A Nosocomial Outbreak of Human Monkeypox in the Central African Republic

A time of decline: An eco-anthropological and ethnohistorical investigation of mpox in the Central African Republic

The Central African Republic (CAR) has experienced repeated mpox outbreaks since 2001. Although several mpox epidemiological risk factors for zoonotic and interhuman transmission have been documented, the reasons for more frequent epidemic outbreaks are less well understood, relying on vague explanatory categories, including deforestation, hunting, and civil unrest. To gain insight into increasingly frequent outbreaks, we undertook an ethnohistorical, eco-anthropological analysis in two CAR regions: the Lobaye prefecture, experiencing one or more annual outbreaks in the past decade, and the Sangha-Mbaere prefecture, with a longer history of mpox but less frequent outbreaks. We comparatively examined changing political economies, forest use practices, and understandings of mpox. In 2022, we conducted 40 qualitative ethnohistorical, anthropological interviews and participant-observation of forest activities in two languages (Sango and French). We compared contemporary practices with hunting, trapping, and meet consumption practices, documented through quantitative and qualitative observation in one research site, over 6 months in 1993. We find increased rodent capture and consumption in both sites in the past 30 years and expanded practices of other potentially risky activities. Simultaneously, we also identify important differences in risky practices between our Lobaye and Sangha-Mbaere participants. In addition, Lobaye and Sangha participants underscored historical processes of decline producing mpox among other emergences, but they framed these declension processes diversely as economic, political, nutritional, and moral. Our findings are important because they mobilize new types of evidence to shed light on the processual dynamics of mpox outbreaks in the CAR. This study also reveals variability across two sites within the same country, highlighting the importance of comparative, fine-grained anthropological and historical research to identify underlying dynamics of mpox outbreaks. Finally, our study points to the need for mpox interventions and risk communication accounting for these regional differences, even within a single country.

Aggregation-Induced Emission-Based Macrophage-Like Nanoparticles for Targeted Photothermal Therapy and Virus Transmission Blockage in Monkeypox

The recent prevalence of monkeypox has led to the declaration of a Public Health Emergency of International Concern. Monkeypox lesions are typically ulcers or pustules (containing high titers of replication-competent virus) in the skin and mucous membranes, which allow monkeypox virus to transmit predominantly through intimate contact. Currently, effective clinical treatments for monkeypox are lacking, and strategies for blocking virus transmission are fraught with drawbacks. Herein, this work constructs a biomimetic nanotemplate (termed TBD@M NPs) with macrophage membranes as the coat and polymeric nanoparticles loading a versatile aggregation-induced emission featured photothermal molecule TPE-BT-DPTQ as the core. In a surrogate mouse model of monkeypox (vaccinia-virus-infected tail scarification model), intravenously injected TBD@M NPs show precise tracking and near-infrared region II fluorescence imaging of the lesions. Upon 808 nm laser irradiation, the virus is eliminated by the photothermal effect and the infected wound heals rapidly. More importantly, the inoculation of treated lesion tissue suspensions does not trigger tail infection or inflammatory activation in healthy mice, indicating successful blockage of virus transmission. This study demonstrates for the first time monkeypox theranostics using nanomedicine, and may bring a new insight into the development of a viable strategy for monkeypox management in clinical trials.

Concurrent Clade I and Clade II Monkeypox Virus Circulation, Cameroon, 1979-2022

During 1979-2022, Cameroon recorded 32 laboratory-confirmed mpox cases among 137 suspected mpox cases identified by the national surveillance network. The highest positivity rate occurred in 2022, indicating potential mpox re-emergence in Cameroon. Both clade I (n = 12) and clade II (n = 18) monkeypox virus (MPXV) were reported, a unique feature of mpox in Cameroon. The overall case-fatality ratio of 2.2% was associated with clade II. We found mpox occurred only in the forested southern part of the country, and MPXV phylogeographic structure revealed a clear geographic separation among concurrent circulating clades. Clade I originated from eastern regions close to neighboring mpox-endemic countries in Central Africa; clade II was prevalent in western regions close to West Africa. Our findings suggest that MPXV re-emerged after a 30-year lapse and might arise from different viral reservoirs unique to ecosystems in eastern and western rainforests of Cameroon.

Supercritical and homogenous transmission of monkeypox in the capital of China

Starting from May 31, 2023, the local transmission of monkeypox (Mpox) in mainland China began in Beijing. Till now, the transmission characteristics have not been explored. Based on the daily Mpox incidence data in the first 3 weeks of Beijing (from May 31 to June 21, 2023), we employed the instant-individual heterogeneity transmission model to simultaneously calculate the effective reproduction number (Re ) and the degree of heterogeneity (k) of the Beijing epidemic. We additionally simulated the monthly infection size in Beijing from July to November and compared with the reported data to project subsequent transmission dynamics. We estimated Re to be 1.68 (95% highest posterior density [HPD]: 1.12-2.41), and k to be 2.57 [95% HPD: 0.54-83.88], suggesting the transmission of Mpox in Beijing was supercritical and didn't have considerable transmission heterogeneity. We projected that Re fell in the range of 0.95-1.0 from July to November, highlighting more efforts needed to further reduce the Mpox transmissibility. Our findings revealed supercritical and homogeneous transmission of the Mpox epidemic in Beijing. Our results could serve as a reference for understanding and predicting the ongoing Mpox transmission in other regions of China and evaluating the effect of control measures.

Infection prevention and control measures to reduce the transmission of mpox: A systematic review

OBJECTIVES

To make inferences regarding the effectiveness of respiratory interventions and case isolation measures in reducing or preventing the transmission of mpox based on synthesis of available literature.

METHODS

The WHO Clinical Management and Infection Prevention and Control 2022 guideline and droplet precautions in healthcare facilities and home isolation infection prevention control measures for patients with mpox. We conducted a systematic review that included a broad search of five electronic databases. In a two-stage process, we initially sought only randomized controlled trials and observational comparative studies; when the search failed to yield eligible studies, the subsequent search included all study designs including clinical and environmental sampling studies.

RESULTS

No studies were identified that directly addressed airborne and droplet precautions and home isolation infection prevention control measures. To inform the review questions the review team synthesized route of transmission data in mpox. There were 2366/4309 (54.9%) cases in which investigators identified mpox infection occurring following transmission through direct physical sexual contact. There were no reported mpox cases in which investigators identified inhalation as a single route of transmission. There were 2/4309 cases in which investigators identified fomite as a single route of transmission. Clinical and environmental sampling studies isolated mpox virus in a minority of saliva, oropharangeal swabs, mpox skin lesions, and hospital room air.

CONCLUSIONS

Current findings provide compelling evidence that transmission of mpox occurs through direct physical contact. Because investigators have not reported any cases of transmission via inhalation alone, the impact of airborne and droplet infection prevention control measures in reducing transmission will be minimal. Avoiding physical contact with others, covering mpox lesions and wearing a medical mask is likely to reduce onward mpox transmission; there may be minimal reduction in transmission from additionally physically isolating patients with mild disease at home.

Monkeypox: Past, Present, and Future

Monkeypox (Mpox) is a zoonotic disease caused by a virus (monkeypox virus-MPV) belonging to the Poxviridae family. In humans, the disease has an incubation period of 5-21 days and then progresses in two phases, the prodromal phase and the rash phase. The prodromal phase is characterized by non-specific symptoms such as fever, muscle pain, malaise, lymphadenopathy, headache, and chills. Skin lesions appear in the rash phase of the disease. These lesions progress through different stages (macules, papules, vesicles, and pustules). In May 2022, WHO reported an outbreak of human Mpox in several countries which were previously Mpox-free. As per the CDC report of March 01, 2023, a total of 86,231 confirmed cases of Mpox and 105 deaths have been reported from 110 countries and territories across the globe. Notably, more than 90% of these countries were reporting Mpox for the first time. The phylogenetic analysis revealed that this outbreak was associated with the virus from the West African clade. However, most of the cases in this outbreak had no evidence of travel histories to MPV-endemic countries in Central or West Africa. This outbreak was primarily driven by the transmission of the virus via intimate contact in men who have sex with men (MSM). The changing epidemiology of Mpox raised concerns about the increasing spread of the disease in non-endemic countries and the urgent need to control and prevent it. In this chapter, we present all the documented cases of Mpox from 1970 to 2023 and discuss the past, present, and future of MPV.

Environmental detection and spreading of mpox in healthcare settings: a narrative review

Monkeypox virus (MPXV), which causes Monkeypox (Mpox), has recently been found outside its usual geographic distribution and has spread to 117 different nations. The World Health Organization (WHO) designated the epidemic a Public Health Emergency of International Concern (PHEIC). Humans are at risk from MPXV's spread, which has raised concerns, particularly in the wake of the SARS-CoV-2 epidemic. The risk of virus transmission may rise due to the persistence of MPXV on surfaces or in wastewater. The risk of infection may also increase due to insufficient wastewater treatment allowing the virus to survive in the environment. To manage the infection cycle, it is essential to investigate the viral shedding from various lesions, the persistence of MPXV on multiple surfaces, and the length of surface contamination. Environmental contamination may contribute to virus persistence and future infection transmission. The best possible infection control and disinfection techniques depend on this knowledge. It is thought to spread mainly through intimate contact. However, the idea of virus transmission by environmental contamination creates great concern and discussion. There are more cases of environmental surfaces and wastewater contamination. We will talk about wastewater contamination, methods of disinfection, and the present wastewater treatment in this review as well as the persistence of MPXV on various environmental surfaces.

Otolaryngologic manifestations among MPOX patients: A systematic review and meta-analysis

PURPOSE

MPOX has numerous otolaryngologic presentations that have been recognized as clinically important, especially with the onset of the 2022 outbreak. However, how these features vary across region and outbreak have yet to be elucidated or supported by meta-analysis. The objective of this study is to identify the otolaryngologic manifestations of MPOX across previous and current outbreaks and among endemic and non-endemic regions.

BASIC PROCEDURES

Data sources of MEDLINE (PubMed), the Cochrane Library, Scopus, Embase, Web of Science, Google Scholar, and OpenGrey were searched through August 2022. All observational studies reporting data on laboratory-confirmed MPOX patients with otolaryngologic symptoms were included. Two authors independently performed the screening process while a third resolved disagreements. Data were extracted into a structured form by two authors independently. We performed a meta-analysis of the prevalence of otorhinolaryngologic symptoms using MetaXL software (version 5.3) under a random-effects model.

MAIN FINDINGS

38 studies with 5952 patients were included. The four most prevalent manifestations were headache at 31 % (95 % CI [0.16-0.49], I 2  = 99 %), sore throat at 22 % (95 % CI [0.09-0.37], I 2  = 99 %), cough at 16 % (95 % CI [0.05-0.30], I 2  = 99 %), and cervical lymphadenopathy at 10 % (95 % CI [0.01-0.26], I 2  = 100 %). Otolaryngologic features were more prevalent in previous outbreaks as compared to the 2022 outbreak including 37 % prevalence of headache (95 % CI [0.11-0.66], I 2  = 100 %), 33 % prevalence of cough (95 % CI [0.21-0.47], I 2  = 98 %), 27 % prevalence of sore throat (95 % CI [0.07-0.53], I 2  = 99 %), 15 % prevalence of cervical lymphadenopathy (95 % CI [0.00-0.428], I 2  = 100 %), 13 % prevalence of oral ulcers (95 % CI [0.02-0.30], I 2  = 99 %), 6 % prevalence of oral exanthem (95 % CI [0.00-0.17], I 2  = 99 %), 5 % prevalence of dysphagia (95 % CI [0.00-0.18], I 2  = 99 %), and 5 % prevalence of tonsillar signs (95 % CI [0.00-0.13], I 2  = 99 %). Features that were more prevalent in endemic areas versus non-endemic areas include 27 % prevalence of cough (95 % CI [0.14-0.41], I 2  = 99 %), 15 % prevalence of oral ulcers (95 % CI [0.02-0.36], I 2  = 99 %), 6 % prevalence of tonsillar signs (95 % CI [0.00-0.18], I 2  = 99 %), and 19 % prevalence of cervical lymphadenopathy (95 % CI [0.00-0.48], I 2  = 100 %), while the only feature more prevalent in non-endemic areas was headache with a prevalence of 36 % (95 % CI [0.24-0.47], I 2  = 96 %).

PRINCIPAL CONCLUSIONS

In this systematic review and meta-analysis, four symptoms - headache, sore throat, cough, and cervical lymphadenopathy - were found to be the most prevalent otolaryngologic features of MPOX. Otolaryngologic manifestations of MPOX were more pronounced in prior outbreaks and in endemic areas as compared to the 2022 outbreak and non-endemic areas. These findings may aid MPOX recognition in an otolaryngology setting.

Emerging infectious diseases, focus on infection prevention, environmental survival and germicide susceptibility: SARS-CoV-2, Mpox, and Candida auris

BACKGROUND

New and emerging infectious diseases continue to represent a public health threat. Emerging infectious disease threats include pathogens increasing in range (eg, Mpox), zoonotic microbes jumping species lines to cause sustained infections in humans via person-to-person transmission (SARS-CoV-2) and multidrug-resistant pathogens (eg, Candida auris).

MATERIALS AND METHODS

We searched the published English literature and reviewed the selected articles on SARS-CoV-2, Mpox, and Candida auris with a focus on environmental survival, contamination of the patient's hospital environment, susceptibility of the pathogen to antiseptics and disinfectants and infection prevention recommendations.

RESULTS

All three pathogens (ie, SARS-CoV-2, Mpox, and Candida auris) can survive on surfaces for minutes to hours and for Mpox and C auris for days. Currently available antiseptics (eg, 70%-90% alcohol hand hygiene products) are active against SARS-CoV-2, Mpox and C auris. The U.S Environmental Protection Agency provides separate lists of surface disinfectants active against SARS-CoV-2, Mpox, and C auris.

DISCUSSION

The risk of environment-to-patient transmission of SARS-CoV-2, Mpox and Candida auris, is very low, low-moderate and high, respectively. In the absence of appropriate patient isolation and use of personal protection equipment, the risk of patient-to-health care provider transmission of SARS-CoV-2, Mpox, and C auris is high, moderate and low, respectively.

CONCLUSIONS

Appropriate patient isolation, use of personal protective equipment by health care personnel, hand hygiene, and surface disinfection can protect patients and health care personnel from acquiring SARS-CoV-2, Mpox, and C auris from infected patients.

Molecular epidemiology, transmission and clinical features of 2022-mpox outbreak: A systematic review

Background and Aims

The 2022-mpox outbreak has spread worldwide in a short time. Integrated knowledge of the epidemiology, clinical characteristics, and transmission of mpox are limited. This systematic review of peer-reviewed articles and gray literature was conducted to shed light on the epidemiology, clinical features, and transmission of 2022-mpox outbreak.

Methods

We identified 45 peer-reviewed manuscripts for data analysis. The standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement and Cochrane Collaboration were followed for conducting the study.

Results

The case number of mpox has increased about 100 times worldwide. About 99% of the cases in 2022 outbreak was from non-endemic regions. Men (70%-98% cases) were mostly infected with homosexual and bisexual behavior (30%-60%). The ages of the infected people ranged between 30 and 40 years. The presence of HIV and sexually transmitted infections among 30%-60% of cases were reported. Human-to-human transmission via direct contact and different body fluids were involved in the majority of the cases (90%-100%). Lesions in genitals, perianal, and anogenital areas were more prevalent. Unusually, pharyngitis (15%-40%) and proctitis (20%-40%) were more common during 2022 outbreak than pre-2022 outbreaks. Brincidofovir is approved for the treatment of smallpox by FDA (USA). Two vaccines, including JYNNEOSTM and ACAM2000®, are approved and used for pre- and post-prophylaxis in cases. About 100% of the cases in non-endemic regions were associated with isolates of IIb clade with a divergence of 0.0018-0.0035. Isolates from B.1 lineage were the most predominant followed by B.1.2 and B.1.10.

Conclusion

This study will add integrated knowledge of the epidemiology, clinical features, and transmission of mpox.

Healthcare worker protection against mpox contamination: position paper of the French Society for Hospital Hygiene

In the context of the recent re-emergence of mpox worldwide, the French Society for Hospital Hygiene (SF2H) performed a literature review of the transmission paths and proposed specific recommendations for healthcare workers (HCWs) caring for patients with suspected or confirmed MPXV. In developed countries, the risk of contamination among HCWs in healthcare facilities seemed to be very low, limited to contamination through needle stick injuries. Two additional contamination cases were reported and not fully explained. Beyond healthcare settings, the analysis of the literature highlighted (i) a main contamination route during sexual intercourse, mainly among men who have sex with men, and (ii) a very low secondary attack rate in other contexts, such as schools or jails. Numerous studies have reported molecular or virus identification on surfaces or in the air surrounding patients, without any association with the low secondary case incidence; moreover, the minimum infectious dose through air or mucosal exposure is still unknown. Owing to the lack of evidence of MPXV respiratory transmission in the healthcare setting, the SF2H recommends the implementation of standard and contact precautions combined with medical/surgical mask use. Owing to the lack of evidence of transcutaneous contamination, the SF2H recommends the use of gloves only if contact with cutaneous lesions or mucous membranes occurs. Regarding the risk of contamination from the environment in healthcare facilities, additional studies must be conducted to investigate this.

The Changing Global Epidemiology of Re-emerging Human Monkeypox Virus Infection: A Systematic Review

Human monkeypox virus (MPVX) infection represents an emerging zoonotic disease caused by an orthopoxvirus, resulting in a condition reminiscent of smallpox. More recent developments have witnessed a notable surge in global MPVX outbreaks, eliciting significant concerns. We aimed to investigate the epidemiological factors of the emerging human monkeypox virus infection, including the number of suspected, confirmed, and fatal cases, as well as the risk factors for contracting monkeypox infection. We performed a systematic review of peer-reviewed literature by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic database search (PubMed, Wiley Online Library, and Science Direct) was undertaken. For monkeypox-related studies, we included 25 peer-reviewed articles from 2018 and 2022, and data were extracted on the current evidence on the cases and the risk factors for MPVX infection, to develop public health advisories. Our reports show a rapid rise of MPVX cases in the highly endemic African regions after the 1970s, spread to other countries, and an increase in the median age from young children to young adults. The cessation of smallpox vaccination might have been one of the factors responsible for these findings. As of 2022, the genomic sequences of ten MPVX strains associated with the recent countrywide outbreak have been determined. While the West African Clade has been primarily implicated in the recent viral surge, data were insufficient to determine which mutation contributed to increased transmissibility. In the Democratic Republic of the Congo (DRC), sleeping on the floor was significantly associated with contracting MPVX, while eating or processing of animal foods was not a significant risk factor. In the United States, cleaning the cages and bedding of sick animals, touching infected animals, and daily exposure to sick animals were associated with an increased probability of contracting the MPVX infection. Recent global outbreaks and the rising incidence of MPVX infections among young adults in the endemic zones might be a result of the cessation of the smallpox vaccine. The increased risk associated with exposure to sick animals or sleeping on the floor suggests high infectivity from animal excretions. Increasing awareness, strict surveillance, and contact tracing can help contain global outbreaks. The ring vaccination approach for exposed individuals is another potential disease containment strategy. Future studies should investigate measures for rapid laboratory diagnosis, maintaining lab safety, and transmissibility.

Re-emergence of monkeypox virus outbreak in Nigeria: epidemic preparedness and response (Review-Commentary)

The re-emergence of the monkeypox virus has come with many burdens on nations. This is partly after the effects of the coronavirus disease 2019 virus is subsiding. The burden of the monkeypox virus is seen even more in developing and third-world countries. Beyond the monkeypox virus re-emergence, there have also been several other viruses within the world and in Nigeria. This study assessed Nigeria's preparedness and response to the re-emergence of the monkeypox virus. The Nigerian Government showed its preparedness in the fight against the monkeypox virus by bringing together both Human and Animal Health Sectors. It ensured interventions and programs were created. Among these is Surveillance Outbreak, Response, Management, and Analysis System, a Surveillance and monitoring intervention to manage any outbreak. A second intervention is the Emergency Operation Center. It is recommended that vaccines should be made available, personnel should be adequately trained, and improved diagnostics equipment be made available. Nigeria has had cases of the monkeypox virus, and we wanted to see how far it has come in its preparedness and how it will respond if the need arises. This study reviewed existing literature on Nigeria's battle against the monkeypox virus in times past, the actions taken, and the programs developed.

Investigation of a mpox outbreak in Central African Republic, 2021-2022

Human monkeypox virus is spreading globally, and more information is required about its epidemiological and clinical disease characteristics in endemic countries. We report the investigation of an outbreak in November 2021 in Central African Republic (CAR). The primary case, a hunter, fell ill after contact with a non-human primate at the frontier between forest and savannah. The ensuing investigation in a small nearby town concerned two families and four waves of inter-human transmission, with 14 confirmed cases, 11 suspected cases and 17 non-infected contacts, and a secondary attack rate of 59.5% (25/42). Complications were observed in 12 of the 19 (63.2%) confirmed and suspected cases with available clinical follow-up data: eight cases of bronchopneumonia, two of severe dehydration, one corneal ulcer, one abscess, two cutaneous superinfections, and six cutaneous sequelae (cheloid scars, or depigmentation). There was one death, giving a case fatality ratio of 1/25 (4.0%) for confirmed and suspected cases. This outbreak, with the largest number of confirmed cases ever described in CAR, confirms the potential severity of the disease associated with clade I monkeypox viruses, and highlights the need for rapid control over virus circulation to prevent the further national and international spread of infection.

Clinical and Epidemiological Interventions for Monkeypox Management in Children: A Systematic Review

This review aims to compile the available literature on monkeypox, identify risk factors for developing the disease, and recommend effective preventative methods to reduce the number of reported cases and fatalities in children and pregnant women. In seeking out pertinent studies on monkeypox virus in children and pregnant women, we searched the literature using the databases Cochrane Library, Google Scholar, PubMed, EMBASE, Web of Science, and Scopus up to 1st February 2023. This study analyzed data from case studies of monkeypox in children and pregnant women. Clinical data and test findings of monkeypox patients less than 18 years old and pregnant women were analyzed. The Newcastle-Ottawa Scale was used to do the quality evaluation. Our record examination spanned the years 1985 to 2023 and found 17 children and five pregnant female patients treated with monkeypox in various hospitals/community centers. Zaire, Gabon, Chicago, Sierra Leone, Central African Republic, Northern DR Congo, Liberia, Cameroon, the Democratic Republic of the Congo, the United Kingdom, the Netherlands, and Florida all contributed to the 14 studies analyzed. There were no studies identified for meta-analysis of selected case studies of hospitalized children and pregnant women who were diagnosed with monkeypox. The incidence, prevalence, clinical characteristics, diagnosis, management, prevention, vaccinations, infant care, and care for expectant mothers are all discussed in this systematic review of monkeypox in children. Our research findings may provide a foundation for further focused research and the development of related recommendations or guidelines.

Making Sense of Monkeypox: A Comparison of Other Poxviruses to the Monkeypox

The current monkeypox (MPX) outbreak has been declared a public health emergency of international concern (PHEIC) by the World Health Organization (WHO). It is a zoonotic disease that has persisted in the African basin for decades but suddenly exploded into the international sphere this year. In this paper, we provide a comprehensive overview of monkeypox, including a hypothesis of the rapid spread of the virus, its epidemiology and clinical features, a comparison with other orthopoxviruses such as chickenpox and smallpox, past and present outbreaks, and strategies for its prevention and treatment.

Demographic, Epidemiologic, and Clinical Characteristics of Human Monkeypox Disease Pre- and Post-2022 Outbreaks: A Systematic Review and Meta-Analysis

(1) Background: In early May 2022, an increasing number of human monkeypox (mpox) cases were reported in non-endemic disparate regions of the world, which raised concerns. Here, we provide a systematic review and meta-analysis of mpox-confirmed patients presented in peer-reviewed publications over the 10 years before and during the 2022 outbreak from demographic, epidemiological, and clinical perspectives. (2) Methods: A systematic search was performed for relevant studies published in Pubmed/Medline, Embase, Scopus, and Google Scholar from 1 January 2012 up to 15 February 2023. Pooled frequencies with 95% confidence intervals (CIs) were assessed using the random or fixed effect model due to the estimated heterogeneity of the true effect sizes. (3) Results: Out of 10,163 articles, 67 met the inclusion criteria, and 31 cross-sectional studies were included for meta-analysis. Animal-to-human transmission was dominant in pre-2022 cases (61.64%), but almost all post-2022 reported cases had a history of human contact, especially sexual contact. The pooled frequency of MSM individuals was 93.5% (95% CI 91.0-95.4, I2: 86.60%) and was reported only in post-2022 included studies. The male gender was predominant in both pre- and post-2022 outbreaks, and the mean age of confirmed cases was 29.92 years (5.77-41, SD: 9.38). The most common clinical manifestations were rash, fever, lymphadenopathy, and malaise/fatigue. Proctalgia/proctitis (16.6%, 95% CI 10.3-25.6, I2: 97.76) and anal/perianal lesions (39.8%, 95% CI 30.4-49.9, I2: 98.10) were the unprecedented clinical manifestations during the 2022 outbreak, which were not described before. Genitalia involvement was more common in post-2022 mpox patients (55.6%, 95% CI 51.7-59.4, I2: 88.11). (4) Conclusions: There are speculations about the possibility of changes in the pathogenic properties of the virus. It seems that post-2022 mpox cases experience a milder disease with fewer rashes and lower mortality rates. Moreover, the vast majority of post-2022 cases are managed on an outpatient basis. Our study could serve as a basis for ongoing investigations to identify the different aspects of previous mpox outbreaks and compare them with the current ones.

When a neglected tropical zoonotic disease emerges in non-endemic countries: need to proactively fill the unveiled knowledge gaps towards human monkeypox among the Lebanese population

INTRODUCTION

The ongoing multi-country outbreak of monkeypox (MPX) that emerges in non-endemic areas is a rare and unprecedented event that has sparked a widespread public health concern. Lebanon has reported four confirmed cases of MPX so far. Since good knowledge about the MPX virus and its associated disease is paramount for helping the Lebanese population prepare for a possible outbreak, therefore, it is important to assess their current level of knowledge regarding MPX and to identify its associated factors to highlight any knowledge gaps that need to be filled.

METHODS

An online cross-sectional study was conducted over the first 2 weeks of August 2022 among adults aged 18 years and above recruited from all Lebanese provinces using a convenience sampling technique. An anonymous, Arabic, self-reported questionnaire covering all main aspects of knowledge regarding MPX was developed and adapted based on the available literature. The Chi-square test was used to determine the associations between knowledge levels and independent variables including baseline characteristics. Multivariable logistic regression was also carried out on the significant variables in the bivariate analyses to identify the factors associated with the good knowledge level.

RESULTS

A total of 793 Lebanese adults participated in the study. The overall level of knowledge level regarding human MPX was poor among the Lebanese population; with only 33.04% of them having a good knowledge level ≥ 60%. Knowledge gaps and a substantial poor knowledge level were found in the majority of MPX knowledge domains especially those related to the routes of transmission (76.67%), clinical presentation and symptoms (71.63%), treatment (86.25%), and severity of the disease (91.3%). Interestingly, participants have a good knowledge level of the precautionary measures (80.45%), and the response to a suspected infection (65.20%). Female gender [(aOR = 0.870, CI 95% (0.613-0.941)], increased age 49 [aOR = 0.743, CI 95% (0.381-0.908)], and living in rural areas [aOR = 0.412, CI 95% (0.227-0.861)] were found negatively associated with a good level of knowledge. However, participants with higher educational levels [aOR = 1.243, CI 95% (1.032-3.801)], those working in the medical field [aOR = 1.932, CI 95% (1.331-3.419)], those suffering from chronic disease/immunodeficiency [aOR = 1.231, CI 95% (1.128-2.002)], and participants with moderate/high economic situations [aOR = 2.131, CI 95% (1.431-4.221)] were more likely to have a good knowledge score compared to their counterparts.

CONCLUSIONS

The current study pointed out to poor knowledge level regarding MPX among the Lebanese population with substantial knowledge gaps in most aspects of MPX knowledge. The findings stress the urgent need to raise awareness and proactively fill the unveiled gaps, especially among less informed groups.

The recent re-emergence of human monkeypox: Would it become endemic beyond Africa?

Viral outbreaks still become global health challenges, for instance, influenza A viruses, Japanese encephalitis, Ebola virus, Yellow fever, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Since 7 May 2022, another outbreak of monkeypox also has been reported in European countries and the United States. Meanwhile, the monkeypox virus is previously endemic only in the western and central parts of Africa. Monkeypox is a zoonotic disease, although the primary animal reservoir remains unknown. This article concisely reviews the monkeypox virus, its transmission, pathogenesis, and clinical manifestation, its changing global epidemiology before and during the current outbreak, and possible driving factors of the recent outbreak. Furthermore, we also discuss whether the monkeypox virus would become endemic beyond Africa. Even though the available data suggests that human-to-human transmission is currently happening and unconnected clusters exist, many efforts have been made to tackle this outbreak, such as active case detection, contact tracing, isolation, and postexposure vaccination.

Risk profile and mode of transmission of Mpox: A rapid review and individual patient data meta-analysis of case studies

Since May 2022, an outbreak of Mpox in non-endemic countries has become a potential public health threat. The objective of this rapid review was to examine the risk profile and modes of transmission of Mpox. PubMed, Web of Science, and Scopus were searched from inception through July 30 to collect case reports/series on patients with Mpox infection. For meta-analysis, data on the total number of participants and deaths by binary categories of exposure (age, sex, country, other co-infections or existing conditions, and mode of contagion) were used. A total of 62 studies (4659 cases) were included. Most cases came from Africa (84.3%), followed by Europe (13.9%). In 63.6% of the cases, the mode of contagion was human contact, while 22.8% of the cases were by animal contact, and 13.5% were unknown or not reported. The mortality rate was 6.5% throughout these studies. The risk of mortality was higher in the younger age group (risk difference: 0.19; 95% CI: 0.02-0.36), in cases with other co-infections or current chronic conditions (risk difference: 0.03; 95% CI: 0.01-0.05) and in the category of low- and middle-income countries (risk difference: 0.06; 95% CI: 0.05-0.08). There were no significant differences with respect to sex or mode of contagion. These results help to understand the major infection pathways and mortality risk profiles of Mpox and underscores the importance of preventing outbreaks in specific settings, especially in settings densely populated by children, such as day care centres and schools.

Global Epidemiological Features of Human Monkeypox Cases and Their Associations With Social-Economic Level and International Travel Arrivals: A Systematic Review and Ecological Study

Objectives: We aimed to evaluate global epidemiological features of human monkeypox (mpox) cases and their associations with social-economic level and international travel arrivals. Methods: We estimated the pooled value by random-effects models. Then, we conducted an ecological study to evaluate the relationship of confirmed cases with social-economic indices and international travel arrivals using correlation analyses. Results: The average age (2022: 35.52, 95% CI [28.09, 42.94] vs. before 2022: 18.38, 95% CI [14.74, 22.02]) and comorbidity rate (2022: 15.7%, 95% CI [8.9%, 22.4%] vs. before 2022: 14.9%, 95% CI [8.5%, 21.3%]) of mpox cases in the 2022 human mpox outbreak were significantly higher than those of cases before 2022. During the 2022 mpox outbreak, the proportion of men who have sex with men (MSM) was high (79.8%, 95% CI [65.5%, 94.2%]). The number of confirmed mpox cases in 2022 significantly correlated with high social-economic levels and international travel arrivals (all p < 0.05). Conclusion: Our findings highlighted the importance of early surveillance and timely detection in high-risk populations, including older people, MSM, and travelers, which is crucial to curb the wide transmission of mpox.

The changing epidemiology of monkeypox and preventive measures: an update

Monkeypox is a systemic exanthematous viral disease presenting with fever, lymphadenopathy, and vesicular rash. The zoonotic virus causing this disease is endemic to many sub-Saharan African countries, where a steady rise in cases has been witnessed for the past 30 years. However, monkeypox re-emerged as the largest outbreak of the West African clade (clade II) of monkeypox virus in Nigeria in 2017. This poxvirus received only minimal global attention until recently, when cases emerged in Europe and rapidly spread globally in certain sections of the community, such as men having sex with men or bisexuals, with human-to-human transmission. Monkeypox virus has established its presence in humans, crossing geographical boundaries, and clusters of infections may occur among individuals in close contact. All six WHO regions have reported monkeypox cases without any epidemiological association with endemic regions. The ongoing multicountry outbreak suggests that silent human-to-human transmission has been happening in Europe and the United States for a while. For containment of the outbreak, active surveillance and rapid identification of new cases are essential. The availability of vaccines is currently limited. Policymakers must focus on awareness programmes, primary preventive or post-exposure vaccination, and treatment with antivirals to control the ongoing outbreak.

Transmission characteristics, replication patterns and clinical manifestations of human monkeypox virus-an in-depth analysis of four cases from Germany

OBJECTIVE

Since April 2022, increasing numbers of monkeypox (MPX) cases have been reported outside endemic areas as part of an international outbreak. Our study shows aspects of clinical manifestations as well as epidemiological and virological features impacting transmission, for which only scarce data are available so far.

METHODS

We present a descriptive study consisting of epidemiological, clinical and virological data of four patients with confirmed MPX diagnosis. Follow-up examinations included in-depth virological investigations, including MPX virus-specific quantitative PCR and virus isolation.

RESULTS

Between 22 May 2022, and 21 June 2022, four patients with MPX were evaluated. The number of lesions ranged between one and more than 30, with asynchronous eruptions. The periorificial distribution of initial lesions together with the case histories strongly suggest human-to-human transmission during intimate contacts in sexual activities. None of the patients reported about memorable lesions on the skin of potential risk contacts. Virological sampling showed positive MPX virus-specific quantitative PCR results from swabs of the primary lesions (until day 22 after symptom onset), pharyngeal and anal mucosa, urine, seminal fluid, blood and samples of non-affected skin. Virus isolation was positive in 6/14 samples (lesional skin, anal and pharyngeal mucosa). One patient required inpatient treatment for bacterial superinfection; in another patient, three sexually transmitted co-infections were present.

CONCLUSIONS

Our report demonstrates asynchronous multiple-site lesions of MPX with prolonged PCR positivity in mucosal swabs, swabs of non-affected skin, urine and seminal fluid. In addition, infectious virus was confirmed on lesional skin and mucosal swabs. The observed virological kinetics together with the suspected pre-symptomatic transmission may lead to effective and sustained human-to-human transmission, particularly in sexual networks. Preventive measures such as vaccination and post-exposure prophylaxis may become important for MPX control in vulnerable groups.

Healthcare workers and monkeypox: The case for risk mitigation

Potentially more at risk of contracting the monkeypox virus are healthcare workers. Most healthcare workers come into direct contact with the disease's infected people, which can spread directly and indirectly. Healthcare professionals must contact patients with the disease and any infected objects or fluids to effectively manage the disease, which further increases the risk of transmission. It is crucial to put safety measures in place and protect healthcare workers. To stop the spread of the monkeypox virus, countries must develop the necessary safeguards and countermeasures. In this emergency, healthcare systems must be strengthened. All healthcare systems should offer staff sufficient personal protective equipment (PPE) and facilitate risk assessment among those with a high risk of exposure. Any suspected case of monkeypox requires caution on the part of healthcare professionals. They must abide by infection control safety rules and protective measures.

As the World Struggles With the COVID-19 Pandemic, Another Emergency Threat Arrives on the Horizon, the Monkeypox: A Systematic Review

The whole world got threatened by COVID-19, which made a significant loss in various sectors and pushed the world into a deep valley. Now a new threat, the emerging outbreak of monkeypox is rapidly spreading across the globe and is currently being observed in more than 110 countries with 79,473 confirmed cases and 50 deaths. Data were collected from PubMed, EMBASE, MEDLINE, Cochrane, Scopus database, African Journals OnLine, internet library sub-Saharan Africa, and Google Scholar. Most data were taken from the democratic Republic of Congo, the Central African Republic, Cameroon, the Republic of Congo, Liberia, Nigeria, the US, and the UK. Case reports, outbreak investigations, epidemiological studies, and surveillance studies were reviewed to find epidemiological details about the outbreak. A total of 50 peer-reviewed articles and 20 grey literature articles, including 9050 cases, were identified for data extraction. Our systematic review revealed that the group most affected is male (95.5%), with a median age of 33.8 years. A total of 55% of the transmission was sexually transmitted. The most commonly reported symptoms such as vesicular-pustular rashes (97.54%), fever (55.25%), inguinal lymphadenopathy (53.6%), exanthema (40.21%), fatigue, headache, asthenia (26.32%), myalgia (16.33%), vesicles and ulcers (30.61%) in the anogenital regions were some of the significant findings. The case fatality rate was observed to be up to 8.65%. The most affected country was the USA, which has the most fatalities in younger ages involved in homosexuality, suffering from HIV or sexually transmitted diseases (STDs).

Human monkeypox and preparedness of Bangladesh: A knowledge and attitude assessment study among medical doctors

OBJECTIVE

The recent increasing incidence of human monkeypox cases highlights the necessity of early detection, prompt response and preventive management to stop it in its tracks, and healthcare workers play the most crucial role here. This study aims at assessing the preparedness of Bangladeshi medical doctors by assessing their knowledge and attitude regarding monkeypox.

METHODOLOGY

This cross-sectional study was conducted among the practicing medical doctors all over Bangladesh. The data was collected from 26th May to 4th June of 2022 using a semi-structured and self-administered questionnaire which was distributed through the internet, and a total of 389 data was collected. The cut-off points for defining good knowledge and positive attitude towards human monkeypox were considered as 70% and 80% of total values, respectively. Multivariable logistic regression analyses were carried out to identify the factors associated with good knowledge and a positive attitude. Statistical software R version 4.2.0 was used for data analysis.

RESULT

Of all, 330 (84.83%) doctors displayed a positive attitude towards preventive practices, but only 119 (30.59%) participants had good knowledge regarding monkeypox. In multivariable logistic regression analysis, getting any information about monkeypox in the medical curriculum and learning about monkeypox within the last one month had a significant association with good knowledge. Apart from the participant's age, no other variables revealed any significant association with a positive attitude toward preventive practices. Good knowledge showed a significant association with positive attitude (p < 0.05).

CONCLUSION

Knowledge regarding human monkeypox among medical doctors in Bangladesh was comparatively lower than the attitude towards its preventive measures. Developing and implementing practical sessions regarding the virus to enhance the knowledge and capacity of the medical doctors could be an effective strategy to get prepared for the monkeypox outbreak in Bangladesh.

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.

Human monkeypox: a comparison of the characteristics of the new epidemic to the endemic disease

In May 2022, a new global outbreak of mpox (formerly, human monkeypox) emerged that was declared a public health emergency of international concern by the World Health Organization on July 23, 2022. With new patterns of person-to-person spread within sexual networks in nonendemic countries and several differences from the classic disease course, we performed a comprehensive review of existing literature on human monkeypox to discuss epidemiology, modes of transmission, clinical presentation and asymptomatic infection, diagnostics, therapeutics, and vaccines with the primary aim to identify important areas for future research of this new epidemic form of the disease. A comprehensive literature search was performed of all published literature to August 15, 2022. Historically, in regions of monkeypox virus endemicity, human outbreaks have occurred related to discrete zoonotic events. The animal reservoir is unknown, but the virus has been isolated from rodents. Traditionally, transmission occurred by direct or indirect contact with an infected animal. In nonendemic countries affected in the 2022 outbreak, almost exclusive person-to-person spread has been observed, and most cases are connected to sexual networks of gay, bisexual, and other men who have sex with men. After an incubation period of approximately 13 days, in traditional human cases affected persons developed a febrile prodrome preceding a rash that started on the face and body, spread centrifugally to the palms and soles and healed monomorphically over two to four weeks. However, in the 2022 outbreak, the febrile illness is often absent or occurs after the onset of the rash. The rash presents primarily in the anogenital region and face before disseminating throughout the body, with lesions displaying regional pleomorphism. There is a paucity of data for the role of antiviral agents or vaccines. The epidemiology and clinical course of mpox has changed in the 2022 epidemic from that observed with the endemic disease. There is an urgent need to establish rapid and collaborative research platforms to diagnose, treat and prevent disease and inform important public health and other strategies to stop the spread of disease.

Contact Tracing and Exposure Investigation in Response to the First Case of Monkeypox Virus Infection in the United States During the 2022 Global Monkeypox Outbreak

BACKGROUND

In May 2022, the first case of monkeypox virus (MPXV) infection in the United States in the current global outbreak was identified. As part of the public health and health care facility response, a contact tracing and exposure investigation was done.

OBJECTIVE

To describe the contact tracing, exposure identification, risk stratification, administration of postexposure prophylaxis (PEP), and exposure period monitoring for contacts of the index patient, including evaluation of persons who developed symptoms possibly consistent with MPXV infection.

DESIGN

Contact tracing and exposure investigation.

SETTING

Multiple health care facilities and community settings in Massachusetts.

PARTICIPANTS

Persons identified as contacts of the index patient.

INTERVENTION

Contact notification, risk stratification, and symptom monitoring; PEP administration in a subset of contacts.

MEASUREMENTS

Epidemiologic and clinical data collected through standard surveillance procedures at each facility and then aggregated and analyzed.

RESULTS

There were 37 community and 129 health care contacts identified, with 4 at high risk, 49 at intermediate risk, and 113 at low or uncertain risk. Fifteen health care contacts developed symptoms during the monitoring period. Three met criteria for MPXV testing, with negative results. Two community contacts developed symptoms. Neither met criteria for MPXV testing, and neither showed disease progression consistent with monkeypox. Among 4 persons with high-risk exposures offered PEP, 3 elected to receive PEP. Among 10 HCP with intermediate-risk exposures for which PEP was offered as part of informed clinical decision making, 2 elected to receive PEP. No transmissions were identified at the conclusion of the 21-day monitoring period, despite the delay in recognition of monkeypox in the index patient.

LIMITATION

Descriptions of exposures are subject to recall bias, which affects risk stratification.

CONCLUSION

In a contact tracing investigation involving 166 community and health care contacts of a patient with monkeypox, no secondary cases were identified.

PRIMARY FUNDING SOURCE

None.

Monkeypox-What Pediatricians Need to Know

Monkeypox is a zoonotic disease, presenting with fever, lymphadenopathy and vesicular-pustular skin lesions, that historically has rarely been reported outside the endemic regions of Central and West Africa. It was previously thought that human-to-human transmission was too low to sustain spread. During 2022, the number of cases of monkeypox, caused by clade II, rose rapidly globally, predominantly among men who have sex with men. In previous outbreaks with monkeypox clade 1 in endemic areas, children were disproportionately more affected with higher morbidity and mortality. It is unclear whether children are at similarly higher risk from monkeypox clade II. Nonetheless, children and pregnant women are considered high-risk groups and antiviral treatment should be considered for those affected. While smallpox vaccination offers good protection against monkeypox, the duration of protection is unknown, and infection occurs in vaccinated individuals. Should the current outbreak spread to children, authorities should be prepared to rapidly implement vaccination for children. In this review, we summarize epidemiological and clinical features, as well as the pathogenesis, treatment, and prevention options for monkeypox with a focus on considerations for children.

The Global Human Monkeypox Outbreak and Management: A Comprehensive Literature Review

Monkeypox (MPX) belongs to the genus Orthopoxvirus (OPV), family Poxviridae, and sub-family Chordopoxvirinae. Human monkeypox (HMPX) is a viral zoonotic illness caused by the monkeypox virus (MPXV). Several non-endemic countries have confirmed MPX cases across the globe. Therefore, consider an outbreak to be a global health emergency. MPXV transmits from animals to humans via infected animals, and there is currently human-to-human transmission, notably among guys who have sexual relations with males. Healthcare interventions are required to stop outbreaks. These include strict isolation and care for MPX patients while they are still contagious or until the skin lesions dry out and crust over. JYNNEOS was approved as a vaccine for the prevention of MPXV. Tecovirimat is licensed to treat severe MPX or risk developing a serious disease. We should encourage international cooperation to conduct clinical trials investigating the effectiveness and safety of MPXV vaccines and antiviral medications. Precautions must be taken at the global level to prevent an MPXV outbreak.

Global monkeypox case hospitalisation rates: A rapid systematic review and meta-analysis

BACKGROUND

Estimates of the case hospitalization rate and case fatality rate when hospital care is available for monkeypox (MPX) infections have not been well defined. This rapid systematic review and meta-analysis aimed to estimate the case hospitalisation rate and case fatality rate where hospital care is available.

METHODS

We systematically searched PubMed, Embase, the Lancet Preprints, and MedRxiv for studies published between Jan 1, 1950 and Aug 2, 2022. We included documents which contained both the number of cases and associated hospitalisations of MPX infections. From eligible studies we extracted the country, the year of the study, the study design type, the clade of MPX, the participant characteristics, transmission type, any treatments used, number of cases (including suspected, probable, or laboratory confirmed diagnosis), number of hospitalizations, hospitalized patient outcomes, and case definition. Case hospitalization rate (CHR) was defined as the proportion of cases that were admitted to hospital care while case fatality rate (CFR) was defined as the proportion of cases that died. CHR and CFR were analysed in a fully Bayesian meta-analytic framework using random effects models, including sub-group analysis with heterogeneity assessed using I².

FINDINGS

Of the 259 unique documents identified, 19 studies were eligible for inclusion. Included studies represented 7553 reported cases among which there were 555 hospitalizations. Of the 7540 cases for which outcomes were available, there were 15 recorded deaths. The median age of cases was 35 years (interquartile range 28-38, n = 2010) and primarily male (7339/7489, 98%) in studies where age or sex were available. Combined CHR was estimated to be 14.1% (95% credible interval, 7.5-25.0, I² 97.4%), with a high degree of heterogeneity. Further analysis by outbreak period indicates CHRs of 49.8% (28.2-74.0, I² 81.4%), 21.7% (7.2-52.1, I² 57.7%), and 5.8% (3.2-9.4, I² 92.4%) during the pre-2017, 2017-2021, and 2022 outbreaks, respectively, again with high levels of heterogeneity. CFR was estimated to be 0.03% (0.0-0.44, I² 99.9%), with evidence of large heterogeneity between the studies.

INTERPRETATION

There is limited data for MPX hospitalization rates in countries where MPX has been traditionally non-endemic until the current outbreak. Due to substantial heterogeneity, caution is needed when interpreting these findings. Health care organizations should be cognizant of the potential increase in healthcare utilization. Rapid identification of infection and use of appropriate therapies such as antivirals play a role reducing the CHR and associated CFR.

FUNDING

None.

Risk of Monkeypox virus (MPXV) transmission through the handling and consumption of food

Monkeypox (MPX) is a zoonotic infectious disease caused by Monkeypox virus (MPXV), an enveloped DNA virus belonging to the Poxviridae family and the Orthopoxvirus genus. Since early May 2022, a growing number of human cases of Monkeypox have been reported in non-endemic countries, with no history of contact with animals imported from endemic and enzootic areas, or travel to an area where the virus usually circulated before May 2022. This qualitative risk assessment aimed to investigate the probability that MPXV transmission occurs through food during its handling and consumption. The risk assessment used "top-down" (based on epidemiological data) and "bottom-up" (following the agent through the food chain to assess the risk of foodborne transmission to human) approaches, which were combined. The "top-down" approach first concluded that bushmeat was the only food suspected as a source of contamination in recorded cases of MPXV, by contact or ingestion. The "bottom-up" approach then evaluated the chain of events required for a human to become ill after handling or consuming food. This approach involves several conditions: (i) the food must be contaminated with MPXV (naturally, by an infected handler or after contact with a contaminated surface); (ii) the food must contain viable virus when it reaches the handler or consumer; (iii) the person must be exposed to the virus and; (iv) the person must be infected after exposure. Throughout the risk assessment, some data gaps were identified and highlighted. The conclusions of the top-down and bottom-up approaches are consistent and suggest that the risk of transmission of MPXV through food is hypothetical and that such an occurrence was never reported. In case of contamination, cooking (e.g., 12 min at 70°C) could be considered effective in inactivating Poxviridae in foods. Recommendations for risk management are proposed. To our knowledge, this is the first risk assessment performed on foodborne transmission of MPXV.

National Monkeypox Surveillance, Central African Republic, 2001-2021

We analyzed monkeypox disease surveillance in Central African Republic (CAR) during 2001-2021. Surveillance data show 95 suspected outbreaks, 40 of which were confirmed as monkeypox, comprising 99 confirmed and 61 suspected monkeypox cases. After 2018, CAR's annual rate of confirmed outbreaks increased, and 65% of outbreaks occurred in 2 forested regions bordering the Democratic Republic of the Congo. The median patient age for confirmed cases was 15.5 years. The overall case-fatality ratio was 7.5% (12/160) for confirmed and suspected cases, 9.6% (8/83) for children <16 years of age. Decreasing cross-protective immunity from smallpox vaccination and recent ecologic alterations likely contribute to increased monkeypox outbreaks in Central Africa. High fatality rates associated with monkeypox virus clade I also are a local and international concern. Ongoing investigations of zoonotic sources and environmental changes that increase human exposure could inform practices to prevent monkeypox expansion into local communities and beyond endemic areas.

Rapid Detection of the Varicella-Zoster Virus Using a Recombinase-Aided Amplification-Lateral Flow System

Varicella-zoster virus (VZV) is the etiological agent of varicella (chickenpox) and herpes zoster (shingles). VZV infections are ubiquitous and highly contagious, and diagnosis is mostly based on the assessment of signs and symptoms. However, monkeypox, an emerging infectious disease caused by the monkeypox virus (MPXV), has clinical manifestations that are similar to those of VZV infections. With the recent monkeypox outbreak in non-endemic regions, VZV infections are likely to be misdiagnosed in the absence of laboratory testing. Considering the lack of accessible diagnostic tests that discriminate VZV from MPXV or other poxviruses, a handy and affordable detection system for VZV is crucial for rapid differential diagnosis. Here, we developed a new detection method for VZV using recombinase-aided amplification technology, combined with the lateral flow system (RAA-LF). Given the prevalence of VZV worldwide, this method can be applied not only to distinguish VZV from other viruses causing rash, but also to foster early detection, contributing substantially to disease control.

Animal Models Used in Monkeypox Research

Monkeypox is an emerging zoonotic disease with a growing prevalence outside of its endemic area, posing a significant threat to public health. Despite the epidemiological and field investigations of monkeypox, little is known about its maintenance in natural reservoirs, biological implications or disease management. African rodents are considered possible reservoirs, although many mammalian species have been naturally infected with the monkeypox virus (MPXV). The involvement of domestic livestock and pets in spillover events cannot be ruled out, which may facilitate secondary virus transmission to humans. Investigation of MPXV infection in putative reservoir species and non-human primates experimentally uncovered novel findings relevant to the course of pathogenesis, virulence factors and transmission of MPXV that provided valuable information for designing appropriate prevention measures and effective vaccines.

Comprehensive Literature Review of Monkeypox

The current outbreak of monkeypox (MPX) infection has emerged as a global matter of concern in the last few months. MPX is a zoonosis caused by the MPX virus (MPXV), which is one of the Orthopoxvirus species. Thus, it is similar to smallpox caused by the variola virus, and smallpox vaccines and drugs have been shown to be protective against MPX. Although MPX is not a new disease and is rarely fatal, the current multi-country MPX outbreak is unusual because it is occurring in countries that are not endemic for MPXV. In this work, we reviewed the extensive literature available on MPXV to summarize the available data on the major biological, clinical and epidemiological aspects of the virus and the important scientific findings. This review may be helpful in raising awareness of MPXV transmission, symptoms and signs, prevention and protective measures. It may also be of interest as a basis for performance of studies to further understand MPXV, with the goal of combating the current outbreak and boosting healthcare services and hygiene practices.Trial registration: ClinicalTrials.gov identifier: NCT02977715..Trial registration: ClinicalTrials.gov identifier: NCT03745131..Trial registration: ClinicalTrials.gov identifier: NCT00728689..Trial registration: ClinicalTrials.gov identifier: NCT02080767..

Symptomatology, prognosis, and clinical findings of Monkeypox infected patients during COVID-19 era: A systematic-review

BACKGROUND

The recent outbreak of Human Monkeypox (MPXV) in nonendemic regions of the world is of great concern.

OBJECTIVE

We aimed to systematically analyze the current epidemiology, clinical presentation, and outcomes of the Monkeypox virus.

METHOD

Systematic literature was conducted in PubMed, Embase, Google Scholar, and Scopus using predefined MESH terms by using "AND" and "OR." The following search terms were used: Monkeypox [MeSH] OR "Monkeypox virus" [MeSH] OR "POX" OR "Monkeypox" AND "Outbreak" AND "Outcomes" from December 2019 till 14th June 2022 without restrictions of language.

RESULTS

A total of 1074 (99.90%) patients tested positive for Monkeypox virus through RT-PCR while 1 (0.09) patient was suspected. There was a gender difference with male predominance (54.23% vs. 45.48%) compared with female patients. Mean age (±SD) of patients was 20.66 ± 16.45 years. The major symptoms were rash (100%), fever (96%), and other important symptoms were upper respiratory symptoms (97%), headache (95%), vomiting (95%), oral ulcers (96%), conjunctivitis (96%) and lymphadenopathy (85%). The average mean duration of treatment was 5 days, while the mean hospitalization duration was 13.3 ± 6.37 days. The outcome of 20 patients was available, 19 of 20 patients recovered fully from monkeypox, however, 1 patient was not able to survive resulting in death.

CONCLUSION

The recent monkeypox virus outbreak has shown that the virus could transmit in ways that were not previously expected. Further research is needed to understand the possible outcomes and association with humans and their different organ systems.

Atypical and Unique Transmission of Monkeypox Virus during the 2022 Outbreak: An Overview of the Current State of Knowledge

An ongoing monkeypox outbreak in non-endemic countries has resulted in the declaration of a public health emergency of international concern by the World Health Organization (WHO). Though monkeypox has long been endemic in regions of sub-Saharan Africa, relatively little is known about its ecology, epidemiology, and transmission. Here, we consider the relevant research on both monkeypox and smallpox, a close relative, to make inferences about the current outbreak. Undetected circulation combined with atypical transmission and case presentation, including mild and asymptomatic disease, have facilitated the spread of monkeypox in non-endemic regions. A broader availability of diagnostics, enhanced surveillance, and targeted education, combined with a better understanding of the routes of transmission, are critical to identify at-risk populations and design science-based countermeasures to control the current outbreak.

Monkeypox: disease epidemiology, host immunity and clinical interventions

Monkeypox virus (MPXV), which causes disease in humans, has for many years been restricted to the African continent, with only a handful of sporadic cases in other parts of the world. However, unprecedented outbreaks of monkeypox in non-endemic regions have recently taken the world by surprise. In less than 4 months, the number of detected MPXV infections has soared to more than 48,000 cases, recording a total of 13 deaths. In this Review, we discuss the clinical, epidemiological and immunological features of MPXV infections. We also highlight important research questions and new opportunities to tackle the ongoing monkeypox outbreak.

In this Review, Ng and colleagues examine the clinical, epidemiological and immunological aspects of monkeypox virus (MPXV) infections, with a focus on mechanisms of host immunity to MPXV. The authors also consider the unique epidemiological and pathological characteristics of the current non-endemic outbreak of the virus and discuss vaccines, therapeutics and outstanding research questions.

Vaccination for Monkeypox Virus Infection in Humans: A Review of Key Considerations

Monkeypox virus infection in humans (MVIH) is currently an evolving public health concern given that >3000 MVIH cases have been reported in >50 countries globally, and the World Health Organization declared monkeypox a global health emergency on 23 July 2022. Adults (≥16 years old) usually have mild disease in contemporary studies, with a pooled case fatality rate of 0.03% (1/2941 cases). In comparison, poorer outcomes have been reported in children <16 years old (pooled case fatality rate 19% (4/21 cases)), immunocompromised patients, and pregnant women, with high rates of fetal demise in this group. Monkeypox-specific treatments include oral or intravenous tecovirimat, intravenous or topical cidofovir, oral brincidofovir, and vaccinia immunoglobulin, but the overall risk−benefit balance of monkeypox-specific treatment is unclear. Two effective vaccines exist for the prevention of MVIH: modified vaccinia Ankara and ACAM2000. Most probably, vaccination will be a key strategy for mitigating MVIH given the current rapid global spread of monkeypox, the existence of efficacious vaccines, and the uncertain risk−benefit profile of current antivirals. Priority groups for vaccination should include healthcare workers at high risk for occupational exposure, immunocompromised patients, and children. Vaccination strategies include pre-exposure vaccination, post-exposure prophylaxis, and ring vaccination of close contacts.

Unusual global outbreak of monkeypox: what should we do?

Recently, monkeypox has become a global concern amid the ongoing COVID-19 pandemic. Monkeypox is an acute rash zoonosis caused by the monkeypox virus, which was previously concentrated in Africa. The re-emergence of this pathogen seems unusual on account of outbreaks in multiple nonendemic countries and the incline to spread from person to person. We need to revisit this virus to prevent the epidemic from getting worse. In this review, we comprehensively summarize studies on monkeypox, including its epidemiology, biological characteristics, pathogenesis, and clinical characteristics, as well as therapeutics and vaccines, highlighting its unusual outbreak attributed to the transformation of transmission. We also analyze the present situation and put forward countermeasures from both clinical and scientific research to address it.

Adding New Fuel to the Fire: Monkeypox in the Time of COVID-19-Implications for Health Care Personnel

Monkeypox virus is reemerging, with cases reported on every inhabited continent at a time when clinical and public health resources have been stretched to the limit by COVID-19. As the monkeypox outbreak grows, health care workers must understand the threat and be prepared to address an infectious disease risk that may herald yet another unprecedented epidemic.

Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series

OBJECTIVE

To characterise the clinical features of monkeypox infection in humans.

DESIGN

Descriptive case series.

SETTING

A regional high consequences infectious disease centre with associated primary and secondary care referrals, and affiliated sexual health centres in south London between May and July 2022.

PARTICIPANTS

197 patients with polymerase chain reaction confirmed monkeypox infection.

RESULTS

The median age of participants was 38 years. All 197 participants were men, and 196 identified as gay, bisexual, or other men who have sex with men. All presented with mucocutaneous lesions, most commonly on the genitals (n=111 participants, 56.3%) or in the perianal area (n=82, 41.6%). 170 (86.3%) participants reported systemic illness. The most common systemic symptoms were fever (n=122, 61.9%), lymphadenopathy (114, 57.9%), and myalgia (n=62, 31.5%). 102/166 (61.5%) developed systemic features before the onset of mucocutaneous manifestations and 64 (38.5%) after (n=4 unknown). 27 (13.7%) presented exclusively with mucocutaneous manifestations without systemic features. 71 (36.0%) reported rectal pain, 33 (16.8%) sore throat, and 31 (15.7%) penile oedema. 27 (13.7%) had oral lesions and 9 (4.6%) had tonsillar signs. 70/195 (35.9%) participants had concomitant HIV infection. 56 (31.5%) of those screened for sexually transmitted infections had a concomitant sexually transmitted infection. Overall, 20 (10.2%) participants were admitted to hospital for the management of symptoms, most commonly rectal pain and penile swelling.

CONCLUSIONS

These findings confirm the ongoing unprecedented community transmission of monkeypox virus among gay, bisexual, and other men who have sex with men seen in the UK and many other non-endemic countries. A variable temporal association was observed between mucocutaneous and systemic features, suggesting a new clinical course to the disease. New clinical presentations of monkeypox infection were identified, including rectal pain and penile oedema. These presentations should be included in public health messaging to aid early diagnosis and reduce onward transmission.

Monkeypox transmission following exposure in healthcare facilities in nonendemic settings: Low risk but limited literature

Transmission risk of monkeypox in healthcare settings outside endemic regions has not been well defined. A rapid review of the literature, including cases outside monkeypox-endemic regions from 2000 to 2022 identified a single reported case of transmission. Available literature is limited by nonstandardized exposure definitions and limited detail describing exposures.

Nanopore sequencing of a monkeypox virus strain isolated from a pustular lesion in the Central African Republic

Monkeypox is an emerging and neglected zoonotic disease whose number of reported cases has been gradually increasing in Central Africa since 1980. This disease is caused by the monkeypox virus (MPXV), which belongs to the genus Orthopoxvirus in the family Poxviridae. Obtaining molecular data is particularly useful for establishing the relationships between the viral strains involved in outbreaks in countries affected by this disease. In this study, we evaluated the use of the MinION real-time sequencer as well as different polishing tools on MinION-sequenced genome for sequencing the MPXV genome originating from a pustular lesion in the context of an epidemic in a remote area of the Central African Republic. The reads corresponding to the MPXV genome were identified using two taxonomic classifiers, Kraken2 and Kaiju. Assembly of these reads led to a complete sequence of 196,956 bases, which is 6322 bases longer than the sequence previously obtained with Illumina sequencing from the same sample. The comparison of the two sequences showed mainly indels at the homopolymeric regions. However, the combined use of Canu with specific polishing tools such as Medaka and Homopolish was the best combination that reduced their numbers without adding mismatches. Although MinION sequencing is known to introduce a number of characteristic errors compared to Illumina sequencing, the new polishing tools allow a better-quality MinION-sequenced genome, thus to be used to help determine strain origin through phylogenetic analysis.