After the widespread of Monkeypox across the globe, two questions were doing the rounds. Why is a virus that has never managed to spread beyond a few cases outside Africa suddenly caused such a big, global outbreak? Why are the overwhelming majority affected are Man who have sex with Man (MSM).
Researchers point out that the long history of work on sexually transmitted infections and early studies of the present outbreak suggest the link of sex involved, especially MSM. A study published as a preprint last week by researchers at the London School of Hygiene & Tropical Medicine (LSHTM) supports this view.
Since early May, more than 2000 monkey cases have been reported in more than 30 countries where the virus is not normally seen. Reports suggest that majority of cases have been in MSM. Researchers at the UK Health Security Agency (UKHSA) for example, asked patients to fill out questionnaires. Of the 152 who did, 151 said they were MSM. Researchers note that this might may be the same in other countries.
Of the 152 people in the UKHSA set, 82 were invited for additional interviews focusing on their sexual health. Among the 46 who participated, 44 per cent reported more than 10 sexual partners in the previous three months, and 44 per cent reported group sex during the incubation period. Viral DNA and even infectious virus was traced in the semen of some patients but the researchers are not sure if this was important for transmission,
THE OUTBREAK
Between January 1 to June 15, 2022, the WHO reported a cumulative total of 2103 laboratory confirmed cases, one probable case, and one death from 42 countries in five Regions. The majorly of cases (98 per cent) have been reported since May 2012.
Majority (84 per cent) of confirmed cases (1773) are from the WHO European Region, Confirmed cases have also been reported from the African Region (64 numbers; 3%), the Region of the Americas (245 numbers:12 per cent), Eastern Mediterranean Region (14 numbers; less than one per cent) and Western Pacific Region (7 numbers; less than one per cent). Of the cases reported , 99 per cent are reported in men aged 0 to 65 years, of which most self-identify as men who have sex with other men.
To date the clinical presentation of monkeypox cases associated with this outbreak has been variable. Many cases in this outbreak are not presenting with the classically described clinical picture for a monkeypox (fever, swollen lymph nodes, followed by a centrifugal evolving rash). Atypical features described include: presentation of only a few or even just a single lesion; lesions that begin in the genital or perineal area and do not spread further lesions; lesions appearing at different (asynchronous) stages of development, and the appearance of lesions before the onset of fever, malaise and other constitutional symptoms. The modes of transmission during sexual contact remain unknown; while it is known that close physical and intimate skin-to-skein or face-to-face contact can lead to transmission through direct contact with infectious skin or lesions), it is not clear what role sexual bodily fluids, such as semen and vaginal fluids, play in the transmission of monkeypox.
PUBLIC HEALTH RESPONSE
The WHO says that Genomic sequencing of viral deoxyribonucleic acid (DNA), where available, is being undertaken. Several European countries (Belgium, Finland, France, Germany, Israel, Italy, the Netherlands, Portugal, Slovenia, Spain, Switzerland, and the United Kingdom of Great Britain and Northern Ireland), Australia, Canada, Nigeria, Singapore and the United States of America have published full-length or partial genome sequences of the monkeypox virus found in the current outbreak. While investigations are ongoing, preliminary data from polymerase chain reaction (PCR) assays indicate that the monkeypox virus genes detected belong to the West African clade.
The AC AM-2000 and MMA-BN vaccines are being deployed by some Member States to manage close contacts Others may hold supplies of LCI 6 or other vaccines,
WHO ADVICE
All countries should be on the alert for signals related to patients presenting with a rash that progresses in sequential stages – macules, papules, vesicles, pustules, scabs, at the same stage of development over all affected areas of the body – that may be associated with fever, enlarged lymph nodes, back pain, and muscle aches. During this current outbreak, many individuals are presenting with atypical symptoms, which includes a localized rash that may present as little as one lesion. The appearance of lesions may be asynchronous and persons may have primarily or exclusively peri-genital and/or peri-anal distribution associated with local, painful swollen lymph nodes. Some patients may also present with sexually transmitted infections and should be tested and treated appropriately. These individuals may present to various community and health care settings including but not limited to primary and secondary care, fever clinics, sexual health services, infectious disease units, obstetrics and gynaecology, emergency departments and dermatology clinics.
Increasing awareness among potentially affected communities, as well as health care providers and laboratory workers, is essential for identifying and preventing further cases and effective management of the current outbreak.
Any individual meeting the definition for a suspected case should be offered testing. The decision to test should be based on both clinical and epidemiological factors, linked to an assessment of the likelihood of infection. Due to the range of conditions that cause skin rashes and because clinical presentation may more often be atypical in this outbreak, it can be challenging to differentiate monkeypox solely based on the clinical presentation.
Caring for patients with suspected or confirmed monkeypox requires early recognition through screening adapted to local settings, prompt isolation and rapid implementation of appropriate IPC measures (standard and transmission-based precautions, including the addition of respirator use for health workers caring for patients with suspected/confirmed monkeypox, and an emphasis on safe handling of linen and management of the environment), physical examination of patient, testing to confirm diagnosis, symptomatic management of patients with mild or uncomplicated monkeypox and monitoring for and treatment of complications and life-threatening conditions such as progression of skin lesions, secondary bacterial infection of skin lesions, ocular lesions, and rarely, severe dehydration, severe pneumonia or sepsis. Patients with less severe monkeypox who isolate at home require careful assessment of the ability to safely isolate and maintain required IPC precautions in their home to prevent transmission to other household and community members.
Precautions (isolation) should remain in place until lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath.
