Monkeypox: What you need to know in 2022

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Living in a post-pandemic world has changed our perceptions about potentially contracting foreign viruses. Our once carefree outlook on global diseases is forever changed and we are on full alert when new strains are diagnosed on the other side of the planet. 

To no surprise, the recent outbreak of monkeypox has rattled our cages and many of us are asking how this could impact us.

This article will review current knowledge about Monkeypox, its symptoms and risk factors, and how we can prepare for a potential outbreak in South Africa. 

What is monkeypox?

Monkeypox is a highly contagious disease caused by infection with an Orthopoxvirus. It is a zoonotic disease, which means that it can be transmitted between animals and humans.

This virus was named, based on its first discovery in a population of research monkeys in a Danish laboratory in 1958. Soon after, the virus was first diagnosed in humans in the 1970s in the Democratic Republic of Congo (DRC), from where it rapidly spread throughout Central and West Africa. 

The first confirmed cases outside of Africa were reported as late as 2003, largely due to the effective eradication of the smallpox virus through large-scale vaccination programs. These smallpox vaccines provided additional protection against monkeypox, limiting the spread.

The recent outbreaks

The recent outbreak of Monkeypox took the world by surprise and spread rapidly.

In the first week of May 2022, the first new non-endemic Monkeypox cases were confirmed by the UK Health Security Agency. After rapid spread, there are now 3308 confirmed cases by the end of June 2022, of which 156 cases were reported in the United States.

The first reported patient in the UK had travel links to Nigeria whereas the next two confirmed cases had no travel history to Africa and were not related to the first case in any way. The World Health Organisation (WHO) has since reported cases from 12 member states from the UK, the USA, Canada, France, Germany, Belgium, Spain, Portugal, Italy, Sweden, and Australia. 

Although South Africa has come off unscathed, South Africa’s Health Minister Joe Phaahla publically reported the first confirmed case of monkeypox on Thursday, 23 June 2022.

More cases are expected to surface continuously. 

How does it spread?

Although less contagious than smallpox, monkeypox can spread rapidly through close human contact. 

The main vehicles for transmission of the virus include large respiratory droplets, bodily fluids, or prolonged direct contact with an infected person or animal.

The first monkeypox outbreak outside of Africa in 2003 was caused by direct contact with prairie dogs in the United States. These animals were held in close confinement with infected Gambian pouched rats and dormice that were imported from Ghana to be kept as pets in the United States. This infection caused an outbreak of at least 70 confirmed cases.

The popularity and accessibility of international travel have further exacerbated the spread of monkeypox. 

In 2018, 2019, and 2021, travelers linked to Israel, the UK, Singapore, and the USA have caused multiple cases of monkeypox to be diagnosed in numerous countries, traditionally non-endemic to the virus.

Symptoms of Monkeypox

Fortunately, Monkeypox is considered to be a self-limiting disease with symptoms naturally lasting from 2 to 4 weeks. 

The period between the onset of the infection and the onset of symptoms is known as the incubation period. For Monkeypox, the incubation period can range from 5 to 21 days and the infection and illness can be divided into two periods:

  1. The invasion period:

 This interval can last between 0 and 5 days and is characterized by lymphadenopathy, i.e. swelling of the lymph nodes, alongside intense exhaustion, body aches, fever, and headaches. Lymphadenopathy is a unique monkeypox feature when comparing other diseases with similar initial symptoms, including chickenpox, measles, and smallpox.

  1. Skin rash:

Once a fever appears during the invasion period, a skin rash normally occurs 1-3 days thereafter. These skin eruptions are more prevalent on the face and other extremities than on the body/trunk. It is also seen on the oral mucous membranes, genitalia, and cornea.

The skin eruptions evolve from flat lesions to slightly raised, to clear fluid-filled blisters. The lesions then become filled with yellowish fluid and then eventually dry before falling off. 

Because the symptoms of monkeypox closely overlap with those of smallpox, it could be easy to overlook. As a result, infection rates could potentially be much higher, due to inappropriate diagnoses. 

In summary, here is a list of typical monkeypox symptoms according to the WHO:

  • Fever
  • Swollen lymph nodes
  • Muscle and joint aches
  • Fatigue
  • Later, a rash develops that presents as flat, red, fluid-filled lesions

Should we be worried?

It depends.

All the global monkeypox outbreaks throughout history have been assigned to two distinct genetic viral clades: the first clade endemic to West Africa and the second endemic to the Congo basin. The Congo basin clade is considered to be more dangerous because it causes more severe disease symptoms and is more contagious than the West African clade. 

Fortunately, the recent non-endemic outbreaks were caused by the West African viral clade and there have been no reported deaths linked to the 2022 monkeypox outbreak.

Although monkeypox symptoms rarely lead to a fatal outcome, the projected mortality rate is currently at 3%. 

Infection may also lead to a wide range of indirect medical complications and may require medical intervention. Some complications may include secondary infections, pneumonia, sepsis, encephalitis, and infection of the cornea that may lead to a loss of vision. 

Depending on the extent of the viral exposure and the health status of the person at infection, severe cases more commonly occur among children. Furthermore, people with compromised immune systems are more vulnerable to harsh symptoms and mortality as a result of monkeypox.

Because smallpox was eradicated during the previous century, many countries have ceased large-scale smallpox vaccination campaigns. As a result, people younger than 40 – 50 years of age may be at greater risk of infection, due to a lack of early childhood vaccination. 

Despite ongoing monitoring and research, the outcome of monkeypox and its true level of threat remains unknown. For example, some of the more aggressive outbreaks in the DRC ran concurrently with an outbreak of chickenpox (unrelated to monkeypox), making accurate diagnosis problematic. Furthermore, because it is still a relatively uncommon occurrence in the developed world, with highly generalised initial symptoms, it is often misdiagnosed. 

As a result, true infection and mortality rates may still be higher than projected. 

Beating monkeypox starts with the proper diagnosis.

The WHO recommends a standardised protocol when monkeypox is suspected in patients:

  • Health workers should collect an appropriate sample and have it transported safely to a laboratory with appropriate capability. 
  • Confirmation of monkeypox depends on the type and quality of the specimen and the type of laboratory test. Thus, specimens should be packaged and shipped in accordance with national and international requirements. 
  • Polymerase chain reaction (PCR) is the preferred laboratory test given its accuracy and sensitivity. For this, optimal diagnostic samples for monkeypox are from skin lesions – the roof or fluid from vesicles and pustules, and dry crusts. Where feasible, a biopsy is an option. Lesion samples must be stored in a dry, sterile tube (no viral transport media) and kept cold. PCR blood tests are usually inconclusive because of the short duration of viremia relative to the timing of specimen collection after symptoms begin and should not be routinely collected from patients.

They have also confirmed that the antiviral treatment proven to be effective in the treatment of smallpox is also licensed and effective in treating monkeypox.

Take-home message

According to the City of Johannesburg’s Deputy Director of Communications and Stakeholder Management, Ewan Botha, South Africans need not panic: 

“The current strain of the disease is not considered fatal and sufferers begin to experience symptoms within seven to 14 days of exposure. Anyone with monkeypox must be kept in isolation and anyone who finds they had contact with someone with monkeypox must be traced and isolated too,” Botha urged.

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