A zoonotic orthopoxvirus known as monkeypox inadvertently produces a smallpox-like illness in humans but with far fewer fatalities. This infection is indigenous to most parts of the African continent, with outbreaks throughout the Western World linked to the exotic animal trade and travel abroad, making it therapeutically significant. Vaccinating against smallpox had historically resulted in coincidental immunization against monkeypox, but the eradication of smallpox and the consequent absence of vaccination has allowed monkeypox to develop prognostic significance. In this article, we discuss our interdisciplinary group’s involvement in patient care and epidemic prevention along with a study of the assessment and treatment of monkeypox, and we provide an overview of the outbreak, describe the most frequent effects of monkeypox, and the healthcare professional’s role in preventing infection and reducing fatalities from monkeypox.
Monkeypox, Orthopoxvirus, Epidemiology
Initial Detection of Monkeypox virus
This pathogen, known as monkeypox, was initially discovered and quarantined in 1959 after diseased monkeys were transported across Singapore to a Danish research laboratory.1 In 1970, the pathogen was identified in a 9-month-old child from the Democratic Republic of Congo (formerly Zaire), who was initially assumed to have smallpox and became the first acknowledged monkeypox infection in humans.2
Immunization against monkeypox has historically resulted from coincidental immunization against smallpox, but the eradication of smallpox and the resultant absence of immunization has permitted monkeypox to spread.3 A probable misclassification of monkeypox cases may also have resulted in an underestimation of the disease’s potential for harm because most incidents were in rural African areas.4
Symptomatic clues of Monkeypox
Multiple criteria can be used to indicate monkeypox infection, including recent travel to an endemic country, contact with wild animals from endemic regions, and caring for an infected individual or animal, but clinical signs are crucial for diagnosis. Fever, headaches, chronic fatigue, and lymphadenitis are the early signs of monkey-pox, which sets it apart from smallpox.
It is followed in one to two days by skin lesions on the face and extremities, including the palms and soles, and oral ulcers begin to form. These ulcers appear centrifugally concentrated. Skin involvement may range from a few lesions to thousands, and the rash may not always extend to the entire body.5
The ulcers progress in 1- to 2-day intervals from mild to severe over the next two to four weeks. The lesions are rigid, deeply embedded, and range in size from 2–10 mm, and lesions of a similar age alter simultaneously. The lesions are blister-like sores before crusting for five to seven days. Most often, the illness resolves spontaneously three to four weeks after the commencement of symptoms, with crusts developing and desquamating over the next seven to fourteen days. Once the crusts have completely fallen off, the patient is no longer considered contagious.6
According to many sources, the gay and bisexual community is particularly vulnerable to the current monkeypox pandemic. Vesicles and depressed, white, solid papules on the body, as well as fever, lethargy, exhaustion, headaches, and localized lymphadenitis, are the main clinical characteristics. Lesion clusters and frequent involvement of the pubic or perineal regions are assumed to be related to the personal penetration of propagation.7,8 A clinical assessment should consider all conditions that might be responsible for the symptoms of monkeypox, such as a drug eruption, microbiological skin infections, measles, rickettsia, scabies, yaws, syphilis, herpes infection, herpetic eczema, chickenpox, herpes zoster, universal vaccinia and small-pox.5,9 Complications of monkeypox infection include encephalitis, sepsis, dehydration due to diarrhea, loss of appetite due to painful oral ulcers, vomiting, fluid loss from skin blisters, pneumonia, loss of vision, hyperpigmentation, skin scarring, bacteria superinfection, and death.10
Risk factors and Causes of Monkeypox Virus Spread
The Republic of the Congo had the highest concentration of monkeypox, a zoonotic virus that was common throughout Africa’s central and western regions. Despite being initially discovered in captivity, evidence shows that the primary hosts are African rodents. Rats, mice, monkeys, prairie canines, and humans have all contracted the virus.4,9 There are now two clades that are genetically different from one another. In contrast to the West African group, the Central African group is found to be more common and there are confirmed incidents of transmitted disease among humans.4 Human monkeypox has rarely been reported outside Africa. However, when smuggled from Ghana, Gambian giant rats contaminated nearby prairie dogs that were being marketed as home pets throughout the Midwest region of the United States in 2003. This led to 53 incidents of human monkeypox infection.11 One incident involving an individual traveling from Nigeria to Israel happened in October 2018.12 One incident involving a passenger traveling from Nigeria to Singapore happened in May 2019.13
Three members of the same family who had visited Nigeria returned to the UK in May 2021 after contracting monkeypox there.14 The orderly onset of symptoms for each patient within the group was days 0, 19, and 33 were thought to indicate transfer from person to person. Another incident included a person who flew between Nigeria and Texas in July 2021,15 and another involved an individual who relocated from Nigeria to Maryland in November 2021,16 Investigations into one occurrence of human monkeypox in a person who was repatriated back to Massachusetts from Canada and a group of people infected with monkeypox in the UK are ongoing as of May 2022.
Given the limitations in symptom monitoring and identification, it is challenging to determine the exact frequency and severity of diseases. Conversely, since the regular smallpox vaccine was stopped, both frequency and severity have grown.4,17 Living in the densely forested northern parts of western and central Africa, managing and cooking raw or undercooked meat, providing medical care to infected persons, and not receiving the smallpox vaccine are all proven potential risks for monkeypox transmission.17,18 The likelihood of transmission has also been linked to men who sleep with men (MSM). The societal expectation that males routinely hunt and interact with animals in the wild could complicate this.
In 2022, a monkeypox epidemic broke out in many countries around the globe, mainly among MSM, with a clinical appearance that mostly consisted of pubic lesions.19 Ninety-nine percent of instances of monkeypox in a group of 595 patients diagnosed in Spain in 2022 were identified to be among the Gay and bisexual populations, with the symptoms primarily involving the genitals or anal region. Perineal lymphadenopathy had also been shown to be a common characteristic, supporting the idea that sexual transmission was indeed the primary route of infection.20 As of July 6, 2022, Germany reported 1304 documented cases, primarily among MSM.21 Sequencing information from several nations shows that perhaps the West African lineage of the monkeypox infection is what is causing the 2022 outbreak.20,22 Nevertheless, recent information indicates that the current epidemic could belong to a whole new lineage.23
Direct engagement with bodily secretions, ulceration, coughing, or sneezing of infectious animals can result in infection, as can passive exposure to contaminated surfaces. Computational analysis based on the perspective of diminishing vaccination coverage against the Poxviridae revealed that monkeypox might be more virulent, despite the statistics that state that the transference was historically restricted between humans.24 In the hospital sector, the Centers for Disease Control and Prevention (CDC) advise confinement in a low-pressure chamber as well as basic, touch, including droplets safeguards with progression to aerial safeguards if feasible.
Assessment, Dealing, and Controlling
PCR testing for monkeypox in patient material or isolating it in viral culture are two ways to identify monkeypox infection. Alternately, tests demonstrating the presence of the Orthopoxvirus in a patient’s sample may be adequate for diagnosis, assuming that the patient has not been exposed to another orthopoxvirus within the same genus. These modalities include electron microscopy, immunohistochemistry, immunofluorescence for orthopoxvirus antibodies, and serum examination for anti-orthopoxvirus antibodies showing recent exposure or prior vaccination.5
There are presently no known effective therapies for monkeypox disease. The therapeutic approach for viral infections is comprehensive symptomatic control. Some precautions may be taken to avoid an epidemic. Until the blisters have completely crusted and sloughed off, the infected person should be isolated, wear a protective mask, and keep the lesions covered as much as is practical. Compounds with established effectiveness towards orthopoxviruses in animal trials and significant vaccinia vaccination sequelae may be investigated for experimental use in extreme situations.
The effectiveness of the intravenous vaccinia immunoglobulin, the intracellular viral discharge inhibitor tecovirimat, and the oral DNA polymerase inhibitor brin-cidofovir against the monkeypox pathogen is uncertain.5 In extreme situations, dual treatment using tecovirimat and brincidofovir might be tried. Tecovirimat pre-vents viral development and virus discharge from contaminated cells by inhibiting the viral protein component VP37.25
Although 21 days is the generally regarded maximum incubation period, incubation temperatures and indicators should be checked twice daily for those exposed to the infection. Close contacts are not required to quarantine when asymptomatic since infectiousness coincides with the start of symptoms. In some circumstances, post-exposure immunization with enhanced vaccinia, Ankara vaccine (non-replicating smallpox and monkeypox vaccine), is suggested. A “serious risk” approach necessitates post-exposure immunization as soon as feasible. This exposure occurs when injured skin encounters a contaminated patient’s bodily secretions, respiratory secretions, or open sores. The CDC states that immunizations within four days of exposure could stop the start of the illness, and immunizations within 14 days might lessen its impact.
The enhanced vaccinia with replication flaws compared to ordinal level and second generation smallpox vaccinations, the Ankara vaccine seems to have a greater safety record. It is administered in a two-shot series at four-week intervals. Giving an attenuated vaccine, Ankara, does not cause skin ulceration or increase the danger of local or widespread transmission, in contrast, to live vaccinia viral treatments.5 Additionally, clinical studies have demonstrated that the customized vaccinia Ankara is harmless and promotes the formation of antibodies in individuals with atopy and weakened immune systems—conditions that are thought to be contraindicated for the injection of live vaccinia.18
More information and practical research are needed to determine the possible advantages and disadvantages of prophylactic monkeypox immunization in endemic areas. In addition, making educated choices regarding how to deal with this overlooked tropical virus effectively is hampered by a lack of access to healthcare, diagnostic tools, and infrastructure.4,18,10
Prognostication and Prevention of Monkeypox, and Improvements in Symptom Identification
The monkeypox pathogen is divided into two separate clades, with the current epi-demic perhaps describing a novel clade.23 A mortality rate under 1% gives the Western African lineage a better outlook. The Central African group, on the contrary, seems to be more deadly, with a high mortality rate ranging from to 11percent in young immunocompromised individuals. Other than possible scars and hyperpigmentation, patients commonly recover within four weeks of the start of symptoms.4
Despite including a fraction of people infected with HIV, there were no fatal attacks in a dataset of 1119 patients diagnosed with the monkeypox virus from the continuing epidemic in European countries like Germany, the United Kingdom, Italy, and Spain. This suggests that the spreading variant could be less deadly.20,21
It is essential to disseminate information among hospitalized individuals and medical experts, especially within those communities most affected. Quarantine is the best method to overcome this outbreak. Monkeypox can be transmitted from person to person. Very few individuals are interested in being vaccinated for smallpox disease, and due to this fact, there is serious concern that the increase in the number of people being infected with monkeypox will create a breeding ground for new clades. Hence, updating the patients’ hospital records requires cognizance of the kind of illness, documentation accuracy, and availability of screening methods, always initial requirements for data collection as further to comprehend this disease (monkeypox), therefore, fortify protection against it.4,18
Infectious illnesses need a vulnerable population and places where they may prop-agate. Since the 1980s, the degree of risk and collective immunization to monkeypox that was formerly attained by mass vaccination against vaccinia has decreased, making people more susceptible to breakouts.3 Furthermore, transient environmental and sociocultural shifts in endemicity probably enhanced people’s exposure to susceptible animals.17
An infected individual may visit the Hospital, emergency treatment, or primary healthcare setting, depending on the seriousness of the monkeypox infection. A barrier against a disastrous epidemic is created by the capacity of an interdisciplinary team of doctors, nurses, research scientists, veterinarians, and healthcare workers to detect monkeypox infections in individuals and animals quickly, adopt safety precautions, and start public health documentation. In addition to possessing knowledge of infectious diseases, a specialist communicable diseases pharmacist may do medication reconciliation and provide medication management counseling, which may be beneficial in addressing the instance. The interdisciplinary team approach would facilitate an improved care experience.26 Recently, on 28th November 2022, WHO (World Health Organization) announced that it will gradually replace the word “monkeypox” with “mpox” over the upcoming year. The choice was made in response to several requests for the title to be changed following the disease’s contemporary international epidemic discovered in May of last year, 2021.27
As a result, individuals who have had monkeypox may need emergency surgery, particularly if they have dermatological or mucosal lesions that are oozing pus. Even though there is a modest mortality rate, this virus may be quite infectious. To interact with the environment and reduce the danger of transmissions, a local protocol should be devised, concentrating upon every operative phase.
The authors would like to articulate our wholehearted appreciation to the Institute of Big Data Analytics and Artificial Intelligence (IBDAAI), Kompleks Al-Khawarizmi and Universiti Teknologi MARA (UiTM) for their high gratitude support and assistance.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.
This study was supported by the Institute of Big Data Analytics and Artificial Intelligence (IBDAAI), Kompleks Al-Khawarizmi and Universiti Teknologi MARA (UiTM), Malaysia with grant number 600-TNCPI/PBT5/3(135/2021).
All datasets generated or analyzed during this study are included in the manuscript.
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