Insights into the emergence and evolution of monkeypox virus:Historical perspectives,epidemiology,genetic diversity,transmission,and preventative measures

In 2022,just before the COVID-19 pandemic ended,many countries noticed a viral monkeypox outbreak.Monkeypox virus,a zoonotic pathogen,causes a febrile illness in humans and resembles smallpox.Prevention strategies encompass vaccination,strict infection control measures,and avoiding contact with infected persons.As monkeypox and related poxviruses continue to pose challenges,ongoing surveillance,early diagnosis,prompt isolation,and effective control measures are crucial for limiting transmission and mitigating the impact of outbreaks on public health.This review provides valuable insights into the evolution of the monkeypox virus and its various modes of transmission,including postmortem transmission,and offers an overall perspective on the guidelines issued by the Government of India to prevent and effectively control the spread of this disease.

Assessing healthcare workers’knowledge and confidence in the diagnosis,management and prevention of Monkeypox

BACKGROUND Monkeypox(Mpox),is a disease of global public health concern,as it does not affect only countries in western and central Africa.AIM To assess Burundi healthcare workers(HCWs)s’level of knowledge and confidence in the diagnosis and management of Mpox.METHODS We conducted a cross-sectional study via an online survey designed mainly from the World Health Organization course distributed among Burundi HCWs from June-July 2023.The questionnaire comprises 8 socioprofessional-related questions,22 questions about Mpox disease knowledge,and 3 questions to assess confidence in Mpox diagnosis and management.The data were analyzed via SPSS software version 25.0.A P value<0.05 was considered to indicate statistical significance.RESULTS The study sample comprised 471 HCWs who were mainly medical doctors(63.9%)and nurses(30.1%).None of the 22 questions concerning Mpox knowledge had at least 50%correct responses.A very low number of HCWs(17.4%)knew that Mpox has a vaccine.The confidence level to diagnose(21.20%),treat(18.00%)or prevent(23.30%)Mpox was low among HCWs.The confidence level in the diagnosis of Mpox was associated with the HCWs’age(P value=0.009),sex(P value<0.001),work experience(P value=0.002),and residence(P value<0.001).The confidence level to treat Mpox was significantly associated with the HCWs’age(P value=0.050),sex(P value<0.001),education(P value=0.033)and occupation(P value=0.005).The confidence level to prevent Mpox was associated with the HCWs’education(P value<0.001),work experience(P value=0.002),residence(P value<0.001)and type of work institution(P value=0.003).CONCLUSION This study revealed that HCWs have the lowest level of knowledge regarding Mpox and a lack of confidence in the ability to diagnose,treat or prevent it.There is an urgent need to organize continuing medical education programs on Mpox epidemiology and preparedness for Burundi HCWs.We encourage future researchers to assess potential hesitancy toward Mpox vaccination and its associated factors.

Weighing in on monkeypox against the criteria of public health emergency

The monkeypox,a viral zoonotic disease usually found in forest areas of Central and Western Africa,has spread worldwide through new modes of transmission little understood.The WHO on 23 July 2022,declared the virus a Public Health Emergency of International Concern(PHEIC).The declaration has stirred criticism from leading scientists that the criteria for PHEIC as defined by International Health Regulation have not been met and it is non-transparent and contradictory.This paper reviews the criteria of PHEIC and weighs the rationales behind the declaration to increase the clarity of the WHO's decision,justifications,and legitimacy in the ongoing outbreak.

Monkeypox outbreak: a novel threat after COVID-19?

Dear Editor,Monkeypox is a zoonosis caused by monkeypox virus (MPXV)infection first reported in Central and West Africa[1]. The first outbreak of monkeypox outside of Africa was reported in2003[2].Afterthat,Israel,theUnitedKingdom(UK),Singapore, and other countries have reported monkeypox cases among travelers back from Nigeria since 2018[3].

Introduction of monkeypox virus in Benin,2022

Dear Editor,Monkeypox is an infectious disease that is endemic in a dozen of African countries.Some imported cases have been also reported outside of Africa in the past[1].Since early May 2022,monkeypox infections including human-to-human transmission,were reported in a multi-country outbreak in non-endemic countries and declared Public Health Emergency of International Concern(PHEIC)by the World Health Organization(WHO)in July 2022[2].As of 20 September 2022,a total of at least 62,798 human cases of monkeypox with 20 deaths have been confirmed in 115 countries in five WHO regions[3].

Emergency department approach to monkeypox

BACKGROUND:Monkeypox(mpox) is a viral infection that is primarily endemic to countries in Africa,but large outbreaks outside of Africa have been historically rare.In June 2022,mpox began to spread across Europe and North America,causing the World Health Organization(WHO) to declare mpox a public health emergency of international concern.This article aims to review clinical presentation,diagnosis,and prevention and treatment strategies on mpox,providing the basic knowledge for prevention and control for emergency providers.METHODS:We conducted a review of the literature using PubMed and SCOPUS databases from their beginnings to the end of July 2023.The inclusion criteria were studies on adult patients focusing on emerging infections that described an approach to a public health emergency of international concern,systematic reviews,clinical guidelines,and retrospective studies.Studies that were not published in English were excluded.RESULTS:We included 50 studies in this review.The initial symptoms of mpox are non-specific:fever,malaise,myalgias,and sore throat.Rash,a common presentation of mpox,usually occurs 2–4 weeks after the prodrome,but the presence of lymphadenopathy may distinguish mpox from other infections from the Poxviridae family.Life-threatening complications such as pneumonia,sepsis,encephalitis,myocarditis,and death can occur.There are documented co-occurrences of human immunodeficiency virus(HIV) and other sexually transmitted infections that can worsen morbidity.CONCLUSION:The initial presentation of mpox is non-specific.The preferred treatment included tecovirimat in patients with severe illness or at high risk of developing severe disease and vaccination with two doses of JYNNEOS.However,careful history and physical examination can raise the clinicians’ suspicion and point toward a prompt diagnosis.There are diff erent modalities to prevent and treat mpox infection.

An unfolding monkeypox outbreak in Europe and beyond

Dear Editor,Monkeypox is a zoonotic disease caused by the monkeypox virus(MPXV),a double-stranded DNA virus in the genus Orthopoxvirus,family Poxviridae.MPXV is known to be transmitted between animals such as rats and squirrels,but animal-to-human and human-to-human transmission has been known in Africa since 1970.Transmission is linked to direct contact with body fluids,skin lesions,and patient items as well as respiratory droplets in case of prolonged face-to-face contact[1].Until recently,only a few cases were associated with travel to endemic countries or contact with infected animals imported from endemic countries.

Severe Monkeypox Infection in a Patient with AIDS: An Illustrative Case Report

The Monkeypox (Mpox) virus (MPXV) is endemic in Africa, and cases outside West and Central Africa were previously considered rare. However, around May 2022, outbreaks of multiple cases were reported worldwide including the USA thus presenting a new public health emergency. We present a case report of MPXV infection in a 49-year-old gay male with AIDS who was admitted for management of severe perianal cellulitis. Three days into hospitalization, he developed pustules over the genitals and scattered lesions over the face, trunk and extremities. PCR testing from a pustule was positive for MPXV. He was initiated on tecovirimat as well as antiretroviral therapy. There was a worsening of his rash over the first three days of therapy, followed by a gradual but complete resolution of all the skin lesions. The perianal and gluteal lesions were the most persistent and took more than two months to resolve. A primary contact source of infection was never identified. The differential diagnoses for cutaneous lesions of MPXV infection are also discussed.

Monkeypox presenting as a chancre-like rash:A case report

BACKGROUND Since May 2022,outbreaks of monkeypox have occurred in many countries around the world,and several cases have been reported in China.CASE SUMMARY A 38-year-old man presented with a small,painless,shallow ulcer on the coronary groove for 8 d.One day after the rash appeared,the patient developed inguinal lymphadenopathy with fever.The patient had a history of male-male sexual activity and denied a recent history of travel abroad.Monkeypox virus was detected by quantitative polymerase chain reaction from the rash site and throat swab.Based on the epidemiological history,clinical manifestations and nucleic acid test results,the patient was diagnosed with monkeypox.CONCLUSION Monkeypox is an emerging infectious disease in China.Monkeypox presenting as a chancre-like rash is easily misdiagnosed.Diagnosis can be made based on exposure history,clinical manifestations and nucleic acid test results.

Monkeypox outbreak in the age of COVID‑19:a new global health emergency

Dear Editor,The World Health Organization recently declared monkeypox as a global emergency after reporting more than 57,000 new cases worldwide[1].Monkeypox is an orthopoxvirus similar in nature to the Variola virus,which is a causative agent for smallpox[2].Monkeypox virus presents as a unique challenge for global health and should be regarded with grave concern as the vast majority of cases are occurring in countries where the disease is not considered endemic.Furthermore,the spread of this pathogen is occurring concomitantly as the world is still engaged in a battle with the coronavirus disease 2019(COVID-19)pandemic,which has caused substantial damage to global healthcare infrastructure.If monkeypox continues its rapid spread,hospitals could be quickly overwhelmed by both COVID-19 and monkeypox cases.Now more than ever,early symptom recognition and use of all available treatments to contain monkeypox outbreaks are vital.Early precautions including early recognition of symptoms by physicians,use of currently available treatments,and promoting precautionary measures in at-risk populations may be vital in preventing hospital burden and further physician burnout.

Inequity in the global distribution of monkeypox vaccines

Monkeypox(mpox)has been a public health emergency of international concern that emerged in mid-2022 and has spread to 110 countries.The clinical findings of the disease vary according to the seriousness of the cases.Although its case fatality risk has not been high,a significant percentage of patients require hospitalization.In this context,local initiatives were taken to extend the limited supply of vaccines against the disease;however,such measures have not been sufficient to contain the spread of cases and ensure an equitable distribution of health resources.As a result,endemic regions of low-income countries continue to have insufficient access to mpox vaccination.Despite this and considering the global scope of the disease,there is still little discussion in the literature about the difficulties in achieving adequate vaccination coverage rates for the target population of interest.In this article,we briefly discussed general aspects of the disease,including its surveillance,the current global context of challenges for mpox vaccination,and issues on global allocation of health resources as well as proposed related recommendations.

Monkeypox in humans:Transmission,pathophysiology,diagnosis,treatment,prevention,and all recent updates

The Centers for Disease Control and Prevention(CDC)is monitoring an epidemic of monkeypox infection in the United States.The outbreak is now global and more than 6900 cases have already been reported.There are 83 confirmed cases among children and adolescents,as shown in the report published on November 3,2022,in the USA.However,monkeypox in pediatric patients is still infrequent(<0.3%of total cases).Among cases in the United States,16 cases were in children<5 years,12 in the age group 5-12 years,and 55 cases in adolescents 13-17 years old.In the adolescent age group,89%were male.For children<12 years of age,close physical contact with an adult household with monkeypox was the primary exposure,but for adolescents,male-to-male sexual contact was found more frequently.The CDC advised United States healthcare providers to remain vigilant for patients with a rash resembling monkeypox,even if there is no history of travel to a country with high risk.This article summarizes the history and epidemiology of monkeypox with a specific emphasis on clinical features and management in pediatric patients.

Near obstructing painful anorectal mass and facial rash in a man with monkeypox: A case report

BACKGROUND Monkeypox(MPX)is a zoonotic infection that is endemic in Western and Central Africa along the Congo River basin.It has a high case fatality rate especially in younger age groups.It belongs to the virus family orthopoxvirus like smallpox.It is transmitted from wild animals to humans but human to human transmission has been established.It is often a self-limited infection in endemic regions.Recently,attention has been given to MPX with the spread of infection to Europe and the United States of America(USA).There is currently sporadic infection of MPX in the USA especially amongst men who have sex with men(MSM).It is a serious life-threatening infection in human immunodeficiency virus/acquired immunodeficiency syndrome co-infected individuals especially those who are treatment naïve with severe immunosuppression.CASE SUMMARY We report a 38-year old man who presented with rectal pain,and anal,torso,and facial rash.Abdominal computed tomography scan showed a near obstructive rectal mass with peri-anal fistula.MPX was positive.He was started on tecovirimat(TPOXX)and HAART therapy.Additional treatment provided included vaccinia immunoglobulin following his clinical deterioration.CONCLUSION This case highlights a rare presentation of MPX with peri-anal fistula and near obstructive rectal mass,and the significance of MPX as a differential diagnosis in proctitis in MSM in addition to other sexually transmitted infection like gonorrhea and chlamydia.

云南省首例女性感染猴痘病例的发现与调查处置

目的对云南省昆明市1例女性感染猴痘病例进行调查处置,为全国预防控制猴痘疫情,特别是女性感染猴痘疫情的早期发现和调查处置提供科学依据。方法按照《猴痘诊疗指南(2022版)》对病例进行诊断,依据《猴痘防控方案(2023版)》开展流行病学调查分析和处置,采集相关标本开展实验室检测。结果经流行病学调查,患者发病前与新婚丈夫发生过1次性行为,其丈夫向其隐瞒男男同性恋史及男男性行为史;该女子及其丈夫实验室检测结果为“猴痘病毒核酸阳性”;该女子及其丈夫均出现典型出疹等临床症状。结论结合流行病学调查、临床症状表现及实验室检测结果,及既往云南省猴痘疫情材料,确认该女子为云南省首例女性感染猴痘病例,可疑暴露为早于其发病的男性配偶。

七例猴痘临床特征分析

对上海市浦东新区人民医院2023年7~12月收治的7例猴痘患者临床症状及实验室检查等资料进行分析。7例患者皮疹部位和咽拭子标本猴痘病毒核酸检测阳性。7例猴痘患者均为MSM人群,年龄26~41岁;发病前21天内均有男男性行为史;6例患者首发部位为阴阜或生殖器区域,1例患者首发部位为口周及肛周;6例出现发热;6例伴有其他性传播疾病;病例发现方式均为主动就诊。

艾滋病合并猴痘临床病理分析

本文分析了近期确诊的3例艾滋病合并猴痘患者临床表现和皮损组织学特征。3例患者均为青年男性,生殖器周围皮疹为首发表现,后扩散至全身,2例伴发热、1例有腹股沟淋巴结肿大,外周血HIV抗体阳性。咽拭子、皮疹拭子及肛拭子等标本猴痘病毒PCR检测均阳性;活检皮肤病理组织学表现一致:局部表皮全层及真皮浅层碎屑状坏死,坏死周围表皮细胞水肿及气球样变、多量中性粒细胞浸润伴核尘,表皮细胞胞质见嗜酸性小体,真皮层多量淋巴细胞、中性及嗜酸性粒细胞浸润。

江苏省23例猴痘病例病毒基因组特征分析

目的分析2023年6月至9月江苏省23例猴痘病例病毒全基因组序列并研究其分子进化特征。方法收集猴痘病例口咽拭子、痘疱液、痘疱渗出物拭子等样本,以实时定量PCR进行病毒核酸检测,利用扩增子测序技术捕获猴痘样本中病毒全基因组,通过MiniSeq高通量测序仪进行二代测序,对序列进行病毒进化和变异分析。结果23份样本的平均测序深度907.30×~11578.58×,基因组覆盖度(测序深度≥10×)95.50%~99.94%。系统发育分析显示,病毒均属于MPXVⅡb C.1(2023)谱系,与来自同时期日本、韩国、葡萄牙和中国的序列同属一个分支,并分布于3个聚类簇中。单核苷酸多态性(single nucleotide polymorphism,SNPs)分析共发现60个SNPs,包含59处碱基替换和1处碱基缺失,其中非同义突变26个,分别影响宿主免疫调控、膜蛋白和病毒转录调控功能。26个非同义突变中有25个SNPs为载脂蛋白B mRNA编辑催化多肽样(APOBEC3-like)突变,且23份样本中的6个共享突变均为APOBEC3-like突变。样本23010与23011只有C177833T一个突变位点的区别,且C76450T和G80405A位点均只在这两个样本中出现。结论江苏省2023年6月至9月23例猴痘病毒均为Ⅱb进化分支C.1(2023)谱系,病毒来源为多个源头输入,应持续开展猴痘病毒全基因组监测和研究,密切关注病毒来源和在本地传播后的变异进化方式。

北京市海淀区猴痘疫情流行病学特征分析

采用描述性流行病学方法分析2023年6月10日至2024年4月30日海淀区猴痘确诊病例的流行病学和临床特征等资料,以了解北京市海淀区猴痘病例流行特征。共分析20例猴痘病例,均为男性,85.0%(17/20)为男男性行为人群(men who have sex with men,MSM)。年龄M(Q1,Q3)为28(26.5,32.5)岁。临床特征以皮疹(95.0%,19/20)、发热(65.0%,13/20)、淋巴结肿大(35.0%,7/20)为主,皮疹多发于生殖器及肛周(65.0%,13/20)。合并HIV感染者和合并梅毒者各3例(15.0%,3/20)。报告病例医院主要为传染病医院(84.21%,16/19),报告科室主要为皮肤科(57.89%,11/19)和发热门诊(36.84%,7/19)。7条猴痘病毒(monkeypox virus,MPXV)序列均属于猴痘病毒西非型IIb分支,C.1家系。海淀区猴痘病例呈散发传播,MSM人群为高危人群。

猴痘病毒实时荧光LAMP检测方法的建立

为建立一种特异性强、灵敏度高、操作简单的猴痘病毒(Monkeypox virus, MPXV)检测方法,试验针对MPXV保守区OPG002基因片段设计特异性引物,通过优化环介导等温扩增技术(loop-mediated isothermal amplification, LAMP)反应体系中内引物、环引物体积及反应温度建立了一种MPXV实时荧光LAMP检测方法,对该方法的特异性和灵敏度进行了分析,并应用该方法检测了临床样品和模拟样品。结果表明:建立的MPXV实时荧光LAMP检测方法于64℃恒温反应60 min即可完成DNA检测;该方法能特异性地检出MPXV,最低检出限为25 copies/μL,灵敏度是普通PCR方法的20倍;该方法对12份临床样品的检测结果均为阴性,可检测出质粒浓度为0.5×10~2~0.5×10~6 copies/μL的模拟阳性样品。说明建立的MPXV荧光LAMP检测方法具有特异性强、灵敏度高、操作简单的优点,可用于MPXV的快速鉴别诊断。

核酸检测试剂cobas MPX v2.0降低输血HBV残余风险的评估

目的评估新一代核酸检测试剂cobas Taq Screen MPX Test,v2.0(MPX v2.0)应用于献血者血液HBV筛查中降低输血残余风险的效果。方法对5 165例血清学无反应性标本以6人份混样模式,分别采用试剂MPX v2.0与MPX v1.0(对照)做平行核酸检测;对2种(代)试剂检出的反应性标本进行追踪。以CAP/CTM核酸定量检测系统做核酸鉴别试验、电化学发光法做乙肝血清学5项检测、QPCR法测定HBV载量、巢氏-PCR法做HBV基因分型。结果 MPX v2.0与MPX v1.0的拆分阳性率分别为66.7%(10/15)vs 75.0%(9/12)。2种试剂共检出14例HBV DNA反应性标本,核酸鉴别试验结果均为HBV DNA反应性;2种试剂阳性符合数(率)为5/9个(55.60%),阴性符合数(率)为5 151/5 156个(99.90%),总符合率为99.83%(5 156/5 165)(P>0.05)。随访3个月时有5例MPX v1.0HBV DNA反应性,7例MPX v2.0HBV DNA反应性;MPX v2.0与MPX v1.0追踪检测的HBV DNA结果与初次检测结果阳性符合率分别为75.00%(6/8)vs 50.00%(3/6)。结论 MPX v2.0核酸联合检测试剂较上一代试剂可有效降低HBV输血残余风险,适合血液筛查。