By Dr Ranganathan N Iyer
As we swim through the fourth wave of the COVID-19 pandemic, there unfolds a new microorganism, a virus that stands poised to infect mankind and be another reason for concern. This is the monkeypox infection caused by the monkeypox virus, similar to smallpox (which was declared eradicated worldwide in 1980), but leads to less severe infections than the latter.
A multi-country outbreak of this infection is noted at the time of writing. The WHO has declared monkeypox as PHEIC (Public Health Emergency of International Concern) on July 23, which is a step before being declared as a pandemic. This comes with more than 16,000 cases spread across 75 countries and 10 deaths reported the world over by early August. India reported 8 cases and one death in the same period. The infection, till recently, was geographically restricted to Central and West Africa.
The incubation period of this viral infection ranges from 5 to 21 days, which means that a person who has had close contact with a diagnosed or suspected case may begin to exhibit symptoms till day 21 after exposure. Patients are known to present initially (1-5 days) with fever, headache, back pain, muscle aches and enlarged painful lymph nodes in the face, neck, axilla or groin. In fact, the presence of enlarged and painful lymph glands serves to differentiate monkeypox from smallpox and other poxvirus infections. Soon (within the next week), the infected patient may develop a rash which enlarges to form blebs, pustules and then dries up to form a scab which falls off to be replaced by newly formed skin. The entire clinical presentation may take 2-4 weeks till the last scab falls off. Patients are infectious to others at all stages of the illness, till the last scab has fallen off. This includes skin scabs, all of which may contain the virus, hence be infectious.
Whilst the present outbreak, exemplified by the description of cases in the UK and countries of Western Europe, is largely seen in gay men, the role of sexual transmission of this infection is not proven. Hence, at this point, monkeypox is not a sexually transmitted infectious disease as may be mistaken by people in the community. The close contact during sexual encounters with skin-skin, mouth-mouth, skin-mouth contact probably aids in spreading the infection to a vulnerable individual. Any person who is in close contact with an infected case could suffer from the infection. This infection may not be life-threatening in the majority of cases, however there may be complications with scars, superadded bacterial and fungal infections of the skin pustules, and a loss of vision if the lesions are found in the eyes of infected patients.
Transmission of this infection could occur from animals, close contact with an infected patient as well as from the inanimate environment, particularly from contaminated clothing, bed linen and bedding that may have the infectious viral particles. These, when dispersed in the air, could lead to infections when they infect another person. During pregnancy, the virus can cross the placenta causing intrauterine exposure of the foetus to cause congenital infection of the infant. Transmission in the present outbreak appears to have been amplified by mass and social gatherings, parties and widespread travel in recent times. Hence, precautions to prevent the spread of the virus in social gatherings and parties are very important to control monkeypox outbreaks.
All suspected cases must be referred to a physician, as home isolation without a diagnosis may facilitate local and community transmission of the infection. The patient may have to be isolated for 2-4 weeks till the last of the scabs are formed and fall off and the new skin forms underneath. Specimens must be collected (both blood samples and skin lesion fluid) by trained and designated staff in hospitals and sent to NIV (National Institute of Virology) Pune alone. Constant vigil, surveillance and rapid identification with isolation of proven and suspected cases is important in the containment of outbreaks.
This infection could be treated with an antiviral agent Tecovirimat. The use of this agent must be monitored if used on patients. Two vaccines, namely Imvamune/Imvanex and the ACAM200 have been licensed by the US FDA for use to prevent monkeypox. However, the use of Tecovirimat or the vaccines is not an alternative to infection control precautions for the control of monkeypox in the community.
It is time for robust infection prevention practices to be established and monitored across the country. Infection control precautions are vital to the control of the infection. A combination of contact, droplet precautions, similar to that practised by the common man for COVID-19 pandemic would be sufficient to control the spread of monkeypox. Using a standard three-layered surgical face mask and frequent hand hygiene and following laid down rules and precautions in social gatherings and meetings would help contain this infection. Guidelines have been issued in detail by the Ministry of Health and Family Welfare, Govt. of India (updated on July 15, 2022), the Centre for Disease Control (CDC Atlanta, Georgia), the ECDC (European CDC) and the WHO (World Health Organisation). They are freely available on the respective websites for a quick reference, should the need arise.
Dr. Ranganathan N Iyer MD FRCPath ( UK) DNB DPB MAMS
Consultant Clinical Microbiology, Infections and Infection Control
Rainbow Children’s Hospitals, Banjara Hills
This article was published in association with Rainbow Children's Hospital.