Re‐Emergence of monkeypox amidst delta variant concerns: A point of contention for public health virology?

Abstract

Monkeypox is a rare viral illness caused by the monkeypox virus, which belongs to the Orthopoxvirus family similar to the smallpox virus. Transmission occurs via direct contact with infected animals, possibly rodents, through blood, body fluids, or cutaneous lesions.1, 2 The period of incubation is 6–13 days and the disease sequence usually lasts 2–3 weeks.1 After a period of flu-like symptoms with fever, muscle pain, and headache, lymph node swelling ensues, with the rash going through various stages of crusting and scabbing across the face and body.1-3 Monkeypox as the name suggests was first identified in 1958 among colonies of monkeys that were kept for research,4 and the first human case was identified in the Democratic Republic of Congo in 1970 after the eradication of the smallpox virus in 1968.2, 4, 5 It is now endemic in 11 countries around West and Central Africa.2, 4 Nigeria had seen the largest outbreak in 2017.2 Outside of the African region, there have been several reported cases including 47 cases in the United States and three cases in the UK in 2003, one case in Israel in 2018, and one case in Singapore in 2019.2 Media reports have recently noted an outbreak of the virus in the United States and the UK. On July 17, 2021, a case was reported to the World Health Organization from the Dallas city of Texas in the United States. The patient had traveled from the United States to Nigeria on June 25, 2021, when he started having fever, vomiting, and a mild cough followed by a rash during his stay. On arrival to the United States on July 9, 2021, his rash became more widespread for which he acquired medical attention and was put under isolation immediately. On July 15, the Center for Disease Control and Prevention confirmed the disease to be positive for the West African clade of monkeypox virus.6 Similarly, an outbreak of three cases of Monkeypox was also reported between May 25, 2021, and June 15, 2021, in the UK. The first case traveled from Nigeria to the UK on May 8, 2021, and developed a rash after 2 days for which he self-isolated but was admitted to the hospital eventually after 10 days. On May 25, 2021, the West African clade of monkeypox was confirmed by polymerase chain reaction. Subsequently, on May 29, 2021, and on June 15, 2021, two other family members were also diagnosed with the same disease and treated.1, 7 Infections with the monkeypox virus are usually self-limiting. Two subtypes have been identified: (1) West African clade and (2) Congo Basin (Central African) clade. The Congo Basin type has a more severe disease with a case fatality ratio of 10% while the West African type 1%.1 The death rate in children is estimated to be 15%.8 The halt in the smallpox vaccination in recent times could be the cause for these outbreaks and different measures need to be taken to prevent the spread of this disease. Public awareness about the risk factors and the transmission from animals and from humans to humans should be reinforced. When diagnosed, patients should be kept under strict isolation. Use of personal protective equipment with disposable gowns and gloves, N95 mask, eye protection (face shields and goggles), hand and respiratory hygiene is the standard approach for safety.4 Restrictions of animal trade especially rodents and nonhuman primates should be implemented. Immediate notification of new cases and surveillance of outbreaks and close monitoring are critical for containment. Health workers dealing with infected patients should be well trained and provided with standard precautions. Handling of specimens and samples must be done by well-trained staff and in well-equipped laboratories.2 Even though cases of monkeypox are rarely reported outside the African countries, very little effort has been implemented to develop a vaccine specific for disease elimination. With comprehending that the smallpox vaccine is 85% effective, a similar vaccine targeting the monkeypox virus ought to be developed.2 The re-emergence of infectious diseases during an ongoing pandemic is alarming as an overburdened healthcare infrastructure runs the risk of resource saturation. The outbreak in the UK occurred at a time when it was already battling one of the deadliest outbreaks of the delta variant of the severe acute respiratory syndrome coronavirus 2.9 This crisis fueled added concerns and demanded more attention. As global citizens, we are not exempt from outbreaks occurring in any corner of the world. Health care leaders in coordination with public health virologists are recommended to formulate a plan to eradicate this disease. We are thankful to Dr. Jack Michel and the Larkin Health System, South Miami, FL, USA. All the authors declare that there are no conflicts of interest. All authors contributed equally. Zouina Sarfraz is the guarantor of the study.

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