Monkeypox is a rare zoonosis caused by monkeypox virus. This disease is similar to smallpox disease but with lesser severity. This disease is common among Africans. It can be prevented by avoiding contact with contaminated animal and human fluids as well as respiratory droplets. It require a multidisciplinary approach to achieve cure and prevention.

1. By
Dr. O.O. Afuye
81 Division Medical Services and Hospital, Lagos

2. OUTLINE• Introduction
• Epidemiology
• Transmission
• Signs and Symptoms
• Differential Diagnosis
• Diagnosis
• Treatment andVaccination
• Prevention
• Prognosis
• Summary
Dr O.O.Afuye 2

3. INTRODUCTION
Dr O.O.Afuye 3

4. • Aetiology: MonkeypoxVirus
• Familiy - poxviridae
• genus - Orthopoxvirus
(Members:Variola virus-Smallpox,Vaccinia virus – Smallpox vaccine,
cowpox virus)
• Rare viral zoonosis
• Has symptoms similar to those of smallpox but with less severity
• Occurs sporadically in Central and West Africa’s tropical rainforest
• Monkeypox first discovered in 1958, 2 outbreaks of pox-like disease
occurred in colonies of monkeys kept for research, hence the name
‘monkeypox’ Dr O.O.Afuye 4

5. EPIDEMIOLOGY
Dr O.O.Afuye 5

6. • Human monkeypox – first identified in 1970 in a 9 year old boy – Democratic
republic of Congo
• It is endemic in this region
• NATURAL HOST
• In Africa: rope & tree squirrels, Gambian rats, Striped mice, Dormice, Primates
• In USA: transmission fromAfrican Animals to susceptible non-African species
(e.g. prairie dogs) with which they were co-housed
• Major outbreaks:
• 1996-1997 – DRC
• 2003 – USA (from close contact with pets infected by African rodents) 47 cases
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7. Dr O.O.Afuye 7

8. • Sporadic cases:
• 10 African countries has been affected - DRC, Republic of the Congo,
Cameroon, Central African Republic, Nigeria, Ivory Coast, Liberia, Sierra
Leone, Gabon and South Sudan.
• Nigeria – 2017 –2019: largest documented outbreak (~ 40years after last
confirmation)
• 2018- UK with 3 cases
• 2018 - Israel with 1 case
• 2019 – Singapore with 1 case
• Monkeypox virus has only been isolated twice from animals in nature:
• First – ill African rodent (rope squirrel) in DRC – 1958
• Second – dead infant Mangabey inTai National Park, Cote d’Ivoire -2012
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9. Dr O.O.Afuye 9

10. • Epidemiology in Nigeria
• Nigeria continues to report sporadic cases of Monkeypox after the index
case reported in September 2017
• All reported cases (suspected and confirmed) are males
• The confirmed cases are all between 32-39 years of age
• The South-South region of the country has the highest burden of
Monkeypox
• Since the beginning of the outbreak in September 2017, 311 suspected
cases and 7 deaths have been reported in 26 states.
• Of this, 132 were confirmed in 17 states (Rivers, Bayelsa, Cross River,
Imo, Akwa Ibom, Lagos, Delta, Edo, FCT, Abia, Oyo, Enugu, Ekiti,
Nasarawa, Benue, Plateau, Anambra)
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11. Aug 1970-
May 2018
Jan 2017 –
May 2018
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12. TRANSMISSION
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13. • Natural reservoir of monkeypox is
unknown
• Most likely reservoir host – African
rodents
• In Africa human infection has been
documented from handling of
infected monkeys, Gambian giant
rats, squirrels
• Index cases infection results from:
direct contact with bodily fluids,
cutaneous or mucosal lesions of
infected animals
Points of entry:
• Broken skin (even if invisible)
• Respiratory tract
• Mucous membrane (eyes, nose,
mouth)
Animal –to-human transmission:
• bite/scratch
• bush meat preparation
• direct contact with body
fluids/lesion material
• indirect contact with lesion material
Dr O.O.Afuye 13

14. Secondary or human-to-human
transmission:
• respiratory droplets –usually
face-to-face contact needed
• direct contact with body
fluids/lesion material
• indirect contact- contaminated
cloths, linens
• Inoculation
• Via the placenta (congenital
monkeypox)
*no evidence to the chance of
person-to-person transmission
alone sustaining monkeypox
infections in human
population
• Genetic groups/Clades of the
virus:
• The Congo Basin (more
virulent- severity,
motality,spread) or Central
African
• TheWest African
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15. SIGNAND SYMPTOMS
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16. Incubation period: 6-16 days
(accepted range: 5-21days)
Asymptomatic
Infection period:
The invasion period/
prodrome (0-5days)
Fever, intense headache,
lymphadenopathy(occurs with fever, 1-
2 days before rash, rarely with rash,
Affects submandibular, cervical,
axillary or inguinal LN, on both or either
sides) , back pain, myalgia, intense
asthenia, chills, unproductive cough. Dr O.O.Afuye 16
The skin eruption period (1-
3days after appearance of fever)
Centrifugal in nature
Affects the Face – 95% of cases
The palms and soles – 75%
Oral mucous membranes – 70%
Genitalia – 30%
Conjunctivae/cornea – 20%

17. • The lesion progress through
several stages before falling
off.
• The person is contagious from
onset of enanthem through
scab stage
• Person no longer contagious
after all scabs falls off
• Pitted scars and or areas of
lighter/darker skin may remain
all scabs fall off
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18. EnanthemThrough the Scab Stage
Stage Stage Duration Characteristics
Enanthem  The first lesions to develop are on the tongue and in the mouth.
Macules 1−2 days  Following the enanthem, a macular rash appears on the skin, starting on the
face and spreading to the arms and legs and then to the hands and feet,
including the palms and soles.
 The rash typically spreads to all parts of the body within 24 hours becoming
most concentrated on the face, arms, and legs (centrifugal distribution).
Papules 1−2 days  By the third day of rash, lesions have progressed from macular (flat) to papular (raised).
Vesicles 1−2 days  By the fourth to fifth day, lesions have become vesicular (raised and filled with clear
fluid).
Pustules 5−7 days  By the sixth to seventh day, lesions have become pustular (filled with opaque fluid) –
sharply raised, usually round, and firm to the touch (deep seated).
 Lesions will develop a depression in the center (umbilication).
 The pustules will remain for approximately 5 to 7 days before beginning to crust.
Scabs 7−14 days  By the end of the second week, pustules have crusted and scabbed over.
 Scabs will remain for about a week before beginning to fall off.
Dr O.O.Afuye 18

19. • Crusts might take about 3 weeks to completely disappear
• Number of lesions varies from few to several thousands
• Usually self-limiting
• Duration of symptoms: 14-21days (2-4weeks)
• Severe cases seen more in children.This is related to:
The extent of virus exposure
Patient’s health status
Severity of complications
• ? Asymptomatic infections – people living in or near forested
areas or low-level exposure to infected animals
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20. DIFFERENTIAL DIAGNOSIS
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 Smallpox
 Chickenpox
 Measles
 Bacterial skin infections
 Scabies
 Syphilis
 Medication-associated allergies

21. DIAGNOSIS
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22. The following types of specimens should be collected in accordance with stage of disease
Disease Phase Specimens to Collect
Prodrome Tonsillar tissue swab
Nasopharyngeal swab
Acute serum and whole blood
Rash*
Macules or Papules Tonsillar tissue swab
Lesion biopsy
Acute serum and whole blood
Vesicles or Pustules Lesion fluid, roof, or biopsy
Electron microscopy grid (if supplies available)
Acute serum and whole blood
Scabs or Crusts Lesion scab or crust
Acute serum and whole blood
Post-Rash Convalescent serum
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23. • Definitive diagnosis – Laboratory
* More than one lesion should be
sampled, preferably from different
locations on the body and/or from
different looking lesions.
• Optimal diagnostic specimen are
from lesions:
Vesicular swabs of lesion
exudate/crust
• Store in dry, sterile tube
• Keep cold
Blood/serum – often inconclusive
• Short duration of viremia
• Timing of specimen collection
Information needed for result
interpretation:
• Approximate date of onset of fever
• Date of onset of rash
• Date of specimen collection
• Current status of the individual
(stage of rash)
• AgeDr O.O.Afuye 23

24. TREATMENTANDVACCINATION
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25. • No specific treatments/ vaccines
• Outbreaks can be controlled
• Vaccination against smallpox = 85% effective prevention of
monkeypox
*vaccine no longer available since discontinued following global
smallpox eradication
• Prior smallpox vaccination will likely result in milder disease course.
• Antivirals [Cidofovir, Brincidofovir (CMX001),Tecovirimat (ST-246)]
and vaccinia immune globulin (VIG) can also be used, but no data
supports this.
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26. PREVENTION
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27. A. Reducing the risk of infection in people
In outbreaks, most significant risk factor is close contact.
• Raise awareness of the risk factors
• Education on measures to reduce exposure to the virus
• Surveillance measures
• Rapid identification of new cases
Public health educational messages should focus on the following risks:
Reduce risk of animal-to-human transmission
• Avoid contact with rodents and primates
• Limit direct exposure to blood and meat
• Thorough cooking of meat prior to consumption
• Personal protective equipment should be worn while handling sick animals, infected
tissues and in slaughtering procedures
Dr O.O.Afuye 27

28. B. Reduce risk of human-to-human transmission
• Avoid close contact with infected person/contaminated
materials
• PPE worn while caring for ill persons
• Regular hand washing after caring or visiting infected person
• Isolation of patients – either at home or health facilities
*Following discontinuation of isolation precaution, affected
individuals should avoid close contact with
immunocompromised persons like:
• - Immunologic disorders: HIV infection, congenital immune
deficiency syndrome
• - Chronic dx e.g. Dm, Ca, Emphysema, CF
• - Immunosuppressive therapy e.g. radiation, Cytotoxic chemo,
anti-rejection Dr O.O.Afuye 28

29. C. Controlling infection in health-care settings
• Standard infection control precautions among health workers in caring for
suspects and confirmed case and their specimens
• Immunization of health workers against smallpox
*Older smallpox vaccines should not be administered to immune-
compromised people.
• Suspected samples should be handled by trained staff working in suitably
equipped laboratories
• In transporting samples, ensure safe packaging
and follow infectious substances guidelines.
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30. Clinicians
• High index of suspicion when symptoms are present
• Specimen Collection
• Effective communication and precautions between specimen
collection teams and laboratory staff is essential
• Clear labelling systems for all infected samples
• Proper sample collection techniques
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31. • Laboratory personnel
• Laboratory exposures to poxviruses occurs primarily through:
• Needle pricks
• Direct contact with specimen
• Aerosols generated by lab procedures
• Limit number of staff testing specimens
• PPE
• Rigorously applied standard precautions
• Avoid any procedures that could generate infectious aerosols
Dr O.O.Afuye 31

32. Veterinarians
• Consider all mammals as susceptible to monkeypox
• Beware of animal-to-animal transmission
• Ensure good hand hygiene, waste disposal, environmental
sanitation, laundry
• In treating suspected animals use PPE, protect staff, clients and
other animals
• Preventing monkeypox expansion through restrictions on animal
trade
• Restrict/ban the movement of small African mammals and
monkeys
• Isolate/quarantine potentially infected animals
• Quarantine all contact animals, handle with standard precautions
and observe for monkeypox symptoms for 30 days.Dr O.O.Afuye 32

33. COMPLICATIONS
Pitted scars
Deforming scars
Secondary bacterial infection
Bronchopneumonia
Respiratory distress
Keratitis
Corneal ulceration
Blindness
Septicemia
Encephalitis Dr O.O.Afuye 33

34. PROGNOSIS
• Mortality rates ranging from 1-10% have been reported in Africa
• No fatalities occurred in the United States 2003 outbreak.
• Death rates are disproportionately high in African children.
• Factors influencing prognosis:
Health status
Comorbidities
Vaccination status
Severity of complications
Uncomplicated cases resolve in 2-4 weeks, with only pock scars
remaining.
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35. SUMMARY
• smallpox vaccination was highly effective in preventing monkeypox as well.Dr O.O.Afuye 35

36. REFERENCES
• Centers for Disease Control and Prevention (28 Sptember, 2018) Monkeypox.
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
• Graham M.B. et al (28 August, 2018) Monkeypox. Medscape
https://emedicine.medscape.com/article/1134714-overview#a4
• Nigeria Centre for Disease Control (January 2019) Nigeria monkeypox monthly
situation report.
file:///C:/Users/QBAS/Downloads/An%20Update%20of%20Monkeypox%20Outbr
eak%20in%20Nigeria_310119_5.pdf
• World Health Organisation (6 June, 2018) Monkeypox. https://www.who.int/news-
room/fact-sheets/detail/monkeypox
Dr O.O.Afuye 36