Just a short update to bring awareness to health care professionals of the monkeypox virus dilemma in 2022,and to inform professionals in Nigeria to be alert as to make diagnosis and inform appropriate authorities. Also, to alert of some of the impediments we face in the undeveloped world in measures against viral infections.

1. MONKEYPOX
BY
DR IRIKEFE IKIE
DEPARTMENT OF FAMILY MEDICINE
WUSE DISTRICT HOSPITAL
ABUJA

2. OUTLINE
• Introduction
• Epidemiology
• Etiology
• Pathophysiology
• Clinical features
• Differential diagnoses
• Workup
• Treatment
• Prognosis
• Prevention
• Current situation in Nigeria
• Conclusions

3. Introduction
• Monkeypox is a viral zoonosis(a virus transmitted to humans from
animals) with symptoms similar to those seen in the past in smallpox
patients,although it is clinically less severe. With the eradication of
smallpox in 1980 and subsequent cessation of smallpox
vaccination,monkeypox has emerged as the most important
orthopoxvirus for public health.
• Monkeypox primarily occurs in Central and West Africa,often in
proximity to tropical rainforests,and has been increasingly appearing
in urban areas.
• Animal hosts include a range of rodents and non-human primates.

4. Epidemiology
• This condition is rare and only known to be indigenous to the rainforests of
western and central Africa. It was first recognized in humans in 1970 after the
eradication of smallpox,possibly because of the subsequent unmasking of the
infection.
• Surveillance reports from 1981-1986 documented 338 cases in the Democratic
Republic of Congo(DRC) out of a 1982 estimated population of 5 million. In the
1996-1997 outbreak in the DRC,the attack rate was 22 cases per 1000 population.
• The 2022 outbreak involved 51 locations as of June 29,2022,and involved 5,115
confirmed cases.
• In Nigeria,from January 1st to 12th June 2022,there have been 141 suspected
cases in total and 36 confirmed cases from 15 states:
Lagos(7),Adamawa(5),Delta(3),River(3),Cross
River(2),FCT(2),Kano(2),Bayelsa(2),Edo(2),Imo(2),Plateau(2),Nassarawa(1),Niger(1
),Oyo(1),and Ondo(1). One death was recorded in a 40 year old man with co-
morbidity that was receiving immunosuppressive drugs.

5. Etiology
• Monkeypox virus is an enveloped double-stranded DNA virus that
belongs to the Orthopoxvirus genus of the Poxviridae family. There
are two distinct genetic clades of the monkeypox virus: the central
African(Congo Basin) clade and the west African clade. The Congo
Basin clade has historically caused more severe disease and was
thought to be more transmissible. The geographical division between
the two clades has so far been in Cameroon, the only country where
both virus clades have been found.

6. Pathophysiology
• It is a zoonotic virus with primary transmission believed to occur through
direct contact with infected animals or possibly by ingestion of their
inadequately cooked flesh. Inoculations may be from cutaneous or mucosal
lesions on the animal,especially when the sun barrier is compromised
secondary to bites,scratches,or other trauma. First seen in monkeys in
1958,but rodents are a major reservoir in Africa. People living near forests
may have subclinical infection.
• Human to human transmission disease transmission was found to be
possible route in the outbreak in the DRC in 1996-1997.
• Human-to-human transmission has been confirmed as a major factor in the
2022 outbreak in multiple area across the world. While many of the
patients are men who have sex with men,sexual transmission of
monkeypox has not been confirmed.

7. Clinical features
• Charasteristic rash preceded by prodromal symptoms(e.g
fever,lymphadenopathy,flu-like symptoms)
• Monkeypox in contrast to chickenpox gives enlarged lymph nodes
especially in the submental,submandibular,cervical,and inguinal regions.
• Non-specific lesions and inflammation of the pharyngeal,conjunctival,and
genital mucosae have been observed.
• UnlIke smallpox,skin lesions appear in crops.
• Usually no pain except in super-imposed bacterial infection.
• There may be pruritus.
• Men who have sex with men have shown have had perianal and genital
regions as the first sites of lesion appearance.

10. Differential diagnoses
Infectious
• Herpes simplex virus
• Syphilis
• Chancroid
• Lymphogranuloma venereum
• Granuloma inguinale
Non-infectious
• Recurrent apthous stomatitis
• Behcet’s disease
• Trauma
• Squamous cell carcinoma
• Drug induced

11. Differential diagnoses
Diffuse rash
• Varicella
• Disseminated herpes
• Molluscum contagiosum
• Other pox viruses
• Disseminated fungal infections
• Disseminated gonococcal infection
Proctitis
• Gonorrhoea
• Chlamydia
• Herpes simplex virus

13. Workup
• Precautionary measures by health care providers with respect to
Covid 19 should also apply when attending to these suspected
patients.
• Comphrehensive history should be taken: History of present
illness,and social history that includes travel history,contact with a
person that is confirmed or suspected,and history of sexual
orientation.
• Thorough physical examination in a room with good lighting.

14. Confirmed case- meets one or more of the following laboratory
criteria.
• Isolation of the monkeypox virus in culture from a sample obtained from
the patient.
• Demonstration of the monkeypox virus on PCR in a specimen obtained
from the patient
• Demonstration of the orthopoxvirus by electron microscopy in samples
obtained from the patient in the absence of exposure to other
orthopoxviruses.
• Demonstration of the monkeypox virus by immunohistochemical methods
in samples obtained from the patient in the absence of exposure to
another orthopoxvirus.

15. Probable case
• This is contact that meets current epidemiologic criteria per the CDC. It is
the occurrence of fever and vesicular-pustular rash,with the onset of the
first sign of symptom at most 21 days after the last exposure,meeting the
epidemiologic exposure.
Suspected case
• This sis contact that meets current epidemiologic criteria per the CDC. It is
the occurrence of fever or unexplained rash and 2 or more other signs or
symptoms,with the onset of the first sign or symptom at most 21 days after
exposure, meeting the epidemiologic criteria. Symptoms are as
follows:Chills and/or sweats,lymphadenopathy,sorethroat,cough,shortness
of breath,headache,backache.

16. Laboratory studies
• Viral culture obtained from an oropharyngeal or nasopharyngeal swab.
• Tissue for PCR of DNA sequence-specific for the monkeypox virus may be
obtained
• Paired sera for acute and convalescent titers may be analysed. Serum
collected more than 5 days for IgM detection or serum collected more than
8 days after rash onset for IgG detection was most efficient for the
detection of the monkeypox virus infection.
• A Tzanck smear can help differentiate monkeypox from other nonviral
disorders in the differential diagnoses. However, a Tzanck smear does not
differentiate a monkeypox infection from a smallpox or herpetic infections.

17. Treatment
Medical care
• The disease is usually self-limited;resolution occurs in 2-4 weeks. In
African cases,the mortality rate was 1-10%,and death was related to
the patients’ health status and other comorbidities. Most patients
died of secondary infections. No fatalities were recorded in the 2003
US outbreak.
• Patients often feed poorly during the febrile stage of the
illness;therefore,bedrest along with supportive care may be
necessary. Hospitalization may be necessary in more severe cases.
• To avoid infection of healthcare workers and close contacts,airborne
and contact precautions should be applied.

18. Antiviral agents
• Cidofovir: Data on the effectiveness of cidofovir in human cases of
monkeypox are not available. It is indicated for cytomegalovirus in the
United States. Although cidofovir has proven activity against poxviruses in
in vitro and animal studies, it is not known whether or not a patient with
severe monkeypox infection will benefit from treatment.
• Brincidofovir is indicated for treatment of smallpox caused by virola virus in
adults and children,including neonates. It is a prodrug of cidofovir
diphosphate. It has improved safety profile over cidofovir because severe
renal toxicity is not seen with it with treatment of cytomegalovirus.

19. • Tecovirimat: It is approved by the FDA and is indicated for treatment
of human smallpox disease caused by variola virus. The CDC holds an
expanded access investigational new drug(EA-IND) policy that allows
for the use of stockpiled tecorvirimat to treat monkeypox during an
outbreak.
• Vaccinia immune globulin(VIG): Data are not available on the
effectiveness of VIG in treatment of monkeypox complications. Use of
VIG is administered under an EA-IND for treatment of
orthopoxviruses(including monkeypox) in an outbreak. It is not known
whether a patient with severe monkeypox infection will benefit from
VIG treatment.

20. Prognosis
• Mortality rates ranging from 1-10%,have been reported in Africa,but
no fatalities occurred in the United States 2003 outbreak. Death rates
are proportionately high in African children. Health
status,comorbidities,vaccination staus,and severity of complications
influence the prognosis in the United States and Africa.
• Uncomplicated cases resolve in 2 to 4 weeks , with only pock scars
remaining.

21. Prevention
Immunization
• JYNNEOS: JYNNEOS is a live vaccine produced from the strain
Modified Vaccinia Ankara-Bavarian Nordic(MVA-BN), an
attenuated,non replicating orthopoxvirus.
• Also known as IMVAMUNE,IMVANEX,MVA
• Licensed by FDA in September 2019
• JYNNEOS is indicated for prevention of smallpox and monkeypox
disease in adults 18 years of age and older determined to be at high
risk for smallpox or monkeypox infection.

22. • ACAM2000: ACAM2000 is a live vaccinia virus vaccine.
• Licensed by FDA in August 2007.
• Replaced Dryvax- license withdrawn by manufacturer and remaining
vaccine destroyed.
• ACAM2000 is indicated for active immunization against smallpox
disease for persons determined to be at high risk for smallpox
infection.
• CDC held Emergency Access Investigational New Drug Protocol allows
use for Non-Variola Orthopoxvirus infection(e.g., monkeypox) during
an outbreak.

23. Current situation in Nigeria
• On the May 26 this year, monkeypox emergency response centre was activated to facilitate
preparedness across all the state of the federation.
• Surveillance is cased based,which means that every case encountered,sample is collected to
ascertain whether it is positive or negative and followed by contact tracing as the case may be.
• The NDDC National Reference laboratory is the only reference laboratory in the country for now
with a turn around time of less than 24 hours and reports to all parts of the federation.
• There is knowledge gap because of different animal reservoirs.
• No evidence of sexual transmission in Nigeria.
• The clade present here is the west African;genomic sequencing can take place in the laboratory.
• There is strengthened surveillance to the grassroots.
• Screening points are in the international airports with screening forms and physical examination if
necessary.
• Partner with International Veternary Research Institute in Jos to test animals for monkeypox.
• There is no vaccine for monkeypox in the country for now.

24. Conclusions
• There is a still a great knowledge gap in monkeypox ,not only in this
country,but all over the world.
• There is need for more research and funding.
• There is need for health care professionals to update their
information as to make quick diagnosis and appropriate response.

25. References
• https://emedicine.Medscape.com/article/1134714
• https://who.int/news-room/fact-sheets/detail/monkeypox

26. THANK YOU FOR YOUR ATTENTION!!!