"Mpox (Monkeypox) Crisis: Rapid Spread of Deadliest Strain in Africa Sparks WHO Emergency Response"

The World Health Organization (WHO) has once again declared Mpox a Public Health Emergency of International Concern (PHEIC) and classified it as an "acute" Grade 3 emergency, following a significant outbreak in the Democratic Republic of Congo. In 2024 alone, Africa has reported over 17,000 suspected Mpox cases and 517 deaths, marking a 160% surge compared to the same period last year. In India, 27 laboratory-confirmed cases were documented between January 2022 and June 2024, with one fatality. PHEIC is WHO's highest health alert, previously declared for H1N1, poliovirus, Ebola, Zika, Covid-19, and now Mpox.

WHAT IS Mpox ?

• Mpox, formerly known as monkeypox, is a viral zoonotic disease that can infect both humans and animals. It is caused by the Mpox virus, which belongs to the Orthopoxvirus family, the same family of viruses as smallpox. Although related to smallpox, Mpox typically presents with milder symptoms.

KEY FEATURES OF Mpox :

Transmission

• Mpox was first identified in monkeys in 1958, hence its former name. However, rodents are now believed to be the primary reservoir.
• Mpox is mainly transmitted through direct contact with bodily fluids, skin lesions, or respiratory droplets of an infected person or animal.
• Close contact with infected animals, like rodents and primates, can also transmit the virus.
• Human-to-human transmission often occurs through prolonged face-to-face interaction or physical contact, especially in households or healthcare settings.
• The recent outbreak ( 2024 ) in Africa is being driven by a new clade 1b strain that is spreading through sexual contact
• The earlier global outbreak in 2022-2023 was caused by the clade IIb strain, which had not previously spread widely outside West and?Central?Africa
• The new clade 1b strain suggests the virus is evolving, potentially altering transmission, severity, and vaccine effectiveness. Its spread through sexual contact complicates control efforts, making the recent outbreak especially concerning.

Typical Symptoms of Mpox :

Mpox symptoms usually develop within 6 to 13 days after exposure but can range from 5 to 21 days. Early detection is crucial to prevent the spread of the virus and ensure timely medical intervention. The symptoms of Mpox generally occur in two phases:

1. Initial Symptoms (Prodromal Phase):

• Fever: Typically high, often ranging between 38°C and 40°C (100.4°F - 104°F). Persistent fever is an early hallmark, lasting 1-4 days before the appearance of the rash. Can be associated with photophobia in more severe cases.
• Headache: Often described as intense and throbbing, requiring analgesics for relief.
• Myalgia and Fatigue : Fatigue may persist even after the acute phase of the illness, affecting recovery time.
• Swollen Lymph Nodes (Lymphadenopathy): Lymphadenopathy is a key differentiator from similar conditions, such as smallpox or chickenpox. Swelling can occur in the submandibular, cervical, and inguinal lymph nodes. Lymph nodes can become tender and visibly enlarged, signalling a robust immune response.

2. Eruptive Phase (Rash Development):

The evolution of the Mpox rash is a defining feature of the disease. However, the presentation can vary based on factors like age, immune status, and prior vaccination against smallpox.

Rash Onset and Distribution:

• The rash typically begins on the face (95% of cases) before spreading to the trunk and extremities, including the palms of the hands and soles of the feet.
• Lesions often appear simultaneously at the same stage of development, which distinguishes Mpox from chickenpox, where lesions appear in crops.
• The density and number of lesions can vary, ranging from a few to thousands. Severe cases may see lesions coalescing, leading to large areas of skin involvement.

Lesion Stages:

• Macular Stage: Small, flat, red spots appear first, which then progress to raised bumps.
• Papular Stage: These firm, raised lesions are typically 1-5 mm in diameter.
• Vesicular Stage: The lesions fill with clear fluid, resembling small blisters.
• Pustular Stage: The fluid in the vesicles becomes cloudy or purulent, indicating a pus-filled lesion. This stage is often the most painful, and pustules may become umbilicated (having a central depression).
• Scabbing Stage: The pustules crust over and eventually scab, which can take 2-4 weeks. Scabs fall off, often leaving pitted scars.

Mucosal Involvement:

• Lesions can also appear on the mucous membranes, including the mouth, genitalia, and conjunctivae. Oral lesions can be particularly painful, making eating difficult.
• Genital and rectal lesions have been reported more frequently in recent outbreaks, particularly among individuals with a history of intimate contact.

3. Systemic Complications:

Open skin lesions create a pathway for bacterial infections, which can complicate the healing process and prolong recovery.

Sepsis

Pneumonia

Encephalitis

Corneal Ulcers and Vision Loss

IMPORTANCE OF EARLY DETECTION AND DIFFERENTIAL DIAGNOSIS of MPOX:

Importance of Early Detection:

1. Outbreak Control:

Strategic Isolation: Early detection enables effective isolation and targeted interventions, like ring vaccination, to control spread.

2. Preventing Complications:

• Severe Case Management: Identifies high-risk patients needing intensive care.
• Co-Infection Prevention: Prevents secondary infections by timely diagnosis.

3. Resource Allocation:

Efficient Use: Ensures optimal use of medical resources and prevents misuse by accurate diagnosis.

Advanced Detection and Diagnosis Procedure:

1. Clinical Assessment:

• Symptom Analysis: Monitoring rash progression and assess specific risk factors (e.g., travel, exposure, sexual contact ).
• Immune Status: Evaluating immune-compromised patients for atypical symptoms.

2. Laboratory Testing:

• Molecular Diagnostics: Using real-time PCR and consider next-generation sequencing NGS for clade identification.
• Serological Testing: Detection of Mpox-specific antibodies (IgM, IgG).
• Viral Culture: For research and epidemiological studies.

3. Differential Diagnosis:

Algorithmic Approach: Use systematic methods (algorithms, flowcharts) to differentiate Mpox from similar diseases.

• Cross-Reactivity: Utilize orthogonal testing methods (e.g., PCR and serology) to confirm the diagnosis.
• Imaging: Use MRI or CT for complex cases, especially with neurological symptoms.

4. Isolation and Reporting:

• Biosafety Measures: Implement strict protocols, including negative pressure rooms and PPE.
• Surveillance: Use real-time data systems to report cases to health authorities.

5. Follow-Up and Management:

• Monitoring: Regular follow-up, potentially via telemedicine.
• Contact Tracing: Use digital tools for efficient contact tracing.
• Vaccination & Antivirals: Administer smallpox vaccines (e.g., Jynneos or ACAM2000) as post-exposure prophylaxis; consider antivirals like tecovirimat for severe cases.

HISTORY OF MPOX OUTBREAKS :

Mpox, formerly known as monkeypox, was first identified in 1970 in the Democratic Republic of the Congo (DRC). It has remained endemic in Central and West Africa, with sporadic outbreaks increasing after the cessation of smallpox vaccination, which had provided some cross-protection. Notable outbreaks include the 2003 U.S. outbreak linked to imported animals and a resurgence in Nigeria starting in 2017, with 230 confirmed cases by 2021 and a 3.3% fatality rate.

The 2022-2023 Outbreak

The global Mpox outbreak beginning in May 2022 marked a significant public health challenge, particularly as the virus spread beyond endemic regions. The initial case was detected in the UK in a patient returning from Nigeria. Over 87,000 cases were reported in 110 countries, with 112 deaths. The outbreak exposed vulnerabilities in public health systems, including issues of stigma, limited vaccine availability, and varying responses across countries. The emergence of a new strain in the DRC raised further concerns.

Global Response Efforts

In response to the outbreak, the WHO declared Mpox a Public Health Emergency of International Concern (PHEIC) on July 23, 2022. The WHO's strategic response included enhanced surveillance, risk communication, and coordination for vaccine distribution. The PHEIC was lifted in May 2023 after a decline in cases, but was re-declared in August 2024 due to a resurgence in Africa, highlighting the ongoing global threat. Vaccine deployment efforts by WHO and CDC focused on improving access, especially in lower-income countries, to curb the virus’s spread.

RECENT ADVANCES IN MPOX PREVENTION AND TREATMENT: IN-DEPTH ANALYSIS

1. Vaccination Efforts

• JYNNEOS (Imvamune or Imvanex):

- A third-generation vaccine using a modified vaccinia Ankara (MVA) virus, safe for immunocompromised individuals.

- Effective as post-exposure prophylaxis; reduces disease severity if given within 14 days of exposure.

- Prioritized in outbreak regions due to global supply constraints.

• ACAM2000:

- A live, replicating vaccine offering robust immunity but with higher risks (e.g., myocarditis).

- Used primarily in emergencies or for military personnel, with strict screening to minimize adverse effects.

• Target Populations:

- Focus on healthcare workers, high-risk groups, and immunocompromised individuals, with ongoing monitoring and targeted vaccination campaigns.

2. Antiviral Treatments

• Tecovirimat (TPOXX):

- Inhibits viral dissemination by targeting the F13L gene.

- Expanded use under emergency authorizations, with ongoing research into combination therapies.

• Cidofovir:

- Prevents viral replication; effective in severe cases, especially when Tecovirimat is ineffective.

- Managed for nephrotoxicity with advanced dosing protocols and hydration therapy.

• Brincidofovir:

- A prodrug of Cidofovir with improved safety, reducing nephrotoxicity.

- Undergoing trials for severe Mpox cases, particularly CNS complications.

3. Genomic Research

• Tracking Viral Evolution:

- Next-generation sequencing (NGS) enables real-time mutation tracking and global strain comparison.

- Studies focus on mutations affecting transmissibility, vaccine efficacy, and therapeutic resistance.

• Improving Vaccine and Treatment Responses:

- Genomic insights guide next-gen vaccine development and the identification of novel drug targets for more effective treatments.

• Global Collaboration:

- International data-sharing initiatives standardize genomic analysis and feed into predictive models to guide public health policies and resource allocation.

LESSONS LEARNED AND FUTURE IMPLICATIONS FROM THE MPOX OUTBREAK

1. Public Health Preparedness

• Global Coordination: The outbreak revealed gaps in public health infrastructure, underscoring the need for unified global protocols and emergency stockpiles of vaccines, antivirals, and PPE.
• Adaptive Response: Emphasized the need for flexible strategies and strong community engagement to adapt to new pathogen information and address cultural factors.
• Training: Highlighted the need for specialized training in zoonotic disease management and a multidisciplinary approach in response teams.

2. Vaccination Strategies

• Targeted Campaigns: Demonstrated the effectiveness of risk-based and ring vaccination strategies, focusing on high-risk groups and close contacts.
• Vaccine Development: Stressed the importance of accelerated vaccine approval processes and ongoing research into broad-spectrum vaccines.
• Addressing Hesitancy: Public education and culturally sensitive communication are key to overcoming vaccine hesitancy.

3. Importance of Surveillance

• Integrated Systems: Required robust global surveillance systems for early detection and response in both endemic and non-endemic regions.
• Genomic Monitoring: Continuous genomic surveillance is crucial for tracking mutations and predicting outbreaks.
• One Health Approach: Reinforced the need for cross-sector collaboration and wildlife monitoring to prevent zoonotic disease spill overs.

CONCLUSION :

• Recap: The rise of the more virulent Mpox clade 1b is alarming, emphasizing the need for vigilant public health measures.
• Call to Action: Stay informed, advocate for stronger public health systems, and promote global cooperation to combat Mpox.
• Closing Thought: Innovation in healthcare and continued research are vital to understanding and controlling future outbreaks.