Monkeypox outbreak: On the cusp of another pandemic?

Mumbai: In the last few weeks, several countries have reported cases of monkeypox, raising concerns globally as the world is still reeling from the impact of the COVID-19 pandemic. Since May 13, 2022, several cases have been reported to the World Health Organisation (WHO) from 12 countries that are not endemic to the virus.

Epidemiological investigations are ongoing, however, reported cases thus far have no established travel links to endemic areas. Based on currently available information, cases have mainly but not exclusively been identified amongst men who have sex with men (MSM) seeking care in primary care and sexual health clinics.

According to the WHO as of May 21, 92 confirmed cases, and 28 suspected cases of monkeypox have been reported. What is more alarming is that in these cases there is no history of travel to endemic countries.

Monkeypox disease- a cause of concern

The disease is caused by the monkeypox virus, similar to the smallpox virus. It is a viral zoonotic disease (a virus transmitted to humans from animals); that occurs primarily in tropical rainforest areas of Central and West Africa. Animal hosts include a range of rodents and non-human primates.

Speaking about the disease, Dr Vinod Kumar Anand, Senior Consultant- Health, Save the Children, India, said, “The clinical presentation of monkeypox resembles that of smallpox, which was declared eradicated worldwide in 1980. Monkeypox is less contagious than smallpox and causes less severe illness. Transmission of the virus to humans is from infected animals. However human-to-human transmission is possible through contact with body secretions, skin lesions, respiratory droplets or contact with bedding and clothing of the patient and sexual contact. An infected person may transmit the disease from one to two days before the appearance of the rash and remain contagious till all the scabs fall off."

Informing that monkeypox typically presents clinically with fever, rash and swollen lymph nodes, Dr Shuchin Bajaj, Founder, Director, Ujala Cygnus Group of Hospitals, said, "Monkeypox virus is mostly transmitted to people from wild animals such as rodents and primates, but human-to-human transmission also occurs. The virus is transmitted from one person to another by contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding. Typically, up to a tenth of persons suffering from monkeypox may die, with most deaths occurring in younger age groups."

Monkeypox disease in children

No cases have been reported in India, but with new cases being detected from various countries chances of this disease occurring in India cannot be ruled out. Monkeypox is more common in children. “Of cases in Africa, 90 per cent were among children under 15 years old. In general, more severe cases are seen among children. Case fatality ratio is also on the higher side in young children. Immunocompromised children like children with severe malnutrition are at greater risk,” added Dr Anand.

Prevention and treatment

The virus enters the human host through broken skin or mucous membranes: eyes/nose/mouth. The exposure can occur from handling bushmeat, or animal bite/scratch. Human to human spread occurs through close contact with an infected person. Skin lesions due to monkeypox are mainly seen on the face and extremities. It is usually a self-limited disease that subsides in 2-4 weeks. Treatment includes supportive care with antipyretics and fluids. Antivirals include tecovirimat and brincidofovir as first-line treatments.

The disease is mild in nature and self-limiting. In most cases, symptomatic management is required. Preventive measures are to be followed like avoiding skin to skin or face to face contact with anyone who has symptoms, practising safer sex, keeping hands clean with water and soap or alcohol-based hand rub, and maintaining respiratory etiquette.

“Interestingly, the previously used smallpox vaccine offers 80-85 pre cent prevention against this disease, hence making people younger than 40-50 yrs more susceptible. A still newer vaccine based on a modified attenuated vaccinia virus was approved for the prevention of monkeypox in 2019.”

“Complications include pitted scars, deforming scars, secondary bacterial infections, keratitis, and blindness, encephalitis. The case fatality ratio of monkeypox has historically ranged from 0-11 per cent in the general population and has been higher among young children,” remarked Dr Vineet Arora, Director - Internal Medicine & Dr Parul Kakkar, Consultant - Internal Medicine, Max Super Speciality Hospital, Shalimar Bagh

Measures for prevention include:

• Food containing animal meat should be thoroughly cooked.
• Healthcare workers/family members taking care of infected patients should wear a PPE kit when around the patients, and inform healthcare experts.

Sharing his views Dr Prabhat Ranjan Sinha, Senior Consultant, Internal Medicine, Aakash Healthcare, Dwarka commented, “According to the first findings, infection is spread by intimate contact with infected animals such as rodents and monkeys. Anyone can spread monkeypox by coming into contact with a person's body fluids, sores, or sharing things (such as clothing and bedding) that have been contaminated with a person's fluids or sores. On surfaces, household disinfectants can kill the virus. Although monkeypox has only been deadly on a few occasions, it is critical to maintain hygiene and follow the same measures that we did for COVID-19. Even though it has not yet reached India, we must heighten our vigilance at the airports. The WHO has warned that more cases of monkeypox will emerge and that increased surveillance of incoming passengers will be required to prevent this. As a result, all efforts must be taken to prevent it from entering India.”

To date, all cases whose samples were confirmed by PCR have been identified as being infected with the West African clade. Genome sequence from a swab sample from a confirmed case in Portugal indicated a close match of the monkeypox virus causing the current outbreak, to exported cases from Nigeria to the United Kingdom, Israel and Singapore in 2018 and 2019.

Historically, vaccination against smallpox was protective against monkeypox. While one vaccine (MVA-BN) and one specific treatment (tecovirimat) were approved for monkeypox, in 2019 and 2022 respectively, these countermeasures are not yet widely available.

Indian government response

The Ministry of Health & Family Welfare has asked the National Centre for Disease Control and the ICMR to keep a strict vigil on possible monkeypox outbreaks. The Ministry has reportedly asked port authorities to be vigilant. National and several state governments have also issued advisories regarding the disease.

Parents are advised not to panic and to be vigilant and aware of the manifestations of monkeypox disease. They should be aware of the protective measures. Parents should immediately seek medical care if their child or any family member develops symptoms of the disease like an acute rash with fever, headache, muscle aches, lymph node swelling, and profound weakness.