Monkey pox latest updates 2024 description

Monkey pox

1. Mpox (Monkeypox) 4 th September 2024 1

2. Introduction Mpox is a viral zoonotic disease caused by DNA Monkeypox virus (MPXV) belongs to Orthopoxvirus genus. Mpox was first discovered in 1958 in colonies of monkeys kept for research, hence the name ‘monkeypox.’ It was first identified in humans in 1970 in the Democratic Republic of the Congo. In 2003, the first Mpox outbreak outside Africa was reported in USA and was linked to contact with infected pet prairie dogs . 2

3. Introduction Clade I Congo Basin Clade -more virulent and transmissible Responsible for 2024 epidemic (Clade I b). Clade II West African Clade responsible for 2022 upsurge (clade II b) 3

4. Introduction WHO declares PHEIC twice - 23rd July 2022 (clade II b) - 14 th August 2024 (clade I b) 4

5. Global distribution of confirmed Mpox cases 5

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7. 7 Global distribution of confirmed mpox cases 01 Jan 2022 – 2 nd September 2024

8. The Epicentre (Source: African and US CDC) 8 There are several outbreaks happening at the same time in DRC , with cases reported throughout the country, in the capital city of Kinshasa, and in some other large cities. In some provinces, patients have acquired infection through contact with infected dead or live wild animals, household transmission, or patient care (transmitted when appropriate PPE wasn’t used or available) A high proportion of cases have been reported in children younger than 15 years of age. In other provinces, the cases are associated with sexual contact among men who have sex with men and female sex workers and their contacts. These are first reported cases of sexual transmission with clade I mpox.

9. Timeline of Important events 9 May,2022 MoHFW released guidelines on management of Monkey pox disease 14 th July, 2022 25 th July, 2022 2 nd August,2022 01 st June, 2022 1 st case reported in Kerala, India NCDC PHEOC activated First case reported from a non-endemic country 23 rd July, 2022 WHO declared PHEIC NCDC issued CD Alert on Monkey pox 28 th Nov., 2022 WHO recommended using the word mpox 10 th May ,2023 WHO revoked the PHEIC status 14 th Aug, 2024 WHO declares mpox as a PHEIC once again.

10. Mpox in India The first case of Mpox was reported in Kollam, Kerala on 14 th July 2022 . On 27 th March 2024 , the last case was reported from Kerala . Total 30 laboratory confirmed cases were reported from Kerala (15 cases) and Delhi (15 cases ). The cases belonged to age range 22-48 years, affecting 18 males and 12 females. Deaths- 1 case in Kerala 10 Source: IDSP, NCDC

11. Epidemiology AGENT enveloped double stranded DNA virus two distinct genetic clades of the Mpox virus Clade I Congo Basin Clade -more virulent and transmissible clade I a & Ib Responsible for 2024 epidemic (Clade I b). Clade II - West African Clade clade II a & II b responsible for 2022 upsurge (clade II b) 11

12. Epidemiology Host Natural reservoir : yet unknown. certain rodents and non-human primates . Incubation period : 6 to 13 days but can range from 5 to 21 days currently recommended to monitor patients up to 21 days . Period of communicability: 1-2 days before the rash to until all the scabs fall off/get subsided. 12

13. Mode of transmission Person to Person From animals to humans From humans to animals: 13

14. Transmission –human to human Direct transmission : large respiratory droplets ( prolonged close contact with infected person). ⁠ Close contact - face-to-face skin-to-skin mouth-to-mouth mouth-to-skin contact Indirect transmission -contaminated clothing or linens of an infected person. Vertical transmission. ⁠ live monkeypox virus has been isolated from semen 14

15. Transmission - From animals to humans bite or scratch of infected rodents (rats, squirrels) and non-human primates (monkeys, apes) . bush meat preparation ( activities such as hunting, skinning, trapping, or cooking not thoroughly). Close contact with a infected pet ( petting, cuddling, hugging, kissing, licking, and sharing sleeping spaces or food ) . 15

16. Transmission - From humans to animals There have been a few reports of the monkeypox virus being identified in pet dogs. However, it is not confirmed whether these were true infections, or whether the detection of virus was related to surface contamination 16

17. Clinical Course 17

18. Prodrome (0 – 5 days): Fever Headache, muscle aches, Body ache, Malaise Lymphadenopathy (key sign that differentiates monkeypox from chickenpox) chills and/or sweats Sore throat & Cough Rash: 1 – 3 days of fever onset, lasting 2 – 4 weeks Lesions, often painful, predominate on the face but may develop on the palms, soles and dorsal hand & feet Genital & Perigenital lesions have been conspicuous in recent 2022 outbreak. Signs & Symptoms 18

19. The prodrome followed by an enanthem in the form of oral ulcers on tongue and buccal mucosa. (symptomatic and compromise oral intake) Followed by an exanthem within 24 hours. The hallmark of monkeypox is a disseminated vesico-pustular rash. Dermatological manifestations Typical lesions of monkeypox present on the genital area in a male patient The lesions crust over a period of 7 days 19

20. The skin lesions start as macules, progressing to papules, vesicles, and pustules over a period of 3–6 days. The pustules commonly develop central umbilication and heal with scab formation, which falls off in 7–14 days, leaving behind hypopigmented or hyperpigmented pitted scars. The lesions are monomorphic, exhibiting a centrifugal distribution, with predilection for mucosae (oral and genital) and extremities (palms and soles). The number of lesions can vary from 10 to over 500 with size ranging from 0.5 to 2.5 cm. The lesions are initially painful, become pruritic once healing starts. In the current multicountry outbreak, atypical presentations of monkeypox are being described Dermatological manifestations 20

21. Dermatological Atypical manifestations 21

22. MONKEY POX IN CHILDREN 22

23. INTRODUCTION Why are we worried about Monkey Pox in children ? - Small pox - Orthopox virus family - Eradicated in 1980 - case fatality of 30% for small pox - case fatality 3-6% for monkey pox. - children prone for severe disease 23

24. AUGUST 2024 OUTBREAK CDC current mpox outbreak, cases of mpox in children and adolescents are infrequent (<0.01% of total cases) and disease not severe. Exposure to a household contact with mpox is the predominant route of exposure for children. Infants, children with eczema and other skin conditions, and children with immunocompromising conditions may be at increased risk of severe disease . 24

25. CLINICAL FEATURES Incubation period – 10 -12 days Prodromal phase – 1- 4 days F ever, B ody ache, F atigue, H eadache, Sore throat, L ymphadenopathy Rash 25

26. CLINICAL FEATURES Rash – number of lesions – 1-500 lesions The rash passes through macular, papular , vesicular, and then pustular phase, and lasts for 2–4 weeks. The rash appears first on the face and hands and legs and spreads inward. Private parts, palms, and soles are involved. Difficulty swallowing or cough – oropharyngeal lesions Intraocular lesions, eyelid swelling, or eyelid crusting -touches these sites with their hand after touching a lesion L esions are intensely painful till they crust when they become itchy. The lesions heal with scarring. 26

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28. COMPLICATIONS S econdary skin infections, Encephalitis, P neumonia, Ocular complications leading to blindness, S cars Pregnant women- abortions and stillbirth 28

29. DIFFERENTIAL DIAGNOSIS 29

30. DIFFERENTIAL DIAGNOSIS 30

31. DIAGNOSIS PCR on lesions, nasopharyngeal swab, blood, and urine. 31

32. TREATMENT Isolation > 2 yrs mask, caregivers also avoid contact, wear mask. Contact and droplet precautions have to be followed till all scabs have fallen off. K eep skin lesions covered and prevent children from scratching lesions or touching their eyes after touching lesions, which may result in auto-inoculation and more severe illness. An ophthalmologist should be consulted and a careful ocular exam performed. Optimal fluid intake should be encouraged. S upportive and symptomatic and includes fluids, antipyretics, and analgesia for pain. 32

33. TREATMENT Indications for Drugs and Biologicals: Severe disease, including disseminated rash, a large number of lesions that are confluent, hemorrhagic or necrotic lesions, severe lymphadenopathy Multisystem involvement. Immunocompromised Infants Tecovirimat (ST-246) approved in USA and Europe in children – oral/ IV both formulations. Vaccinia immunoglobulin (obtained from serum of people vaccinated for smallpox) - immunocompromised in conjunction with antivirals. Other antivirals – brincidofovir and cidofovir in severe cases. Topical trifluridine eye drops. 33

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43. Principles of Management  Patient isolation  Protection of compromised skin and mucous membranes  Rehydration therapy and Nutritional support  Symptom alleviation  Monitoring and treatment of complications 7.2 Patient Isolation  Isolation of the patient in an isolation room of the hospital/ at home in a separate room with separate ventilation  Patient to wear a triple layer mask  Skin lesions should be covered to the best extent possible (e.g. long sleeves, long pants) to minimize risk of contact with others  Isolation to be continued until all lesions have resolved and scabs have completely fallen off 43

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45. Monitoring and treatment of complications The patient should closely monitor for the appearance of any of the following symptoms during the period of isolation:  Pain in eye or blurring of vision  Shortness of breath, chest pain, difficulty in breathing  Altered consciousness, seizure  Decrease in urine output  Poor oral intake  Lethargy 45

46. Case definitions Suspected case: A person of any age having history of travel to affected countries within the last 21 days presenting with an unexplained acute rash AND one or more of the following signs or symptoms • Swollen lymph nodes • Fever • Headache • Body aches • profound weakness 46

47. Case definitions Probable case: A person meeting the case definition for a suspected case, clinically compatible illness and has an epidemiological link to a confirmed case. (Examples of epidemiological link include face-to-face exposure, including health care workers without appropriate PPE; direct physical contact with skin or skin lesions, including sexual contact; or contact with contaminated materials such as clothing, bedding or utensils). 47

48. Case definitions- Confirmed case: Any case which is laboratory confirmed for Mpox virus (by detection of unique sequences of viral DNA either by polymerase chain reaction (PCR) and/or sequencing ). 48

49. Prevention Contact Tracing Definition of a Contact: A contact is someone who, from the onset of a source case's symptoms until all scabs have fallen off , has had: Face-to-face exposure (including healthcare workers without proper PPE ) Direct physical contact, including sexual contact Contact with contaminated materials (e.g., clothing, bedding ) Contact Identification: Contacts should be identified across various settings such as household, workplace, school, sexual contacts, healthcare, religious gatherings, transportation, sports, social events, and any other recalled interactions. 49

50. Contact Monitoring: Monitor contacts daily for 21 days from their last exposure for any signs or symptoms . If fever develops, clinical or lab evaluation is required. Asymptomatic contacts should avoid donating blood, cells, tissue, organs, or semen during surveillance. Pre-school children may be excluded from group settings. Health workers with unprotected exposure do not need to be excluded from duty if asymptomatic but should undergo active symptom monitoring for 21 days. 50

51. Reducing Human-to-Human Transmission Key Strategy: Surveillance and rapid identification of new cases are crucial for containing outbreaks. Close contact with infected persons is the highest risk for transmission , especially for health workers and household members. Precautions for Health Workers: Implement standard infection control when caring for suspected or confirmed cases. Handle specimens with care in appropriately equipped labs. Ensure safe specimen transport with triple packaging as per WHO guidelines. 51

52. Infection Prevention and Control (IPC) Precautionary Measures: Apply a combination of standard, contact, and droplet precautions in all healthcare settings. Consider airborne precautions based on risk assessment due to the potential airborne transmission. Clinical Triage: Early recognition and immediate isolation of patients with fever and vesicular/pustular rash. Ensure source control by separating the patient from others . Family members, visitors, and healthcare workers should adhere to standard, contact, and droplet precautions. 52

53. Risk Communication Public Health Messaging: Provide clear advice on disease transmission, symptoms, prevention, and actions for suspected or confirmed infections. Use channels that effectively reach target audiences, particularly those most at risk. Collaborate with healthcare providers, including STD clinics, and civil society organizations. Community Engagement: Focus on populations at highest risk, ensuring inclusive and non-stigmatizing communication. Utilize social listening to monitor public sentiment and address rumors and misinformation promptly. Key Preventive Measures: Isolate infected individuals to prevent the spread. Avoid contact with contaminated materials (e.g., bedding). Practice good hand hygiene with soap and water or alcohol-based sanitizer. Use masks and gloves when caring for infected patients. 53

54. Management Rehydration therapy and Nutritional support. Monitoring and treatment of complications . Contact tracing: Daily for 21 days from the last contact. Identification of dedicated Isolation Facilities for patient management. Timely referral and end to end patient management including ambulance transfer. Treatment for smallpox may be used to prevent and treat monkey pox virus infections. Drugs: Tecovirimat Vaccinia Immune Globulin Intravenous (VIGIV) Cidofovir & Brincidofovir - effective against orthopoxviruses in  in vitro  and animal studies.  *Source: https://www.cdc.gov/poxvirus/mpox/clinicians/treatment.html 54

55. Vaccines Overview All current smallpox and mpox vaccines are based on Live Vaccinia Virus , an orthopoxvirus . First-Generation Vaccines : Developed during the 1950s-1970s smallpox eradication program . Used strains like New York City Board of Health (NYCBH) and Lister, cultivated on animal skins. Second-Generation Vaccines : Examples: ACAM2000 . Use the same strains as first-generation but produced in tissue culture cells . Free of adventitious agents and can be further attenuated. Both first- and second-generation vaccines are replication-competent. 55

56. Third-Generation Vaccines : Developed post-smallpox eradication, more attenuated for enhanced safety. Examples: LC16m8 : Minimally replicating , developed from the Lister strain (Japan). Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN): Non-replicating , with significant deletions in the viral genome. Fourth-Generation Vaccines : VacΔ6/ OrthopoxVac : Modified vaccinia virus with targeted deletion of virulence genes, that encodes virulence proteins. 56

57. MVA-BN Administration : 2-dose subcutaneous injection, 0.5 mL dose containing 1x10 8 PFU(plaque forming units), given 4 weeks apart. Alternative : In some regions, 0.1 mL intradermal dose used during the global mpox outbreak as a dose-sparing option . Storage : Frozen at -15 to -25°C or -45 to -55°C, or -75 to -85°C. Thawing : Use immediately after thawing, or store at 2-8°C for up to 4 weeks (if previously at -15°C to -25°C). Do not refreeze . 57

58. LC16m8 Administration : Single dose via scarification with a bifurcated needle. Preparation : Freeze-dried, multi-dose vials. Dissolve in 0.5 mL diluent before use. Storage : -35°C to -20°C for long-term ; 5°C for 2 years; 37°C for 4 weeks. Avoid sunlight. Post-reconstitution : Store at 2-6°C for 1 month or at room temperature (23-27°C) for 24 hours. 58

59. ACAM2000 Administration : Single dose via scarification with a bifurcated needle. Dose : Each vial contains approximately 100 doses (0.0025 mL per dose, 2.5-12.5x10 5 PFU per dose). Preparation : Lyophilized vaccine, reconstituted with 0.3 mL diluent. Use within 6-8 hours at room temperature. Storage : -5°C to -25°C in a freezer . 59

60. Vaccine protection Correlate of Protection : No definitive correlate of protection against MPXV infection has been established. Significance of orthopoxvirus and MPXV neutralizing antibodies in providing protection remains uncertain. MVA-BN Vaccine Study : Cohort: 999 health-care workers in an mpox-endemic region of the DRC-published in 2022 Findings: Strong orthopoxvirus -specific antibody response peaking 2 weeks post-second dose . Total orthopoxvirus -specific IgG and neutralizing antibody titres decline close to baseline by 2 years . 60

61. Breakthrough Infections : Global study from 9 countries reported 29 breakthrough mpox cases post-MVA-BN vaccination. Post-vaccination infections: Few lesions, minimal mucosal disease, and low analgesia requirements. Infections post vaccination/re-inf ection are usually mild and less severe. Duration of Immunity : Duration of immunity for ACAM2000 and LC16m8 vaccines against mpox has not been studied . 61

62. Local and Systemic Side-Effects of Vaccination Generally mild with current licensed vaccines . Rare but serious complications documented during the smallpox eradication phase with first-generation vaccines: Generalized vaccinia Eczema vaccinatum Progressive vaccinia (vaccinia necrosum ) Post- vaccinial encephalitis ( PvE ) Risk Analysis: PvE and Death : Highest risk in infants under 1 year: 6.8 PvE cases and 3 deaths per million vaccinations. Lower risk in primary vaccinees aged 1 year and older: 1.8-3.3 PvE cases and 0-1.2 deaths per million vaccinations. 62

63. Myopericarditis: Rarely diagnosed during smallpox eradication. Emerged with the re-introduction of Dryvax in 2002 among military personnel , healthcare workers, and first responders. Monitoring of myopericarditis emphasized with second and third-generation vaccines designed to be safer. 63