The re‐emerging human monkeypox virus: An urgent global health alert

To the Editor, The coronavirus disease 2019 (COVID‐19) showed that any viral outbreak may cause a pandemic; the periodic outbreaks of novel or reemerging viruses remind us that zoonotic infections will continue to emerge. In 2022, Monkeypox (MPX) outbreaks were reported in nonendemic places, causing a worldwide wave of public health concern and demands for action from international authorities. On May 2, 2022, the World Health Organization (WHO) received a report of a case of monkeypox in a patient from United Kingdom who had a travel history to Nigeria. Zoonotic monkeypox disease is endemic in Central and Western Africa. The monkeypox virus (MPXV), a virus belonging to the genus Orthopoxvirus (OPXV), which also includes variola, the causative agent of smallpox, and resembles smallpox symptoms. The West African and Congo basin clades are the two main groups of MPXV of which theWest African clade is the least deadly, with a 1% death rate, and is believed to be responsible for the current pandemic. In the past, the illness was relatively uncommon outside of Africa, with occasional outbreaks mainly in the Democratic Republic of the Congo (DRC) and Nigeria. On the current scenario, for a global Public health alert, we further illustrated the historical timeline of outbreaks of the human monkeypox virus until 2022 (Figure 1). Due to interaction with infected pet Prairie dogs imported from Ghana, the first MPX cases in humans were identified in the United States in 2003, resulting in an outbreak of more than 70 cases. A major human MPX epidemic brought on by theWest African clade was also reported in Nigeria in October 2017, with approximately 146 clinically suspected and 42 confirmed cases. As a consequence of MPXV exports from Africa, human MPX cases were later reported in Israel (2018), the United Kingdom (2018, 2019, 2021, and 2022), Singapore (2019), and the United States (2021). Figure 1 shows the historical timeline of human MPX outbreaks; for further references and ideas, we recommend the following resource for viewing updates. As of August 1, 2022, four deaths have been documented in nonendemic nations (two in Spain, one in Brazil, and one in India), contributing to 10 deaths globally during this COVID‐19 pandemic (four from non endemic countries and six from endemic countries). The MPXV transmission to humans is still a mystery. A zoonotic animal‐to‐human transfer may result from direct contact with infected animals (e.g., Bites, Scratches) or indirect contact with contaminated animal fluids or wound material. Direct contact with an infected person is the primary mode of transmission by respiratory droplets and exposure to infectious wounds or body fluids. Human to human transmission occurs via direct skin to skin contact with gaping sores and indirect contact with infected fomites such as bedding or clothes. Additionally, it is important to consider a vertical transfer from the mother to the fetus. To date, there is no evidence that only human to human transmission in the general population can spread monkeypox infection. Monkeypox transmission in both endemic and nonendemic environments is summarized in Figure 2. The typical clinical presentation of monkeypox is characterized by fever, enlarged lymph nodes, and rashes. Prodromal symptoms such as chills, myalgia, fatigue, headache, back pain, and, in rare cases, sore throat and cough may appear. Many symptoms of monkeypox are similar to those of smallpox. Itching in the mouth rashes leading to impaired food intake. Secondary bacterial infections of the skin lesions are common in patients. The cutaneous signs of monkeypox may be misinterpreted as chickenpox, distinctive rash might be restricted to the vaginal, perigenital, and perianal regions; individuals may also present with/absent or minor prodromal symptoms after a localized rash appears. Laboratory confirmation can be established using immunological techniques such as ELISA, polymerase chain reaction, electron microscopy, and sequencing. There is no specific therapy for Monkeypox at the moment. The major suggestions for treating MPXV infection are supportive care, symptomatic management, and treatment of subsequent bacterial infections. Since the monkeypox virus is similar to smallpox virus, antiviral drugs developed against smallpox can be used for protection against monkeypox too. Based on smallpox treatment results, antiviral drugs such as Cidofovir, Brincidofovir, and Tecovirimat can be effective against MPXV. Tecovirimat which inhibits viral envelope protein p37 by stopping viral egress from infected cells is approved by the Food and Drug Administration (FDA) for the treatment of smallpox in children and adults. For monkeypox, all antiviral drugs are still investigational drugs that have not been approved by FDA and should be used only in people with severe monkeypox disease or in high risk people with weakened immune

The re-emerging human monkeypox virus: An urgent global health alert To the Editor, The coronavirus disease 2019  showed that any viral outbreak may cause a pandemic; the periodic outbreaks of novel or reemerging viruses remind us that zoonotic infections will continue to emerge. 1 In 2022, Monkeypox (MPX) outbreaks were reported in nonendemic places, causing a worldwide wave of public health concern and demands for action from international authorities. On May 2 nd , 2022, the World Health Organization (WHO) received a report of a case of monkeypox in a patient from United Kingdom who had a travel history to Nigeria. Zoonotic monkeypox disease is endemic in Central and Western Africa. [2][3][4][5] The monkeypox virus (MPXV), a virus belonging to the genus Orthopoxvirus (OPXV), which also includes variola, the causative agent of smallpox, and resembles smallpox symptoms. 3,4 The West African and Congo basin clades are the two main groups of MPXV of which the West African clade is the least deadly, with a 1% death rate, and is believed to be responsible for the current pandemic. In the past, the illness was relatively  Figure 1 shows the historical timeline of human MPX outbreaks; for further references and ideas, we recommend the following resource for viewing updates. 6 As of August 1 st , 2022, four deaths have been documented in nonendemic nations (two in Spain, one in Brazil, and one in India), contributing to 10 deaths globally during this COVID-19 pandemic (four from non endemic countries and six from endemic countries). 10 The MPXV transmission to humans is still a mystery. A zoonotic animal-to-human transfer may result from direct contact with infected animals (e.g., Bites, Scratches) or indirect contact with contaminated animal fluids or wound material. [11][12][13] Direct contact with an infected person is the primary mode of transmission by respiratory droplets and exposure to infectious wounds or body fluids. 13 Human to human transmission occurs via direct skin to skin contact with gaping sores and indirect contact with infected fomites such as bedding or clothes. 14 Additionally, it is important to consider a vertical transfer from the mother to the fetus. 15,16 To date, there is no evidence that only human to human transmission in the general population can spread monkeypox infection. Monkeypox transmission in both endemic and nonendemic environments is summarized in Figure 2.
The typical clinical presentation of monkeypox is characterized by fever, enlarged lymph nodes, and rashes. Prodromal symptoms such as chills, myalgia, fatigue, headache, back pain, and, in rare cases, sore throat and cough may appear. 17 Many symptoms of monkeypox are similar to those of smallpox. 18 Itching in the mouth rashes leading to impaired food intake. Secondary bacterial infections of the skin lesions are common in patients. [19][20][21] The cutaneous signs of monkeypox may be misinterpreted as chickenpox, distinctive rash might be restricted to the vaginal, perigenital, and perianal regions; individuals may also present with/absent or minor prodromal symptoms after a localized rash appears. 22 Laboratory confirmation can be established using immunological techniques such as ELISA, polymerase chain reaction, electron microscopy, and sequencing. 21,23 There is no specific therapy for Monkeypox at the moment. The

F I G U R E 1
Timeline of reported human monkeypox outbreaks in the World from 1958 till 2022. Source: based on data from the Centres for Disease Control and Prevention.

F I G U R E 2
Summarizes the monkeypox transmission in both endemic and nonendemic environments

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data sets included in this study are available upon request from the corresponding author.