Monkey pox disease: world's new problem

This is the slide I had presented in to my teachers while I was on 1st year residency.

1. MONKEY POX DISEASE Presented by: Sunil Timilsina 1 st year Resident General Practice and Emergency Medicine NAIHS

2. Contents Introduction History Transmission Incubation Period Clinical Picture Case definitions Complications Differential diagnosis Patient Management Prognosis Prevention 6/2/2022 12:35:32 AM 2

3. Introduction a viral zoonotic infection caused by Monkey Pox virus of Orthopox genus of Poxviridae family. Endemic in central and western parts of Africa. Illness similar to that of smallpox but less lethal. was first isolated in the late 1950s from a colony of sick monkeys. 6/2/2022 12:35:32 AM 3

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5. History Isolation in lab sick monkyes in Copenhagen, Denmark 1958 A 9 month old child got infected in DRC (Index case) 1971 59 cases encountered 1971-1980 100 cases in West and Central Africa 1996-1998 71 cases in 6 states of USA 2003 2017 Outbreak in Nigeria Cases seen in UK ( 2019/2021 ), Israel, Singapore July 2021 Cases seen in Dallas, Texas in persons who had recent travel to Nigeria May 2022 Endemic in USA,UK, Canada, Europe, Australia, Singapore (500 cases till May 31) 2018 6/2/2022 12:35:32 AM 5

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10. Transmission Animal-to-human transmission Human-to-human transmission Fomite-to-human transmission 6/2/2022 12:35:32 AM 10

11. Incubation Period 6 to 13 days but can range from 5 to 21 days. Depends upon type of exposure World Health Organization. Multi-country monkeypox outbreak in non-endemic countries. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385 (Accessed on June 01, 2022). 6/2/2022 12:35:32 AM 11

12. Clinical Picture 6/2/2022 12:35:32 AM 12

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14. Ref: Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox , and risk factors for severe disease. Clin Infect Dis 2005; 41:1742. 6/2/2022 12:35:32 AM 14

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16. Complications Secondary bacterial infection of lesions Dehydration Pneumonia Encephalitis Septicemia 6/2/2022 12:35:32 AM 16

17. Complications Ocular infections Corneal Ulceration and scarring Permanent visual loss Miscarriage Pitted scarring ( most common chronic sequeale ) 6/2/2022 12:35:32 AM 17

18. Diagnostics Tools Virus culture/Isolation Real time PCR Electron Microscopy Immunohistochemistry Anti- Orthopox virus IgG and IgM assays Tetracore Orthopox Biothreat alert 18 6/2/2022 12:35:32 AM

19. Epidemiological criteria Within 21 days of illness onset ( any one of the following): H /o contact with person who have similar appearing rash or received diagnosis of confirmed or probable monkey pox. A man having regular close or intimate in-person contact with other men. H/o recent travel to country with confirmed cases of monkeypox and meets criteria 1 and 2 H/o travel to monkeypox endemic country. H/o contact with dead or live wildlife animal or exotic pet that is an African endemic species or used a product derived from such animals. 6/2/2022 12:35:32 AM 19

20. Clinical criteria New Rash Fever(any one) Other signs and symptoms Macular Subjective Chills and/or sweats Papular Measured temperature of ≥100.4 F (>38 C) New lymphadenopathy Vesicular Pustular Generalized or Localized Discrete or Confluent 6/2/2022 12:35:32 AM 20

21. Laboratory criteria Detection of orthopox virus DNA by PCR test of a specimen. Detection of orthopox virus by Immunohistochemistry or Electron microscopy. Isolation of monkey pox virus in culture from a clinical specimen. Demonstration of detectable levels of anti- orthopox virus IgM Ab 4 to 56 days after rash. 6/2/2022 12:35:32 AM 21

22. Case Definations – CDC 2022 Possible case Meets one of epidemiological criteria AND clinical criteria Probable case Meets one of epidemiological criteria AND Has new rash with or without fever AND Has at least one other sign or symptom AND Has detectable levels of anti- orthopox IgM Ab during the period of 4 to 56 days Confirmed case Meets possible case definition AND Monkey pox virus DNA detected by PCR testing OR virus isolated in a culture from clinical specimen 6/2/2022 12:35:32 AM 22

23. Differential Diagnosis Characteristics Variola Monkeypox Varicella Incubation period 7-17 days 6-13 days 10 -21 days Prodormal period 1-4 days 1-4 days 0-2 days Rash period 14-28 days 14-28 days 10-21 days Prodormal fever Yes Yes Uncommon Fever Often > 40 C Often between 38.5-40 .5 C Upto 38.8 C Lymphadenopathy No Yes No Lesions on palm and soles Yes Yes Rare Lesion Appearance Hard and deep, well-circumscribed, umbilicated Hard and deep, well-circumscribed, umbilicated Superficial, irregular borders, “dew drop on a rose petal” 6/2/2022 12:35:32 AM 23

24. Patient Management Mild cases: Supportive care Serious cases: ADEQUATE HYDRATION is must Antivirals: Tecovirimat Cidofovir Brincidofovir 6/2/2022 12:35:32 AM 24

25. Antivirals Indications: Immunocompromised patients Younger than eight years of age Pregnant or breastfeeding women Patients with complications of the infection Infection in traditionally atypical sites ( eg , mouth, eyes, genital area)  United States Centers for Diseae Control and Prevention. Interim clinical guidance for the treatment of monkeypox . https://www.cdc.gov/poxvirus/monkeypox/treatment.html (Accessed on June 01, 2022). 6/2/2022 12:35:32 AM 25

26. Agents Drugs Mechanism Of Action Clinical considerations Adverse reactions Tecovirimat inhibitor of an orthopoxvirus protein required for the formation of an infectious virus particle that is essential for dissemination within an infected host. Causes Nephrotoxicity Headache, Tachycardia, GI distress Cidofovir Inhibits DNA polymerase Intravenous administration with hydration and probenecid Nephrotoxicity, Neutropenia, Ocular Hypotonia , GI distress Brincidofovir Analouge of Cidofovir . MOA similar Liver enzymes to be monitored. Not considered or stopped if AST, ALT increases 5x of upper normal limit 6/2/2022 12:35:32 AM 26

27. Adult Child IV Oral IV Oral 35 to< 120 kg: 200mg 12 hrly 600 mg 12 hourly 3 to <35kg: 6mg/kg/dose every- 12 hours 13 to <25kg : 200mg every 12 hourly ≥ 120 kg: 300mg 12 hly 600 mg 8 hourly 35 to < 120 kg: 200mg every 12 hours 25 to <40kg: 400mg every 12 hourly ≥ 120 kg: 300 mg every 12 hours 40 to <120kg: 600 mg every 12 hrly ≥ 120kg : 600 mg every 8 hourly Tecovirimat : Dosing (total duration: 14 days) 6/2/2022 12:35:32 AM 27

28. CIDOFOVIR: Dosing IV 5mg/kg/dose over 1 hour once weekly for 3 weeks then, 5mg/kg/dose every 2 weeks for 3 doses. Topical 1% gel once daily for 5 days. Observe for 10 days Can be repeated upto 6 cycles. 6/2/2022 12:35:32 AM 28

29. Prognosis In Central Africa, the fatality rate is approximately 10 percent and deaths generally occur in the second week of illness. no deaths in the outbreak in the United States in 2003. Nalca A, Rimoin AW, Bavari S, Whitehouse CA. Reemergence of monkeypox : prevalence, diagnostics, and countermeasures . Clin Infect Dis 2005; 41:1765. 6/2/2022 12:35:32 AM 29

30. Prevention Tier 1 Policy making Awareness programmes Media Strategies Tier 2 Orientation to HCWs Screening Helpline/hotlines Tier 3 Vaccination Immunoglobulin Follow up care and access 6/2/2022 12:35:32 AM 30

31. Vaccination Prior smallpox vaccination with vaccinia virus has a significant protective effect against acquisition of monkeypox virus and may ameliorate the clinical manifestations of this infection. Lowers diseases occurrence by five times. a modified vaccinia Ankara (MVA) vaccine (sold under the trade names Imvamune and Jynneos )  Hammarlund E, Lewis MW, Carter SV, et al. Multiple diagnostic techniques identify previously vaccinated individuals with protective immunity against monkeypox . Nat Med 2005; 11:1005. 6/2/2022 12:35:32 AM 31

32. Post exposure Vaccination Risk Group Description Post exposure vaccination No risk No known contact with a symptomatic monkey pox case OR Lab staff handling specimens from a monkeypox case patient following standard precautions Not recommended Low risk HCW involved in care of monkeypox case patient with appropriate PPE OR HCW involved in care of monkeypox case patient without wearing PPE for all contact episodes but nit within 1m and with no direct contact with body fluids OR Community contact not within 1m Not recommended 6/2/2022 12:35:32 AM 32

33. Post exposure Vaccination Risk Group Description Post exposure vaccination Intermediate Intact skin-only contact with a symptomatic monkeypox case patient, their body fluids, or potentially infectious material or contaminated fomite. OR No direct contact within 1m of symptomatic monkeypox case patient without wearing appropriate PPE May be considered High Direct exposure of broken skin or mucous membrane to symptomatic case patient, body fluids or fomites without wearing proper PPE Recommended 6/2/2022 12:35:32 AM 33

34. optimal time for monkeypox postexposure vaccination is within four days ; can be considered for up to 14 days of a close contact exposure. Dose: 0.5ml Administration: 2 doses; 4 weeks interval Post exposure Vaccination 6/2/2022 12:35:32 AM 34

35. Immunoglobulin considered in immunosuppressed patients with an exposure history, since immunization with vaccinia virus vaccine is contraindicated. Dose: 6000U/kg IV and can be repeated based on severity of symptoms and response to treatment. 6/2/2022 12:35:32 AM 35

36. THANK YOU 6/2/2022 12:35:32 AM 36