Monkeypox now a global health emergency

The WHO has declared the monkeypox outbreak a global health emergency – the agency’s highest alert level – following a worldwide upsurge in cases. There are currently 5 deaths tied to the outbreak – Spain has seen two deaths, India has one, while Brazil and Ecuador have one each. As of the latest reports, cases have crossed 38,800 in 80 countries where monkeypox is not endemic.

In the UK, there have been over 2,000 confirmed cases. The US has 25 percent of the world’s cases, and over 99 percent of people infected with monkeypox are men who have sex with men (MSM). This has posed a delicate task for public health experts to keep those most at risk informed, without stigmatizing or hurting them.

“The infections are not about sexuality,” said Mateo Prochazka, an epidemiologist from the UK Health Security Agency. “We are concerned about monkeypox in general as a public threat.”

“This is an outbreak that can be stopped with the right strategies in the right groups,” commented WHO Director-General Tedros Adhanom Ghebreyesus. But he warned that anyone can get infected regardless of gender or sexual orientation.

He added the WHO declaration would help speed up the development of vaccines, free up emergency funds, and trigger a coordinated international response to limit the transmission of the virus.

Vaccine for monkeypox

As MIMS Doctor goes to press, the US FDA has granted emergency use authorization (EUA) to the monkeypox vaccine Jynneos (produced from the strain of the Modified Vaccinia Ankara-Bavarian Nordic) as a two-dose series in individuals 18 years and older via intradermal injection (0.1 mL each dose), or by subcutaneous injection (0.5 mL each dose) in those younger than 18 years. The two-dose shots will be given 4 weeks (28 days) apart.

The vaccine received FDA approval in 2019 for adults 18 years and older who are at high risk for smallpox or monkeypox infection, at 0.5 mL each dose given subcutaneously. Under the EUA, this has been reduced to 0.1 mL each dose in the 18 and older age group and to be administered intradermally. As the intradermal route requires less vaccine dose, this will help extend scarce supplies during the monkeypox outbreak.

How is monkeypox transmitted?

Monkeypox transmission occurs through close contact with skin lesions of an infected person, for example during sexual activities, through respiratory droplets in prolonged face-to-face contact, and through fomites.

The predominance of diagnosed cases among MSM in the current outbreak, and the nature of the presenting lesions, suggest that the risk is high in this group. 

Symptoms to watch out for and therapeutics

A constellation of symptoms includes high fever, headache, swollen lymph nodes, back pain, muscle ache, and asthenia. [https://www.cdc.gov/poxvirus/monkeypox/symptoms.html] A blistery, chickenpox-like rash on the face appears 1–3 days after the fever onset, spreading to the hands and feet. Recent reports also found cutaneous lesions in the mouth and genitals, first presenting as macules, then evolving to papules, vesicles, pustules, crusts, and scabs. Infections are usually mild.

Monkeypox is a zoonotic viral disease caused by the monkeypox virus (MPXV) that currently has no FDA-approved treatment. Treatment is mainly symptomatic and supportive, including prevention and treatment of secondary bacterial infections.

The antiviral agent tecovirimat (also known as TPOXX or ST-246) is approved for smallpox disease caused by the Variola virus in adults and children, but not for monkeypox.

Although the FDA has an expanded access programme for tecovirimat use in primary or early empiric treatment of non-variola orthopox virus, including monkeypox, doctors often have to navigate excessively complicated rules to request tecovirimat for their monkeypox patients. Randomized controlled trials in infected patients are also warranted.

How to protect against monkeypox

Infected people should remain isolated until the scabs fall off.  Avoiding close contact with immunosuppressed individuals and abstaining from sexual activity and close physical contact is also recommended until the rash heals. Non-sharing of towels, plates, glasses, and eating utensils is advised, and so is strict hand hygiene.

Although the use of condoms is encouraged to prevent HIV and other STDs, condoms alone cannot fully protect against the monkeypox virus as contact with skin lesions may be sufficient for any transmission to occur.