MONKEY POX

By,
Dr.Jithu K Mathew MBBS,MD
Consultant Microbiologist
Sreevalsam Institute of Medical Science Edappal
 Virology
• enveloped double-stranded
DNA virus
• Family : Poxviridae
• Genus :Orthopoxvirus .
• Two clades of monkeypox virus:
1) West African clade and
2) the Congo Basin (Central African) clade.

Clade West African Congo Basin

clade clade
Severity less severe More severe

Case fatality rate 3.6% 10.6%

Transmissibility Less More

 History

• The term monkeypox originates from the initial

discovery of the virus in monkeys in a Danish
laboratory in 1958.
• The first human case was identified in a 9-year-old
boy in the Democratic Republic of the Congo in 1970
 EPIDEMIOLOGY
• Viral zoonosis 
• Since 1970, human cases of monkeypox have been
reported in 11 African countries: Benin, Cameroon, the
Central African Republic, the Democratic Republic of
the Congo, Gabon, Cote d’Ivoire, Liberia, Nigeria, the
Republic of the Congo, Sierra Leone and South Sudan.
• The true burden of monkeypox is not known.
 Cases of monkeypox in non-endemic countries
reported to WHO between 13 to 21 May 2022
Geographical distribution of confirmed and suspected
cases of monkeypox in non-endemic between 13 to 21
May 2022
 Mode of transmission
Virus enters body through broken skin,respiratory tract, or mucous
membranes[eye,nose,mouth].

Human to human Animal to human

Direct contact Indirect contact Bites

close contact with contaminated Scratches
lesions, body fluids, materials such as Bush meat preparation
respiratory droplets bedding.
 Transmission of Monkey Pox

Human
Terrestrial
Arboreal rodents
rodents

Uncertainty remains on the

natural history of the monkeypox Monkey
virus
 CLINICAL FEATURES
Incubation period :6 to 13 days but can range from 5 to 21 days.

Atypical rash that

progresses in sequential
stages – macules, papules,
vesicles, pustules, scabs,
at the same stage of
development over all
affected areas of the body
The infection can be divided into two periods:
a. Invasion period
 lasts between 0–5 days
 Characterized by fever, intense
headache, lymphadenopathy
(swelling of the lymph nodes),
back pain, myalgia (muscle
aches) and intense asthenia (lack
of energy).
 Lymphadenopathy is a
distinctive feature of
monkeypox compared to other
diseases that may initially
appear similar (chickenpox,
measles, smallpox)
b. Period of rash
the skin eruption usually begins
within 1–3 days of appearance of fever.
more on the face and extremities rather than
on the trunk.
It affects the face (in 95% of cases), and palms
of the hands and soles of the feet (in 75% of
cases). Also affected are oral mucous
membranes (in 70% of cases), genitalia (30%),
and conjunctivae (20%), as well as the cornea.
The rash evolves sequentially from macules
(lesions with a flat base) to papules (slightly
raised firm lesions), vesicles (lesions filled
with clear fluid), pustules (lesions filled with
yellowish fluid), and crusts which dry up and
fall off.
The number of lesions varies from a few to
several thousand.
• Usually self-limiting
• Symptoms may last from 2-4 weeks.
• May be severe in some individuals, such as children,
pregnant women or persons with immune suppression
due to other health conditions.
 Complications
• Secondary infections
• Bronchopneumonia
• Sepsis
• Encephalitis
• Infection of the cornea with ensuing loss of vision
 Diagnosis
Lymphadenopathy during the prodromal
stage of illness can be a clinical feature to
distinguish monkeypox from chickenpox
or smallpox. Polymerase chain
reaction (PCR) is
the preferred
laboratory test
 
• Optimal diagnostic samples :skin lesions – the
roof or fluid from vesicles and pustules, and
dry crusts. Where feasible, biopsy is an
option.
• Lesion samples must be stored in a dry, sterile
tube (no viral transport media) and kept cold. 
•  PCR blood tests are • As orthopoxviruses are
usually inconclusive
because of the short
duration of viremia
relative to the timing of
specimen collection
after symptoms begin
and should not be
routinely collected from
patients.
serologically cross-
reactive, antigen and
antibody detection
methods do not provide
monkeypox-specific
confirmation
 Infection control Precautions
By Health workers
• implement standard, contact
and droplet precautions
• Recommended personal
protective equipment (PPE)
includes gloves, gown, medical
mask and eye protection –
goggles or face shield
• aerosol generating procedures
(AGPs) a respirator
By the patient
• wear medical mask when
they come into close contact
(under 1m) with health
workers or other patients, if
they can tolerate it.
• A bandage, sheet or gown
can be used to cover lesions
in order to minimize
potential contact with
lesions.
 Period of communicability:
1-2 days before appearance of the rash ,till all scabs fall off

Any patient with suspected monkeypox should be investigated

and if confirmed, isolated until their lesions have crusted,
the scab has fallen off and a fresh layer of skin has formed
underneath.
 Definition of a contact
• A contact is defined as a person who, in the period
beginning with the onset of the source case’s first
symptoms, and ending when all scabs have fallen off,
has had one or more of the following exposures with a
probable or confirmed case of monkeypox:
• face-to-face exposure (including health care workers
without appropriate PPE)
• direct physical contact, including sexual contact
• contact with contaminated materials such as clothing or
bedding
 Surveillance definitions for the
monkeypox outbreak in non-endemic
countries.
Suspected case:
• A person of any age presenting in a monkeypox non-endemic country with an
unexplained acute rash
• AND                                        
• One or more of the following signs or symptoms, since 15 March 2022:
• Headache
• Acute onset of fever (>38.5oC),
• Lymphadenopathy (swollen lymph nodes)
• Myalgia (muscle and body aches)
• Back pain
• Asthenia (profound weakness)
• AND
• for which the following common causes of acute rash do not explain the clinical
picture:
Probable case:
•  A person meeting the case definition for a suspected case
• AND
• One or more of the following:
• has an epidemiological link in the 21 days before symptom onset
• reported travel history to a monkeypox endemic country  in the
21 days before symptom onset
• has had multiple or anonymous sexual partners in the 21 days
before symptom onset
• has a positive result of an orthopoxvirus serological assay, in the
absence of smallpox vaccination or other known exposure to
orthopoxviruses
• is hospitalized due to the illness
Confirmed case:
• A case meeting the definition of either a suspected or probable case and is
laboratory confirmed for monkeypox virus by detection of unique
sequences of viral DNA either by real-time polymerase chain reaction
(PCR) and/or sequencing.

Discarded case:
• A suspected or probable case for which laboratory testing by PCR
and/or sequencing is negative for monkeypox virus.
 Vaccination
 Data from Africa suggests that smallpox vaccine is at least 85%
effective in preventing monkeypox. 
 JYNNEOSTM (also known as Imvamune or Imvanex), has been licensed
in the United States to prevent monkeypox and smallpox.
 ACAM2000, which contains a live vaccinia virus, is licensed for
immunization in people who are at least 18 years old and at high risk
for smallpox infection. It can be used in people exposed to monkeypox
if used under an expanded access investigational new drug protocol.
 Treatment
• An antiviral agent known as TECOVIRIMAT[ST-246 ] that was
developed for smallpox was licensed by the European Medical
Association (EMA) for monkeypox in 2022.But limited data available.

• Data is not available on the effectiveness of Cidofovir and

Brincidofovir in treating human cases of monkeypox.  However, both
have proven activity against poxviruses in in vitro and animal studies.
• Currently, there is no proven, safe treatment
for monkeypox virus infection.
• For purposes of controlling a monkeypox
outbreak, smallpox vaccine, antivirals, and
vaccinia immune globulin (VIG) can be used

Ref: https://www.cdc.gov/poxvirus/monkeypox/treatment.html
Recommended Public Health Actions
–NCDC,MoHFW,May 2022
1.Health care facilities to keep heightened suspicion in people
who;
a. Present with otherwise unexplained rash and
b. Who have travelled,in the last 21 days to a country that has
recently confirmed or suspected cases of monkeypox or
c. Report contact with a person or people with confirmed or
suspected monkeypox.
2.All suspected cases to be isolated at designated healthcare facilities
untill all lesions have resolved and a fresh layer of skin has
formed OR until the treating physician decides to end isolation.
3.All such patients to be reported to the District Surveillance Officer
of IDSP.
4.All infection control practices to be followed while treating such
patients.
5.Laboratory samples consisting of fluid from vesicle ,blood, sputum
etc to be sent to NIV Pune for testing in case of suspicion

6.In case a positive case is detected, contact tracing has to be

initiated immediately to identify the contacts of the patient in the
last 21 days.
 References

1. Interim advisory for IDSP SSUs in view of

monkeypox cases reported from few countries.
2.
https://www.who.int/news-room/fact-sheets/detail/mo
nkeypox  
3. www.cdc.gov/poxvirus/monkeypox