Management strategies for common viral infections in pediatric renal transplant recipients

Viral infections have been considered as a major cause of morbidity and mortality after kidney transplantation in pediatric cohort.Children are at high risk of acquiring virus-related complications due to immunological immaturity and the enhanced alloreactivity risk that led to maintenance of high immunosuppressive regimes.Hence,prevention,early detection,and prompt treatment of such infections are of paramount importance.Among all viral infections,herpes viruses(herpes simplex virus,varicella zoster virus,Epstein-Barr virus,cytomegalovirus),hepatitis B and C viruses,BK polyomavirus,and respiratory viruses(respiratory syncytial virus,parainfluenza virus,influenza virus and adenovirus)are common in kidney transplant recipients.These viruses can cause systemic disease or allograft dysfunction affecting the clinical outcome.Recent advances in technology and antiviral therapy have improved management strategies in screening,monitoring,adoption of prophylactic or preemptive therapy and precise treatment in the immunocompromised host,with significant impact on the outcome.This review discusses the etiology,screening and monitoring,diagnosis,prevention,and treatment of common viral infections in pediatric renal transplant recipients.

Monocyte and macrophage function in respiratory viral infections

Pulmonary macrophages,such as tissue-resident alveolar and interstitial macrophages and recruited monocyte-derived macrophages,are the major macrophages present in the lungs during homeostasis and diseased conditions.While tissue-resident macrophages act as sentinels of the alveolar space and play an important role in maintaining homeostasis and immune regulation,recruited macrophages accumulate in the respiratory tract after acute viral infections.Despite sharing similar anatomical niches,these macrophages are distinct in terms of their origins,surface marker expression,and transcriptional profiles,which impart macrophages with distinguished characteristics in physi-ological and pathophysiological conditions.In this review,we summarize the current view on these macrophage populations,their shared functions,and what makes them distinct from each other in the context of homeostasis andrespiratoryviral infections.

Stem cell-like memory T cells:Role in viral infections and autoimmunity

Stem cell-like memory T(TSCM)cells possess stem cell properties including multipotency and self-renewal and are being recognized as emerging players in various human diseases.Advanced technologies such as multiparametric flowcytometry and single cell sequencing have enabled their identification and molecular characterization.In case of chronic viral diseases such as human immunodeficiency virus-1,CD4+T_(SCM) cells,serve as major reservoirs of the latent virus.However,during immune activation and functional exhaustion of effector T cells,these cells also possess the potential to replenish the pool of functional effector cells to curtail the infection.More recently,these cells are speculated to play important role in protective immunity following acute viral infections such as coronavirus disease 2019 and might be amenable for therapeutics by ex vivo expansion.Similarly,studies are also investigating their pathological role in driving autoimmune responses.However,there are several gaps in the understanding of the role of T_(SCM) cells in viral and autoimmune diseases to make them potential therapeutic targets.In this minireview,we have attempted an updated compilation of the dyadic role of these complex T_(SCM) cells during such human diseases along with their biology and transcriptional programs.

Viral infections in inflammatory bowel disease:Tips and tricks for correct management

Over the past decades,the treatment of inflammatory bowel diseases(IBD)has become more targeted,anticipating the use of immune-modifying therapies at an earlier stage.This top-down approach has been correlated with favorable short and long-term outcomes,but it has also brought with it concerns regarding potential infectious complications.This large IBD population treated with immunemodifying therapies,especially if combined,has an increased risk of severe infections,including opportunistic infections that are sustained by viral,bacterial,parasitic,and fungal agents.Viral infections have emerged as a focal safety concern in patients with IBD,representing a challenge for the clinician:they are often difficult to diagnose and are associated with significant morbidity and mortality.The first step is to improve effective preventive strategies,such as applying vaccination protocols,adopt adequate prophylaxis and educate patients about potential risk factors.Since viral infections in immunosuppressed patients may present atypical signs and symptoms,the challenges for the gastroenterologist are to suspect,recognize and diagnose such complications.Appropriate treatment of common viral infections allows us to minimize their impact on disease outcomes and patients’lives.This practical review supports this standard of care to improve knowledge in this subject area.

Renal cell carcinoma and viral infections:A dangerous relationship?

Virus-related cancers in humans are widely recognized,but in the case of renal cancer,the link with the world of viruses is not clearly established in humans,despite being known in animal biology.In the present review,we aimed to explore the literature on renal cell carcinoma(RCC)for a possible role of viruses in human RCC tumorigenesis and immune homeostasis,hypothesizing the contribution of viruses to the immunogenicity of this tumor.A scientific literature search was conducted using the PubMed,Web of Science,and Google Scholar databases with the keywords“virus”or“viruses”or“viral infection”matched with(“AND”)“renal cell carcinoma”or“kidney cancer”or“renal cancer”or“renal carcinoma”or“renal tumor”or“RCC”.The retrieved findings evidenced two main aspects testifying to the relationship between RCC and viruses:The presence of viruses within the tumor,especially in non-clear cell RCC cases,and RCC occurrence in cases with pre-existing chronic viral infections.Some retrieved translational and clinical data suggest the possible contribution of viruses,particularly Epstein-Barr virus,to the marked immunogenicity of sarcomatoid RCC.In addition,it was revealed the possible role of endogenous retrovirus reactivation in RCC oncogenesis,introducing new fascinating hypotheses about this tumor’s immunogenicity and likeliness of response to immune checkpoint inhibitors.

Changes in Phyto-Chemical Status upon Viral Infections in Plant:A Critical Review

Most damaging plant diseases have been caused by viruses in the entire world.In tropical and subtropical areas,the damage caused by plant virus leads to great economic and agricultural losses.Single stranded DNA viruses(geminiviruses)are the most perilous pathogens which are responsible for major diseases in agronomic and horticultural crops.Significantly begomoviruses and mastreviruses are the biggest genus of plant infecting viruses,transmitted though Bemisia tabaci and members of Cicadellidae respectively.Plants possesses some naturally existing chemicals term as phyto-chemicals which perform important functions in the plant.Some antioxidant enzymes are used by plants for selfdefense upon foreign invasion of infection.This review explains the present perceptive of influence of viral infections on phyto-chemicals,oxidative enzymes and biochemical changes occurring in the plant.Viral infection mediated phytochemical changes in plants mainly includes:up and down regulation of photosynthetic pigment,increase in the concentration of phenolic compounds,elevation of starch content in the leaf and up&down regulation of anti-oxidative enzymes including(GPX)guaiacol peroxidase,(PPO)polyphenol oxidase,(APX)ascorbate peroxidase,(SOD)superoxide dismutase and(CTA)catalase.These changes lead to initiation of hypersensitive response,by thicken of the leaf lamina,lignification under the leaf surface,blocking to stomatal openings,systematic cell death,generation of reactive oxidative species(ROS),activation of pathogen mediated resistance pathways i.e.,production of salicylic acid and jasmonic acid.Collectively all the physiological changes in the plant due to viral infection supports the activation of defense mechanism of the plant to combat against viral infection by limiting virus in specific area,followed with the production of barriers for pathogen,accumulation of starch in the leaf and excess production of(ROS).These strategies used by the plant to prevent the spread of virus in whole plant and to minimize the risk of severe yield loss.

Viral infections in orthopedics: A systematic review and classification proposal

BACKGROUND Although the impact of microbial infections on orthopedic clinical outcomes is well recognized,the influence of viral infections on the musculoskeletal system might have been underestimated.AIM To systematically review the available evidence on risk factors and musculoskeletal manifestations following viral infections and to propose a pertinent classification scheme.METHODS We searched MEDLINE,Cochrane Central Register of Controlled Trials(CENTRAL),the Reference Citation Analysis(RCA),and Scopus for completed studies published before January 30,2021,to evaluate risk factors and bone and joint manifestations of viral infection in animal models and patient registries.Quality assessment was performed using SYRCLE's risk of bias tool for animal studies,Moga score for case series,Wylde score for registry studies,and Newcastle-Ottawa Scale for case-control studies.RESULTS Six human and four animal studies were eligible for inclusion in the qualitative synthesis.Hepatitis C virus was implicated in several peri-and post-operative complications in patients without cirrhosis after major orthopedic surgery.Herpes virus may affect the integrity of lumbar discs,whereas Ross River and Chikungunya viruses provoke viral arthritis and bone loss.CONCLUSION Evidence of moderate strength suggested that viruses can cause moderate to severe arthritis and osteitis.Risk factors such as pre-existing rheumatologic disease contributed to higher disease severity and duration of symptoms.Therefore,based on our literature search,the proposed clinical and pathogenetic classification scheme is as follows:(1)Viral infections of bone or joint;(2)Active bone and joint inflammatory diseases secondary to viral infections in other organs or tissues;and(3)Viral infection as a risk factor for post-surgical bacterial infection.

Protein-based biomaterials for combating viral infections:Current status and future prospects for development

The outbreak of viral infections are serious threat to human life and health.However,there remains to be a lack of effective treatments and prophylactic measures against some viral infections.Additionally,there are numerous challenges in developing vaccines and antiviral drugs(e.g.,antibodies and protein inhibitors),such as low immunogenicity of vaccines,difficulties in storing vaccines,instability and easy degradation of protein drugs,and lack of drug selectivity.Protein-based biomaterials can interact with antiviral drugs or vaccines to achieve synergistic or enhanced effects,making them a promising antiviral tool with many advantages.Silk fibroin has the potential to stabilize liquid vaccines at room temperature.Elastin-like polypeptide modification can improve the stability and yield of virus-neutralizing antibodies.Drugs in combination withβ-casein or serum albumin(SA)has good prospects in treating human immunodeficiency virus(HIV)infections.Moreover,the greatest value of SA as a protein-based antiviral material lies in its ability to target the liver and macrophages.In the future,combination with SA(direct conjugation or encapsulation with drugs)may be a better treatment strategy for viral hepatitis and HIV infections because it leads to fewer adverse reactions.In addition,selfassembling protein nanoparticles(SApNPs)are found to improve vaccine immunogenicity.The combination of multiple viral immunogens and multiple SApNPs produces different promising vaccine candidates,thus highlighting the value of SApNPs.This review aimed to discuss the current status and future prospects for the development of protein-based biomaterials to combat viral infections.

Exosomes in viral infection:Effects for pathogenesis and treatment strategies

Exosomes are small vesicles that carry molecules from one cell to another.They have many features that make them interesting for research,such as their stability,low immunogenicity,size of the nanoscale,toxicity,and selective delivery.Exosomes can also interact with viruses in diverse ways.Emerging research highlights the significant role of exosomes in viral infections,particularly in the context of diseases like COVID-19,HIV,HBV and HCV.Understanding the intricate interplay between exosomes and the human immune system holds great promise for the development of effective antiviral therapies.An important aspect is gaining clarity on how exosomes influence the immune system and enhance viral infectivity through their inherent characteristics.By leveraging the innate properties of exosomes,viruses exploit the machinery involved in exosome biogenesis to set replication,facilitate the spread of infection,and eliminate immune responses.They can either help or hinder viral infection by modulating the immune system.This review summarizes the recent findings on how exosomes mediate viral infection and how they can be used for diagnosis or therapy.This could lead to new clinical applications of exosomes in disease management.

Effects of viral infection and microbial diversity on patients with sepsis:A retrospective study based on metagenomic next-generation sequencing

BACKGROUND: The study aims to investigate the performance of a metagenomic next-generationsequencing (NGS)-based diagnostic technique for the identifi cation of potential bacterial and viral infectionsand eff ects of concomitant viral infection on the survival rate of intensive care unit (ICU) sepsis patients.METHODS: A total of 74 ICU patients with sepsis who were admitted to our institution from February1, 2018 to June 30, 2019 were enrolled. Separate blood samples were collected from patients for bloodcultures and metagenomic NGS when the patients’ body temperature was higher than 38 °C. Patients’demographic data, including gender, age, ICU duration, ICU scores, and laboratory results, were recorded.The correlations between pathogen types and sepsis severity and survival rate were evaluated.RESULTS: NGS produced higher positive results (105 of 118;88.98%) than blood cultures(18 of 118;15.25%) over the whole study period. Concomitant viral infection correlated closelywith sepsis severity and had the negative effect on the survival of patients with sepsis. However,correlation analysis indicated that the bacterial variety did not correlate with the severity of sepsis.CONCLUSIONS: Concurrent viral load correlates closely with the severity of sepsis and thesurvival rate of the ICU sepsis patients. This suggests that prophylactic administration of antiviraldrugs combined with antibiotics may be benefi cial to ICU sepsis patients.

Harnessing immunity:Immunomodulatory therapies in COVID-19

An overly exuberant immune response,characterized by a cytokine storm and uncontrolled inflammation,has been identified as a significant driver of severe coronavirus disease 2019(COVID-19)cases.Consequently,deciphering the intricacies of immune dysregulation in COVID-19 is imperative to identify specific targets for intervention and modulation.With these delicate dynamics in mind,immunomodulatory therapies have emerged as a promising avenue for miti-gating the challenges posed by COVID-19.Precision in manipulating immune pathways presents an opportunity to alter the host response,optimizing antiviral defenses while curbing deleterious inflammation.This review article compre-hensively analyzes immunomodulatory interventions in managing COVID-19.We explore diverse approaches to mitigating the hyperactive immune response and its impact,from corticosteroids and non-steroidal drugs to targeted biologics,including anti-viral drugs,cytokine inhibitors,JAK inhibitors,convalescent plasma,monoclonal antibodies(mAbs)to severe acute respiratory syndrome coronavirus 2,cell-based therapies(i.e.,CAR T,etc.).By summarizing the current evidence,we aim to provide a clear roadmap for clinicians and researchers navigating the complex landscape of immunomodulation in COVID-19 treatment.CS Glucocorticoids are among the most widely prescribed drugs with their immune-suppressive and anti-inflammatory effect[84].The current guidelines for the treatment of COVID-19 recommend against the use of dexamethasone or other systemic CS in non-hospitalized patients in the absence of another indication[70].The RECOVERY trial demonstrates the reduced 28-d mortality among hospitalized patients with COVID-19 using dexamethasone compared to the usual standard of care,along with other investigators,such as Ahmed and Hassan[85].The benefit of dexamethasone was seen only among participants receiving either oxygen alone or invasive mechanical ventilation at randomization but not among those receiving no respiratory support at enrollment[85].In a systematic review and meta-analysis,Albuquerque et al[86]showed that in comparison to tocilizumab,baricitinib,and sarilumab are associated with high probabilities of similar mortality reductions among hospitalized COVID-19 concurrently treated with CS.As a result of the absence of SARS-CoV-2-specific antiviral medications,the effectiveness of COVID-19 treatments is reduced.Several COVID-19 therapies are now under investigation.However,the majority of them lack specificity,efficacy,and safety[87].Immunotherapy is a ground-breaking medical treatment that manipulates the immune system to fight diseases.Translational research is rapidly progressing,recognized as a significant breakthrough in 2013[88].Among the immunotherapeutic options for treating COVID-19 are Immunoglobulin,CP,antibodies,mAbs(mAbs),NK cells,T cells,TLR,cytokine therapies and immune modulators.

Fertility Care Provided by a Public Health Hospital to Viral-Infected Couples: A Case-Control Study

Objective: To evaluate the results of ART (clinical pregnancies and baby home rates) in couples infected with HBV, HCV, HIV or mixed in a Referral center. Patients: The study is a retrospective case-control study comprising 1587 cycles/1064 couples in the control group and 237 cycles/164 couples in the infected group, submitted to in vitro fertilization, intracytoplasmic sperm injection and embryo transfer. Two branches from the infected group were created: the HIV subgroup, comprising couples with one or both partners infected with HIV-1 (84 cycles/67 couples), and the HCV subgroup, including at least one partner infected with HCV (45 cycles/29 couples). Results: The infected group presented higher infertility duration (P < 0.001) and so did the HCV subgroup (P < 0.001). Tubal infertility was increased in the infected group (P < 0.001), and in the HIV (P < 0.001) and HCV (P = 0.01) subgroups. Oocytes and oocytes in metaphase II numbers were lower in the infected group, but not in the HIV and HCV subgroups. Clinical pregnancy rate was lower in the infected group (25.74%) when compared to the control (34.66%), probably due to the contribution of HCV individuals (17.78%), but not of HIV (28.57%). Baby home rate was lower in the infected group (21.52%) relative to the control group (28.42%), but no differences were found in the HIV (27.38%) and HCV (15.56%) subgroups. Conclusions: Despite the low clinical pregnancy rate in the HCV subgroup, baby home rates did not change from control. These data seem promising for couples with viral infections who wish to conceive.

Molecular mechanisms of viral hepatitis induced hepatocellular carcinoma

Chronic infection with viral hepatitis affects half a billion individuals worldwide and can lead to cirrhosis,cancer,and liver failure.Liver cancer is the third leading cause of cancer-associated mortality,of which hepatocellular carcinoma(HCC)represents 90%of all primary liver cancers.Solid tumors like HCC are complex and have heterogeneous tumor genomic profiles contributing to complexity in diagnosis and management.Chronic infection with hepatitis B virus(HBV),hepatitis delta virus(HDV),and hepatitis C virus(HCV)are the greatest etiological risk factors for HCC.Due to the significant role of chronic viral infection in HCC development,it is important to investigate direct(viral associated)and indirect(immune-associated)mechanisms involved in the pathogenesis of HCC.Common mechanisms used by HBV,HCV,and HDV that drive hepatocarcinogenesis include persistent liver inflammation with an impaired antiviral immune response,immune and viral protein-mediated oxidative stress,and deregulation of cellular signaling pathways by viral proteins.DNA integration to promote genome instability is a feature of HBV infection,and metabolic reprogramming leading to steatosis is driven by HCV infection.The current review aims to provide a brief overview of HBV,HCV and HDV molecular biology,and highlight specific viral-associated oncogenic mechanisms and common molecular pathways deregulated in HCC,and current as well as emerging treatments for HCC.

COVID-19 Pandemic, Part I: What to Do and Who to Blame? Susceptibility to Viral Infection via Jeopardized Immunity

When this tragedy ends, it will become clear whether it is a pandemic, epidemic, mass infection, or mass psychosis (initiated by mass media with heavy engagement from political and economic establishments). The USA and other countries are raining accusations upon China, and vice versa. This problem will have future impacts on human society and civilization will be quite different following the “Pandemic of COVID-19”. Although this series of papers will discuss a broad array of related problems, the author contends that the most important priorities are developing medications against diseases and improving our scientific understanding of the social situations and substances that jeopardize human health and increase our susceptibility to viral infection. Later papers in this series will provide support for the Chinese claim that chloroquine may be a useful medication for patients with viral infection.

Comparison on Serum Levels of Procalcitonin of Children with Viral and Bacterial Infection

Objective To compare and analyze serum levels of procalcitonin (PCT) of children with viral and bacterial infection and probe into the importance of determining the level of serum PCT in the diagnosis of bacterial infection in order to provide evidences of the clinical use of antibiotics. Methods A total of 85 cases of children with an average age of 8.9 years (10 months-12 years) were enrolled in this study, 53 cases were with viral infection and 32 cases with bacterial infection. We determined serum levels of PCT by semi-quantitative solid phase immunoassay, and the serum levels of PCT were divided into four grades as<0.5μg/L,≥ 0.5μg/L,≥2.0μg/L and≥10μg/L forχ2 test and Ridit analysis. Results The serum level of PCT of the group with bacterial infection were signiifcantly higher than that of the group with viral infection (P<0.001). The sensitivity of diagnosis of bacterial infection in children with determination of serum levels of PCT was 87.50%while the speciifcity was 92.13%, and positive predictive value was 73.68%while negative predictive value was 91.49%, and positive likelihood ratio was 4.65 while negative likelihood ratio was 0.15, and the diagnostic accuracy was 83.53%. Conclusions Serum PCT is a bacterial sensitive marker of bacterial infection in children, and the determination of the level of serum PCT is helpful for the diagnosis of bacterial infection, which can also be a basis for the use of antibiotics.

Cell Signaling in Viral and Oncogenic Pathogenesis and Its Implications in Disease Diagnosis and Prognosis

Both viral diseases and cancer account for a large proportion of serious health problems. Viral infection and cancer are biologically and medically correlated and in many ways share common cellular pathways that lead to disease development or progression. Better understanding how these signaling events are specifically activated by different pathogenic stimuli and how they activate different downstream transcriptions in response to these stimuli at high specificity and efficiency will provide a new molecular basis for the development of novel disease biomarkers and therapeutic or preventive targets against both classes of diseases. Research in our laboratory has been prompted to investigate the regulation and modes of action of these pathways, with a more intensive focus on the NF-κB signaling, in the settings of severe or oncogenic viral infection as well as cancer development. It is hoped that our research will lead to eventual clinical application of biomarkers derived from these signaling pathways.

A novel real-time RT-PCR with TaqM an-MGB probes and its application in detecting BVDV infections in dairy farms

A real-time RT-PCR assay using Taq Man-MGB probes was developed to detect and type the bovine viral diarrhea virus（BVDV） in cattle.Universal primers and Taq Man-MGB probes were designed from the 5′-untranslated region of known pestiviral sequences.Prior to optimizing the assay, c RNAs were transcribed in vitro from the BVDV 1 and BVDV 2 RTPCR products to make standard curves.The detection limit of the assay was 1.72×102 copies for BVDV 1 and 2.14×102copies for BVDV 2.The specificity of the assay evaluated on several BVDV strains including bovine herpesvirus 1（BHV 1）, foot and mouth disease virus（FMDV） and several classical swine fever virus（CSFV） strains showed specific detection of the positive virus over 40 cycles.The assay was highly reproducible with the coefficient of variance ranging from 1.04 to 1.33% for BVDV 1 and from 0.83 to 1.48% for BVDV 2, respectively.Using this method, we tested a total of 2 327 cattle from three dairy farms for the presence of BVDV persistently infected（PI） animals.In this assay, each RT-PCR template contained a mixture of ten samples from different animals.The occurrence rate of PI cattle in three farms ranging from 0.9 to 2.54% could represent partly the PI rates in cattle farm in China.In conclusion, using our real-time PCR assay, we could effectively detect and type BVDV and identify PI cattle in a rapid and cost-effective manner.

Air Pollutants and Viral Transmission

Viral infection,especially respiratory viral infection(RVI),is currently one of the infectious diseases with the highest mortality,and the hospital admissions of viral infection rises every year particularly in the developing coumtries.Researchers currently suspect that there is a certain correlation between leveis of air pollution and the ease of viral transmission.In most cases,the hospital admissions of airborne diseases show a positive correlation with the level of air pollutant in that area.Several reasonable explanations for this association have been given based on observations.but none of these theories has yet been well justified,and more researches have to be done.The aim of this article is to discuss the correlation between level of alr pollution and the ease of viral transmission,the possible causes of thisassociation,including the physical fraits of air pollutant trapping viruses,and the reduced amount of virus-killing rays insunlight due to air pollution,to offer possible solutions to lower incidence rate of viral infections.and to attract more attentions on exploring this correlation.

STUDY OF PERSISTENT VIRAL INFECTION IN AN ANIMAL MODEL OF VIRAL MYOCARDITIS BY PCR

Objective To study the role of persistent viral infection in the mechanism of viral myocarditis. Methods A mice model of CVB3m viral myocarditis wes made and the viral RNA in mice myocardium and whole bind sample wes tested by using polymerase chain reaction (PCR ) technique. The pathological changes in mice myocardium were determined. Results De day 3, the viral gene in whole bind and myocardium wes found, which portly became negative on day 8, but the change of myocardial anthology borne obvious. Although the bind specimens wers tested negatively on day 12, the viral gene in mice myocardium remained positive within 120d. Conclusion This study indicates that persistent viral infection plays a role in the pathogenesis of viral myocarditis.

Knowledge and awareness of human mpox infection among healthcare workers:A cross-sectional study in southwestern Nigeria

Objective:To identify the knowledge and awareness level of human mpox viral infection among healthcare workers in southwestern Nigeria.Methods:A cross-sectional study was conducted in Ekiti State,southwest Nigeria among 316 healthcare workers that were selected through a systematic random sampling.Data were collected with the aid of a semi-structured,self-administered questionnaire.The Chi-square test and binary logistic regression were used to find the association between the independent and dependent variables.The significance level was set at P-value<0.05.Results:Two hundred and twenty-two(70.3%)of the respondents were aged≤40 years,mean age(36±9)years,189(59.8%)were female,306(96.8%)were Christians,and 203(64.2%)were married.Three hundred and fourteen(99.4%)of the respondents were aware of mpox infection.Main sources of information about mpox were medical education(44.0%),radio/television(32.0%)and newspaper(21.0%).However,among those aware of the disease,209(67.0%)demonstrated poor knowledge levels.Longer than 5 years’experience of medical practice was the only significant predictor of higher knowledge level of the disease(OR 1.76,95%CI 1.01-3.06;P=0.046).Conclusions:Despite the high awareness level of mpox infection among healthcare workers,there still exists a huge knowledge gap.It is recommended that targeted intervention could be directed towards continuous medical education and simulation exercises on re-emerging infectious diseases like mpox to improve the knowledge of the healthcare workers.