SEMINAR PRESENTATION

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 THE BASICS OF MONKEYPOX

Guided By: Presented By:

Dr Naresh Gadara Dr Umesh Chhotala
Professor & HOD PG Resident
Department of Community Medicine Department of Community Medicine
Parul Institute of Medical Sciences & Research Parul Institute of Medical Sciences & Research

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 Introduction

OpenWHO.org ©WHO2020 30
 Monkeypox: Illness

▪ infectious disease caused by monkeypox

virus and characterized by a severe rash

▪ typically self-limiting, but can lead to severe

illness or death

▪ death occurs in up to 11% of cases, most

often in younger age groups (<40 yrs)

Credit: WHO/ M. V. Szczeniowski

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Monkeypox: Zoonotic transmission

▪ Monkeypox occurs primarily around rainforests of West

and Central Africa.
▪ The natural host of monkeypox is not known.
▪ Many species of small rodents and non-human
primates are susceptible to monkeypox virus.
▪ Following the eradication of smallpox, monkeypox virus
emerged as the most significant orthopoxvirus in humans.

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Monkeypox: The orthopoxviruses

▪ Like cowpox virus and variola virus (which

causes smallpox), the monkeypox virus is a
species of the genus Orthopoxvirus in the
family Poxviridae.
▪ Monkeypox is a zoonosis (transmitted to
humans from animals) with symptoms similar
to smallpox, although less severe.
▪ Smallpox was eradicated in 1980 and
vaccination ceased.
▪ Waning immunity may be a factor in the
emergence of monkeypox.

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 Monkeypox: Virus characteristics

▪ Distinct virus subtypes group in two clades:

▪ The Central African clade, prevalent in the
Central African Republic, the Democratic
Republic of the Congo and other countries.
▪ Clinically, virus in this clade causes more
severe illness and case fatality up to 11%
▪ The West African clade, found in Nigeria,
Côte d’Ivoire, Liberia and Sierra Leone.
▪ This monkeypox virus causes less severe

Credit: The Centers for Disease Control and

illness.
Prevention (CDC), USA

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 History of monkeypox

▪ Monkeypox was first identified as an

illness of non-human primates. The
virus is also found in rodents.
▪ Monkeypox in humans was first
identified in 1970 in the Democratic
Republic of Congo.
▪ Democratic Republic of the Congo
routinely reports a high number of
cases: more than 1,000 suspected
cases per year since 2005.
Credit: Exp Anim / C. Milhaud, et al., 1969

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Monkeypox: Geographic distribution

▪ Since 2016, human monkeypox has

been confirmed in
▪ the Central African Republic,
▪ the Democratic Republic of the
Congo
▪ Liberia
▪ Nigeria
▪ the Republic of the Congo
▪ Sierra Leone.

▪ In 2018-19, cases were confirmed

among travelers from Nigeria in
▪ Israel
▪ Singapore
▪ the United Kingdom

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 Monkeypox : Animal-to-human transmission

▪ Human infection has occurred from handling

infected animals: giant poached rats, rope
squirrels, and monkeys.
▪ Infection results from direct contact with the blood,
bodily fluids, or external lesions of infected animals.
▪ Eating inadequately cooked meat of infected
animals is a possible risk factor.
▪ For most human infections, the source is not
known.
Credit: 123rf

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 Animal species in Africa found to host monkeypox virus
Gambian pouched rat Dwarf dormouse Sun squirrel
Cricetomys gambianus
Graphiurus murinus * Heliosciurus sp.*
*

Rope squirrel Colobus monkey Sooty mangabey

Funisciurus sp.* Colobus sp. ** Cercocebus atys **

* Credit: The Centers for Disease Control

and Prevention (CDC), USA
** Credit: 123rf
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Monkeypox transmission: Human-to-human

▪Human-to-human transmission results from close contact

with infected respiratory droplets, skin lesions, or
contaminated objects.
▪Based on currently available information, cases have
mainly but not exclusively been identified amongst men
who have sex with men (MSM) seeking care in primary
care and sexual health clinics.
▪Health care workers and household members of
active cases are at higher risk of infection.
▪As human-to-human transmission is limited, most
outbreaks consist of only a few cases within families.

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 Monkeypox: Incubation period

▪The interval from infection to onset of

symptoms is usually 6 to 13 days, but
can range from 5 to 21 days.

WHO/ M. V. Szczeniowski

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 Monkeypox: Disease course

▪ The infection progresses in two phases:

▪ the invasion period (0-5 days)

characterized by fever, headache,
lymphadenopathy (swelling of the lymph
nodes), back pain, myalgia (muscle aches),
and fatigue; and

▪ A characteristicrash appearing in stages

1-3 days after the onset of fever, beginning Credit: Nigeria Centre for Disease Control

on the face and spreading to the trunk and

limbs.

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 Monkeypox: An evolving rash

▪ The rash lesions evolve from macules (lesions with

a flat base) to papules (raised firm lesions) to
vesicles (filled with clear fluid) to pustules (filled
with yellowish fluid), followed by crusts

▪ The rash affects

▪ the face in 95% of cases,
▪ the palms and soles of the feet (75%),
▪ oral mucous membranes (70%),
▪ genitalia (30%),
▪ the conjunctivae and cornea (20%).
Credit: CDC/ B. W. J. Mahy

▪ It may take three weeks for crusts to disappear.

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 Monkeypox: Extent and duration of illness

▪ Lesions range from a few to several thousand and

are often painful.

▪ Severe lymphadenopathy (swollen lymph nodes)

is a distinctive feature of monkeypox generally
develops before the rash.

▪ Monkeypox usually lasts 3 to 4 weeks.

Swollen lymph nodes

▪ Severe illness occurs more commonly in Credit: CDC/ B. W. J. Mahy

children.

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 Monkeypox: Differential diagnosis

▪ Monkeypox can resemble other infectious illnesses

with fever and rash, such as:
▪ varicella (chickenpox)
▪ measles
▪ smallpox (now eradicated).
▪ Other conditions to ruled out:
▪ bacterial skin infections, scabies, syphilis and
medication allergies
▪ Early considerations include other febrile illnesses
▪ Laboratory confirmation is necessary to make a
WHO/ M. V. Szczeniowski
definitive diagnosis.

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 Monkeypox: Clinical features
Symptoms Monkeypox Chickenpox Measles

Fever Fever > 38 °C Rash Fever to 39 °C Rash High fever to 40.5 °C,
after 1-3 days after 0-2 days Rash after 2-4 days
Rash Macules, papules, Macules, papules, Non-vesicular rash in
appearance vesicles, pustules vesicles, present in different stages
present at the same several stages
stage on any area
Rash Slow, 3-4 weeks Rapid, appear in crops Rapid, 5-7 days
development over several days
Rash Starts on head; more Starts on head; more Starts on head and
distribution dense on face and dense on body; absent spreads; may reach
limbs; appears on on palms and soles hands and feet
palms and soles
Classic Lymphadenopathy Itchy rash Koplik spots

feature
Death Up to 11% Rare Varies widely

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 Monkeypox: Laboratory diagnosis

▪ Monkeypox can be confirmed in the laboratory.

▪ The best specimens are from lesions (fluid, roof and crust).

▪ The virus can be best identified with nucleic acid tests by PCR.
Antigen and antibody detection methods are not specific

▪ Specimens from persons and animals should be handled by

trained staff, wearing personal protective equipment and working
in suitably equipped laboratories.
Credit: Am. J. Trop. Med. Hyg. /
McCollum, 2017

▪ Procedures for safe storage and transport of samples must be

followed.
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Diagnostic tests – overview

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 Nucleic acid detection: PCR

▪ Polymerase chain reaction (PCR) is the

technique most commonly used to
confirm monkeypox.

▪ Tests conducted on lesion

material
▪ Small amount of DNA is
enough
▪ Detects monkeypox virus +
identifies the viral clade Credit: WHO / WHO Eduardo Soteras Jalil

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Monkeypox: Infection prevention and control

▪ Health care workers caring for patients or handling

specimens must take standard, contact and droplet
precautions:
▪ wash hands before and after caring for a patient, touching

surroundings or handling specimens

▪ wear appropriate personal protective equipment including

gowns, gloves, masks, goggles and boots

▪ ensure isolation of the patient in hospital or at home

▪ ensure proper waste disposal and environmental

decontamination
▪ ensure safe and dignified burial.

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Monkeypox: Reducing human-to-human transmission

▪ Any person in contact with or taking care of a person

with monkeypox should:

▪ avoid close contact

▪ wear gloves and other protective equipment
▪ always wash hands before and after caring for or
visiting sick persons.

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 Monkeypox: Prevention and treatment

▪ Case management is based on

symptom-specific, supportive care.
▪ First generation vaccinia vaccines used to
prevent smallpox also largely protected
vaccinees from monkeypox.
▪ In 2019, a newer vaccinia vaccine for
smallpox was also approved for prevention of
monkeypox in adults.
▪ Further vaccination and treatment studies are
underway.

WHO/ M. V. Szczeniowski

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 Monkeypox: Elements of patient care

▪ Fever and pain management

▪ Skin, eye and mouth care
▪ Respiratory care
▪ Hydration and nutritional support
▪ Mental health support
▪ Prevention & treatment of complications
▪ Infection prevention and control

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 Skin care

Rash may lead to severe or permanent

skin damage and fluid loss
Rash and skin care:
▪ avoid touching or scratching lesions
▪ gentle washing
▪ keep clean and dry
▪ protect and hydrate with moist dressings
▪ gentian violet or nystatin cream
Credit P.K. Mbala. L’Institut National de Recherche Biomédicale. DRC
▪ topical or oral antibiotics as needed
Source: Pocket book of hospital care for children (2013) ▪ treat inguinal or genital ulcers with a warm
https://apps.who.int/iris/handle/10665/81170
saline sitz bath.

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 Mouth care

Mouth sores can be painful

▪ wash mouth with warm clean salted
water
▪ for severe ulcers, consider gentian violet or
antibiotics
▪ Vitamin C and other multivitamins
Credit Andrea McCollum CDC

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 Eye care

Eyes may develop infection or ulcers

▪ vitamin A supplements
Credit D.Ogoina. Nigerian Centre for ▪ protective eye pads
DIsease Control
▪ topical or oral antibiotics in combination
▪ tetracycline eye drops / ointment
▪ do not use steroid ointment or drops

Source: Improving the Care and Treatment of

Monkeypox Patients in Low-Resource ,
Settings: Applying Evidence from
Contemporary Biomedical and Smallpox Credit P.K. Mbala. L’Institut National de
Biodefense Research Recherche Biomédicale. DRC

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 Respiratory care

▪ Bronchopneumonia may occur in up to one in

ten cases
▪ There can be tissue damage throughout the
lungs or consolidation in just one area, with or
without a bacterial infection
▪ Supportive treatment
▪ pulmonary hygiene and physiotherapy
▪ supplementary oxygen
▪ empirical treatment with antibiotics
▪ bronchodilator medication
▪ ventilation support
X-ray of bronchopneumonia: multifocal lung consolidationbilaterally
Franquet, Tomás; Chung, Johnathan H. (2019). "Imaging of Pulmonary Infection”

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 Rehydration therapy and nutritional support

Ensure patients eat and drink

▪ liquids: water, soups, teas, oral rehydration
solution
▪ intravenous fluids if needed

Treat conditions affecting nutrition

(mouth sores, vomiting, diarrhea)
Consideration for young patients
▪ oral vitamin A
▪ breast feeding, breast milk or infant
formula according to the situation
▪ caregiver precautions, masks, hygiene
Retrieved from: 123rf

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 Mental health and social support

Provide psychological support

▪ psychologist
▪ social worker or
▪ specially trained nurse

Offer non-intrusive practical help to:

▪ calm patient and family
▪ keep them informed
▪ what to know, what to expect
Retrieved from: 123rf
▪ how to care for themselves
▪ how to take precautions

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 Complications of monkeypox
Eye Lesions
The course of illness depends
Fever

on a person’s overall health

status
Mouth & Throat
Sores
Lymphadenopath
y Complications
▪ Bacterial infection of eyes or skin
Abscess
▪ Diarrhea and vomiting leading to dehydration
Pneumonia Vomiting & Diahrrea
▪ airway obstruction
▪ Bronchopneumonia
▪ Encephalitis (<1%), sepsis (<1%)

Danger signs
Skin
Compromise Sepsis ▪ loss of vision
▪ delirium, loss of consciousness, convulsions
▪ respiratory distress
▪ bleeding, inability to produce urine
Source: Improving the Care and Treatment of Monkeypox Patients in Low-Resource , Settings: ▪ signs of sepsis
Applying Evidence from Contemporary Biomedical and Smallpox Biodefense Research
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Monkeypox: Surveillance

▪ Countries at risk should include monkeypox in their

integrated disease surveillance and response system
▪ The goal is to detect and immediately respond to any
suspected case of monkeypox
▪ Develop case definitions: e.g. a suspected case may be
▪ an acute illness with fever > 38 °C, intense headache, lymphadenopathy**,
back pain, myalgia, and intense fatigue followed one to three days later by a
progressively developing rash on the face and spreading to the body, palms
of hands and soles of feet.
▪ Safely collect patient information and lesion samples
from every suspected case for laboratory testing.

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 Steps to take if you suspect monkeypox

1 2 4
3
Confirm the Convene a
Report to Develop a case
authorities outbreak multidisciplinary definition
team

5 6 7 8
Identify all Describe and Conduct special Communicate
cases analyze data studies results

4
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Monkeypox: Outbreak response

▪ Each suspected or confirmed case of monkeypox

requires immediate response.
▪ Report all case information to health authorities.
▪ Initiate outbreak coordination.
▪ Put in place laboratory confirmation, contact tracing, active
search, rumour tracking, and enhance surveillance.
▪ Initiate community education and risk communication.
▪ Institute infection prevention and control measures in all
situations.

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Monkeypox: Prevention

Focus health education on measures to reduce exposure:

▪ understand the risk of handling or consuming wild
animals and avoid contact.
▪ wear gloves and other protective clothing to handle or
slaughter animals.
▪ avoid close contact with patients during human
monkeypox outbreaks.

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 Monkeypox: Implications for global preparedness
and disease control

▪ WHO and partners are working to improve

understanding and control of monkeypox
▪ One Health approach
▪ Early detection and diagnostics:
▪ clinical knowledge;
▪ laboratory capacity.
▪ Better capacity for disease control:
▪ coordinating global expertise
▪ vaccines and treatments.

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Monkeypox: Key messages

▪Monkeypox is an emerging disease

▪Monkeypox can be seen in endemic
countries or anywhere in the world
▪Report any suspected case
▪Take all precautions to prevent
spread

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 References :

• Monkeypox - WHO | World Health Organization

• Wikipedia

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THANK YOU

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THANK YOU

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