The document discusses the monkeypox virus, its epidemiology, transmission modes, and outbreaks, including significant events from 2003 to 2022. It emphasizes the importance of prevention, vaccination, diagnosis, and treatment approaches, as well as the role of family physicians in case management. Additionally, the document outlines the public health response to outbreaks, contact tracing protocols, and patient isolation measures.

1. Monkeypox
outbreak
by/ Kholoud Mohamed
Family Medicine Resident
Under supervision of
Dr/ Samar Osama
Assistant lecturer
at the Family Medicine Department

2. The Causative Agent:
Monkeypox is an infectious disease caused by the
Monkeypox virus which is a double-stranded
DNA, zoonotic virus and a species of the genus
Orthopoxvirus in the family Poxviridae. Other
human orthopoxviruses include variola, cowpox ,
and vaccinia viruses.

3. • The virus is found mainly in tropical rainforest regions of
Central and West Africa.
• The virus is split into Congo Basin and West African
clades.
• The Central African clade is reported more frequently and
more severely than the West African clade .
• The case fatality rate for the West African clade is around
3.6 %, whereas for the Central African clade, it may be as
high as 10.6 %.

4. Epidemiology:

6. 2003 U.S. outbreak:
 It was the first outbreak of monkeypox outside of
Africa.
 In May 2003, a young child became ill with fever and
rash after being bitten by a prairie dog.
 In total, 71 cases of monkeypox were reported & all
cases were traced to Gambian pouched rats imported
from Ghana.
 No deaths were reported.
2003 Midwest monkeypox
outbreak

7. 2017 Nigeria outbreak:
In 2017, Nigeria has experienced a large outbreak, with over 500
suspected cases and over 200 confirmed cases and a case fatality rate of
approximately 3%.
2018 United Kingdom cases:
 In Sept 2018, the United Kingdom's first case of monkeypox was
recorded.
 The person contracted monkeypox in Nigeria before travelling to the
United Kingdom.
 Till December 2019, 3 cases were recorded, and 2 of them were
travelling to the UK from Nigeria. One of them was a medical worker
who cared for a case.

8. 2018 Israel case:
In October 2018, one case occurred in a man who traveled from
Nigeria to Israel.
2019 Singapore case:
On May 2019, Singapore reported the first case of monkeypox who
travelled from Nigeria.
2021 cases:
 On 24 May in the UK, three cases of monkeypox from a single
household were reported.
 On 16 July in the US, an American returning from a trip in Nigeria
was diagnosed with monkeypox.

9. Countries reporting confirmed human cases of
monkeypox 1970 – 2021, WHO

10. 2022 UK outbreak:
The index case:
 In late April 2022, the case was reported of a British
resident who travelled to Nigeria.
 The patient developed symptoms of monkeypox on 29
April while still in Nigeria.
 On 4 May, the patient flew back to the UK, presented to
hospital later the same day. The monkeypox infection was
immediately suspected.
 The patient was hospitalized and isolated.

11.  Extensive contact tracing of people who had been in contact with the
index case both on the international flight from Nigeria to the United
Kingdom and within the country following their arrival was carried out.
 The potential contacts were advised to remain aware of the symptoms of
monkeypox and immediately isolate if any symptom develops within 21
days of the contact event.
 Monkeypox (West African clade) was laboratory confirmed by polymerase
chain reaction (PCR) on a vesicular swab on 6 May by the United Kingdom
Health Security Agency (UKHSA).

12. on 12 May, two new cases of monkeypox were
confirmed by the UKHSA in London. There was no
known link between either of them and the index
case or travel to endemic regions.
on 17 May, Four additional cases of monkeypox
were confirmed by the UKHSA. None of these new
cases had any known contact history with the
previous three confirmed cases, suggesting wider
community transmission of the virus in London.
On 20 May, it was reported that another eleven
cases had been confirmed in the UK, bringing the
total number in the country to 20.

13. Europe, North America and Australia:
On May 18
Portugal: 14 confirmed cases
20 suspected cases
Spain: 7 confirmed cases
23 suspected cases
The USA: confirmed single case
Canada: 13 suspected cases

14. On May 19 On May 20
Sweden : the first confirmed case
Belgium: the first confirmed case
Italy: the first confirmed case
France: a suspected case
Australia : 2 confirmed cases
Germany : first confirmed case

15.  On May 20, the World Health Organization held
an emergency meeting to discuss the outbreak.
 The WHO European chief expressed concern
that infections could accelerate in Europe as
people gather for parties and festivals over the
summer.
 The WHO is expected to provide an update on
sequencing of the virus genome from different
cases to determine the cause.

16. Cases of monkeypox in
non-endemic countries
reported to WHO
between 13 to 21 May
2022

17. Geographical distribution of confirmed and suspected cases of monkeypox in
non-endemic between 13 to 21 May 2022

18. Cases of monkeypox in
endemic countries
between 15 December
2021 to 1 May 2022

19. Cases of monkeypox in
non-endemic countries till
27 May 2022

20. The current situation in Egypt:
On May 20, Dr. Hossam Abdel Ghaffar, the
spokesman of the Egyptian Ministry of Health
and population confirmed that there are no
cases of infection or suspected infection with
the monkeypox virus so far.

21. Animal Reservoir:
• Monkeys
•Dormice
•Gambian pouched
rats
•African squirrels
Monkeys
dormouse
Gambian pouched rat African squirrel

22. Mode of Transmission:
The virus enters the body through:
 Broken skin (even if not visible).
 The mucous membranes (eyes, nose, or mouth).
 Respiratory tract.
Animal-to-human transmission may occur by:
 Bite or scratch.
 Bushmeat preparation.
 Direct contact with body fluids or lesion material.
 Indirect contact with lesion material, such as contaminated bedding.

23. Human-to-human transmission occurs through:
 Large respiratory droplets.
 Direct contact with body fluids or lesion
material.
 Indirect contact with lesion material, such as
contaminated clothing or linens.
Human-to-human transmission is occurring
among people in close physical contact with
cases who are symptomatic.

24. Is it a sexually
transmitted
disease??!
Almost all of the case clusters include men
aged 20–50, many of whom are gay, bisexual
and have sex with men (GBMSM). Although
monkeypox isn’t known to be sexually
transmitted, sexual activity certainly
constitutes close contact.
The most likely explanation is that the virus
was coincidentally introduced into a GBMSM
community, and the virus has continued
circulating there.

25. Is the virus
genetically
mutated??!
In Portugal, the first draft genome sequence of
the monkeypox virus was obtained from a swab
collected on May 4th from skin lesions from a
male patient.
The draft genome indicates that the 2022 virus
belongs to the West African clade and is most
closely related to viruses associated with the
exportation of monkeypox virus from Nigeria to
several countries in 2018 and 2019, namely the
United Kingdom, Israel and Singapore.

26. The incubation
period:
usually 6-13 days but
can range from 5-21
days.

27. History taking:
Important clues:
 Recent travel to endemic areas.
 Interaction with wild animals imported
from endemic areas.
 Providing care to an infected animal or
human.

28. Clinical picture:
Initial symptoms :
Fever.
Headache.
Myalgia.
Fatigue.
Lymphadenopathy.
(a key differentiating
feature of monkeypox from
smallpox)

29. Within 1 to 3 days after the fever, the patient
develops a rash:
• Begins on the face and extremities (including palms
and soles).
• Centrifugally concentrated.
• The total number of lesions may vary from a small
amount to thousands.
Lesions progress through the following
sequential stages before falling off:
• Macules
• Papules
• Vesicles
• Pustules
• Scabs

30. Monkeypox lesions

31. Differential Diagnosis:
Smallpox
Chickenpox
Disseminated zoster
Eczema herpeticum
Disseminated herpes simplex
Syphilis
Scabies
Rickettsia
Measles
Bacterial skin infections
Drug-associated eruption

32. Diagnosis:
Clinically.
Laboratory testing:
• Polymerase chain reaction (PCR) testing of
samples from skin lesions.
• Specimens should be collected from at least 3
lesions and from different sites on the body.
• Viral culture
• Anti-orthopoxvirus IgM and IgG.
WHO-Laboratory testing for the monkeypox virus:
Interim guidance is available at:
https://www.who.int/publications/i/item/WHO-
MPX-laboratory-2022.1

33. Prevention:
 Avoid contact with animals that could harbor the virus
 Avoid contact with any materials of a sick animal.
 Isolate infected patients from others who could be at risk for
infection.
 Practice good hand hygiene after contact with infected
animals or humans.
 Use personal protective equipment (PPE) when caring for
patients including gown, gloves and masks.

34. Vaccination:
Smallpox vaccine (ACAM2000):
• It contains live vaccinia virus, and it was approved by
the Food and Drug Administration (FDA) on 31 August
2007.
• It is administered by (scarification) using a bifurcated
needle.
• Following a successful inoculation, a lesion will develop
at the site of the vaccination. The virus growing at the
site of this inoculation lesion can be spread to other
parts of the body or even to other people.

35. The vaccine is not routinely available for public.
It is licensed for immunization in people who are at
least 18 years old and at high risk for smallpox infection
such as laboratorians working with certain
orthopoxviruses and military personnel.
The smallpox vaccine is thought to be at least 85%
effective in preventing monkeypox.

36. JYNNEOS (also known as Imvamune or Imvanex)
 JYNNEOS is a live, attenuated vaccinia virus, incapable of replicating.
 On Sept 2019, it was approved by the U.S. Food and Drug Administration
(FDA).
 It is administered as two subcutaneous injections four weeks apart.
 There is no visible “take” and as a result, no risk of spread to other parts
of the body or other people.

37. People who receive JYNNEOS are not considered
vaccinated until they receive both doses of the
vaccine.
It is indicated for preventing smallpox and
monkeypox disease in adults 18 years of age and
older who are at high risk for smallpox or monkeypox
infection.
It can be used for patients with weakened immune
systems or atopic dermatitis.

38. When to take the vaccine?
• Vaccines are effective at protecting people against monkeypox
when given before exposure to monkeypox virus.
• The vaccine can be given within 4 days from the date of exposure
in order to prevent onset of the disease.
• If given between 4–14 days after the date of exposure, vaccination
may reduce the symptoms of disease, but may not prevent the
disease.

39. Monkeypox Disease vs Vaccine Risks.
 In Central Africa—where
people live in remote
areas and are medically
underserved—showed
that the monkeypox
disease killed 1–10% of
people infected.
 Complications of the vaccines include
eczema vaccinatum, progressive vaccinia
resulting in death, contact transmission of
vaccine virus, and fetal vaccinia.
 Between 1 and 2 people out of every 1
million people vaccinated will die as a
result of life-threatening complications
from the vaccine

40. Ring Vaccination
This would vaccinate the
close contacts of people
who have been infected
with monkeypox to cut off
any routes of transmission
and contain the spread of
monkeypox.

41. Treatment:
Supportive care:
• Antipyretic.
• Treatment of fluid & electrolytes
disturbance.
• Oxygenation if needed.
• Empirical antibiotic therapy if secondary
bacterial infection is suspected.
• Acyclovir if varicella zoster infection is
suspected.

42. Tecovirimat (ST-246):
• On 13 July 2018, it was approved the U.S. Food and Drug
Administration (FDA) and was approved for medical use in
the European Union in January 2022.
• Animal Studies have shown that ST-246 is effective in
treating orthopoxvirus-induced disease.
• Human clinical trials indicated the drug was safe and
tolerable with only minor side effects.

43. Brincidofovir & Cidofovir:
• Cidofovir was approved for medical use in 1996.
• Brincidofovir was approved for medical use in June
2021. Brincidofovir is a prodrug of cidofovir.
• Brincidofovir may have an improved safety profile over
Cidofovir.
• It have proven activity against poxviruses in in vitro
and animal studies.

44. Vaccinia Immune Globulin (VIG)
• It has no proven benefit in the treatment of smallpox
complications.
• IVIG can be considered for prophylactic use in an exposed
person with severe immunodeficiency in T-cell function for
which smallpox vaccination following exposure to monkeypox is
contraindicated.

45. Complications:
 Bacterial superinfection of skin
 Permanent skin scarring
 Hyperpigmentation or
hypopigmentation
 Permanent corneal scarring (vision loss)
 Pneumonia
 Dehydration
 Sepsis
 Encephalitis
 Death

46. Complications among Pregnant
Women With Human Monkeypox:
In 2017, Mbala et al.
reported the fetal
outcomes of 4 pregnant
women who were
infected by monkeypox
virus.
Variable
Case 1 Case 2 Case 3 Case 4
severity Moderate Severe Mild Moderate
Age, y 20 25 29 22
Time of
gestation,
wk
6 6–7 14 18
Event Miscarriage Miscarriage Live birth Fetal
death

47. Pathologic findings for the stillborn fetus from
case 4:
 Diffuse cutaneous maculopapular lesions.
 Hydrops fetalis
 Marked hepatomegaly with peritoneal effusion.
 No congenital malformations or deformities.
 Postmortem autopsy was consistent with
intrauterine fetal demise.
 Placental hemorrhages on the maternal
surface.

48.  Monkeypox is usually self-limiting.
 The condition resolves around 3 to
4 weeks after symptom onset in
most cases.
 Patients are no longer considered
infectious after all crusts fall off.
 The West African clade has a more
favorable prognosis with a case
fatality rate 3.6% .
 The Central Basin clade is more
lethal, with a case fatality rate of up
to 10.6% in unvaccinated children.

49. The role of
Family
Physicians:

52. Case and Contact Definitions:

53. CASE INVESTIGATIONS:
• Once a suspected case is detected, the physician should notify health
care authority to start intensified surveillance.
CDC case Investigation Form available at:
https://www.cdc.gov/poxvirus/monkeypox/pdf/Monkeypox-Exposure-
Questionnaire.pdf
• Referral to the isolation facility.
• The patient should wear a surgical mask& skin lesions should be
covered (e.g., long sleeves, long pants).

54. During hospitalization:
• The patients should be isolated in a negative air
pressure room as soon as possible.
• If it is not available, place patients in a private
examination room.
• If neither option is feasible, these following
precautions must be applied : a surgical mask
over the patient’s nose and mouth and covering
any of the patient’s exposed skin lesions with a
sheet or gown.
• Confirmation of the diagnosis with lab tests and
proper treatment and follow up of the patient.

55. Personal protective measures :
• PPE should be donned before entering the patient’s room.
• All PPE should be disposed prior to leaving the patient’s room.
 Disposable gown.
 Gloves whenever in contact with the patient, and with the patient
surroundings.
 NIOSH-certified N95 (or comparable) filtering disposable respirator.
 Eye protection (e.g., face shields or goggles).

56. In case of home isolation:
• The patient should be isolated in a room or area separate from other
family members when possible.
• Persons with monkeypox should not leave the home except as
required for follow-up medical care.
• They also should avoid contact with wild or domestic animals.
• Unexposed persons who do not have an essential need to be in the
home should not visit.

57. • The patients should wear a surgical mask & if this is not feasible, other
household members should wear a surgical mask when in the
presence of the person with monkeypox.
• Disposable gloves should be worn for direct contact with lesions and
disposed of after use.
• Skin lesions should be covered to the best extent possible (e.g., long
sleeves, long pants).
• Contain and dispose of contaminated waste after consultation with
state or local health officials. Do not dispose of waste in landfills or
dumps.

58. Duration of Isolation Procedures
Isolation should be continued until all lesions have resolved
and a fresh layer of skin has formed.
Following the discontinuation of isolation, the patients
should avoid close contact with immunocompromised
persons until all crusts are gone.
• Immunologic disorders.
• Chronic diseases.
• Immunosuppressive therapy.

59. Contact tracing:
• Identification of all contacts of every suspected case during case
investigation .
• All contacts should be included in a line-list and the contact listing
section of the MPX Case investigation form.
• If the laboratory result of a suspected case comes back as negative,
the contacts are immediately dropped from further follow-up.
• The contacts of confirmed animals or humans and contacts of
probable cases should be placed under symptom surveillance for
21 days calculated from the last day of exposure.

60. Case investigation form - U.S. Centers for Disease Control
and Prevention

62. Contacts should be instructed to monitor their temperature twice
daily. If fever or rash develop, contacts should self-isolate and contact
their local health department immediately.
If only chills or lymphadenopathy develop, the contact should remain
at their residence and self-isolate for 24-hours. During this time, the
individual should monitor their temperature for fever; if a fever or rash
develop, the health department should be contacted immediately.
If fever or rash do not develop and chills or lymphadenopathy persist,
the contact should be evaluated by a clinician for potential cause.

63. • Contacts who remain asymptomatic can be
permitted to continue routine daily activities (e.g.,
go to work, school).
• Contacts should not donate blood, cells, tissue,
breast milk, semen, or organs while they are
under symptom surveillance.

64. Monitoring of the exposed
healthcare workers:
 All healthcare worker should be alert to the symptoms and
should notify the infection control department if develop any
symptoms.
 Healthcare workers who have unprotected exposures do not
need to be excluded from work duty if asymptomatic, but
should undergo active surveillance, which includes
measurement of temperature at least twice daily for 21 days
following the exposure.
 Prior to reporting for work each day, the healthcare worker
should be interviewed regarding evidence of fever or rash.

65. Could it be a new
pandemic ??!
• Unlike SARS-CoV-2, It is related to the
smallpox virus, there are already
treatments and vaccines on hand.
• Unlike SARS-CoV-2, which spreads through
tiny air-borne droplets, monkeypox
spreads mainly through close contact with
bodily fluids, and less extent through large
respiratory droplets.

66. • Unlike SARS-CoV-2, RNA virus, monkeypox virus is a
relatively large DNA virus. DNA viruses are better
at detecting and repairing mutations than RNA
viruses.
• According to the World Health Organization (WHO),
Monkeypox can be contained in countries outside
of Africa where the virus is not usually detected.
• The current outbreak probably won’t necessitate
containment strategies beyond ring vaccination.
“This is a containable situation”
Maria Van Kerkhove, the WHO's emerging disease lead

67. References:
• CDC. About Monkeypox | Monkeypox| Poxvirus | CDC [Internet]. 2018 [cited 2019 Oct
19]. Available from: https://www.cdc.gov/poxvirus/monkeypox/about.html
• WHO. Monkeypox [Internet]. WHO. 2016 [cited 2019 Oct 19]. Available from:
https://www.who.int/news-room/fact-sheets/detail/monkeypox
• "Monkeypox," UK Health Security Agency, 18 May 2022. [Online]. Available:
https://www.gov.uk/guidance/monkeypox#transmission.
• https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-
updates
• Durski KN, McCollum AM, Nakazawa Y, Petersen BW, Reynolds MG, Briand S, et al.
Emergence of monkeypox – West and Central Africa, 1970–2017. Morb Mortal Wkly Rep.
2018 Mar 16;67(10):306–10.
• NCDC. Nigeria Centre for Disease Control: Weekly Epidemiological Report [Internet].
2017 [cited 2019 Oct 19]. Available from: https://ncdc.gov.ng/reports/101/2017-december-
week-52

68. • "Epidemiological update: Monkeypox outbreak," European Centre for Disease Prevention
and Control, 20 May 2022. [Online]
• Placide K Mbala, John W Huggins, Therese Riu-Rovira, Steve M Ahuka, Prime
Mulembakani, Anne W Rimoin, James W Martin, Jean-Jacques T Muyembe, Maternal and
Fetal Outcomes Among Pregnant Women With Human Monkeypox Infection in the
Democratic Republic of Congo, The Journal of Infectious Diseases, Volume 216, Issue 7, 1
October 2017, Pages 824–828, https://doi.org/10.1093/infdis/jix260
• https://www.nature.com/articles/d41586-022-
014218?utm_source=Nature+Briefing&utm_campaign=722ea2a64d-briefing-wk-
20220520&utm_medium=email&utm_term=0_c9dfd39373-722ea2a64d-42456515
• https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1