INTRODUCTION

Earlier than shielding the entire world from Covid-19, another crisis is looming around the globe due to the Monkeypox virus (MPXV). The Monkeypox virus was first time discovered in Copenhagen in 1958 and first human infection is diagnosed in Democratic Republic of Cango in 1970. This pathogen comes under the genus of Orthopox virus (OPXV), Poxviridae family and Chordopox viridae sub family.¹ It is enveloped doubled stranded DNA virus that has two distinctive genetic clades i.e. Central Africa and West Africa (Natural source), however the genome sequence that is found in the current outbreak found in United Kingdom on 14^th May 2022 is slightly vary from their basic clades, Clade 3, however the origin is untraceable till today.²

The MPXV falls under bio-Safety level-III category. The smallpox is eradicated from world but Monkeypox is often seen in un-eradicated countries, especially central and western African countries (Gabon, Zaire, Ivory Coast, Sierra Leone, Nigeria, and Liberia). The case of MPX is recorded in USA outside Africa. Studies revealed that the environmental changes, deforestation, armed conflicts, displacement of humans and animals are enhancing the scope for the virus to transmit from animals to human beings.³

The squirrels, African rats, dormice, non-human primates and pet dogs are susceptible and act as host for the virus pathogen. The symptoms that prevail in chickenpox, scabies, syphilis and other allergic reactions also experience in the Monkeypox (MPX) infection also.⁴ The Smallpox vaccine provides 85% of cross immunity to the MPX virus, since smallpox vaccination is stopped globally (WHO),⁵ the MPX is increased eventually. The un-vaccinated people are at greater risk of exposure to the MPXV. The WHO promulgated the eradication of Smallpox in 1980 in UN general Assembly, since then the vaccination is stopped and the serological immunity is started waning out at 1.29% per year.⁶ A research reports published by Nigeria³ in 2017-20 reveals that 78% of the MPX cases between the age group of 21-40 years but historical data reveal most of the cases are >15 years age. Therefore, the children under age of 15 years are highly susceptible to MPXV.⁷

The virus transmission takes place due to the close attachment with infected person or animal or materials. Through the face to face contact, cuddling, kissing and sexual intercourse with infected persons, the virus breathing in respiratory secretions, oral droplets, body fluids enters into un-infected person. Even pregnant can transmit the virus to their fetus. Even though, it is self-limiting disease, it will last for two to four weeks in human beings. As per the MPX studies, the historically case fatality rate was 0 to11% in MPXV Central African clade (Congo clade) and <1% in West African clade, where as it was between 3 to 6% in recent times.⁷ India recorded first monkeypox death on 31^st July 2022 and it alarms both the administration and public to be vigilant.

The incubation period for Monkeypox usually ranges between one to two weeks after exposed to virus onset fever, in some cases, it may take up to three weeks to get the symptoms. The symptoms appear in two phases. The first one is pathogen invades into human cells, which last for (0-5 days), is characterized by high fever, sore throat, severe headache, back and muscle pains. Swollen lymph nodes are hallmark symptom of Monkeypox.⁸ Patients may suffer from complication of secondary infections like bacterial infections, bronchopneumonia, septicemia, respiratory distress, dehydration, encephalitis, corneal infections leading to blindness, and gastro-intestinal disorders.⁹ In later stage, within 3 days of fever, one can witness the skin eruption on face (95%) extremities, palms, hands and feet (75%), genitalia (30%), and conjunctivae (20%). The Polymerase chain reaction (PCR), Virus culture and Positive IgM for anti OPXV antibody, electron microscopy are used for laboratory investigation to detect the MPX infection. The samples will be collected from the bodily fluids, lesions, skin rash and blisters.

As per the WHO data, 92 confirmed and 28 suspected Monkeypox virus cases are reported from 12 non-endemic countries during 13 to 21 May 2022. As per WHO R&D Blue print 1405 cases 66 deaths are reported in endemic countries such as Cameroon, Central African Republic, Congo and Nigeria. An overwhelming laboratory confirmed cases of 15328 cases reported between 1 January to 21 July 2022, out of which in Europe (~76%), and Africa (~2%), America (21%), Eastern Mediterranean (<1%) and Western Pacific regions (<1%) of WHO regions and a fatality is reported from Nigeria (Table 1). After careful analysis of the situation prevailing in various the countries and regions, the WHO IHR (International Health Regulations) emergency committee declared MPX outbreak as ‘Public Health Emergency of Internal National Concern’ (PHEIC), and temporary recommendations were also issued by the WHO through which the countries started responding to the international public health protocols on emergency basis in their respective countries. In connection with the 2022 Multi-National epidemic, the CDC is monitoring 17,492 confirmed cases of monkeypox in near about 75 non-endemic nations, territories, and regions. The mathematical model to assess Basic reproduction value of an infection denoted by R₀ indicates the average number of secondary transmission cases reproduced by a single case during the whole infectious period in a community without immunity and without interventions. The zoonotic viruses such as MPXV usually have R₀ near to one, and have a scope for higher transmission in human beings.¹⁰ The R₀ value is slightly higher in Spain (1.8), United Kingdom (1.6) and Portugal (1.4) indicates probability of higher community transmission of virus cannot be ruled out in near future.¹¹

Table 1: Total Monkeypox cases by WHO region from 1 Jan 2022 to 21 Jul 2022

	Total Confirmed Cases	Total Probable Cases	% Confirmed Cases
European Region	11,638	0	75.93
Region of the Americas	3,316	72	21.63
African Region	301	0	1.97
Western Pacific Region	53	0	0.34
Eastern Mediterranean Region	18	0	0.12
South-East Asia Region	2	0	0.01
Total	15,328	72

(Source: WHO)

According to researchers who published their findings in The Lancet, monkey pox's relatively low reproductive number-which determines how many people an infected person can infect; in the case of monkeypox, it was estimated to be around 1.29-actually gives the virus much more time to evolve before it is likely to spike into an outbreak of major concern for the entire world. And when the virus once again captures the attention of the world, it might be more difficult to contain. These recommendations are broadly categorized into four groups. Group 1: Members/countries who have not reported a single case in last 21 days. Group 2: Members/countries who have imported a virus from other countries and experiencing human to human transmission presently. Group 3: countries that have history of zoonotic transmission of virus in the past and their animal sources Group 4: States and parties who have capacity for medical support measurer to counter virus. The objectives of WHO recommendation include, having coordinated response to the human-to-human transmission to protect vulnerable groups, to protect communities suffering from epidemic, to have greater surveillance measures and accelerate research in vaccines and therapeutic treatment.¹² People with sepsis, encephalitis, hemorrhagic diseases are falls under severe risk category that require immediate hospitalization. People with HIV/AIDS, leukemia, lymphoma, malignancy, organ transplantation, anti-metabolites, auto-immune disease; people with severe dermatitis problems like eczema and psoriasis; people with secondary bacterial skin, gastrointestinal problems, dehydration, bronchopneumonia children below 8 years, and pregnant and breast feeding women falls under high risk category.⁶

In contrary to WHO global commission certification, the research studies identified the role of Smallpox vaccination in eradicating MPX is unjustified. By 2006-07, the cases are increased much 20 times. The cases reported during the period, is born after the cessation of Smallpox virus. The first generation vaccine has life threatening complications such as severe pneumonia and cryptococcal meningitis in immune-compromised patients. MPX epidemic hit USA, after 2003 the CDC (Centers for Disease Control) recommended second generation Smallpox vaccine ACAM 2000™ as prophylaxis for virus exposed persons. Later third generation modified attenuated Ankara; Imvamune^® was brought into market. The mass immunization of the existing vaccines can develop myopericarditis to 1 in 145 persons which may further complicate the epidemic situation. Hence it is immunoglobulin and antiviral therapies are more appropriate in this context.¹³

Presently no standardized treatment protocol is prescribed by WHO or Public health authorities as such. However, interim recommendation is approved by various authorities. Globally, the number of new weekly cases fell by 5% from November 14 to November 20, 2022.

Plan of Action:

The MPX is spread into 80 countries. The WHO declared it as epidemic of international health emergency on July 23^rd 2022. The healthcare professionals who have to be on high alert especially belongs infectious diseases, fever hospitals, obstetrics and gynaecology units and dermatological specialties. Sufficient medical supplies (including testing kits, protective equipment, therapeutic hospitals, vaccines and pharmaceutical supplies) are to be made available on priority basis in all the cities where the probability of transmission is much higher. In the current epidemic challenges, the experiences and practices of COVID-19 pandemic are much useful in making people be informative and vigilant and preventive for public health management. The public health authorities should capitalize the applications of information and communication technology for tracking, tracing, isolating and treating patients, which will curtail the spread of MPX to a greater extent. Unlike COVID-19, the preventive measures, disease complications, treatment protocols, is little easier in MPXV, therefore effective transmission of communication to the target communities and vulnerable populations can give expected results.^14-18

In pandemics or epidemics, the role of inter-governmental collaborations are essential for the seamless interconnected supply including vaccines, medicines and protective equipment’s is essential for confining disease to a limited geographical area/region. The neighboring and border sharing countries need to be on high alert on the movement of suspected cases.

Figure 1. History of Monkeypox Outbreak

The third world countries, whose manufacturing capabilities are poor, have to depend on economically stronger countries for medical supplies, the WHO under their endowment; these countries have to be supported. During COVID-19 pandemic, the entire world experienced acute shortage of medical supplies, testing kits; medicines due to dynamic change in the disease symptoms, severity and response to therapies, thus, the pharmaceutical companies were unable to catch-up the dynamic change in demand (Figure 1).^19-28 The response time to the multi-country epidemic MPX is ample, hence it imperative to public health authorities to respond to the requirements of the epidemic. Strategic Drug Reserves (SDR) is to be maintained in all WHO member nations to meet any eventualities. The SDR is the reserve for all the medical supplies notified by the WHO epidemics/pandemics surveillance at least to meet the domestic requirements.The training and deployment of medical and healthcare personnel in the short span to make them epidemic environment is essential.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

Dr. R Varala is thankful to Dr. Ch. V. Rajasekhar (Scrips Pharma) for his continued encouragement and support.

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Received on 12.12.2022 Modified on 24.02.2023

Asian J. Research Chem. 2023; 16(3):221-224.

DOI: 10.52711/0974-4150.2023.00035