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Kuehn R, Fox T, Guyatt G, Lutje V, Gould S. Infection prevention and control measures to reduce the transmission of mpox: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002731. [PMID: 38236835 PMCID: PMC10796032 DOI: 10.1371/journal.pgph.0002731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024]
Abstract
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.
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Affiliation(s)
- Rebecca Kuehn
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Tilly Fox
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Gordon Guyatt
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | - Vittoria Lutje
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Susan Gould
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Baldovin T, Girolametto G, Geppini R, Bordignon M, Alaibac M. Preventing and fighting stigma: a lesson from the first Mpox in Veneto region of Northeast Italy-A case report. Front Public Health 2023; 11:1141742. [PMID: 37275485 PMCID: PMC10235756 DOI: 10.3389/fpubh.2023.1141742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/13/2023] [Indexed: 06/07/2023] Open
Abstract
Since the 1970s, human monkeypox (Mpox) has been referred to as a zoonotic endemic disease of specific regions of Africa until early 2022, when a worldwide epidemic outbreak developed. There are many hypotheses on how Mpox could spread to non-endemic regions; the dominant theory is that it spread from the UK and Spain among men who have sex with men (MSM). Therefore, the first clinical case in the Veneto region (Northeast of Italy) was analyzed-which represented a typical case report of the ongoing outbreak-with lesions located mainly in the areas associated with sexual behaviors (genital and oral). This case report highlights the new challenges of Mpox, as it seems to differ from the previous classic manifestation. Indeed, although the patient achieved restitution ad integrum of lesions and complete recovery from the disease, it is deemed necessary to offer communication strategies to involve a heterogeneous audience based on different risks of exposure but without stigmatizing attitudes, avoiding the mistakes made with HIV. The need for broad public involvement is demonstrated by identifying Mpox even in "anomalous cases." Stigma could be an obstacle in engaging patients in proper care and in getting honest answers while contact tracing, as happened in our patient's case; thus, WHO recently renamed monkeypox as Mpox. Abnormal outbreaks in non-endemic countries, with no causal links, must become a warning signal for governments and health policies to design national plans for managing unexpected outbreaks. For an effective public health response, health institutions must communicate effectively, focus on changes and prevention measures, and formulate a plan based on equity and inclusion of the most vulnerable groups.
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Affiliation(s)
- Tatjana Baldovin
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Unit of Hygiene and Public Health, University of Padua, Padua, Italy
| | - Gloria Girolametto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Unit of Hygiene and Public Health, University of Padua, Padua, Italy
| | - Ruggero Geppini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Unit of Hygiene and Public Health, University of Padua, Padua, Italy
| | | | - Mauro Alaibac
- Unit of Dermatology, University of Padua, Padua, Italy
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Vairo F, Leone S, Mazzotta V, Piselli P, De Carli G, Lanini S, Maggi F, Nicastri E, Gagliardini R, Vita S, Siddu A, Rezza G, Barca A, Vaia F, Antinori A, Girardi E. The possible effect of sociobehavioral factors and public health actions on the mpox epidemic slowdown. Int J Infect Dis 2023; 130:83-85. [PMID: 36906119 DOI: 10.1016/j.ijid.2023.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/16/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVES A pre-exposure vaccination campaign to prevent the spread of the mpox virus was initiated in Italy in August 2022. We explore the possible factors affecting the trend of mpox cases in an Italian region (Lazio) with a rapid roll-out of the vaccination campaign. METHODS We estimated the impact of the communication and vaccination campaign by fitting a Poisson segmented regression model. Results By September 30, 2692, high-risk men who have sex with men had received at least one dose of vaccine, with a vaccination coverage of 37%. The analysis of surveillance data showed a significant decreasing trend in the number of mpox cases starting from the second week after vaccination (incidence rate ratio 0.452 [0.331-0.618]). CONCLUSION The reported trend in mpox cases is likely to result from a combination of multiple social and public health factors combined with a vaccination campaign.
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Affiliation(s)
- Francesco Vairo
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Sara Leone
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Valentina Mazzotta
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy.
| | - Pierluca Piselli
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Gabriella De Carli
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Simone Lanini
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Fabrizio Maggi
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Emanuele Nicastri
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Roberta Gagliardini
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Serena Vita
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Andrea Siddu
- Directorate General of Health Prevention, Ministry of Health, Rome, Italy
| | - Giovanni Rezza
- Directorate General of Health Prevention, Ministry of Health, Rome, Italy
| | - Alessandra Barca
- Unit of Health Promotion and Prevention, Directorate of Health and integration, Lazio Region, Italy
| | - Francesco Vaia
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Andrea Antinori
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
| | - Enrico Girardi
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' (IRCCS), Rome, Italy
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Yang S, Guo X, Zhao Z, Abudunaibi B, Zhao Y, Rui J, Wang Y, Song W, Wei H, Chen T. Possibility of mpox viral transmission and control from high-risk to the general population: a modeling study. BMC Infect Dis 2023; 23:119. [PMID: 36829116 PMCID: PMC9960212 DOI: 10.1186/s12879-023-08083-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/13/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Mpox is an emerging infectious disease that is now a global hazard. The strategies for preventing and controlling mpox should be further investigated in terms of transmission characteristics, infection risk among different populations, and ideal therapeutic approaches. METHODS A multi-group dynamic model was used to quantify the transmissibility of mpox. We further analyzed the transmission risk from men who have sex with men (MSM) to non-MSM and evaluated the effects of three intervention measures, including community-based prevention, early detection, and vaccination. RESULTS The median value of effective reproduction number (Reff) and probability of contact via a single contact (q) among MSM worldwide is 3.11 (interquartile range [IQR]: 2.82-5.57) and 2.15% (IQR: 1.95-3.84%). We found that the cumulative incidence rate of non-MSM is much lower than that of MSM (< 1/2048) when the possibility of infection (including the percentage of high-risk behaviors of contact degree [C] and q) was lowered to less than 1 in 100,000. When comparing the three intervention measures, if we want to control the cumulative incidence rate to 5.96 × 10-8 we need to increase the vaccine coverage to 81% or reduce the transmission rate factor (Cq) to 70% or shorten the transmission period to 74%. CONCLUSIONS Mpox has high transmissibility in MSM, which required minimize the risk of infection and exposure to high-risk populations. Community prevention and control is the top priority of interventions to contain the spread of mpox.
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Affiliation(s)
- Shiting Yang
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Xiaohao Guo
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Zeyu Zhao
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Buasiyamu Abudunaibi
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Yunkang Zhao
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Jia Rui
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Yao Wang
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Wentao Song
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Hongjie Wei
- grid.12955.3a0000 0001 2264 7233State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang’an Road, Xiang’an District, Xiamen City, Fujian Province People’s Republic of China
| | - Tianmu Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, 4221-117 South Xiang'an Road, Xiang'an District, Xiamen City, Fujian Province, People's Republic of China.
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Pourriyahi H, Aryanian Z, Afshar ZM, Goodarzi A. A systematic review and clinical atlas on mucocutaneous presentations of the current monkeypox outbreak: With a comprehensive approach to all dermatologic and nondermatologic aspects of the new and previous monkeypox outbreaks. J Med Virol 2023; 95:e28230. [PMID: 36254380 DOI: 10.1002/jmv.28230] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/03/2022] [Accepted: 10/13/2022] [Indexed: 11/11/2022]
Abstract
Monkeypox is a zoonotic disease, endemic in central and west African regions, and has re-emerged, currently causing an outbreak as of May 2022. In this systematic review, we aimed to characterize the current face of the disease, with a detailed categorization of mucocutaneous, as well as systemic symptoms of the disease. We searched four main online databases with the keywords "monkeypox" and "Orthopoxvirus". A total of 46 articles were included, with a cumulative number of 1984 confirmed cases. Patients were predominantly men who have sex with men, who were mostly in their 30s, with a history of unprotected sexual contact or international travel. Among mucocutaneous manifestations, anogenital lesions were the most commonly observed, followed by lesions on the limbs, face, trunk, and palms or soles. Among lesion types, vesiculopustular, pustular or pseudo-pustular, vesicular-umbilicated and papular lesions were the most common, mainly presenting asynchronously, with less than 10 lesions on each patient. Almost all patients also reported systemic manifestations, namely fever, lymphadenopathy, fatigue, myalgia, headaches, pharyngitis, and proctitis. Sexual contact is the main pathway of transmission in the current outbreak, with viral shedding in bodily fluids playing a key role. We've compared these idiosyncratic findings of the new outbreak with previous outbreaks. We've also gathered and categorized images from our included studies to make a "clinical atlas" for this "new" face of monkeypox, which can be of utmost importance for clinicians to be familiarized with, and have a clear picture of monkeypox for their differential diagnoses.
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Affiliation(s)
- Homa Pourriyahi
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zeinab Aryanian
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Dermatology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Zeinab Mohseni Afshar
- Clinical Research Development Center, Imam Reza Hospital Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Azadeh Goodarzi
- Department of Dermatology, School of Medicine, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
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6
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Chakraborty C, Bhattacharya M, Sharma AR, Dhama K. Evolution, epidemiology, geographical distribution, and mutational landscape of newly emerging monkeypox virus. GeroScience 2022; 44:2895-2911. [PMID: 36094771 PMCID: PMC9466330 DOI: 10.1007/s11357-022-00659-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/05/2022] [Indexed: 01/18/2023] Open
Abstract
Recent monkeypox (MPX) outbreaks are major ones in non-endemic countries. The present study analyzed molecular phylogenetics, divergence, epidemiology, the geographical distribution, entropy diversity of genome, mutational landscape, and evolution of the monkeypox virus (MPXV) genome and the current MPXV is entitled "hMPXV1." We used different in-silico and statistical methods to study our objectives. The developed phylogram from molecular phylogenetics describes the origin and evolution of hMPXV1 of A, A.1, A.1.1, A.2, and B.1 lineages. The microevolution of B.1 lineage shows its evolution from May to August 2022. B.1 lineage is further adapting and showing more mutation and sub-lineages. The scatter plot of all lineages shows the clustering pattern of lineages and the divergence. We also developed two statistical models of confirmed cases and a diagram of the age-related pattern of infected cases to illustrate the epidemiology of the MPX outbreaks. The entropy diversity and mutational landscape of the hMPXV1 genome were analyzed in nucleotide and codon contexts. Our study has shown the in-depth evolution pattern of different lineages of the hMPXV1. We found B.1 lineage is associated with the current outbreaks. The mutational landscape informs about the slow mutation of the virus. Finally, the study might assists the new therapeutic development considering all the above points and would help the researcher to set up their future research directions.
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Affiliation(s)
- Chiranjib Chakraborty
- Department of Biotechnology, School of Life Science and Biotechnology, Adamas University, Kolkata, West Bengal, 700126, India.
| | - Manojit Bhattacharya
- Department of Zoology, Fakir Mohan University, Vyasa Vihar, Balasore, 756020, Odisha, India
| | - Ashish Ranjan Sharma
- Institute for Skeletal Aging & Orthopedic Surgery, Hallym University-Chuncheon Sacred Heart Hospital, Chuncheon-si, 24252, Gangwon-do, Republic of Korea
| | - Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, 243122, Bareilly, India
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7
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Wang F, Zhang J, Wang Y, Chen Y, Han D. Viral tropism for the testis and sexual transmission. Front Immunol 2022; 13:1040172. [PMID: 36439102 PMCID: PMC9682072 DOI: 10.3389/fimmu.2022.1040172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/24/2022] [Indexed: 10/17/2023] Open
Abstract
The mammalian testis adopts an immune privileged environment to protect male germ cells from adverse autoimmune reaction. The testicular immune privileged status can be also hijacked by various microbial pathogens as a sanctuary to escape systemic immune surveillance. In particular, several viruses have a tropism for the testis. To overcome the immune privileged status and mount an effective local defense against invading viruses, testicular cells are well equipped with innate antiviral machinery. However, several viruses may persist an elongated duration in the testis and disrupt the local immune homeostasis, thereby impairing testicular functions and male fertility. Moreover, the viruses in the testis, as well as other organs of the male reproductive system, can shed to the semen, thus allowing sexual transmission to partners. Viral infection in the testis, which can impair male fertility and lead to sexual transmission, is a serious concern in research on known and on new emerging viruses. To provide references for our scientific peers, this article reviews research achievements and suggests future research focuses in the field.
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Affiliation(s)
| | | | | | - Yongmei Chen
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Daishu Han
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
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8
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Muacevic A, Adler JR. Human Monkeypox: An Emerging Zoonosis. Cureus 2022; 14:e31736. [PMID: 36569695 PMCID: PMC9769781 DOI: 10.7759/cureus.31736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
Human monkeypox is caused by a zoonotic Orthopoxvirus that resembles smallpox. It is challenging to identify the illness from varicella and smallpox. The rapid spread of cases across countries has raised serious concerns among public health officials around the world, prompting accelerated investigations to identify the origins and causes of the rapid expansion of cases. When people come into contact with infected animals, they may unintentionally contract monkeypox. The monkeypox virus is transferred by direct exposure to lesions, respiratory droplets, body fluids, and contaminated objects like blood. Fever, rash, and lymph nodes frequent swelling are clinical signs of monkeypox, which can cause a multitude of health problems. The disease's worldwide significance is shown by the advent of outbreaks outside of Africa. To understand the constantly shifting epidemiology of this disease that is reemerging, monkeypox cases require improved monitoring and case identification. Before smallpox's eradication and the consequent absence of immunization attempts, vaccinia vaccination provided coincidental protection to the monkeypox virus; however, monkeypox gained therapeutic relevance. Additionally, given that rural Africa is where monkeypox cases are most common, it is possible that underreporting could result in an underestimate of the pathogen's potential impact. In recent months, cases of human monkeypox have alarmingly increased in nations where the illness is not prevalent. The current monkeypox outbreak, in light of the COVID-19 pandemic, represents a fresh threat. Clinicians need to be aware of this novel scenario, which differs from previous epidemics' scenarios. The transmission of monkeypox should be reduced by the development of efficient solutions by global health systems.
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Kumar R, Singh S, Singh SK. A Systematic Review of 5110 Cases of Monkeypox: What Has Changed Between 1970 and 2022? Cureus 2022; 14:e30841. [DOI: 10.7759/cureus.30841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
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Guzzetta G, Mammone A, Ferraro F, Caraglia A, Rapiti A, Marziano V, Poletti P, Cereda D, Vairo F, Mattei G, Maraglino F, Rezza G, Merler S. Early Estimates of Monkeypox Incubation Period, Generation Time, and Reproduction Number, Italy, May-June 2022. Emerg Infect Dis 2022; 28:2078-2081. [PMID: 35994726 PMCID: PMC9514338 DOI: 10.3201/eid2810.221126] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We analyzed the first 255 PCR-confirmed cases of monkeypox in Italy in 2022. Preliminary estimates indicate mean incubation period of 9.1 (95% CI 6.5-10.9) days, mean generation time of 12.5 (95% CI 7.5-17.3) days, and reproduction number among men who have sex with men of 2.43 (95% CI 1.82-3.26).
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11
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Loconsole D, Sallustio A, Centrone F, Casulli D, Accogli M, Saracino A, Foti C, Grandolfo M, Buccoliero GB, Vitale V, De Nitto S, Conversano M, Desiante F, Del Sambro L, Simone D, Parisi A, Prato R, Martinelli D, Chironna M. Monkeypox Virus Infections in Southern Italy: Is There a Risk for Community Spread? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191811719. [PMID: 36141993 PMCID: PMC9517482 DOI: 10.3390/ijerph191811719] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/06/2022] [Accepted: 09/15/2022] [Indexed: 06/07/2023]
Abstract
The ongoing outbreak of the Monkeypox virus (MPXV) is characterized by sustained human-to-human transmission, particularly among men who have sex with men (MSM). The aim of the study was to describe the characteristics of the MPXV infection identified in Southern Italy. Clinical samples for each suspected case identified from 1 June to 1 August 2022 were tested for MPXV, and whole-genome sequencing (WGS) was performed on two strains. Ten cases were identified: eight were young adult males, including six MSMs, and two were female. Nine subjects reported recent sexual exposure. One female subject without sexual exposure only reported attendance at a social gathering. Overall, 7 of 10 skin lesion samples had a high viral load of MPXV DNA, and 6/9 whole blood samples and 6/8 nasopharyngeal swab samples also tested positive. The analyzed sequences belonged to Clade 3, lineage B.1, and B.1.5, respectively. Despite this recent multinational outbreak of MPXV cases having revealed a high proportion of cases occurring among MSM, the identification of cases among heterosexual subjects and in a female subject without sexual risk factors should raise awareness among clinicians about the possible spread of MPXV in the general population.
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Affiliation(s)
- Daniela Loconsole
- Hygiene Section, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy
| | - Anna Sallustio
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, 70124 Bari, Italy
| | - Francesca Centrone
- Hygiene Section, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy
| | - Daniele Casulli
- Hygiene Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, 70124 Bari, Italy
| | - Marisa Accogli
- Hygiene Section, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy
| | - Annalisa Saracino
- Infectious Diseases Section, Department of Biomedical Sciences and Human Oncology, University of Bari, 70124 Bari, Italy
| | - Caterina Foti
- Section of Dermatology, Department of Biomedical Sciences and Human Oncology, University of Bari, 70124 Bari, Italy
| | - Mauro Grandolfo
- Section of Dermatology, Department of Biomedical Sciences and Human Oncology, University of Bari, 70124 Bari, Italy
| | | | - Viviana Vitale
- Department of Prevention, Local Health Authority of Bari, 70100 Bari, Italy
| | - Sara De Nitto
- Department of Prevention, Local Health Authority of Bari, 70100 Bari, Italy
| | - Michele Conversano
- Department of Prevention, Local Health Authority of Taranto, 74121 Taranto, Italy
| | - Francesco Desiante
- Department of Prevention, Local Health Authority of Taranto, 74121 Taranto, Italy
| | - Laura Del Sambro
- Istituto Zooprofilattico Sperimentale della Puglia e della Basilicata, 71121 Foggia, Italy
| | - Domenico Simone
- Istituto Zooprofilattico Sperimentale della Puglia e della Basilicata, 71121 Foggia, Italy
| | - Antonio Parisi
- Istituto Zooprofilattico Sperimentale della Puglia e della Basilicata, 71121 Foggia, Italy
| | - Rosa Prato
- Hygiene Section, Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Domenico Martinelli
- Hygiene Section, Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Maria Chironna
- Hygiene Section, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy
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12
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Liu D, Chi Y, Song P, Zeng X, Du L, Chen Y, Li S. Risk factors, clinical manifestation, precaution, and management of monkeypox. J Evid Based Med 2022; 15:183-186. [PMID: 35996882 DOI: 10.1111/jebm.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Dan Liu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Chi
- Yealth Network, Beijing Yealth Technology Co., Ltd, Beijing, China
- Cochrane Campbell Global Ageing Partnership, London, UK
| | - Peige Song
- School of Public Health, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiantao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Liang Du
- Division of Guideline and Rapid Recommendation, Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yaolong Chen
- Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China
- Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Guideline International Network Asia, Lanzhou, China
- World Health Organization (WHO) Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, China
- Lanzhou University, an affiliate of the Cochrane China Network, Lanzhou, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Division of Guideline and Rapid Recommendation, Cochrane China Center, MAGIC China Center, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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13
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Petersen E, Zumla A, Hui DS, Blumberg L, Valdoleiros SR, Amao L, Ntoumi F, Asogun D, Simonsen L, Haider N, Traore T, Kapata N, Dar O, Nachega J, Abbara A, Al Balushi A, Kock R, Maeurer M, Lee SS, Lucey DR, Ippolito G, Koopmans M. Vaccination for monkeypox prevention in persons with high-risk sexual behaviours to control on-going outbreak of monkeypox virus clade 3. Int J Infect Dis 2022; 122:569-571. [PMID: 35788415 PMCID: PMC9534076 DOI: 10.1016/j.ijid.2022.06.047] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- E Petersen
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Aarhus, Denmark; European Society for Clinical Microbiology and Infectious Diseases [ESCMID] Task Force for Emerging Infections, Basel, Switzerland.
| | - A Zumla
- Centre for Clinical Microbiology, Division of Infection and Immunity, University College London; NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom
| | - D S Hui
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China
| | - L Blumberg
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa; Faculty of Veterinary Science, University of Pretoria, South Africa
| | - S R Valdoleiros
- European Society for Clinical Microbiology and Infectious Diseases [ESCMID] Task Force for Emerging Infections, Basel, Switzerland; Infectious Diseases Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - L Amao
- Nigeria Centre for Disease Control, Abuja, Nigeria
| | - F Ntoumi
- Congolese Foundation for Medical Research, Brazzaville, Republic of Congo; Institute of Tropical Medicine, University of Tübingen, Germany
| | - D Asogun
- Irrua Specialized Teaching Hospital, Irrua, Nigeria
| | - L Simonsen
- PandemiX Center, Department of Science and Environment, Roskilde University, Denmark
| | - N Haider
- The Royal Veterinary College, University of London, Hatfield, Hertfordshire, United Kingdom
| | - T Traore
- Emergency Preparedness and Response Programme, WHO Regional Office for Africa, Dakar Hub, Dakar, Senegal
| | - N Kapata
- National Public Health Institute, Ministry of Health, Lusaka, Zambia
| | - O Dar
- Chatham House and UK Public health security agency, London, UK
| | - J Nachega
- Department of Medicine and Center for Infectious Diseases, Stellenbosch University, Cape Town, South Africa; University of Pittsburgh Graduate School of Public Health, Pittsburgh, USA; Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - A Abbara
- UK Syria Public Health Network, and Department of Infection, Faculty of Medicine, Imperial College, London, UK
| | - A Al Balushi
- Infectious Diseases Unit, Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - R Kock
- The Royal Veterinary College, University of London, Hatfield, Hertfordshire, UK
| | - M Maeurer
- ImmunoSurgery Unit, Champalimaud Centre for the Unknown, Lisbon, Portugal; Medizinische Klinik, Johannes Gutenberg University Mainz, Germany
| | - S S Lee
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, 206 Postgraduate Education Centre, Prince of Wales Hospital, Hong Kong, China
| | - D R Lucey
- Daniel R. Lucey, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - G Ippolito
- Guiseppe Ippolito: Ministry of Health, Rome, Italy.
| | - Mpg Koopmans
- Viroscience Department, Erasmus Medical Center, Rotterdam, Netherlands; Pandemic and Disaster Preparedness Centre, Rotterdam, Netherlands
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14
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Girometti N, Byrne R, Bracchi M, Heskin J, McOwan A, Tittle V, Gedela K, Scott C, Patel S, Gohil J, Nugent D, Suchak T, Dickinson M, Feeney M, Mora-Peris B, Stegmann K, Plaha K, Davies G, Moore LSP, Mughal N, Asboe D, Boffito M, Jones R, Whitlock G. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis. THE LANCET. INFECTIOUS DISEASES 2022; 22:1321-1328. [PMID: 35785793 PMCID: PMC9534773 DOI: 10.1016/s1473-3099(22)00411-x] [Citation(s) in RCA: 258] [Impact Index Per Article: 129.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/14/2022] [Accepted: 06/14/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Historically, human monkeypox virus cases in the UK have been limited to imported infections from west Africa. Currently, the UK and several other countries are reporting a rapid increase in monkeypox cases among individuals attending sexual health clinics, with no apparent epidemiological links to endemic areas. We describe demographic and clinical characteristics of patients diagnosed with human monkeypox virus attending a sexual health centre. METHODS In this observational analysis, we considered patients with confirmed monkeypox virus infection via PCR detection attending open-access sexual health clinics in London, UK, between May 14 and May 25, 2022. We report hospital admissions and concurrent sexually transmitted infection (STI) proportions, and describe our local response within the first 2 weeks of the outbreak. FINDINGS Monkeypox virus infection was confirmed in 54 individuals, all identifying as men who have sex with men (MSM), with a median age of 41 years (IQR 34-45). 38 (70%) of 54 individuals were White, 26 (48%) were born in the UK, and 13 (24%) were living with HIV. 36 (67%) of 54 individuals reported fatigue or lethargy, 31 (57%) reported fever, and ten (18%) had no prodromal symptoms. All patients presented with skin lesions, of which 51 (94%) were anogenital. 37 (89%) of 54 individuals had skin lesions affecting more than one anatomical site and four (7%) had oropharyngeal lesions. 30 (55%) of 54 individuals had lymphadenopathy. One in four patients had a concurrent STI. Five (9%) of 54 individuals required admission to hospital, mainly due to pain or localised bacterial cellulitis requiring antibiotic intervention or analgesia. We recorded no fatal outcomes. INTERPRETATION Autochthonous community monkeypox virus transmission is currently observed among MSM in the UK. We found a high proportion of concomitant STIs and frequent anogenital symptoms, suggesting transmissibility through local inoculation during close skin-to-skin or mucosal contact, during sexual activity. Additional resources are required to support sexual health and other specialist services in managing this condition. A review of the case definition and better understanding of viral transmission routes are needed to shape infection control policies, education and prevention strategies, and contact tracing. FUNDING None.
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Affiliation(s)
- Nicolò Girometti
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
| | - Ruth Byrne
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Margherita Bracchi
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Joseph Heskin
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Alan McOwan
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Victoria Tittle
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Keerti Gedela
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christopher Scott
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sheel Patel
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Jesal Gohil
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Diarmuid Nugent
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Tara Suchak
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Molly Dickinson
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Margaret Feeney
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Borja Mora-Peris
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Katrina Stegmann
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Falcon Road Clinic (Wandsworth), Central London Community Healthcare NHS Trust, London, UK
| | - Komal Plaha
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Falcon Road Clinic (Wandsworth), Central London Community Healthcare NHS Trust, London, UK
| | - Gary Davies
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Luke S P Moore
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Imperial College Healthcare NHS Trust, London, UK; Department of Infectious Diseases, Imperial College London, London, UK
| | - Nabeela Mughal
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Imperial College Healthcare NHS Trust, London, UK; Department of Infectious Diseases, Imperial College London, London, UK
| | - David Asboe
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Marta Boffito
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Infectious Diseases, Imperial College London, London, UK
| | - Rachael Jones
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Gary Whitlock
- Department of HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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15
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Di Gennaro F, Veronese N, Marotta C, Shin JI, Koyanagi A, Silenzi A, Antunes M, Saracino A, Bavaro DF, Soysal P, Segala FV, Butler L, Milano E, Barbagallo M, Barnett Y, Parris C, Nicastri E, Pizzol D, Smith L. Human Monkeypox: A Comprehensive Narrative Review and Analysis of the Public Health Implications. Microorganisms 2022; 10:microorganisms10081633. [PMID: 36014051 PMCID: PMC9416167 DOI: 10.3390/microorganisms10081633] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 01/13/2023] Open
Abstract
Recently, numerous cases of monkeypox were reported from several non-endemic countries in Europe, North America, and Oceania, suggesting an unusual and alarming public health issue, particularly considering that the disease is not directly related to human or animal travels. Attention is currently being drawn to this phenomenon since more than 70% of the global population is no longer vaccinated against smallpox. Indeed, the smallpox vaccination also confers some indirect degree of protection against other poxviruses, including monkeypox. We performed a narrative review to describe the existing literature with regard to monkeypox using the MEDLINE, EMBASE, and Scopus databases. This review aims to provide updated evidence of findings on the epidemiology, clinical features, diagnosis, management, and prevention of monkeypox, also considering the concurrent zoonotic pandemic caused by the COVID-19 coronavirus, SARS-CoV-2.
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Affiliation(s)
- Francesco Di Gennaro
- Clinic of Infectious Diseases, University of Bari, University Hospital Policlinico, 70121 Bari, Italy
- Correspondence:
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
| | - Claudia Marotta
- General Directorate of Health Prevention, Ministry of Health, 00144 Rome, Italy
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, ISCIII, 08010 Barcelona, Spain
- ICREA, Passeig Lluis Companys 23, 08010 Barcelona, Spain
| | - Andrea Silenzi
- General Directorate of Health Prevention, Ministry of Health, 00144 Rome, Italy
| | - Mario Antunes
- Department of Surgery, Catholic University of Mozambique, Beira 13016, Mozambique
| | - Annalisa Saracino
- Clinic of Infectious Diseases, University of Bari, University Hospital Policlinico, 70121 Bari, Italy
| | - Davide Fiore Bavaro
- Clinic of Infectious Diseases, University of Bari, University Hospital Policlinico, 70121 Bari, Italy
| | - Pinar Soysal
- Department of Geriatric Medicine, Faculty of Medicine, Bezmialem Vakif University, Istanbul 34093, Turkey
| | | | - Laurie Butler
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge CB1 1PT, UK
| | - Eugenio Milano
- Clinic of Infectious Diseases, University of Bari, University Hospital Policlinico, 70121 Bari, Italy
| | - Mario Barbagallo
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
| | - Yvonne Barnett
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge CB1 1PT, UK
| | - Christopher Parris
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge CB1 1PT, UK
| | - Emanuele Nicastri
- National Institute for Infectious Diseases, Lazzaro Spallanzani, IRCCS, Via Portuense, 292, 00149 Rome, Italy
| | - Damiano Pizzol
- Italian Agency for Development Cooperation, 00135 Khartoum, Sudan
| | - Lee Smith
- Centre for Health Performance and Wellbeing, Anglia Ruskin University, Cambridge CB1 1PT, UK
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16
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Lai CC, Hsu CK, Yen MY, Lee PI, Ko WC, Hsueh PR. Monkeypox: An emerging global threat during the COVID-19 pandemic. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:787-794. [PMID: 35970757 PMCID: PMC9352646 DOI: 10.1016/j.jmii.2022.07.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 12/23/2022]
Abstract
The emergence of the monkeypox outbreak in early 2022 has posed a new global health threat. As of July 8, 2022, 9069 laboratory-confirmed cases have been reported, and most of them are from non-endemic countries. The monkeypox virus is an enveloped double-stranded DNA virus, and preliminary genetic data suggest that the 2022 monkeypox virus belongs to the West African clade. In the current outbreak, human-to-human transmission has been the primary transmission mode. Although direct skin-to-skin contact with lesions during sexual activities can spread the virus, it remains unclear whether monkeypox can spread through sexual contact, specifically through contaminated body fluids. The typical presentation of monkeypox includes prodromal symptoms, followed by a rash that usually begins within 1–3 days of symptom onset, and the skin lesions can last for 2–4 weeks and then gradually resolve. However, the monkeypox outbreak in 2022 may exhibit atypical features. A definite diagnosis of monkeypox virus infection requires nucleic acid amplification testing via the polymerase chain reaction method. Supportive care is essential, and antiviral therapy is not considered for all affected patients, but recommended for those at highrisk for severe diseases. The mitigation of monkeypox outbreaks include enhanced case detection, case isolation, contact tracing, and post-exposure vaccination. In conclusion, the current monkeypox outbreak is a new threat during the COVID-19 pandemic. Clinicians should be aware of this new situation, which presents a different scenario from those of prior outbreaks. Global health systems should develop effective strategies to mitigate the spread of monkeypox.
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Affiliation(s)
- Chih-Cheng Lai
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chi-Kuei Hsu
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Muh-Yong Yen
- Division of Infectious Diseases, Cheng Hsin General Hospital, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ping-Ing Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan; Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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