Monkeypox (Mpox): Sign and Symptoms, Causes, Mode of Transmission, Risk factors, Diagnosis, Complications, Treatment and Prevention

Monkeypox, formerly known as Mpox, is a zoonotic viral disease that resembles smallpox but is generally less severe. It is caused by the Monkeypox virus, which belongs to the Orthopoxvirus genus. It primarily found in Central and West Africa but the virus has spread globally in recent years now recognized globally specially Europe and North America due to recent outbreaks. Monkeypox is contagious; the virus spreads through direct contact with infected individuals or animals, as well as through their contaminated materials like an infected person’s body fluids, lesions, or respiratory droplets etc. Early recognition and isolation are crucial to prevent spread.

 

Typical symptoms include fever, swollen lymph nodes, and a characteristic rash that evolves through multiple stages. While it is less severe than smallpox, complications can occur, particularly in vulnerable populations. Treatment mainly involves supportive care and symptom management, with antiviral options like tecovirimat in severe cases. Vaccination against smallpox provides partial protection and is used to curb the spread. The disease's global spread has increased focus on monitoring, rapid diagnostics, and vaccine accessibility.

Sign and Symptoms of Monkeypox

Monkeypox is a zoonotic viral disease characterized by various signs and symptoms that can range from mild to severe. While most cases are mild and self-limiting, severe infections can occur, particularly in immunocompromised individuals, children, or those with underlying health conditions. The Incubation Period of Monkeypox virus infection typically lasts 5 to 21 days, with an average of 7 to 14 days. During this period, the virus is replicating in the body, but the infected individual may not exhibit any symptoms. Symptoms of Monkeypox typically last 2 to 4 weeks before resolving, with the rash stages transitioning throughout the illness period.

A. Initial Symptoms (Prodromal Phase) :

• Fever: Often the first symptom, Sudden onset, usually high-grade. Accompanied by intense warmth, shivering spells, and sweating as the body attempts to regulate temperature.
• Chills: Accompanying the fever, leading to bouts of shivering.
• Headache: Intense and persistent, can range from a dull ache to severe, throbbing pain often generalized but can be more intense in the forehead or behind the eyes.
• Muscle Aches (Myalgia): Usually involves the back, thighs, and shoulders. Muscles may feel sore and tender to touch.
• Fatigue: Severe tiredness or weakness. Profound exhaustion that can limit physical activity and make simple tasks difficult.
• Lymphadenopathy: Swelling of lymph nodes; Painful, firm lumps that can be palpated under the skin in the neck, armpits, and groin. Enlarged lymph nodes are a distinguishing feature of monkeypox; this is a distinguishing feature that helps differentiate monkeypox from smallpox.

B. Rash Development :

The rash typically appears 1 to 3 days after the onset of fever. The rash often starts on the face (notably around the mouth) and then spreads to other parts of the body. Common on the palms and soles, which is less common for many other rash-causing illnesses can cover the trunk, arms, legs, and, in some cases, the genitals or mucosal surfaces (mouth, eyes). The rash generally follows a centrifugal pattern, with higher concentrations on the extremities (hands and feet) compared to the torso. The rash evolves through several stages:

• Macules: Flat, red spots that can be seen but not felt. They may appear slightly discolored or reddish.
• Papules: Raised, firm bumps that start to form in place of the macules.
• Vesicles: Bumps fill with clear fluid, forming small, blister-like structures that may feel tight and itchy.
• Pustules: Vesicles become filled with thick, opaque fluid, taking on a whitish or yellowish appearance. These can be painful and tense to touch.
• Scabs/Crusts: The pustules eventually dry out and form scabs. Once the scabs fall off, healed skin may remain slightly discolored or scarred.

Rash lesions are typically hard and well-circumscribed. The pustules, when touched, feel like small firm balls embedded in the skin.  As the lesions progress, they may become itchy, especially when crusting over, and can be painful during the pustular stage.

C. Associated Symptoms:

• Sore Throat and Cough: May develop if there is upper respiratory tract involvement. Can be accompanied by difficulty swallowing or hoarseness.
• Back Pain: Common due to overall muscle involvement and inflammation.
• Conjunctivitis: Red or irritated eyes with possible discharge if the virus affects ocular tissues.
• Mucosal Lesions: Painful ulcers or lesions can form inside the mouth or on the tongue, making eating and drinking uncomfortable.

Causes of Monkeypox Infection

Monkeypox infection results from exposure to the monkeypox virus (MPXV), which is primarily zoonotic; transmission occurs when humans come into direct or indirect contact with infected animals.  Monkeypox is also transmitted through multiple routes involving animals, humans, and the environment.

A. Zoonotic Transmission (Animal-to-Human)

Monkeypox is primarily a zoonotic disease, transmission occurs when humans come into direct or indirect contact with infected animals. The key causes of zoonotic transmission include:

• Direct Contact with Infected Animals: Physical interaction with animals carrying the virus is a major cause, including Touching the skin, fur, or body lesions of infected animals, Contact with blood, saliva, or other bodily fluids from animals carrying the virus.
• Bites or Scratches from Infected Animals: Rodents and monkeys, which can carry the virus, may bite or scratch humans, introducing the virus through broken skin.
• Consumption of Infected Animal Products:
  • Eating Bush meat: In some endemic regions, infected wild animals are hunted for food, and improperly cooked meat can serve as a source of infection.
  • Handling Carcasses: Preparing or processing bush meat increases the risk of exposure to the virus through cuts or direct contact with infected tissues.
• Reservoir Hosts:
  • Primary Reservoirs: Rodents, especially African squirrels, Gambian pouched rats, and dormice, are the natural hosts of the monkeypox virus.
  • Incidental Hosts: Non-human primates, such as monkeys, can harbor the virus and transmit it to humans, but they are not the main reservoirs.

B. Human-to-Human Transmission

Secondary human-to-human transmission occurs when an infected individual spreads the virus to others. This is less common than zoonotic transmission but still significant.

• Direct Physical Contact: Contact with an infected person’s rash, lesions, or scabs are one of the most common ways the virus spreads. Skin-to-skin contact during care giving, intimate interactions, or sexual contact can result in transmission.
• Respiratory Droplets: Prolonged Exposure of Respiratory droplets from coughing, sneezing, or talking can spread the virus during close, sustained contact. This typically occurs in household settings or healthcare facilities.
• Contact with Bodily Fluids: Exposure to Fluids like Blood, saliva, respiratory secretions, and other bodily fluids of an infected person can carry the virus and cause infection.
• Indirect Contact through Contaminated Items (Fomites): Shared items such as bedding, towels, clothing, and utensils can become contaminated with the virus from an infected person’s lesions or secretions. Handling these items without proper precautions can lead to infection.
• Vertical Transmission: Rarely, the virus can cross the placenta (From Mother to Fetus), causing congenital monkeypox.

C. Environmental Transmission

Environmental contamination plays a significant role in maintaining the spread of the virus.

• Survival of the Virus : The monkeypox virus can survive for extended periods on surfaces and materials. Bedding, clothing, furniture, and medical instruments can retain the virus if not properly disinfected.
• Indirect Contact: Handling contaminated materials without protective gloves or adequate hygiene can result in infection.

D. Risk Behaviors and Activities

Certain behaviors and environmental factors increase the likelihood of exposure to the monkeypox virus.

• Occupational Risks:

• • Healthcare Workers: Treating infected patients without using personal protective equipment (PPE) can lead to exposure.
  • Veterinarians and Wildlife Handlers: Professionals working with animals in endemic regions are at risk, especially if biosecurity measures are inadequate.
  • Laboratory Workers: Those handling the monkeypox virus or infected specimens may be exposed during laboratory procedures.

• Cultural and Social Practices: Hunting, skinning, and preparing bush meat, a common practice in some African communities, poses a direct risk. Overcrowded living conditions facilitate human-to-human transmission, especially when an infected person is not isolated.

•  International Trade and Travel:
  • Exotic Animal Trade: Importing infected animals (e.g., rodents or primates) to non-endemic regions can introduce the virus to new populations.
  • Global Travel: Travelers returning from endemic regions may spread the virus to others if not identified and isolated promptly.

Modes of Transmission of Monkeypox

Monkeypox is a zoonotic viral infection caused by the monkeypox virus. Its transmission occurs through both animal-to-human (zoonotic) and human-to-human pathways, as well as contact with contaminated materials. Understanding the mechanisms of transmission is crucial for controlling outbreaks and implementing effective preventive measures.

A. Animal-to-Human Transmission (Zoonotic Transmission)

Monkeypox is primarily a zoonotic disease, originating from infected animals. This mode of transmission is predominant in endemic regions of Central and West Africa. The following modes facilitate its spread from animals to humans:

• Direct Contact with Infected Animals: Humans can become infected through direct interaction with animals carrying the monkeypox virus. This includes contact with the blood, bodily fluids, or skin lesions of infected animals, such as rodents (e.g., African squirrels, dormice, and Gambian pouched rats), non-human primates, or other wildlife carrying the virus.
• Bites or Scratches: If an infected animal bites or scratches a human, the virus can enter through the broken skin and establish infection. This is a significant mode of transmission in regions where people handle or hunt wildlife.
• Consumption of Contaminated Animal Products: Consuming undercooked or raw meat from infected animals can lead to infection. This is a significant risk factor in regions where bushmeat is consumed.
• Indirect Contact: Exposure to contaminated materials, such as bedding or cages of infected animals.
• Reservoir Hosts: The exact reservoir of the monkeypox virus is not fully identified, but small mammals, particularly rodents in Central and West Africa, are suspected to play a significant role in maintaining the virus in nature.

B. Human-to-Human Transmission

Once the virus infects a human, it can spread to others through direct or indirect means. Human-to-human transmission occurs less efficiently than zoonotic transmission but remains a significant concern in outbreaks. The virus can spread through the following mechanisms:

• Direct Physical Contact: The most common route of human-to-human transmission is direct contact with infected skin lesions, scabs, or body fluids (e.g., pus or blood from a lesion) can transmit the virus. Even microscopic abrasions on the skin can serve as entry points for the virus. Close skin-to-skin contact, such as during caregiving, handling the infected person's wounds, or intimate interactions, is a primary mode of spread.
• Respiratory Transmission: Respiratory droplets can carry the virus during prolonged face-to-face interactions, such as when an infected person coughs, sneezes, or talks. This form of transmission typically requires prolonged exposure in close quarters. Aerosol transmission, while not well-documented, is possible during certain medical procedures or close contact (e.g., intubation).
• Fomite Transmission: The virus can survive on surfaces and objects like bedding, clothing, or utensils contaminated with fluids from an infected person. Handling these materials without protective measures can result in transmission.
• Sexual Transmission: While monkeypox is not classified strictly as a sexually transmitted infection (STI), it can spread during sexual activity due to the close physical contact involved. Studies from recent outbreaks suggest the presence of the virus in genital secretions, supporting its transmission during intimate encounters.
• Vertical Transmission: Pregnant individuals infected with monkeypox can transmit the virus to the fetus via the placenta, potentially causing congenital monkeypox. Postnatally, transmission can occur during close contact with the newborn.

C. Environmental Transmission (Fomite Transmission)

Monkeypox virus can persist on surfaces, particularly those contaminated by fluids, scabs, or other material from an infected individual. Shared items such as bedding, towels, clothing, or medical equipment such as thermometers or stethoscopes etc. (if improperly sanitized) can facilitate transmission. Healthcare workers are at risk of contracting the virus during care of infected patients if appropriate personal protective equipment (PPE) is not used.

Risk factors of Monkeypox Infection

The primary risk factors of Monkeypox infection are depends on the exposure to the virus through zoonotic sources, human-to-human contact, and contaminated environments. Several biological, behavioral, and situational factors can amplify the likelihood of infection.

A. Contact with Infected Animals (Zoonotic Transmission)

One of the most significant risk factors for contracting monkeypox is exposure to infected animals, as the virus originates in animal hosts and spills over to humans.

• Handling or Hunting Wildlife
  • Endemic Regions: In Central and West Africa, where monkeypox is endemic, human interaction with wildlife is a common source of infection. Hunters, farmers, and others who handle animals are particularly at risk.
  • Reservoir Species: African rodents, such as squirrels, dormice, and Gambian pouched rats, are believed to be primary reservoirs of the virus. Contact with these animals significantly increases risk.
• Bites and Scratches from Infected Animals
  • Direct Transmission: Animals infected with monkeypox can bite or scratch, introducing the virus into broken skin.
  • High-Risk Activities: Handling aggressive wildlife or injured animals increases the likelihood of such encounters.
• Consumption of Bushmeat
  • Cultural Practices: In some regions, bushmeat is a staple diet. Handling or consuming undercooked or raw meat from infected animals poses a direct risk.
  • Preparation Methods: Preparing infected animal carcasses for cooking without protective measures can expose individuals to blood, bodily fluids, or tissue harboring the virus.
• Indirect Contact
  • Contaminated Materials: Tools, bedding, or cages used to house infected animals can harbor the virus. Individuals cleaning or transporting these materials without adequate protection face increased risk.

B. Human-to-Human Transmission

While zoonotic transmission is primary, human-to-human transmission becomes significant during outbreaks, especially in close-contact settings.

• Direct Physical Contact
• • Skin-to-Skin Contact: Touching an infected person’s lesions, scabs, or bodily fluids is one of the most common transmission routes.
  • Caregiving: Family members or healthcare providers attending to infected patients without proper protection are at high risk.
• Respiratory Droplets
• • Close and Prolonged Exposure: Large respiratory droplets expelled through coughing, sneezing, or talking can transmit the virus during face-to-face interactions. However, this requires prolonged exposure, unlike highly airborne diseases like measles.
  • Crowded or Enclosed Spaces: Prolonged stays in poorly ventilated areas with infected individuals increase the likelihood of droplet exposure.
• Fomite Transmission
• • Shared Items: Personal items, such as clothing, bedding, towels, and utensils contaminated with fluids from an infected individual, can transmit the virus.
  • Public and Healthcare Settings: Objects or surfaces touched frequently by infected individuals, if not sanitized, pose a risk.
• Sexual and Intimate Contact
• • Close Physical Intimacy: Activities involving prolonged skin-to-skin contact, including sexual encounters, are increasingly associated with transmission.
  • Genital Secretions: Recent studies suggest the presence of the virus in semen and vaginal fluids, though monkeypox is not classified as a sexually transmitted infection (STI).
• Vertical Transmission
• • Maternal Transmission to Fetus: Infected pregnant individuals can transmit the virus to the fetus through the placenta, potentially resulting in congenital monkeypox.
  • Postnatal Transmission: After birth, close physical contact between the infected mother and child can also spread the virus.

C. Environmental Transmission (Fomite and Surface Contamination)

Monkeypox virus is known to survive on surfaces and objects for extended periods under suitable conditions, making indirect transmission a notable risk factor.

• Contaminated Surfaces
  • Household Settings: Bedding, towels, and other frequently used items in households of infected individuals can retain the virus. Unprotected handling of such items facilitates transmission.
  • Healthcare Environments: Medical instruments, clothing, or surfaces in patient care areas, if improperly sterilized, can harbor the virus.
• Communal Areas
  • Public Spaces: Infected individuals may contaminate high-touch areas, such as door handles, chairs, or shared utensils, posing a risk to others.

D. Occupational Risks

Certain professions inherently involve higher exposure to the virus due to frequent interactions with infected animals, individuals, or materials.

• Animal Handlers and Veterinarians
  • Exotic Pet Trade: Handling or caring for exotic animals imported from endemic regions increases exposure to potential reservoirs.
  • Zoonotic Exposure: Veterinarians treating infected animals face risk if proper protective measures are not in place.
• Healthcare Workers
• • Patient Care: Healthcare providers managing monkeypox patients are at risk without proper use of personal protective equipment (PPE).
  • Medical Waste: Improper handling of waste, such as used gloves, syringes, or other materials, can facilitate exposure.
• Laboratory Workers
• • Diagnostic and Research Labs: Handling samples containing monkeypox virus without adequate biosafety protocols can result in accidental infections.

E. Social and Behavioral Factors

• Crowded Living Conditions
• • Overcrowding: Densely populated settings, such as prisons, dormitories, refugee camps, or shelters, can amplify the spread of monkeypox due to close contact.
  • Shared Facilities: Limited access to sanitation and shared usage of bedding or utensils increases fomite transmission risks.
• Lack of Public Awareness
• • Misidentification of Symptoms: Individuals who mistake monkeypox for less serious skin conditions, such as chickenpox or allergic reactions, may delay seeking treatment, increasing the likelihood of unknowingly transmitting the virus.
• Cultural Practices
• • Traditional Healing Practices: In some regions, direct handling of the sick during healing rituals or caregiving without PPE can enhance transmission risk.
• International Travel
• • Travel to Endemic Regions: Individuals visiting Central and West Africa are at higher risk due to potential exposure to infected animals or individuals.
  • Globalization: The movement of people, animals, and products has facilitated the spread of monkeypox to non-endemic areas.

F. Immune Status

• Unvaccinated Populations
  • Discontinuation of Smallpox Vaccination: Since routine smallpox vaccination was discontinued after the global eradication of smallpox, immunity to orthopoxviruses has waned, leaving many individuals susceptible to monkeypox infection..
• Vulnerable Groups
  • Young Children: Due to immature immune systems, children are more prone to severe forms of monkeypox.
  • Immunocompromised Individuals: People with HIV/AIDS, cancer, or undergoing immunosuppressive therapies are at heightened risk of severe infection.

Diagnosis of Monkeypox Infection

The diagnosis of monkeypox infection involves a systematic evaluation of clinical presentation, epidemiological exposure, and confirmatory laboratory investigations. This process is critical for differentiating monkeypox from other illnesses, initiating appropriate treatment, and implementing public health measures. The diagnostic processes of monkeypox infection are as follows.

• Clinical Diagnosis: The clinical presentation of monkeypox is central to identifying suspected cases. While symptoms may vary, they generally follow a recognizable pattern.
  • Clinical Presentation
    • Prodromal Phase: Occurs 1–4 days before rash onset. This phase characterized by non-specific systemic symptoms includes high and sudden fever, persistent and moderate to severe headache, Myalgia and back pain, Fatigue or Malaise and, Lymphadenopathy (Swelling of lymph nodes in the cervical, axillary, or inguinal regions, a hallmark feature distinguishing monkeypox from similar conditions like smallpox or chickenpox.).
    • Rash Phase: Develops 1–4 days after the onset of fever. Rash evolves in distinct stages, progressing synchronously across the body:
      • Macules: Flat, discolored areas that often start on the face.
      • Papules: Raised bumps that expand as inflammation increases.
      • Vesicles: Small, fluid-filled blisters.
      • Pustules: Lesions filled with pus, typically firm and deep-seated.
      • Scabs: Dry, crusted lesions that eventually separate and leave depigmented scars.
      • Distribution: Begins on the face and spreads centrifugally to the palms, soles, arms, legs, and sometimes mucous membranes. Lesions may involve the genital or perianal region in certain outbreaks.
      • Resolution Phase: Rash heals over 2–4 weeks. Patients may remain infectious until all scabs fall off and new skin forms.
  • Epidemiological Assessment: Understanding the patient’s exposure history is critical for linking symptoms to potential sources of infection.
    • • Travel History: Recent travel to endemic areas in Central or West Africa is a key risk factor.
      • Contact with Animals: Direct or indirect contact with rodents or non-human primates, especially in endemic regions. Handling bushmeat or contaminated materials (e.g., bedding, cages) increases risk.
      • Contact with Infected Individuals: Close physical contact with a confirmed or suspected case, including household members or healthcare workers.
      • Occupational Exposure: Healthcare providers, laboratory workers, and veterinarians are at higher risk due to potential contact with infectious patients or animals.

• Laboratory Diagnosis: Laboratory testing is essential for confirming monkeypox infection, especially in cases where clinical and epidemiological data are inconclusive.
  • Specimen Collection: Preferably Lesion swabs (from vesicles, pustules, or crusts) are the most reliable for diagnosis. Other Samples like blood, oropharyngeal swabs, or biopsies of lesions in atypical cases is also be used for laboratory diagnosis. All specimens should be collected using strict biosafety protocols and transport in sterile containers to minimize environmental contamination.
  • Diagnostic Techniques:
    • Polymerase Chain Reaction (PCR): PCR is a Gold Standard Test to detect viral DNA with high sensitivity and specificity and also it can differentiate monkeypox from other orthopoxviruses.
    • Viral Culture: Involves isolating the virus in cell culture. Although definitive, it is time-consuming and requires biosafety level-3 facilities.
    • Serology: Detects IgM (acute infection) and IgG (past exposure) antibodies. Cross-reactivity with other orthopoxviruses limits its specificity.
    • Electron Microscopy: Visualizes viral particles directly from lesion material. Identifies brick-shaped orthopoxvirus morphology.
    • Histopathology: Examines skin biopsies to reveal ballooning degeneration of keratinocytes and cytoplasmic inclusions.
    • Next-Generation Sequencing (NGS): Provides genomic insights into viral strains and mutations. Useful for tracking outbreak dynamics.

1. • Ancillary Testing: While not confirmatory, additional tests can provide insights into the patient's health and disease progression.

• • • Blood Tests: Complete Blood Count (CBC) may show leukocytosis, lymphocytosis, or leucopenia and Inflammatory markers show elevated CRP or ESR suggests secondary bacterial infections.
    • Imaging: Chest X-rays or CT scans may identify complications such as pneumonia or pleural effusion in severe cases.

The diagnosis of monkeypox is a multi-faceted process that requires a combination of clinical acumen, epidemiological investigation, and advanced laboratory testing. Early recognition and accurate confirmation are vital for patient management, outbreak control, and the prevention of further transmission. With the increasing global spread of monkeypox, strengthening diagnostic capabilities and training healthcare providers are essential to mitigate its impact.

 Complications of Monkeypox Infection

Monkeypox infection, though typically self-limiting, can result in several complications, particularly in severe cases, immunocompromised individuals, children, and pregnant women. These complications are often a result of the virus’s systemic spread, secondary infections, or host immune response. The complications associated with monkeypox are as follows...

• Secondary Skin and Soft Tissue Infections: The hallmark of monkeypox is its characteristic rash, which progresses through stages of macules, papules, vesicles, pustules, and crusts. These lesions can become entry points for bacteria, leading to secondary bacterial infections. Common complications include:
  • Cellulitis: Inflammation of the deeper layers of skin, causing redness, warmth, swelling, and pain.
  • Abscess Formation: Localized collections of pus under the skin.
  • Necrotizing Fasciitis (rare): A life-threatening condition involving rapid destruction of soft tissue, requiring surgical intervention. In severe cases, these infections may delay healing, cause extensive scarring, or even progress to systemic infections like sepsis.
• Respiratory Complications: Monkeypox can affect the respiratory tract, especially if the virus is inhaled or spreads hematogenous. Key issues include:
  • Bronchopneumonia: Viral or secondary bacterial pneumonia presenting with fever, cough, difficulty breathing, and low oxygen levels.
  • Upper Respiratory Tract Infections: Inflammation of the throat and nasal passages may accompany early stages of the illness, causing discomfort and breathing difficulties. Respiratory complications can escalate to acute respiratory distress syndrome (ARDS) in severe cases.
• Neurological Complications: Although uncommon, monkeypox can impact the central nervous system, leading to potentially life-threatening conditions such as:
  • Encephalitis: Inflammation of the brain, presenting with severe headache, fever, confusion, altered mental state, seizures, or coma.
  • Meningitis: Inflammation of the meninges surrounding the brain and spinal cord, causing neck stiffness, photophobia, and intense headache.
  • Long-Term Neurological Sequelae: Survivors of neurological complications may suffer from cognitive deficits, motor impairment, or chronic headaches.
• Ocular Complications: The virus can directly affect the eyes or cause complications secondary to the rash spreading to periocular areas. These include:
  • Conjunctivitis: Redness, swelling, and discharge from the eyes.
  • Keratitis: Corneal inflammation that can result in ulceration, scarring, and vision impairment.
  • Blindness: Untreated or severe infections, particularly in resource-limited settings, can result in permanent vision loss.
• Gastrointestinal Complications: Gastrointestinal symptoms are common in severe cases and can include:
  • Nausea and Vomiting: Leading to reduced oral intake.
  • Diarrhea: Causing significant fluid loss, dehydration, and electrolyte imbalances.
    Severe dehydration may necessitate intravenous fluid therapy to prevent organ failure.
• Sepsis and Septic Shock: Secondary bacterial infections of skin lesions or other sites can result in systemic dissemination of pathogens, leading to sepsis. Symptoms include high fever, rapid heart rate, hypotension, and multi-organ dysfunction. Without prompt antibiotic therapy and supportive care, septic shock is often fatal.
• Pregnancy-Related Complications: In pregnant individuals, monkeypox poses significant risks, including:
  • Spontaneous Miscarriage: The virus can cross the placenta, leading to fetal loss.
  • Preterm Birth: Infections can trigger premature labor.
  • Congenital Monkeypox: Fetal infection can result in severe outcomes, including stillbirth or neonatal complications.
• Long-Term Effects and Mortality: Though mortality rates are generally low in non-endemic regions, complications can result in prolonged illness, scarring, and in rare cases, death. Mortality rates are higher among young children and those with underlying health conditions, particularly when infected with the more virulent Central African clade. Visible scarring and stigma associated with the disease may cause mental health challenges, including anxiety and depression.Although the mortality rate for monkeypox is relatively low in non-endemic areas (1-10%), it can be higher in vulnerable populations. Factors influencing mortality include:
  • Strain Virulence: The Central African (Congo Basin) clade has a higher fatality rate compared to the West African clade.
  • Underlying Health Conditions: Immunocompromised patients, such as those with HIV/AIDS or malnutrition, face increased risks of severe disease and death.

 Treatment of Monkeypox Infection

Treatment of monkeypox infection requires a comprehensive, individualized approach depending on the severity of symptoms, the presence of complications, and the patient’s underlying health status. And also the treatment is focuses on supportive care, management of complications, and antiviral therapy in severe cases or high-risk patients. Early diagnosis and intervention are critical to improving outcomes, particularly in high-risk populations. Treatment strategies depend on the severity of the disease, patient comorbidities, and resource availability.

A. Supportive Care

Supportive care is the foundation of treatment, addressing symptoms and preventing complications while the patient’s immune system combats the virus.

• Symptom Management:
  • Fever and Pain Relief: Administer antipyretics such as acetaminophen or ibuprofen for fever and body aches. Ibuprofen can also alleviate inflammation and joint pain. Avoid aspirin in children to prevent Reye’s syndrome. For severe pain, short-term use of opioids or neuropathic pain modulators (e.g., gabapentin) may be considered.
  • Itching Relief: Oral antihistamines (e.g., diphenhydramine or cetirizine) reduce itching. Topical soothing agents, such as calamine lotion or aloe vera gel, can be applied to relieve localized irritation caused by skin lesions.
• Hydration and Nutritional Support:
  • Encourage increased fluid intake (water, oral rehydration solutions, or broths) to prevent dehydration, especially in patients experiencing diarrhea or vomiting. Administer IV fluids to manage dehydration in severe cases where oral intake is inadequate. Add electrolytes as needed to correct imbalances.
  • Provide a high-calorie, nutrient-dense diet to support the immune response. For patients with painful oral or esophageal lesions, soft or liquid diets should be offered to minimize discomfort. Severe cases may require nasogastric feeding.
• Skin and Wound Care: Lesions should be gently cleaned daily with saline or antiseptic solutions to prevent bacterial super infection. Use sterile, non-adherent dressings to cover lesions in areas prone to irritation or contamination (e.g., hands or feet). Apply emollients to prevent skin cracking and enhance wound healing.
• Antiviral Therapy: Antiviral medications are used in patients with severe disease, complications, or those at high risk, such as immunocompromised individuals, children, or pregnant individuals.
  • Tecovirimat (TPOXX): Inhibits the viral envelope protein, preventing viral release and replication. Recommended for severe monkeypox, extensive lesions, or Immunosuppressed patients. Administered orally or intravenously, depending on patient capability. Treatment duration typically lasts 14 days. Tecovirimat has a favorable safety profile and is generally well-tolerated.
  • Brincidofovir: A lipid conjugate of cidofovir with improved tolerability and reduced nephrotoxicity. Brincidofovir used off-label for severe monkeypox; especially with organ involvement. It may include gastrointestinal upset and liver enzyme elevation, requiring close monitoring.
  • Cidofovir: Inhibits viral DNA synthesis. Reserved for life-threatening infections or cases refractory to other treatments due to its nephrotoxicity. Cidofovir medication requires concurrent hydration and renal function monitoring during administration.

B. Management of Complications

Complications require specific and prompt interventions:

• Secondary Bacterial Infections: Treat with empiric or targeted antibiotics, such as cephalosporins or beta-lactamase inhibitors, based on local antimicrobial resistance patterns. Manage skin abscesses or cellulitis with drainage and appropriate systemic antibiotics.
• Respiratory Complications: Address secondary pneumonia with broad-spectrum antibiotics, shifting to narrow-spectrum agents once culture results are available. Provide supplemental oxygen for hypoxemia and consider mechanical ventilation for acute respiratory distress syndrome (ARDS).
• Neurological Complications: Use corticosteroids to reduce inflammation (for encephalitis), antiviral therapy to limit viral replication, and intensive care monitoring. Seizures manage with antiepileptic drugs such as levetiracetam or phenytoin.
• Ocular Involvement: Use antiviral eye drops (e.g., trifluridine) to treat keratitis or conjunctivitis. Artificial tears can prevent corneal dryness and irritation.Refer severe cases to an ophthalmologist to prevent vision loss.
• Dehydration and Electrolyte Imbalances: Correct fluid losses with oral rehydration or IV fluids containing electrolytes. Monitor for signs of hypokalemia or hyponatremia and correct as needed.
• Post-Exposure Prophylaxis and Vaccination: Post-exposure prophylaxis with vaccines can reduce disease severity:
  • JYNNEOS (Modified Vaccinia Ankara) : Safe for immunocompromised individuals and pregnant women. A two-dose subcutaneous series administrated. First dose should ideally be given within 4 days of exposure.
  • ACAM2000 : It’s effective but not recommended for immunosuppressed individuals due to risks of serious side effects like vaccinia necrosis. A single-dose live replicating vaccine is administrated.
• Infection Control and Isolation: Preventing the spread of monkeypox is a critical component of management:
  • Patients must remain isolated until all lesions have scabbed over, fallen off, and new skin has formed.
  • Healthcare providers and caregivers should wear Personal Protective Equipment (PPE), specially gloves, masks, gowns, and eye protection when interacting with infected individuals.
  • Environmental Hygiene should be maintained. Disinfect contaminated surfaces and dispose of contaminated bedding, clothing, and medical supplies appropriately.
• Special Populations: Treatment may require adjustments for specific groups:
  • Pregnant Individuals: Tecovirimat can be used cautiously in severe cases to minimize maternal and fetal risks. Close monitoring is essential.
  • Children: Provide meticulous hydration and nutritional support due to their higher susceptibility to dehydration and malnutrition. Adjust antiviral dosages based on weight.
  • Immunocompromised Individuals: These patients are at heightened risk for severe disease and complications. Early initiation of antiviral therapy, close monitoring, and aggressive management of secondary infections are critical.

Effective management of monkeypox involves supportive care, antiviral therapy in severe cases, and targeted treatment of complications. Prevention through post-exposure prophylaxis, isolation, and infection control measures is essential to limit the spread. Tailored approaches for vulnerable populations and a multidisciplinary strategy are crucial for optimal outcomes.

 Prevention of Monkeypox Infection

Prevention of monkeypox infection involves strategies to reduce transmission, protect vulnerable populations, and minimize outbreak risks. Key measures include:

A. Vaccination

Vaccination plays a critical role in reducing the risk of monkeypox, especially for high-risk individuals and during outbreaks. Two vaccines are commonly used:

Pre-Exposure Prophylaxis

• JYNNEOS (Modified Vaccinia Ankara):
  • A non-replicating live vaccine recommended for healthcare workers, laboratory personnel, and individuals at high risk due to frequent exposure to orthopoxviruses including monkeypox. This vaccine is considered safe for immunocompromised individuals, pregnant women, and those with skin conditions.
  • Administered as a two-dose subcutaneous series, it has a favorable safety profile, including for immunocompromised individuals.
• ACAM2000:
  • A live replicating vaccine available for high-risk individuals. Not recommended for Immunosuppressed persons, pregnant women, or individuals with skin conditions (e.g., eczema) due to potential adverse effects.
  • Single-dose administration but requires monitoring for vaccine site reactions and possible shedding of vaccinia virus.

Post-Exposure Prophylaxis (PEP): Vaccines can be administered after exposure to reduce the risk or severity of monkeypox. The Post-Exposure Prophylaxis (PEP) is most effective when given within 4 days of exposure to prevent infection. It can still reduce disease severity if given up to 14 days post-exposure.

B. Infection Control Measures

Proper hygiene and isolation practices play a critical role in preventing human-to-human and animal-to-human transmission.

• Isolation of Infected Individuals: Confirmed cases should remain isolated until all lesions have scabbed over, fallen off, and a fresh layer of skin has formed. Limit interactions to essential caregivers equipped with proper personal protective equipment (PPE). In healthcare settings, use designated isolation rooms with negative pressure for infected patients.
• Use of Personal Protective Equipment (PPE): Healthcare workers and caregivers should wear Personal Protective Equipment (PPE) like Gloves, surgical masks, gowns, and eye protection when caring for infected individuals. Use N95 or equivalent respirators in cases of potential aerosol-generating procedures.
• Environmental Hygiene: Disinfect contaminated surfaces, clothing, bedding, and utensils using standard detergents or disinfectants such as sodium hypochlorite or hydrogen peroxide-based solutions. Dispose of contaminated items (e.g., dressings) in biohazard waste.
• Hand Hygiene: Wash hands frequently with soap and water, especially after contact with infected individuals or their belongings. Alcohol-based hand sanitizers can be used when soap and water are unavailable.

C. Avoiding High-Risk Behaviors and Exposures

Preventing zoonotic and human-to-human transmission involves behavioral modifications:

• Avoiding Animal Contact: In endemic regions, avoid handling rodents, primates, or other wildlife that may carry the virus. Do not touch sick or dead animals, especially those found in areas of known outbreaks.
• Bushmeat Practices: Refrain from hunting, handling, or consuming bushmeat, as this is a significant source of zoonotic transmission. Promote the proper cooking of meat to eliminate potential pathogens.
• Personal Protective Measures in Community Settings: Avoid close physical contact, including skin-to-skin or face-to-face interactions, with individuals showing symptoms such as rashes, lesions, or respiratory symptoms. Avoid sharing personal items like bedding, towels, or utensils with symptomatic individuals.

D. Community Education and Awareness

Raising awareness is crucial for empowering communities to prevent monkeypox transmission:

• Knowledge of Symptoms: Educate communities about the symptoms of monkeypox, including fever, rash, and swollen lymph nodes, to enable early detection and treatment. Explain modes of transmission, including direct contact with lesions, respiratory droplets, and contaminated materials. Highlight how monkeypox spreads via direct contact with lesions, bodily fluids, respiratory droplets, contact with contaminated materials (e.g., clothing, bedding), or handling infected animals or consuming undercooked meat.
• Safe Caregiving Practices: Teach caregivers proper hygiene and PPE use when caring for infected individuals. Encourage symptomatic individuals to isolate themselves and seek medical care promptly to reduce the risk of spreading the virus.

E. Surveillance and Monitoring

Robust public health systems are vital for early detection and containment. Strengthening public health infrastructure is critical for early detection and containment of monkeypox. Monitor for unusual increases in rash illnesses, particularly in endemic areas or among travelers returning from such regions. Establish protocols for laboratory testing to confirm suspected cases promptly.

Identify and monitor contacts of confirmed cases for signs of illness during the incubation period (6–13 days, up to 21 days). Provide post-exposure prophylaxis where appropriate and educate contacts about early symptom recognition.Isolate symptomatic individuals and implement quarantine measures for high-risk contacts to prevent further spread.

F. Travel and International Control Measures

Preventing the global spread of monkeypox requires international collaboration. Screen travelers from endemic or outbreak regions for symptoms. Restrict movement of potentially infected individuals until they are no longer contagious. Advise travelers to avoid close contact with animals or individuals in areas experiencing outbreaks. Implement quarantine measures for suspected or confirmed cases to limit cross-border transmission.

G. Addressing Vulnerable Populations

Special attention should be given to groups at higher risk of severe outcomes:

• Immunocompromised Individuals: Ensure vaccination and education on avoiding exposures. Offer pre-exposure vaccination (e.g., JYNNEOS) and educate about the risks of exposure and the importance of hygiene.
• Pregnant Women: Provide counseling and ensure access to safe preventive measures, as monkeypox can pose risks to both mother and fetus.
• Children: Protect children by avoiding their exposure to infected individuals or contaminated items, and vaccinate when indicated.

Preventing monkeypox requires a multipronged approach, including vaccination, infection control, behavioral modifications, and public health interventions. Early education, robust surveillance, and prompt vaccination efforts can significantly reduce transmission and protect communities from outbreaks.

Frequently Asked Questions (FAQs) about Monkeypox (Mpox)

1. What is Monkeypox and how is it Spread?

Monkeypox is a viral disease caused by the monkeypox virus (MPXV), a member of the orthopoxvirus family. It is primarily transmitted through close contact with infected individuals, animals, or contaminated materials. It can also spread through respiratory droplets, especially in prolonged face-to-face interactions. The virus can spread via skin lesions, bodily fluids, or during sexual contact, making it possible to transmit both in healthcare settings and through intimate contact.

2. What are the Symptoms of Monkeypox?

Symptoms of monkeypox typically begin with fever, headache, muscle aches, and swollen lymph nodes. After 1-3 days, a characteristic rash appears, starting on the face and spreading to other parts of the body. The rash progresses through stages, from flat spots to raised bumps, fluid-filled vesicles, and eventually scabs. In severe cases, complications can occur, particularly in immunocompromised individuals.

3. Is Monkeypox Contagious?

Yes, monkeypox is contagious. It can be transmitted through direct contact with bodily fluids, lesions, or respiratory droplets of an infected person. It can also spread through contact with contaminated objects like bedding, clothing, or surfaces. The virus can be spread by close contact, including sexual contact, but it is less likely to spread through casual contact like air travel.

4. Can You Get Monkeypox From Animals?

Yes, monkeypox can be transmitted from animals to humans, primarily through direct contact with infected animals' blood, bodily fluids, or skin. Certain mammals, such as monkeys and rodents, are believed to be the primary reservoirs. In Africa, where the disease is more common, people can become infected by handling bush meat or coming into contact with animals in endemic areas.

.5. How Do You Treat Monkeypox?

Monkeypox is typically self-limiting, with most patients recovering in 2-4 weeks. There is no specific antiviral treatment for monkeypox, but antivirals like tecovirimat (TPOXX) and brincidofovir may be used in severe cases. Pain management and supportive care, including hydration and fever control, are essential. The use of vaccines for high-risk individuals is also an important preventive measure.

6. Is There a Vaccine for Monkeypox?

Yes, there are vaccines available for monkeypox, including the Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN) vaccine, which is approved for use in preventing monkeypox. The vaccine is especially recommended for high-risk groups, such as healthcare workers and individuals who have been exposed to the virus. The vaccine has shown effectiveness in preventing infection and reducing disease severity.

7. How Long Does Monkeypox Last?

The duration of monkeypox symptoms can range from 2 to 4 weeks. After the initial fever and symptoms appear, a rash develops, progressing from bumps to fluid-filled vesicles, which then form scabs before healing. While most people recover without complications, the duration of illness can be longer for those with underlying health conditions.

8. Can Monkeypox Be Fatal?

Although monkeypox is rarely fatal, complications can arise, particularly in immunocompromised individuals. The fatality rate is generally below 1% for clade II outbreaks, but it can be higher in certain populations. Proper medical care can significantly reduce the risks of severe illness and death..

9. Can You Get Monkeypox From Eating Meat?

While the primary method of transmission is through direct contact with an infected person or animal, there is a potential risk of contracting monkeypox from consuming undercooked or contaminated meat from infected animals, particularly in regions where the virus is endemic. However, this type of transmission is not considered common.

10. How Do You Prevent Monkeypox?

Preventing monkeypox involves reducing contact with infected individuals and animals. Vaccination is a key preventive measure for high-risk individuals. Wearing protective gear in healthcare settings, practicing good hygiene, and avoiding contact with infected bodily fluids or surfaces can also reduce the risk of transmission.

11. Is Monkeypox the Same as Smallpox?

Monkeypox and smallpox are related, but they are not the same. Both are caused by orthopoxviruses, but monkeypox tends to have milder symptoms than smallpox. Smallpox has been eradicated globally since 1980, while monkeypox continues to cause outbreaks, particularly in Africa. The two diseases share some similarities in symptoms, including a rash, but smallpox has a higher mortality rate (about 30%) compared to monkeypox (less than 1% in most outbreaks).

12. How Long Is Monkeypox Contagious?

Monkeypox is contagious from the onset of symptoms until all lesions have scabbed over and the scabs have fallen off, which usually takes about 2-4 weeks. It is most contagious when the rash is present, especially during the stages when the skin lesions are fluid-filled. People should isolate themselves during this period to prevent transmission.

13. Can Monkeypox Be Prevented by Wearing a Mask?

Wearing a mask may reduce the risk of respiratory transmission of monkeypox, particularly in the early stages when lesions are not yet present or if there are respiratory symptoms. However, monkeypox is mainly transmitted through direct contact with lesions or bodily fluids. Masks alone are not enough for prevention; avoiding direct contact with infected individuals and practicing good hygiene are also essential.

14. Can I Get Monkeypox From a Pet?

Although pets are not the primary source of monkeypox transmission, there have been rare cases where domesticated animals, such as dogs and cats, were found to be infected after close contact with humans. While transmission from pets is uncommon, it's advisable to avoid contact with animals if you're infected and to maintain proper hygiene when handling pets.

​15. What Is the Incubation Period for Monkeypox?

The incubation period for monkeypox typically ranges from 5 to 21 days after exposure to the virus. During this time, individuals may not show symptoms but can still develop the disease. Early symptoms often include fever, headache, muscle aches, and swollen lymph nodes, followed by the characteristic rash.

References : 

1. "Monkeypox Virus: A Zoonotic Threat"-Taylor S. Landis, Nova Science Publishers, 2022
2. "Orthopoxviruses: Past, Present, and Future"-Bernard Moss, Inger K. Damon, Springer Nature, 2021
3. "Emerging Infectious Diseases: Monkeypox and Related Viral Infections"-David R. Harper, Academic Press, 2023
4. "Pathogens on the Move: Monkeypox and Viral Disease Evolution"-Dominic S. Walsh,Cambridge University Press, 2023
5. "Epidemics and Global Health Crises: Case Studies on Monkeypox and Other Viral Threats"-Christina L. Farmer, Routledge, 2023
6. "Zoonotic Viral Diseases: Human-Animal Interface and Risk"- Joachim H. Werner, Sarah L. Stephens, CRC Press, 2022
7. "Monkeypox: A Comprehensive Overview of Its Impact on Global Health"- Samuel J. Evans, Karen T. Lee, Elsevier, 2023
8. "Global Pandemics and Epidemics: Lessons from Monkeypox and Beyond"- Allison P. Jones, Oxford University Press, 2024
9. World Health Organization (WHO). "Mpox Outbreak: Global Trends and Strategic Response Plans." Updated Reports, 2024.