Monkeypox Disease: Causes, Symptoms, Treatment and Prevention

Overview

Monkeypox cases have been reported in many countries this month (May 2022). The virus is rapidly spreading across Europe and North America. The United Kingdom (UK) has confirmed 20 cases of the rare virus since the first week of May 2022.

Since 13 May 2022, cases of Monkeypox have been reported to WHO from 12 Member States that are not endemic for the Monkeypox virus across three WHO regions.

The World Health Organization (WHO) has called for an emergency meeting to discuss Monkeypox to focus on the transmission and vaccines of this virus.

What is Monkeypox? 

Monkeypox is a viral zoonosis transmitted to humans from animals, with symptoms very similar to smallpox but clinically less severe. 

According to the Centers for Disease Control and Prevention (CDC), Monkeypox was first identified in 1958 in monkeys in a Danish laboratory and again in 1970 in humans in the Democratic Republic of the Congo. In the subsequent years, Monkeypox outbreaks have cropped up in areas across Central and West Africa.

How common is Monkeypox?

Monkeypox is a rare disease that primarily occurs in West and Central Africa, often in proximity to tropical rainforests. However, the number of cases is rising in Africa, including those urban regions that have not seen these infections before. 

With 80 per cent of cases in European countries, the WHO confirmed the global outbreak of Monkeypox and sounded its highest level of alert for the disease declaring the virus as a Public Health Emergency of International Concern (PHEIC).

The disease is caused by the Monkeypox virus, the same virus family (variola virus) that causes smallpox. 

The symptoms of Monkeypox are similar to smallpox but are milder. Rarely fatal, this disease is not related to chickenpox.

Where else is Monkeypox found?

For many years, Monkeypox was seen mostly in Africa. However, it is found occasionally in other countries too. The year 2022 brought outbreaks of Monkeypox to regions outside of Africa, including Europe, the Americas, Australia, including the South-East Asia region. Currently, the outbreak of Monkeypox disease, which the WHO has termed “unusual”, has affected nearly 17,000 people in 74 countries. 

The first case of Monkeypox in the South-East Asia Region of the WHO was reported from India – in a 35-year-old-man who arrived from the Middle East. With Delhi confirming a case of Monkeypox recently on July 24, 2022 (a day after the WHO declared a Public Health Emergency of International Concern) India reported its fourth case. The latest Delhi case is of a 31-year-old man with no foreign travel history. 

Who does Monkeypox affect?

While most of the cases are among children aged below 15 years in Africa, anyone in any age group can get Monkeypox disease. Outside Africa, the disease seems to be more common in men having sex with men. However, there are numerous cases seen in individuals who do not fall into this category.

What Causes Monkeypox?

Monkeypox is caused by the Monkeypox virus, a double-stranded DNA virus (genus Orthopoxvirus of the Poxviridae family). According to the CDC, the virus is related closely to other ‘pox’ viruses like: 

• Vaccinia (used for smallpox vaccine)
• Variola major and minor (that cause smallpox)
• Cowpox virus

The virus (found mainly in tropical rainforest regions of West and Central Africa) was first identified in captive monkeys. The two sub-types of the virus are Congo Basin and West African clades that match the geographical regions. 

Along with monkeys, the virus was also identified in African squirrels and Gambian pouched rats. The use of these animals as food could be a vital source of transmission to humans.

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Humans can be infected by an animal via:

1. A scratch/bite
2. Bushmeat preparation
3. By contact with the bodily fluids or lesion material of an infected animal 

The virus is said to enter the body through the respiratory tract, broken skin, or the mucous membranes of the mouth, nose or eyes

Once an individual is infected, transmission to others is common, with family members as well as hospital staff mainly at risk of infection. The virus can spread by airborne (respiratory) contact or by direct contact with the bodily fluids of an infected person. 

There are certain indications that transmission can happen during sexual contact or due to indirect contact with lesion material like contaminated bedding. Risk factors for spread include sharing a bed or room of the infected person, or using the same utensils used by the infected person. Increased transmission risk is linked to factors involving the introduction of virus to the oral mucosa.

What are the Signs and Symptoms of Monkeypox?

The time from infection to symptoms (incubation period) for Monkeypox is generally from 6 to 13 days but can range from 5 to 21 days.

The infection starts with:

1. Headache
2. Fever
3. Backache
4. Muscle aches
5. Chills
6. Exhaustion
7. Swollen lymph nodes

The disease can be divided into two periods:

1. The invasion period, which lasts between 0–5 days, is characterized by intense headache, fever, back pain, swelling of the lymph nodes (lymphadenopathy), muscle aches (myalgia) and lack of energy (intense asthenia). Compared to other diseases that may initially look similar (smallpox chickenpox, measles), lymphadenopathy is a distinctive feature of Monkeypox infection.
2. Usually, the skin eruption starts within 1–3 days of the advent of fever. The rash is likely to be more concentrated on the face including the extremities rather than on the trunk. It affects the palms of the hands and soles of the feet in 75% of cases and in the face in 95% of cases. It also affects the oral mucous membranes in 70% of cases, genitalia in 30% and conjunctivae in 20% of cases, including the cornea. The rash evolves sequentially from lesions with a flat base (macules) to slightly raised firm lesions (papules), lesions filled with clear fluid (vesicles), lesions filled with yellowish fluid (pustules), and crusts that dry up and fall off. The number of lesions varies from a few to several thousand. In many cases, lesions may coalesce until large sections of skin slough off.

Generally, Monkeypox is a self-limited disease with symptoms lasting from 2 – 4 weeks. However, severe cases may occur more commonly among children and are related to the patient’s health status, the nature of complications and the extent of exposure to the virus. Any underlying immune deficiencies may cause worse outcomes. 

While vaccination against smallpox was protective earlier, today people under 40 to 50 years of age, depending upon their country, may be more susceptible to Monkeypox disease due to the end of smallpox vaccination campaigns worldwide after the eradication of this disease.  

The fatality ratio of Monkeypox disease has ranged historically from 0 – 11% in the general populace and has been higher among young children. However, the case fatality ratio has been around 3 – 6% in recent times.

What are the Complications of Monkeypox? 

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

If infection happens during pregnancy, birth defects or stillbirth may occur. The disease may be milder in those vaccinated against smallpox in childhood. 

Remember, no smallpox or Monkeypox vaccine has been approved for use during pregnancy.  

How does Monkeypox Spread? 

Monkeypox virus spreads when an individual comes into contact with the virus from a human, animal, or any materials contaminated with the virus.  This virus enters the human body through the respiratory tract, the mucous membranes (mouth, eyes, or nose) or even through broken skin (although not visible).  

Monkeypox can spread from person to person, but it’s less common. Person-to-person spread (transmission) occurs when you come in contact with the sores, scabs, respiratory droplets or oral fluids of an infected person usually through close, intimate situations like cuddling, kissing or sex. Research is ongoing, but researchers aren’t sure if the virus is transmitted through semen or vaginal fluids.

You can also get monkeypox by coming into contact with recently contaminated materials like clothing, bedding and other linens used by an infected person or animal.

Animal-to-human transmission 

Monkeypox can spread from animal to human through a scratch or a bite, direct contact with the blood, bodily fluids or pox lesions (sores) of an infected animal, or indirect contact with lesion material, like contaminated bedding and bushmeat preparation. The term ‘bushmeat’ refers to raw or minimally processed meat that comes from wild animals.  

Human-to-human transmission 

Monkeypox is thought to spread from human to human mainly through large respiratory droplets. Generally, respiratory droplets cannot travel more than a few feet. Therefore, prolonged face-to-face contact is needed for the virus to spread. Human-to-human transmission can also occur when a person comes in contact with the sores, scabs or oral fluids of an infected individual usually through close, intimate situations such as cuddling, kissing or sex. Studies are underway but researchers are not sure if the virus can transmit through semen or vaginal fluids. Other human-to-human transmission modes include indirect contact with lesion material like linen and clothing contaminated with the virus.

Monkeypox typically lasts 2-4 weeks and can spread from the time symptoms start developing until the rash has healed fully and a fresh layer of skin is formed. Asymptomatic people or those who do not have Monkeypox symptoms cannot transmit the virus to others. 

While African rodents are suspected of playing a part in the spread, the Monkeypox virus’s main disease carrier (or the reservoir host) is still unknown.

How is Monkeypox diagnosed?

As Monkeypox is a rare disease, your doctor may first suspect other rash diseases like smallpox, chickenpox or measles. However, swollen lymph nodes (lymphadenopathy) generally distinguish Monkeypox from other poxes.

To diagnose Monkeypox, the healthcare worker takes a tissue sample from the open lesion (sore) of an infected person and transports it safely (in accordance with national and international requirements) to a laboratory with appropriate capability. Polymerase chain reaction (PCR) is the most preferred lab test given its sensitivity and accurateness. Then, the infected person may have to give a blood sample to check for the Monkeypox virus or antibodies their immune system makes to it.

Is Monkeypox Curable?

Generally, Monkeypox is a self-limited disease with symptoms that last 2-4 weeks. Many people with Monkeypox do not need treatment and get better on their own. Following diagnosis, the doctor will monitor the condition while trying to prevent dehydration, relieve the symptoms, and administer antibiotics for the treatment of secondary bacterial infections if they do develop.

What is the Treatment for Monkeypox? 

Currently, there are no there is no proven Monkeypox-specific treatment. Antiviral medications may help, but they have not been researched as a treatment for Monkeypox. 

However, as smallpox and Monkeypox viruses are genetically similar, antiviral medicines and vaccinations developed to protect against smallpox infection can be used to prevent and treat Monkeypox virus infections.

Antiviral medications like tecovirimat (TPOXX), can be recommended for people who are prone to getting severely sick, such as patients with weakened immune systems.

If you have Monkeypox symptoms, you should talk to your doctor immediately, irrespective of whether you have had contact those with Monkeypox or not.

How to prevent Monkeypox?

The main prevention strategy for Monkeypox is to raise awareness of risk factors and educate everyone about the measures they should take to reduce virus exposure. Currently, studies are underway to assess the appropriateness and feasibility of vaccination to prevent and control Monkeypox.

Prevention depends on reducing human contact with infected animals and limiting human-to-human spread. The best way to help prevent the spread of the Monkeypox is to:

Reducing the risk of human-to-human transmission

To contain the outbreak, surveillance and rapid identification of new cases are critical. During Monkeypox outbreaks, avoid close contact with infected persons. 

Household members and health workers are at a higher risk of infection. Isolate the infected person from other household members who can be at risk 

Health workers taking care of patients with suspected/confirmed virus infection or handling specimens from these patients should implement standard infection control precautions. If possible, individuals vaccinated previously against smallpox should be selected to care for Monkeypox patients.

Reducing the risk of animal-to-human (zoonotic) transmission

Most human infections, over time, have resulted from a primary, animal-to-human spread. Unprotected contact with wild animals, particularly those that are ill or dead, including their blood, meat and other parts should be avoided. In addition, all foods containing animal meat or parts must be cooked thoroughly before eating.

Preventing monkeypox virus through restrictions on animal trade

A few countries have placed regulations restricting import of rodents and non-human primates. Animals in captivity that are possibly infected with monkeypox virus should be isolated from other animals and placed into quarantine immediately. Any animals that may have come into contact with an infected animal should also be quarantined. They should be handled with standard precautions and observed for monkeypox symptoms for 30 days.

Vaccination 

The US-baed Centers for Disease Control and Prevention (CDC) recommends taking vaccination for those who have been exposed to monkeypox virus and individuals who are at greater risk of being exposed to monkeypox, as well as:

1. Those who were identified by public health officials as a contact of a person with monkeypox
2. Individuals who could have been exposed to Monkeypox virus, including:

• People come to know that their sexual partners was diagnosed with monkeypox in the past 2 weeks 
• Persons who have had multiple sexual partners in an region with known monkeypox infections in the past 2 weeks 

3. People engaged in jobs that may expose them to orthopoxviruses, like:

• Lab workers who perform testing for orthopoxviruses
• Lab workers who handle cultures or animals with orthopoxviruses

4. A few designated healthcare or public health workers

How concerned should we be about Monkeypox?

The outbreaks reported so far have been atypical as they are occurring in the countries where the monkeypox virus does not regularly circulate. Most of the reported cases reported have been detected in Spain, Portugal,  the UK and the US. 

However, the mode of transmission for this virus is much easier to prevent and control compared to the virus with aerosolization components like COVID-19 or measles.

The disease prevention strategies in response to COVID-19, such as masking, social distancing, increasing ventilation and staying home if sick, can also help against Monkeypox. Hand hygiene is also a key as this is a DNA virus, which is better suited to survive on surfaces.

Conclusion

There are increasing cases of Monkeypox in many countries. The disease is similar to smallpox but is less severe. Health experts opine that Monkeypox is spread by contact with bodily fluids having the virus rather than through the air like COVID-19 or measles.

Health experts also say that there is no need for concern just yet since vaccines and treatments against smallpox are effective to some extent against infection. In addition, the strategies used against COVID-19, like social distancing and good hand hygiene, can also help prevent this disease.

Frequently Asked Questions (FAQs)

Is anyone from India infected with Monkeypox?

The outbreaks of Monkeypox are occurring in the countries where the monkeypox virus does not regularly circulate. Most of the cases reported have been detected in Spain, Portugal,  the UK and the US. 

In India, a Delhi-based 34-year-old man with no history of any foreign travel tested positive for monkeypox on 24 July 2022 taking the tally of cases in the country to four.

The Union health ministry has directed the Indian Council of Medical Research (ICMR) and the National Centre for Disease Control (NCdC) to watch this outbreak closely. In addition, if cases increase, the government may start screening people arriving from the affected countries.

Which doctor should I consult for Monkeypox?

You should consult a general physician if you suspect Monkeypox. The physician will check you before getting the tests done to confirm the diagnosis. Patients infected with Monkeypox will also be quarantined to prevent its spread.

What are the complications of a monkeypox infection?

There may be soft tissue infections during the skin eruption phase of the disease. Other complications like encephalitis, pneumonitis and other oculars (eyes) issues are also noted in the monkeypox infection though the severity is not likely to be as high as in small pox.

What happens if you get Monkeypox?

Monkeypox causes fever, body aches, headache, swollen lymph nodes and a rash. The rash starts as flat spots that turn into bumps which then fill with fluid. These bumps crust and fall off as they heal. A few individuals may develop spots that look similar to pimples/blisters before having any other symptoms.

Is monkeypox different from smallpox?

Yes. Monkeypox symptoms are similar to smallpox, but are comparatively milder. In addition, Monkeypox is rarely fatal. 

How do you avoid getting monkeypox?

Monkeypox can be avoided by taking the following precautions:

1. Avoid direct contact with animals that could harbor the virus. This includes animals that are sick or that have been found dead in the regions where Monkeypox is spreading
2. Avoid contact with any material that was in contact with a sick animal
3. Isolate the infected person from others who can be at risk
4. Practice hand hygiene after coming into contact with infected humans or animals. For instance, wash your hands with soap and water or use an alcohol-based hand sanitizer
5. Use personal protective equipment (PPE) when caring for the infected patients
6. In addition, the vaccine against smallpox is about 85 percent effective at preventing Monkeypox