MONKEYPOX (INDIA CONFIRMS FIRST MONKEYPOX CASE IN KERALA)

Monkeypox is a rare zoonotic disease caused by infection with monkeypox virus (family of variola virus) with symptoms similar to smallpox patients, although it is clinically less severe.

Monkeypox was discovered in 1958 in colonies of monkeys kept for research. African rodents and non-human primates (like monkeys) harbor the virus and infect people. 

Human monkeypox was first identified in humans in 1970 in Congo in a 9 month old boy. Since then, most cases have been reported from rural, rainforest regions of Congo and from central and west Africa.

The virus

Monkeypox virus is a an enveloped double-stranded DNA virus that belongs to the Orthopoxvirus genus of the Poxviridae family. 

There are two different groups of monkeypox virus: the Central African (Congo Basin) group and the west African group. The Congo Basin group has caused more severe disease and was thought to be more transmissible.

Natural host

Susceptible animal species include rope squirrels, tree squirrels, Gambian pouched rats, dormice, non human primates (monkeys).

Transmission

Animal to human (zoonotic) transmission can occur from direct contact with the blood, body fluids, or cutaneous or mucosal lesions of infected animals. The natural reservoir of monkeypox has not yet been identified, though rodents are the most likely. eating inadequately cooked meat and other animal products of infected animals is a possible risk factor.

Human to human transmission can results from close contact with respiratory secretions, skin lesions of an infected person or recently contaminated objects. Transmission via droplet particles usually requires prolonged face to face contact. Transmission can also occur via the placenta from mother to fetus (congenital monkeypox) or during close contact during and after birth.

Fomite transmission: Environments can become contaminated with monkeypox viruses,  when an infectious person touches clothing, bedding, towels, objects, electronics and surfaces. Someone else who touches these items can then become infected.  

Signs and symptoms

The incubation period is usually from 6 to 13 days but can range from 5 to 21 days.

Infection can be divided into two periods:

• The invasion period (last between 0-5 days) characterized by fever, intense headache, lymphadenopathy, back pain, myalgia and intense asthenia (lack of energy).
• The skin eruption usually begins within 1-3 days of appearance of fever. The rash tend to be more concentrated on face and extremities. The rash evolves sequentially from macules to papules, vesicles, pustules and crusts which dry up and fall off.

Monkeypox is usually a self limited disease with symptoms lasting from 2 to 4 weeks. Severe cases occur more commonly among children and are related to the extent of virus exposure. Underlying immune deficiencies may lead to worse outcomes.

Complications may include secondary infections, bronchopneumonia, sepsis, encephalitis and infection of the cornea with ensuing loss of vision.

Diagnosis

Differential diagnosis that must be considered includes other rash illnesses such as chickenpox, measles, bacterial skin infections, scabies, syphilis, and other allergic conditions.

Lymphadenopathy during the prodromal stage of illness can be a clinical feature to distinguish monkeypox from chickenpox or smallpox.

If monkeypox is suspected, collect an appropriate sample (Samples from skin lesions, the roof or fluid from vesicles and pustules, and dry crusts, biopsy) and transported safely (lesion samples must be stored in dry, sterile tube, no viral transport media required and kept cold) to a reference laboratory with appropriate capability. Polymerase Chain Reaction (PCR) is the preferred test. 

Treatment

No specific treatment is available. Clinical care should be fully optimized to alleviate symptoms, manage complications and prevent long term sequelae. Secondary bacterial infections should be treated. 

Vaccination

Vaccination against smallpox was demonstrated 85% effective in preventing monkeypox. At the present time, the original smallpox vaccines are no longer available to the general public. 

A newer vaccine based on a modified attenuated vaccinia virus (Ankara strain) was approved for the prevention of monkeypox in 2019. This is a two dose vaccine. 

Prevention

• Raising awareness of risk factors and educating people about the measures they can take to reduce exposure to the virus is the main prevention strategy.
• Reduce the risk of getting monkeypox by limiting close contact with people who have suspected or confirmed monkeypox or with animals who could be infected.
• Surveillance and rapid identification of new cases.
• Reducing the risk of zoonotic transmission.

INDIA CONFIRMS FIRST MONKEYPOX CASE

Kerala reports India's first known lab confirmed (National Institute of Virology, Pune)  case of monkeypox. The case has been reported in a 35 year old male, who reached the state from the UAE.

The person, a Kollam native, has been isolated for treatment at the Trivandrum Government Medical College Hospital. He had first consulted a private hospital at Kollam after he developed fever and other symptoms. He himself volunteered the information that close contact of his in the UAE had been confirmed as having contracted monkeypox, he was referred to the MCH here.