|
 
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| REVIEW ARTICLE |
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| Year : 2023 | Volume
: 4
| Issue : 1 | Page : 8-11 |
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Monkeypox 2022: Emerging zoonotic epidemic threat, future implications, and way ahead
Suraj Kapoor1, Ashvin Varadharajan2
1 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Medical Student, Armed Forces Medical College, Pune, Maharashtra, India
| Date of Submission | 28-May-2022 |
| Date of Decision | 20-Jun-2022 |
| Date of Acceptance | 07-Jul-2022 |
| Date of Web Publication | 19-Oct-2022 |
Correspondence Address:
Dr. Suraj Kapoor
Department of Community Medicine, Armed Forces Medical College, Solapur Road, Wanowrie, Pune - 411 040, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jphpc.jphpc_21_22
Introduction: Monkeypox is a rare zoonotic disease that is caused by a virus belonging to the Orthopoxvirus genus and is closely related to smallpox and cowpox viruses. The emerging epidemic amid the current COVID-19 pandemic is a matter of concern and warrants urgent public health attention with key issues discussed in the article. Aim: The aim of this study was to explore emerging zoonotic, epidemic threats, future implications, and the way ahead in respect of monkeypox. Methodology: Secondary data from official government sites, press information, latest articles, newspapers, and the WHO website were extracted and discussed in the article. The current epidemiology of monkeypox with the difference from the COVID-19 pandemic is highlighted in the study. The most probable factors for the emergence and recent outbreak are also discussed. The period of the study was from May 20, 2022, to May 27, 2022, and was conducted in the medical college of Western Maharashtra. Results and Discussion: Total number of 25 articles/government/international websites were assessed. While comparing the number of cases among different countries across the globe, the present outbreak has involved different countries with no geographical continuity, with a maximum number of cases from Portugal, Spain, and the United States of America. A comparison of epidemiological determinants of COVID-19 and monkeypox was done which reveals the lesser pandemic potential of monkeypox as compared to COVID-19. Conclusion: The present monkeypox outbreak scenario is different from the previous outbreaks, but with lesser pandemic potential as compared to COVID-19. However, with the increase in the incidence of monkeypox cases in different countries, the fear of cross-border transmission is real. Robust public health surveillance and control measures are vital to address this threat.
Keywords: COVID-19, monkeypox, smallpox, zoonotic
How to cite this article:
Kapoor S, Varadharajan A. Monkeypox 2022: Emerging zoonotic epidemic threat, future implications, and way ahead. J Public Health Prim Care 2023;4:8-11 |
How to cite this URL:
Kapoor S, Varadharajan A. Monkeypox 2022: Emerging zoonotic epidemic threat, future implications, and way ahead. J Public Health Prim Care [serial online] 2023 [cited 2023 Jun 5];4:8-11. Available from: http://www.jphpc.org/text.asp?2023/4/1/8/358588 |
| Introduction | |  |
Just as the world recovers from the throes of the COVID-19 pandemic, there are reports of monkeypox virus infections in previously unaffected regions. At present, over 100 cases of the disease have been reported across 12 nonendemic countries spanning 3 WHO regions, with no fatalities.[1]
Monkeypox is a rare zoonotic disease that is caused by a virus belonging to the Orthopoxvirus genus[2] and is closely related to smallpox and cowpox viruses. This similarity was supported by a recent systematic review which documented that many cases of monkeypox happen in individuals who are not vaccinated against smallpox.[3]
A diverse variety of animal species, which include squirrels, mice, dormice, and monkeys, act as a natural reservoir for the disease.[4] Primary animal-to-human, as well as secondary human-to-human transmission, occur through direct contact, mucous membranes, and respiratory droplets. Secondary transmission can also occur from close contact with bodily fluids, contaminated linens, and even sexual contact.[5]
The known natural history of the disease typically begins with a viral prodrome of 1–4 days, followed by the appearance of a centrifugal rash containing well-circumscribed, deep-seated, umbilicated lesions which slowly progress over 1–2 weeks. It is estimated that about 90% of cases are associated with characteristic lymphadenopathy, which differentiates it from other pox-like illnesses.[6] The disease is usually self-limiting with a wide case fatality rate ranging between 1% and 10%. Young children, the elderly, and the immunocompromised population are at greater risk for adverse outcomes. Complications such as bronchopneumonia, encephalitis, and corneal infections have also been reported.[4] The emerging epidemic amid the current COVID-19 pandemic is a matter of concern and warrants urgent public health attention. The current literature lacks epidemiological aspects of the current outbreak of monkeypox with a comparison of COVID-19 and monkeypox. Thus, this study was conducted to highlight the key epidemiological aspects of monkeypox, differences with COVID-19, its future implications, and the way ahead.
| Methodology | | |
Secondary data from official government sites, press information, latest articles, newspapers, and the WHO website were extracted and discussed in the article. The current epidemiology of monkeypox with a difference from the COVID-19 pandemic is highlighted in the study. The most probable factors for the emergence and recent outbreak are also discussed. The period of the study was from May 20, 2022, to May 27, 2022, and was conducted in the medical college of Western Maharashtra.
| Results | | |
Total number of 25 articles/government/international websites were assessed. [Table 1] highlights the number of cases across the globe. The present outbreak has involved different countries with no geographical continuity with a maximum number of cases from Portugal, Spain, and the United States of America. As per WHO latest report,[7] there are 92 confirmed and 28 suspected cases. A comparison of epidemiological determinants of COVID-19 and monkeypox was done as highlighted in [Table 2] which reveals the lesser pandemic potential of monkeypox as compared to COVID-19. Most probable factors related to the emergence and current outbreak are also highlighted in [Figure 1]. | Figure 1: Most probable factors related to the emergence and current outbreak
Click here to view |
| Discussion | | |
The present manuscript highlights emerging monkeypox outbreaks across the globe involving various countries. However, the key differences between key epidemiological aspects of COVID-19 and monkeypox reveal less pandemic potential substantiated by lesser reproduction number, with no mutation, and preexisting immunity in the case of monkeypox. The most probable factors related to the emergence and current outbreak are highlighted in [Figure 1]. Other key epidemiological aspects of monkeypox are highlighted below:
History
Monkeypox virus was first discovered in cynomolgus monkeys in a laboratory setting in Copenhagen, Denmark, in 1958. It was in 1970 that the first human case was reported in the Basankusu Territory of the Democratic Republic of the Congo in a 9-month-old child who presented with clinical features similar to smallpox but later was identified as monkeypox virus.[15]
Until 2003, monkeypox cases were sporadically recorded in the Central and West Africa regions. However, outbreaks began to occur in Sudan, the Democratic Republic of the Congo (DRC), and eventually, imported cases were reported in the United States in the early 2000s. There were as many as 47 notified cases in the United States in 2003 with 26% of cases hospitalized and 15% having severe outcomes. However, there was no fatality reported.[16]
Present epidemic different from the previous outbreaks
Following confirmation of the first case of monkeypox in the United Kingdom by the United Kingdom Health Security Agency on May 7th, 2022, the scenario has evolved with dizzying swiftness leading to 92 confirmed cases identified in the United Kingdom, Europe, North America, and Australia with almost similar numbers as suspect cases,[17] later involving more than 10 countries with many suspected cases as well, as highlighted in [Table 1]. The present scenario is quite different from the previous outbreaks. First, there is an unusually higher number of cases involving different countries. Second, there is a lack of travel history to countries in Africa in many cases. Third, the cases are hundreds of miles from each other with a lack of clear-cut contact identification and tracing which signifies the fact that there may be many unnoticed/hidden cases in the community revealing the iceberg phenomenon of the disease.
Comparison of monkeypox with SARS-CoV-2
We are currently facing the challenge of the COVID-19 pandemic. However, the threat of emerging–remerging/zoonotic diseases is on the rise highlighted by the current epidemic of monkeypox across the globe. However, there are subtle differences between the epidemiological aspects of SARS-CoV-2 and monkeypox which are highlighted in [Table 2]. Monkeypox is a less transmissible, more rare disease, and requires large doses of virus for human-to-human transmission as compared to SARS-CoV-2. Moreover, we already have a smallpox proven vaccine effective for monkeypox, enabling the part of the community to have preexisting immunity to monkeypox. This was not the case with SARS-CoV-2, which resulted in a Public Health Emergency of International Concern and the pandemic. Second, the literature suggests the monkeypox virus has not mutated from the past,[18] while SARS-CoV-2 has undergone a series of mutations such as Delta, Omicron, and other variants of concern and interest. All these facts highlight that the pandemic potential of monkeypox seems to be less as compared to COVID-19.
Prevention: Layered preventive strategy
Use of personal protective equipment, such as the use of face masks, respiratory etiquette, and hand hygiene.
Spatial prevention
Defensive isolation and offensive containment/quarantine strategy.
Health education
Public health officials/policymakers must provide health education-related guidelines to the community and apprise health-care workers about prevention and modes of transmission, which should also take into account risk communication strategy to avoid unnecessary panic in the community.
Vaccination and treatment
Evidence from Africa revealed that smallpox vaccination provides 85% protection for those at risk. A monkeypox vaccine (imvamune or imvanex) was approved by the American Regulators for both monkeypox and smallpox. The relative decline in smallpox vaccine immunity over time was thought to account for monkeypox outbreaks in 2017–2020. On May 19, 2022, the drug tecovirimat was approved in the US, Canada, and Europe for treating human smallpox disease. The European Medicines Agency also advocates the treatment of monkeypox using the drug tecovirimat.[19],[20]
Future implications and way ahead
There is a ray of hope with scientists in Portugal describing the first draft genome sequence of the monkeypox virus recently detected in Portugal.[21] The preliminary genetic data indicates that the 2022 virus belongs to the West African clade and is phylogenetically related to the monkeypox viruses linked to the disease spread from Nigeria to the United Kingdom, Israel, and Singapore in 2018 and 2019.[22],[23]
Case definitions of monkeypox disease have been updated to account for possible cases that lack a history of travel to endemic countries.[24] Similarly, new clinical guidelines are being developed to address questions including the use of appropriate personal protective equipment in sexual health clinics and the review of standard operating procedures in laboratories. The distinctive variation in the epidemiology of human monkeypox during this outbreak underlines several issues. For example, some of the cases in this outbreak lack the classical clinical picture. Similarly, the herald skin lesions at the point of sexual contact are strongly suggestive of sexual transmission. Nevertheless, there are concerns that the media projection of men who have sex with men as the at-risk population for the outbreak may unjustifiably stigmatize these groups. With the increase in the incidence of monkeypox cases in different countries, the fear of cross-border transmission is real. Robust public health surveillance and control measures are vital to address this threat. Simultaneously, there it is imperative to explore further whether the recent outbreak is driven by animal reservoirs outside Africa, due to human behavior, or maybe due to viral mutation.
| Conclusion | | |
The present monkeypox outbreak scenario is quite different from the previous outbreaks with the rise in cases in different countries with no geographical continuity. However, monkeypox is a less transmissible, more rare disease, and requires large doses of virus for human-to-human transmission as compared to SARS-CoV-2, thus limiting its pandemic potential. With the increase in the incidence of monkeypox cases in different countries, the fear of cross-border transmission is real. Robust public health surveillance and control measures are vital to address this threat.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2]
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