleeves, long pants).
51. During hospitalization: • The patients should be isolated in a negative air pressure room as soon as possible. • If it is not available, place patients in a private examination room. • If neither option is feasible, these following precautions must be applied : a surgical mask over the patient’s nose and mouth and covering any of the patient’s exposed skin lesions with a sheet or gown. • Confirmation of the diagnosis with lab tests and proper treatment and follow up of the patient.
52. Personal protective measures : • PPE should be donned before entering the patient’s room. • All PPE should be disposed prior to leaving the patient’s room. Disposable gown. Gloves whenever in contact with the patient, and with the patient surroundings. NIOSH-certified N95 (or comparable) filtering disposable respirator. Eye protection (e.g., face shields or goggles).
53. In case of home isolation: • The patient should be isolated in a room or area separate from other family members when possible. • Persons with monkeypox should not leave the home except as required for follow-up medical care. • They also should avoid contact with wild or domestic animals. • Unexposed persons who do not have an essential need to be in the home should not visit.
54. • The patients should wear a surgical mask & if this is not feasible, other household members should wear a surgical mask when in the presence of the person with monkeypox. • Disposable gloves should be worn for direct contact with lesions and disposed of after use. • Skin lesions should be covered to the best extent possible (e.g., long sleeves, long pants). • Contain and dispose of contaminated waste after consultation with state or local health officials. Do not dispose of waste in landfills or dumps.
55. Duration of Isolation Procedures Isolation should be continued until all lesions have resolved and a fresh layer of skin has formed. Following the discontinuation of isolation, the patients should avoid close contact with immunocompromised persons until all crusts are gone. • Immunologic disorders. • Chronic diseases. • Immunosuppressive therapy.
56. Contact tracing: • Identification of all contacts of every suspected case during case investigation . • All contacts should be included in a line-list and the contact listing section of the MPX Case investigation form. • If the laboratory result of a suspected case comes back as negative, the contacts are immediately dropped from further follow-up. • The contacts of confirmed animals or humans and contacts of probable cases should be placed under symptom surveillance for 21 days calculated from the last day of exposure.
57. Case investigation form - U.S. Centers for Disease Control and Prevention
58. Contacts should be instructed to monitor their temperature twice daily. If fever or rash develop, contacts should self-isolate and contact their local health department immediately. If only chills or lymphadenopathy develop, the contact should remain at their residence and self-isolate for 24-hours. During this time, the individual should monitor their temperature for fever; if a fever or rash develop, the health department should be contacted immediately. If fever or rash do not develop and chills or lymphadenopathy persist, the contact should be evaluated by a clinician for potential cause.
59. • Contacts who remain asymptomatic can be permitted to continue routine daily activities (e.g., go to work, school). • Contacts should not donate blood, cells, tissue, breast milk, semen, or organs while they are under symptom surveillance.
60. Monitoring of the exposed healthcare workers: All healthcare worker should be alert to the symptoms and should notify the infection control department if develop any symptoms. Healthcare workers who have unprotected exposures do not need to be excluded from work duty if asymptomatic, but should undergo active surveillance, which includes measurement of temperature at least twice daily for 21 days following the exposure. Prior to reporting for work each day, the healthcare worker should be interviewed regarding evidence of fever or rash.
61. Could it be a new pandemic ??! • Unlike SARS-CoV-2, It is related to the smallpox virus, there are already treatments and vaccines on hand. • Unlike SARS-CoV-2, which spreads through tiny air-borne droplets, monkeypox spreads mainly through close contact with bodily fluids, and less extent through large respiratory droplets.
62. • Unlike SARS-CoV-2, RNA virus, monkeypox virus is a relatively large DNA virus. DNA viruses are better at detecting and repairing mutations than RNA viruses. • According to the World Health Organization (WHO), Monkeypox can be contained in countries outside of Africa where the virus is not usually detected. • The current outbreak probably won’t necessitate containment strategies beyond ring vaccination. “This is a containable situation” Maria Van Kerkhove, the WHO's emerging disease lead
63. References: • CDC. About Monkeypox | Monkeypox| Poxvirus | CDC [Internet]. 2018 [cited 2019 Oct 19]. Available from: https://www.cdc.gov/poxvirus/monkeypox/about.html • WHO. Monkeypox [Internet]. WHO. 2016 [cited 2019 Oct 19]. Available from: https://www.who.int/news-room/fact-sheets/detail/monkeypox • "Monkeypox," UK Health Security Agency, 18 May 2022. [Online]. Available: https://www.gov.uk/guidance/monkeypox#transmission. • https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest- updates • Durski KN, McCollum AM, Nakazawa Y, Petersen BW, Reynolds MG, Briand S, et al. Emergence of monkeypox – West and Central Africa, 1970–2017. Morb Mortal Wkly Rep. 2018 Mar 16;67(10):306–10. • NCDC. Nigeria Centre for Disease Control: Weekly Epidemiological Report [Internet]. 2017 [cited 2019 Oct 19]. Available from: https://ncdc.gov.ng/reports/101/2017-december- week-52
64. • "Epidemiological update: Monkeypox outbreak," European Centre for Disease Prevention and Control, 20 May 2022. [Online] • Placide K Mbala, John W Huggins, Therese Riu-Rovira, Steve M Ahuka, Prime Mulembakani, Anne W Rimoin, James W Martin, Jean-Jacques T Muyembe, Maternal and Fetal Outcomes Among Pregnant Women With Human Monkeypox Infection in the Democratic Republic of Congo, The Journal of Infectious Diseases, Volume 216, Issue 7, 1 October 2017, Pages 824–828, https://doi.org/10.1093/infdis/jix260 • https://www.nature.com/articles/d41586-022- 014218?utm_source=Nature+Briefing&utm_campaign=722ea2a64d-briefing-wk- 20220520&utm_medium=email&utm_term=0_c9dfd39373-722ea2a64d-42456515 • https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1
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