Should not airborne transmission be ignored in the 2022 monkeypox outbreak?

Advancing the understanding and management of Mpox: insights into epidemiology, disease pathways, prevention, and therapeutic strategies

Mpox, previously known as monkeypox, is a zoonotic viral disease caused by the Mpox virus (MPXV), a member of the Orthopoxvirus genus. This disease is of significant concern due to its zoonotic transmission, which can be challenging to control, its ability to spread easily from person to person, the potential for severe symptoms or even fatality, and its history of frequent global outbreaks. Despite the growing threat, there is still limited research on the pathophysiology of the disease and available disease-modifying treatments. To address this gap, the latest developments in Mpox epidemiology, viral variant detection, and advanced diagnostic tools for accurate MPXV detection have been reviewed. Ongoing preventive measures, including vaccination strategies, have also been examined. Additionally, the genomic and proteomic characteristics of MPXV have been explored, and network and pathway enrichment analyses have been performed to identify potential therapeutic targets. The findings presented in this manuscript suggest the potential for novel disease-modifying treatments. Moreover, emerging technologies, such as artificial intelligence and "big data," are playing a crucial role in advancing disease management and enhancing prevention strategies. This review emphasizes the evolving understanding of Mpox and MPXV variants and underscores the importance of continued research and public health initiatives to combat the disease and prevent future global outbreaks.

Insights into the Transmission, Host Range, Genomics, Vaccination, and Current Epidemiology of the Monkeypox Virus

This review delves into the historical context, current epidemiological landscape, genomics, and pathobiology of monkeypox virus (MPXV). Furthermore, it elucidates the present vaccination status and strategies to curb the spread of monkeypox. Monkeypox, caused by the Orthopoxvirus known as MPXV, is a zoonotic ailment. MPXV can be transmitted from person to person through respiratory droplets during prolonged face-to-face interactions. While many cases of monkeypox are self-limiting, vulnerable groups such as young children, pregnant women, and immunocompromised individuals may experience severe manifestations. Diagnosis predominantly relies on clinical presentations, complemented by laboratory techniques like RT-PCR. Although treatment is often not required, severe cases necessitate antiviral medications like tecovirimat, cidofovir, and brincidofovir. Vaccination, particularly using the smallpox vaccine, has proven instrumental in outbreak control, exhibiting an efficacy of at least 85% against mpox as evidenced by data from Africa. Mitigating transmission requires measures like wearing surgical masks, adequately covering skin lesions, and avoiding handling wild animals.

Cytokine storm in human monkeypox: A possible involvement of purinergic signaling

Some evidence has indicated that monkeypox can induce a cytokine storm. Purinergic signaling is a cell pathway related to the cytokine storm. However, the precise mechanisms that lead to cytokine storms in monkeypox infections and the possible involvement of purinergic signaling in the immune response to this virus remain unknown. In this review article, we aimed to highlight a body of scientific evidence that consolidates the role of the cytokine storm in monkeypox infection and proposes a new hypothesis regarding the roles of purinergic signaling in this immune-mediated mechanism. We further suggested some purinergic signaling modulators to mitigate the deleterious and aggravating effects of immune dysregulation in human monkeypox virus infection by inhibiting P2X3, P2X7, P2Y2, and P2Y12, reducing inflammation, and activating A1 and A2A receptors to promote an anti-inflammatory response.

Overcoming Stigma: The Human Side of Monkeypox Virus

Monkeypox (Mpox) virus is a zoonotic disease that was recently declared a public health emergency of international concern (PHEIC) by the World Health Organization (WHO). Symptoms of Mpox include fever, headache, muscle pain, and a rash which starts on the face and spreads to the rest of the body. The stigma surrounding the Mpox virus has been one of the greatest challenges in dealing with the disease. People with Mpox have been often shunned by their communities, and many are afraid to seek medical care for fear of ostracism. For those affected by the virus, this stigma can significantly impact their mental health and quality of life. It is further fueled by misinformation and societal norms. Hence, a multifaceted approach that includes education, awareness campaigns, and community engagement is needed to overcome the stigma associated with Mpox. Effective communication strategies are critical to the dispelling of rumors and the reduction of fear. Interventional measures need to be shaped according to the needs of those affected.

Mpox and healthcare workers — a minireview of our present knowledge

Introduction

Workers in the healthcare industry form the backbone of health systems everywhere. In the face of global health crises like the current monkeypox (mpox) outbreak, healthcare workers like doctors, dentists, pharmacists, nurses, midwives, paramedics, administrators, support staff, laboratory technicians, and community health workers all play crucial roles in providing care and containing the spread of the disease.

Aim

Therefore, in the wake of concerns about mpox recurrence, we seek to shed light on the occupational transmission of mpox infection and the possible risk to healthcare personnel.

Results

Contamination of the environment of the household of cases of mpox and environment of the patient care units with the viral DNA has been reported besides asymptomatic cases and detection of viral DNA in air samples; therefore, more research on non-lesion-based testing for human mpox infection for screening asymptomatic people, particularly among populations at high risk of infection, in the event of asymptomatic transmission and potential transmission via aerosols is necessary. Monitoring efforts can be aided by incorporating mpox testing into locations where people are more likely to contract illnesses and seek medical attention. We must take a precautionary infection control approach to control the spread of the virus while completing urgent research to understand better the human-to-human mpox transmission process.

Conclusions

In this minireview, we discuss the potential routes of mpox transmission to healthcare and preventative strategies and measures that should be taken and considered.

Graphical Abstract

Monkeypox Virus Infections in Humans

Human monkeypox is a viral zoonosis endemic to West and Central Africa that has recently generated increased interest and concern on a global scale as an emerging infectious disease threat in the midst of the slowly relenting COVID-2019 disease pandemic. The hallmark of infection is the development of a flu-like prodrome followed by the appearance of a smallpox-like exanthem. Precipitous person-to-person transmission of the virus among residents of 100 countries where it is nonendemic has motivated the immediate and widespread implementation of public health countermeasures. In this review, we discuss the origins and virology of monkeypox virus, its link with smallpox eradication, its record of causing outbreaks of human disease in regions where it is endemic in wildlife, its association with outbreaks in areas where it is nonendemic, the clinical manifestations of disease, laboratory diagnostic methods, case management, public health interventions, and future directions.

Disease History, Pathogenesis, Diagnostics, and Therapeutics for Human Monkeypox Disease: A Comprehensive Review

The monkeypox disease is a zoonotic-infectious disease that transmits between animals and humans. It is caused by a double-stranded DNA virus belonging to the Orthopoxvirus genus that is closely related to the variola virus -the causative agent of smallpox. Although monkeypox infections were endemic to Western and Central Africa, the newly emerging monkeypox outbreak spread to more than 90 non-African countries. With the exception of the PCR-confirmed case of a return from Nigeria to the United Kingdom, the ongoing outbreak is largely unrelated to travel. In the most recent wave, cases are characteristically males in their thirties. Risk factors include close and particularly sexual contact with an infected person, and contact with fomites, infected animals or aerosolized-infectious material. Clinical diagnosis of monkeypox is confirmed with nucleic-acid amplification testing of samples originating from vesicles or genital lesions and using real-time or conventional PCR. Other methods, such as electron microscopy, immunohistochemistry, and virus culture are costly and time-consuming. In addition to timely diagnosis and contact tracing, restrictive measures to limit spread, such as isolation of infected patients, preventing contact with wild animals, and isolation of animals suspected to be viral reservoirs have shown promise. Although there are no specific treatments for monkeypox disease, the experience with smallpox suggests that the vaccinia vaccine, cidofovir, tecovirimat, and vaccinia immune globulin (IVG) may be beneficial for monkeypox treatment. In this review, we provide an update on the human-monkeypox disease with a special emphasis on its pathogenesis, prevention, diagnostics, and therapeutic measures.

Epidemiology-based analysis of the risks and elimination strategies of the monkeypox outbreak in 2022

Human monkeypox, caused by monkeypox virus, has spread unprecedentedly to more than 100 countries since May 2022. Here we summarized the epidemiology of monkeypox through a literature review and elucidated the risks and elimination strategies of this outbreak mainly based on the summarized epidemiology. We demonstrated that monkeypox virus became more contagious and less virulent in 2022, which could result from the fact that the virus entered a special transmission network favoring close contacts (i.e., sexual behaviors of men who have sex with men outside Africa) and the possibility that the virus accumulated a few adaptive mutations. We gave the reasons to investigate whether cattle, goats, sheep, and pigs are susceptible to monkeypox virus and whether infection with monkeypox virus could be latent in some primates. We listed six potential scenarios for the future of the outbreak (e.g., the outbreak could lead to endemicity outside Africa with increased transmissibility or virulence). We also listed multiple factors aiding or impeding the elimination of the outbreak. We showed that the control measures strengthened worldwide after the World Health Organization declared the outbreak a public health emergency of international concern (PHEIC) could eliminate the outbreak in 2022. We clarified eight strategies, i.e., publicity and education, case isolation, vaccine stockpiling, risk-based vaccination or ring vaccination, importation quarantine, international collaboration, and laboratory management, for the elimination of the outbreak.

Combating Stigma and Health Inequality of Monkeypox: Experience from HIV

With Western Pacific Region reporting more imported cases, the World Health Organization (WHO) declared monkeypox a public health emergency of international concern in July. Currently, we are now at the beginning of forming stigmatization toward monkeypox. Based on the experience of combating HIV stigmatization for over 30 years, in this comment, we proposed measures based on the three stages of the stigma formation process. We believe the paper may be of particular interest to the readers of your journal as it offered implications for both healthcare professionals and researchers in Western Pacific Region.

Monkeypox infection: An update for the practicing physician

As of August 5, 2022, >26,000 cases of monkeypox have been diagnosed worldwide and the steep increase of cases has spurred renewed concern about the risk for another viral pandemic. In this narrative review, we address etiology, epidemiology and virology of monkeypox, describing routes of transmission and modes of spread. We also describe the current clinical presentation of monkeypox, focusing on circumstances where the disease should be suspected, and the methods to diagnose it. Finally, we briefly describe available treatments and strategies for active immune prophylaxis.

Ocular manifestations of recent viral pandemics: A literature review

Viral pandemics often take the world by storm, urging the medical community to prioritize the most evident systemic manifestations, often causing ocular manifestations to go unnoticed. This literature review highlights the ocular complications of the Monkeypox, SARS-CoV-2, MERS, Ebola, H1N1, and Zika viruses as the most recent viral pandemics. Research into the effects of these pandemics began immediately. Moreover, it also discusses the ocular complications of the vaccines and treatments that were used in the scope of the viral pandemics. Additionally, this review discusses the role of the eye as an important route of viral transmission, and thereafter, the International recommendations to reduce the incidence of viral transmission were mentioned. Lastly, this paper wants to lay out a platform for researchers who want to learn more about how viruses show up in the eye.