BAHAGIAN KAWALAN PENYAKIT KEMENTERIAN KESIHATAN MALAYSIA DISEASE CONTROL DIVISION ‘MINISTRY OF HEALTH, MALAYSIA ‘ARAS 3,4 DAN 6 , BLOK E10, PARCEL E, PRESINT 1, PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN (62590, PUTRAJAYA Tel: 03-68834527 Faks : 03-88886270 Ruj. Tuan Ruj, Kami: KKM.600-29/4/54 Jid.2( |) aH Naan SENARAI EDARAN YBhg. Datuk / Dato’ Indera / Dato’ / Datin / Tuan / Puan, MAKLUMAN JANGKITAN VIRUS MONKEYPOX (ICD10:B04) Dengan hormatnya saya merujuk perkara tersebut di atas. 2. Kementerian Kesihatan Singapura telah mengesahkan satu kes jangkitan monkeypox pada 9 Mei 2019. Kes adalah seorang warga Nigeria yang tiba ke Singapura pada 28 April 2019 dan mula menunjukkan gejala jangkitan pada 30 April 2019. Kes mendakwa ada memakan daging haiwan liar di Nigeria sebelum bertolak ke Singapura. Kes telah diberi rawatan dan diletakkan dalam isolasi, manakala kontak langsung kes telah dikenalpasti dan diberi rawatan profilaksis serta arahan kuaratin selama 21 hari dilakukan bagi pengawasan gejala jangkitan monkeypox. 3. Untuk makluman, virus monkeypox ditularkan kepada manusia melalui gigitan atau sentuhan langsung dengan darah binatang atau cecair badan dan luka haiwan yang dijangkiti. Virus ini juga boleh disebarkan melalui titisan pemafasan. Manusia juga boleh dijangkiti melalui hubungan langsung dengan cecair badan orang yang dijangkiti atau dengan objek yang tercemar virus, seperti tempat tidur atau pakaian. Walau bagaimanapun penularan manusia-ke-manusia adalah terhad. 4. Tempoh inkubasi monkeypox ini adalah dari 6 ke 21 hari. Gejala yang lazim ditunjukkan oleh kes adalah demam disertai dengan keletihan, sakit kepala dan ruam makulopapular yang bermula di muka kemudian menyebar ke telapak tangan dan tapak kaki, diikuti oleh bahagian-bahagian tubuh yang lain. Gejala dan tanda jangkitan mirip seperti jangkitan cacar. 5, _ Jangkitan monkeypox dilaporkan berlaku di Afrika Tengah dan Barat_iaitu Democratic Republic of the Congo, Congo, Cameroon, (Gila catatkan rujukan surat ini apabila menjawap) (Please quote our reference white replying)Central African Republic, Nigeria, Ivory Coast, Liberia, Sierra Leone, Gabon dan Sudan Selatan. 6. Sekiranya terdapat pesakit disyaki monkeypox dengan gejala seperti di atas di fasiliti kesihatan KKM, pastikan: i. Kes memenuhi definisi kes yang dinyatakan dalam Perkara 8: Frequently Asked Questions on Monkeypox Infection (Lampiran 1). ii. Kes perlu diletakkan dalam bilik isolasi tekanan negatif sehingga ruam makulopapular atau lepoh sembuh sepenuhnya. Sampel klinikal dihantar ke Makmal Kesihatan Awam Kebangsaan (MKAK) atau Institut Penyelidikan Perubatan (IMR) untuk ujian diagnosa, iv. Kontak langsung kepada kes dikenalpasti dan diletakkan di bawah kuarantin di rumah selama 21 hari, bagi pemantauan gejala monkeypox serta _mengelakkan pendedahan atau kontak dengan orang lain. 7. Bersama ini disertakan maklumat ringkas mengenai monkeypox untuk perhatian pihak YBhg. Datuk / Dato’ Indera / Dato’ / Datin / tuan / puan. Mohon kerjasama untuk makluman ini dikongsikan dengan pengurusan hospital, Pejabat Kesihatan Daerah, Pejabat Kesihatan Pintu Masuk Antarabangsa dan fasiliti swasta di bawah tanggungjawab masing-masing. Sekiranya terdapat sebarang pertanyaan, pihak YBhg. Datuk / Dato’ Indera / Dato’ / Datin / tuan / puan bolehlah menghubungi Dr. Rohani Jahis, Ketua Sektor Zoonosis di talian 03-8883 4412 atau email rohbj@moh.gov.my. 8. Kerjasama YBhg. Datuk / Dato’ Indera / Dato’ / Datin / tuan / puan dalam hal ini amat dihargai dan didahului dengan ribuan terima kasih. Sekian. *BERKHIDMAT UNTUK NEGARA” Saya yang medjalankan amanah, (DR. NORHAYA fal TI RUSLI) Pengarah Kawglan Penyakit Kementerian Kesihatan Malaysias.k Ketua Pengarah Kesihatan Malaysia Timbalan Ketua Pengarah Kesihatan (Kesihatan Awam) Kementerian Kesihatan Malaysia Timbalan Ketua Pengarah Kesihatan (Perubatan) Kementerian Kesihatan Malaysia Timbalan Ketua Pengarah Kesihatan (Penyelidikan & Sokongan Teknikal) Kementerian Kesihatan Malaysia Pengarah Kanan Bahagian Perkhidmatan Farmasi Kementerian Kesihatan Malaysia. Pengarah Makmal Kesihatan Awam Kebangsaan Pengarah Institut Penyelidikan Perubatan Dr. Suresh Kumar a/l Chidambaram Pakar Perunding Kanan Perubatan (Penyakit Berjangkit) Ketua Jabatan Perubatan Hospital Sungai Buloh.SENARAI EDARAN Pengarah Kesihatan Negeri Perlis Jabatan Kesihatan Negeri Perlis Tingkat 8, Bangunan Persekutuan Persiaran Jubli Emas, 01000 Kangar, Perlis Pengarah Kesihatan Negeri Kedah Jabatan Kesihatan Negeri Kedah Jalan Sultanah, 05350 Alor Setar, Kedah Pengarah Kesihatan Negeri Pulau Pinang Jabatan Kesihatan Negeri Pulau Pinang Tingkat 37, Komtar, 10590 Pulau Pinang Pengarah Kesihatan Negeri Perak Jabatan Kesihatan Negeri Perak. Jalan Panglima Bukit Gantang Wahab 30590 Ipoh, Perak Pengarah Kesihatan Negeri Selangor Jabatan Kesihatan Negeri Selangor Tingkat 9,10 & 11 Wisma Sunwaymas Lot 1 Jalan Persiaran Kayangan 40100 Shah Alam, Selangor Pengarah Kesihatan WP Kuala Lumpur & Putrajaya Jabatan Kesihatan WP Kuala Lumpur Kompleks Pejabat-pejabat Kesihatan Jalan Cenderasari, 50490 Kuala Lumpur Pengarah Kesihatan Negeri Sembilan Jabatan Kesihatan Negeri Sembilan Jalan Lee Sam, 70590 Seremban, Negeri Sembilan Pengarah Kesihatan Negeri Melaka Jabatan Kesihatan Negeri Melaka Tingkat 6, Wisma Persekutuan Jalan Hang Tuah, 75300 Melaka Pengarah Kesihatan Negeri JohorJabatan Kesihatan Negeri Johor Tingkat 4 , Blok B , Wisma Persekutuan Jalan Air Molek, 80590 Johor Bharu,Johor Pengarah Kesihatan Negeri Pahang Jabatan Kesihatan Negeri Pahang Tingkat 12, Wisma Persekutuan Jalan Gambut, 25000 Kuantan, Pahang Pengarah Kesihatan Negeri Terengganu Jabatan Kesihatan Negeri Terengganu Tingkat 5, Wisma Persekutuan Jalan Sultan Ismail 29200 Kuala Terengganu, Terengganu Pengarah Kesihatan Negeri Kelantan Jabatan Kesihatan Negeri Kelantan Tingkat 5, Wisma Persekutuan Jalan Bayam, 15590 Kota Bahru, Kelantan Pengarah Kesihatan Negeri Sabah Jabatan Kesihatan Negeri Sabah Tingkat 1, Rumah Persekutuan 88814 Kota Kinabalu, Sabah Pengarah Kesihatan Negeri Sarawak Jabatan Kesihatan Negeri Sarawak. Jalan Tun Abang Hj.Openg 93590 Kuching, Sarawak Pengarah Kesihatan WP Labuan Jabatan Kesihatan WP Labuan Peti surat 80832, 87018 WP Labuan Pengarah Hospital Kuala Lumpur Jalan Pahang, Kuala Lumpur Pengarah Pusat Darah NegaraFREQUENTLY ASKED QUESTION ON MONKEYPOX INFECTION What monkeypox? Monkeypox is a rare zoonotic viral disease caused by the monkeypox virus belonging to the Orthopoxvirus genus of the Poxviridae family, which also includes smallpox, vaccinia, cowpox, camelpox, ectromelia (mousepox) and other viruses. After smallpox eradication in 1980 and consequent to the cessation of smallpox vaccination, monkeypox emerged as the most prevalent orthopoxvirus infection in humans. What is the prevalence of monkeypox? Monkeypox has been reported in the tropical rainforest regions of Central and West Africa. The central and western Africa are Democratic Republic of the Congo, Republic of the Congo, Cameroon, Central African Republic, Nigeria, Ivory Coast, Liberia, Sierra Leone, Gabon and South Sudan. It is considered endemic in Democratic Republic of Congo (DRC), with more than 1,000 suspected cases per year since 2005. Nigeria reported a large multistate outbreak in 2017 to 2018. Monkeypox is a zoonotic disease, What is the implicated animal? Many animal species were found infected with monkeypox virus, including rope and tree species of squirrels, Gambian giant rats, striped mice, dormice and primates. Rodents like Gambian giant rats (Cricetomys gambianus) and squirrels are suspected to be the natural reservoirs of the virus. How widespread is this disease outside Africa? So far, there were few reported cases outside Africa: i. In 2003, the Centres for Disease Control (CDC) reported 47 confirmed and probably human monkeypox cases in six (6) states, Cases were infected after contact with prairie dogs purchased as pet, which was earlier kept in proximity with small mammals imported from Ghana. Investigation revealed some patients get infected after touching sick animals, being bitten or scratched, and cleaning cage and the animal's bedding. No cases attributed to human-to-human transmission. ii, In September 2018, the UK reported two imported cases in travellers returning from Nigeria.iil, On 12 October 2018, Israel reported a case, a 38-year-old Israeli man who was working in Nigeria and came back to Israel who had history of contact with dead rodents. iv. Recently, on 9 May 2019, Singapore reported one case, a Nigerian who entered Singapore on 28 April 2019 and had history of consuming bush meat in Nigeria. How could | become infected with this virus? The monkeypox virus is transmitted to humans through a bite or direct contact with an infected animal's blood, body fluids or cutaneous/mucosal lesions. Human to human transmission is rare and likely to occur by close contact or airborne routes. What are the symptoms of the illness? The incubation period is usually 6 to 21 days. The illness typically lasts for two to four weeks. It is characterised by fever, myalgia, headache, lymphadenopathy and rash. The rash which is first seen about two days after fever onset usually starts in the trunk and spreads peripherally to involve the palms and soles. The rash starts as a macules and papules and then progresses to become vesicles and pustules before scabbing and desquamation over a 2-3 week period. Unlike in chickenpox where lesions at various stages of development and healing are seen, in monkeypox all the lesions are generally at the same stage. Lymphadenopathy is observed prior to and concomitant with the rash, which helps differentiate it from smallpox or varicella, What is the risk of infection in Malaysia? Introduction of monkeypox case might be related to importation. The risk of its spread in Malaysia is very low due to the limited human-to-human transmission. If there is any, early identification of cases is vital for early case management including isolation and contacts tracing. How will new cases be identified? Case will present with maculopapular or vesicular rash or pustular, generalised or localised, discrete or confluent WITH one or more of the following * Fever © Chills10. Sweats Headache Backache Lymphadenopathy Sore throat Cough Shortness of breath WITH epidemiologic criteria i. Exposure to a suspect, probable or confirmed human case of monkeypox within the incubation period, OR ji, Exposure to wild, captive or pet mammal from or in the African monkeypox endemic countries within the incubation period. Is there a laboratory test to confirm diagnosis? National Public Health Laboratory (NPHL) and Institute for Medical Research (IMR) have the capacity to do test for monkeypox virus. Optimal diagnostic specimens are from lesion i.e. vesicular swabs of lesion exudate or crust, stored in a dry sterile tube (without any viral transport media) and send on Ice. Blood and serum is useful if taken at the viremia phase. Monkeypox infection is confirmed via isolation of monkeypox virus in culture OR demonstration of the virus DNA by PCR test. Probable case of monkeypox is when there is a demonstration of virus morphology under electron microscope OR presence of orthopoxvirus in tissue using immunohistochemical test; in the absence of exposure to another orthopoxvirus. How does monkeypox cases being classified? Monkeypox cases are classified into 3: i. Suspect: a clinically compatible case that meets epidemiologic criteria that is awaiting laboratory test result. ii. Probable: a clinically compatible case that meets epidemiologic criteria and probable laboratory criteria for monkeypox. ili, Confirmed: a clinically compatible case with laboratory confirmed for monkeypox infection.11, 12, 13. What is the treatment for monkeypox? There is no specific treatment or vaccine for monkeypox infection. Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 3 weeks. Severe symptoms common among children and is related to extent of virus ‘exposure and patient's health status. McSharry JJ et al (2009) reported on an investigational new-drug cidofovir for treatment of variola infection. The use of an acyclic nucleoside phosphonate analogue (ANPA) was also being studied in animal infected with variola virus. A registered ANPA in Malaysia is Tenofovir®. However, no further studies or articles found to support the effectiveness of these drugs in treating monkeypox. CDC Atlanta reported that monkeypox outbreak can be controlled with smallpox vaccine, antiviral cidofovir, ST-246 (tecovirimat) and vaccinia immune globulin (vic). Are health workers at risk from the monkeypox patient? Even though human-to-human infection is limited, health care workers attending to monkeypox patient must implement standard contact and airborne infection control precautions. What is the management of case and contacts? ‘A monkeypox case should be isolated until all lesions have resolved and scabs separate. Close contact includes; i) Anyone who provided care for the patient including a health care worker or family member, or had other similarly close physical contact, ii) Anyone who stayed at the same place (e.g. lived with, visited) as a probable or confirmed case while the case was symptomatic. Contacts with high risk of infections need to be quarantined and monitored for 21 days from the date of last exposure to the confirmed case; for monkeypox symptoms and signs surveillance. Contacts with low risk of being infected are to be placed under active surveillance with twice daily monitoring of their health status. Asymptomatic contacts should not donate blood, cells, tissue, organs, breast milk or semen while they are under symptom surveillance.14. 15. 16. Does monkeypox case need to be notified? Monkeypox is not in the list of notifiable disease under the Prevention and Control of Infectious Disease Act 1988. However as it is a new and emerging disease, all suspected or probable or confirmed monkeypox cases must be notified via phone or fax or email to nearest district health office within 24 hours. Has WHO recommended any travel or trade restrictions related to this new virus? At this point of time, based on available information, WHO does not recommend any restriction for travel to and trade with Singapore or Nigeria. What should be done when travelling to monkeypox endemic countries? Travelers to monkeypox endemic countries should avoid contact with sick, dead or live animals (rodents, marsupials, primates) that could harbor the virus. Do not eat or handle bush meat. Always practice good self-hygiene including proper hand hygiene using soap and water. Use alcohol-based sanitizer when water and soap is no available. Any illness during travel or upon return should be reported to a health professional. Tell the doctor about all recent travel. For any further information, contact: Zoonosis Sector Bahagian Kawalan Penyakit Kementerian Kesihatan Malaysia Tel — : 03. 8883 4412/4508/4509 Fax 03 8889 1013 Email: zoonosis@moh.gov.my Reference: . Centers for Disease Control and Prevention Atlanta. 2003 United States Outbreak of Monkeypox. Page last reviewed September 28, 2018 . WHO EIS; Event update: Singapore — monkeypox, published 11 May 2019. 3. Ministry of Health Singapore. Press Release: Confirmed Imported Case Of Monkeypox In Singapore. 9 May 2019. |. New Carolina Communicable Disease Manual / Case Definition: Monkeypox. Nov 2007. . WHO, Key Facts on Monkeypox.6. McSharry JJ et al. Pharmacodynamics of cidofovir for vaccinia virus infection in an in vitro hollow-fiber infection model system. Antimicrob Agent Chemother 2009 Jan;53(1):129-35. 7. Centers for Disease Control and Prevention Atlanta. Monkeypox - treatment. Page last reviewed December 7, 2016