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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 99-100

Monkeypox: Is the current outbreak tip of an iceberg?

Department of Microbiology (Former HoD), PIMS, Puducherry, India

Date of Submission06-Aug-2022
Date of Decision16-Sep-2022
Date of Acceptance19-Sep-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Reba Kanungo
Department of Microbiology (Former HoD), PIMS, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_68_22

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How to cite this article:
Kanungo R. Monkeypox: Is the current outbreak tip of an iceberg?. J Curr Res Sci Med 2022;8:99-100

How to cite this URL:
Kanungo R. Monkeypox: Is the current outbreak tip of an iceberg?. J Curr Res Sci Med [serial online] 2022 [cited 2023 May 31];8:99-100. Available from: https://www.jcrsmed.org/text.asp?2022/8/2/99/364505

The current outbreak of monkeypox, close on the heels of the COVID pandemic, appears as the last straw on the camel's back. The health-care systems globally are just recovering from the pandemic that has lasted from 2020 to date. Monkeypox, a hitherto little-known viral infection outside Africa, is a zoonotic infection, geographically restricted to Africa, and was first identified in 1970 in the Democratic Republic of Congo. Epidemiological studies of the virus are limited due to its innocuous nature and geographic limitation. Few cases have been associated with tourists who were not from Africa. However, since April 2022, there has been a sudden increase in the number of cases of monkeypox, globally. This led the World Health Organization (WHO) to declare it first as an “evolving threat of moderate public health concern” on June 23, 2022, and subsequently as a “public health emergency of international concern” in July 2022. More than 18,000 cases of monkeypox have now been reported to the WHO from 78 countries. Of these, around 70% of cases have been reported from the European region, and 25% from the region of the Americas.[1] India has documented nine confirmed cases as of now.

What do we know about the virus? Monkeypox virus (MPXV) is a double-stranded DNA virus of the genus Orthopoxvirus in the Poxviridae family. Monkeypox has two genetically discrete clades, each with apparent distinct clinical and complex epidemiologic parameters.

It is primarily zoonotic, with rodents and squirrels as natural reservoirs. Nonhuman primates can get infected with monkeypox and show signs of disease like humans.[2] Handling infected animals or contact with their body fluids is the main mode of transmission from animals to man. First discovered in 1958 among captive monkeys in the State Serum Institute of Denmark, it was later detected in human infections in Africa. An outbreak outside Africa occurred in the Midwest USA in 2003, with 37 cases that were laboratory confirmed.

As cases increased across countries, clinical features, mode of transmission, and epidemiological factors became clear. Large respiratory droplets and close physical contact have been recognized as common modes of transmission in man. Demographic analysis of case series of 528 patients, in 48 sites, from four WHO regions (Europe, Americas, Western Pacific, and Eastern Mediterranean) over 2-month in the current outbreak, revealed several interesting facts. Homosexual three men having sex with men were the major groups affected. Concomitant sexually transmitted infections, including HIV, were also detected in some cases.[3]

With an incubation period of around 7 days, skin manifestations are the predominant features. Common anatomical sites are the anogenital region, trunk, arms, and legs, rarely the face and the palms. Lesions are typically macular, pustular, vesicular, and crusted, with multiple phases appearing simultaneously. There may be mucosal lesions, an additional important clinical presentation. Some individuals present with pharyngeal symptoms, including pharyngitis, epiglottitis, and oral or tonsillar lesions. Systemic features of the illness include fever, headache, myalgia, and lethargy, which precede a generalized rash. Another predominant feature noted in patients with monkeypox is lymphadenopathy. Some preliminary data show the infection affects gay, bisexual, or men having sex with men as well as other heterosexual men.[3] The disease can be conclusively diagnosed by detecting the viral DNA from vesicular fluids or crusts, nasopharyngeal secretions, and less likely from urine. Tests employed to detect MPXV are real-time or conventional polymerase chain reaction-based nucleic acid amplification assays, targeting an envelope protein gene (B6R), or any other unique gene.

As the number of cases of monkeypox increases globally, as well as in India, it is necessary for health-care professionals to be aware of the disease. Awareness to detect and manage these cases must be created among health-care professionals. In addition, targeted awareness and education of the population, coupled with easy access to health-care setups and enhanced testing capacity in regional laboratories, is urgently needed. There is a lot that is still not clear regarding the transmissibility, route of infection, clinical spectrum, and response to treatment of monkeypox. Ongoing transmission is expected to throw up new information regarding the disease. Can smallpox vaccines, containing vaccinia virus, provide cross-protection against monkeypox? There needs to be a risk assessment to consider immunizing the population at risk, including health-care workers and laboratory personnel, with smallpox vaccine. It is speculated that widespread vaccination against smallpox has kept monkeypox in abeyance. Is waning immunity to smallpox and a young population that has not been vaccinated against smallpox responsible for the current outbreak?[4] There are already initiatives to manufacture MPXV vaccines. One hopes it is sooner than later.

Is there a new transmission pattern for MPXV? Has the virus mutated to become more adaptable to human transmission? How should the health-care system gear up or prepare to detect, diagnose, and treat MPXV infection to prevent the further spread of the disease? It is still too early in the days of the new outbreak to fully answer these questions. A better understanding of the MPXV's history and biology can provide some clues. The long-term outcome of the disease is yet to be understood. Questions arise that are reminiscent of HIV and other sexually transmitted infections regarding their long-term psychosocial effects. Insofar as the virus at the moment is affecting a specific group of people, in addition to early diagnosis and treatment, behavioral interventions may be necessary.

Until more evidence is available, one needs to remain vigilant and put systems in place for disease detection, treatment, and prevention. The WHO has developed clinical characterization case report forms to standardize data collection of clinical features of monkeypox among outpatient and hospitalized cases.[5] Analysis of this data will help reveal additional details about the disease. With global effort, it is hoped that the current outbreak of monkeypox is not the tip of an iceberg.

  References Top

Who is at Risk for Monkeypox? Andy Seale Science Conversation; World Health Organization, 22 July, 2022 Organization: Official WHO Updates – Who.int Ad. Available from: https://www.who.int/monkeypox. [Last accessed on 2022 Jul 27].  Back to cited text no. 1
Monkeypox in Animals; 24 June, 2022. Available from: https://www.cdc.gov/poxvirus/monkeypox/veterinarian/monkeypox-in-animals.html. [Last accessed on 2022 Jul 30].  Back to cited text no. 2
Thornhill JP, Barkati S, Walmsley S, Rockstroh J, Antinori A, Harrison LB, et al. Monkeypox virus infection in humans across 16 countries – April-June 2022. N Engl J Med 2022;387:679-91.  Back to cited text no. 3
Xiang Y, White A. Monkeypox virus emerges from the shadow of its more infamous cousin: Family biology matters. Emerg Microbes Infect 2022;11:1768-77.  Back to cited text no. 4
Global Clinical Data Platform for Monkeypox Case Report Form (CRF). Available from: https://www.who.int/publications/i/item/WHO-MPX-Clinical_CRF-2022.3. [Last accessed on 2022 Aug 04].  Back to cited text no. 5


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