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Monkeypox_An overview.pptx

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🔥HOT TOPIC🔥

Sharing my PowerPoint slides on 🐵 MONKEYPOX🐵

(a potential/sure shot question for MD exam)

This can be used for a 2 hour session of PG seminar since all the aspects of the disease are covered.

It includes a compilation of;

1. Infectious history (in detail)
2. Epidemiology (Global, local)
3. Case definitions
4. Clinical features
5. Differential diagnosis (including comparison with common DDs)
6. Complications
7. Investigations
8. Management
9. Vaccines
10. Other specific preventive measures

Share among Community Medicine residents for maximum reach and benefits...😊

🔥HOT TOPIC🔥

Sharing my PowerPoint slides on 🐵 MONKEYPOX🐵

(a potential/sure shot question for MD exam)

This can be used for a 2 hour session of PG seminar since all the aspects of the disease are covered.

It includes a compilation of;

1. Infectious history (in detail)
2. Epidemiology (Global, local)
3. Case definitions
4. Clinical features
5. Differential diagnosis (including comparison with common DDs)
6. Complications
7. Investigations
8. Management
9. Vaccines
10. Other specific preventive measures

Share among Community Medicine residents for maximum reach and benefits...😊

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Monkeypox_An overview.pptx

  1. 1. OVERVIEW OF MONKEYPOX Dr. Immanuel Joshua. E Junior Resident Dept. of Community Medicine Banaras Hindu University Email: immanuel2346@gmail.com
  2. 2. CONTENTS History Epidemiology Case definitions Clinical features Differential diagnosis Complications Investigation and diagnosis Management Prevention strategies Discussion
  3. 3. Danish virologist Preben von Magnus was the one to identify the naturally occurring pox infection in crab-eating macaques - the species of monkey - fifty days after their arrival on a ship from Singapore.
  4. 4. It was only later detected in humans in 1970 The disease is called monkeypox because it was first identified in colonies of monkeys kept for research in 1958 after two outbreaks of a pox-like disease in them. HISTORY
  5. 5. “Monkeypox” is a misnomer. Consultations with experts are ongoing around whether the disease will be renamed.
  6. 6. Monkeypox is endemic in these 11 countries Republic of congo South Sudan Sierra Leone Nigeria Liberia Cote D'ivoire Gabon Democratic Republic Of Congo Central African Republic Cameroon Benin
  7. 7. Sierra Leone Nigeria Liberia Cote D'ivoire Cameroon Gabon Democratic Republic Of Congo Central African Republic Republic of congo South Sudan Benin AFRICA
  8. 8. 1st September 1970: First human case diagnosed in a 9-month- old baby boy admitted to the Basankusu Hospital in Zaire (now the Democratic Republic of the Congo), during the intensive search for smallpox cases after its elimination in 1968.
  9. 9. Monkeypox chiefly occurs in communities where there is often a high background prevalence of malnutrition, parasitic infections, and other significant heath- compromising conditions, any of which could impact the prognosis of a patient with MPX.
  10. 10. Active surveillance by the WHO between 1981 and 1986, identified 338 cases. Cases were rare in people over the age of 15-years, and over two-thirds of infections could be traced to animal contact within the rainforests. Initially it was uncommon for a family member to contract the infection unless they did not have a smallpox scar.
  11. 11. CONGO: Cases detected particularly in;  people living in forested areas,  males,  age less than 15-years,  no previous smallpox vaccination
  12. 12.  The vaccine against smallpox, a far deadlier and more transmissible virus, also protects against monkeypox, but the world stopped using it in the 1970s, shortly before smallpox was declared eradicated. As a result, there’s a huge, huge number of people who are now susceptible to monkeypox  People are more and more moving to the forest to find food and to build houses, and this increases the contact between the wildlife and the population  Studies in the CAR showed cases spike after villagers move into the forest during the rainy season to collect caterpillars that are sold for food
  13. 13. In 2003, first monkeypox outbreak outside of Africa was reported in USA which was linked to contact with infected pet prairie dogs housed with Gambian pouched rats and dormice imported from Ghana.
  14. 14. An outbreak of monkeypox is ongoing in Nigeria since 2017 2021 34 cases in Nigeria 3 cases in UK and 1 case in USA 2020 8 cases in Nigeria “Neglected tropical disease of the poor gets attention only after it starts to infect people in wealthy countries”
  15. 15. 2022 Monkeypox Outbreak Global Map
  16. 16. Data as of 14 Sep 2022 (since 13 May 2022) 103 Member States across all 6 WHO regions CONFIRMED CASES: 59,147 PROBABLE CASES: 489 DEATHS: 22 10 most affected countries globally: 87.5% of the total burden WHO assesses the global risk as Moderate PROBLEM STATEMENT
  17. 17. COUNTRY CASES Nigeria 277 Democratic Republic of the Congo 195 Ghana 84 Central African Republic 8 Cameroon 7 Liberia 3 Republic of the Congo 3 Countries that historically reported monkeypox Countries that hasn’t historically reported monkeypox T O P C O N T R I B U T O R S COUNTRIES CASES United States 22629 Spain 6947 Brazil 6033 France 3833 United Kingdom 3552 Germany 3547 Peru 1808 Canada 1321 Netherlands 1195 Colombia 938
  18. 18. Deaths due to Monkeypox 2022
  19. 19. DEATHS
  20. 20. INDIAN SCENARIO
  21. 21. CASE DETAILS IN INDIA 1st CASE – 14 July, 2022
  22. 22. 1st DEATH – 31 July, 2022
  23. 23. “An extra-ordinary event that may constitute a public health risk to other countries through international spread of disease and may require an international coordinated response” Monkeypox was declared as PHEIC on Public Health Emergency of International Concern 23rd July 2022
  24. 24. Under the International Health Regulations, five elements in deciding whether an outbreak constitutes a public health emergency of international concern
  25. 25. The information provided by countries – which in this case shows that this virus has spread rapidly to many countries that have not seen it before The three criteria for declaring a public health emergency of international concern, which have been met Scientific principles, evidence and other relevant information – which are currently insufficient and leave us with many unknowns The risk to human health, international spread, and the potential for interference with international traffic The advice of the Emergency Committee, which has not reached consensus 5 4 3 2 1
  26. 26. “So in short, we have an outbreak that has spread around the world rapidly, through new modes of transmission, about which we understand too little, and which meets the criteria in the International Health Regulations. For all of these reasons, I have decided that the global monkeypox outbreak represents a public health emergency of international concern”
  27. 27. • Enveloped double-stranded DNA virus • FAMILY:Poxviridae • GENUS: Orthopoxvirus AGENT: Monkeypox virus (MPXV)
  28. 28. Electron microscopy
  29. 29. CLADES West-African clade Central-African clade Clade I Clade II Clade IIb Clade IIa subclades renamed renamed Largely circulating in the 2022 global outbreak
  30. 30. HOST:
  31. 31. Data as of Sep. 14, 2022 MONKEYPOX: AGE & GENDER DISTRIBUTION
  32. 32. Monkeypox cases by race/ethnicity
  33. 33. INCUBATION PERIOD The incubation period (interval from infection to onset of symptoms) of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days PERIOD OF COMMUNICABILITY 1-2 days before the rash to until all the scabs fall off/gets subsided • Around 10% secondary attack risk (SAR) among household members without smallpox vaccination • Smallpox vaccine has been shown to be protective against monkeypox with estimated effectiveness of 85%
  34. 34. TRANSMISSION OF MONKEYPOX An overview ANIMAL HUMAN HUMAN Primary infection Secondary infection
  35. 35. Animal-to-human transmission • bite or scratch of infected animals like small mammals including rodents (rats, squirrels) and non-human primates (monkeys, apes) • through bush meat preparation.
  36. 36. Human-to-human transmission • Large respiratory droplets -requiring a prolonged close contact • Direct contact with body fluids or lesion material • Indirect contact with lesion material through clothing of an infected person • Transmission between sexual partners, due to intimate contact during sex with infectious skin lesions seems the more likely mode of transmission among men who have sex with men (MSM).
  37. 37. Exposure setting
  38. 38. Basic reproduction number - R0 The expected number of secondary infections per primary infection, when all the population is susceptible/ no interventions 3 possibilities exist for the potential transmission or decline of a disease, depending on its R0 value: R0 <1, each existing infection cause <1 new infection R0=1, each existing infection cause 1 new infection R0 >1, each existing infection cause >1 new infection Disease declines and dies out Disease will be alive; no outbreak/ epidemic Disease will be transmitted; outbreak/ epidemic
  39. 39. • Before 2022, Re is estimated to be less than 1 for the congo basin clade • The estimated Re (1.29) for the outbreaks in 2022 has a value over one across countries; (Du Z et al; pre-print) • The Re for the outbreak was approximately 2.4. (Italy – Lomte TS et al) • It would not denote a risk for the general population, but instead, it would reflect the risk faced by the MSM community • Unable to answer this question because the presence of non-sexually- associated epidemiological links in the current outbreak is so far largely unknown Ro
  40. 40. CASE DEFINITIONS  Swollen lymph nodes  Fever  Headache  Body aches  profound weakness Suspected case: A person of any age having history of travel to affected countries within last 21 days presenting with an unexplained acute rash AND one or more of the following signs or symptoms; Travel + Rash + LN/Prodrome = SUSPECTED
  41. 41. A case which is laboratory confirmed for monkeypox virus (by detection of unique sequences of viral DNA either by polymerase chain reaction (PCR) and/or sequencing) (face-to-face exposure, including health care workers without appropriate PPE; direct physical contact with skin or skin lesions, including sexual contact; or indirect contact with contaminated materials is suggestive of a strong epidemiological link). Probable case: A person meeting the case definition for a suspected case, clinically compatible illness and has an epidemiological link Confirmed case:
  42. 42. CLINICAL FEATURES Monkeypox is usually a self-limiting disease with symptoms lasting from 2 to 4 weeks.  Fever  Lymphadenopathy • Typically occurs with fever onset • Periauricular, axillary, cervical or inguinal • Unilateral or bilateral  Headache, muscle aches, exhaustion  Chills and/or sweats  Sore throat and cough PRODROME (0-5 days)
  43. 43. SKIN INVOLVEMENT  Usually begins within 1-3 days of fever onset, lasting for around 2-4 weeks  Deep-seated, well-circumscribed and often develop umbilication  Lesions are often described as painful until the healing phase when they become itchy (in the crust stage)  The skin manifestation depends on vaccination status, age, nutritional status, HIV status.  The total lesion burden at the apex of rash can be quite high (>500 lesions) or less (<25).
  44. 44. STAGE DURATION CHARACTERISTICS Enanthem Sometimes, lesions first form on the tongue and in the mouth. Macules 1−2 days Macular lesions appear. Papules 1−2 days Lesions typically progress from macular (flat) to papular (raised). Vesicles 1−2 days Lesions then typically become vesicular (raised and filled with clear fluid). Pustules 5−7 days Lesions then typically become pustular Finally, lesions typically develop a depression in the center (umbilication). The pustules will remain for 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.
  45. 45. EVOLUTION OF RASH
  46. 46. SYMPTOM PERCENTAGE Rash 97.8 Fever 76.2 Enlarged Lymph Nodes 68 Pruritis 68.2 Rectal Pain 51.8 Rectal Bleeding 34.1 Pus 24.4 Proctitis 14.8 Tenesmus 27.4 Headache 68.7 Malaise 73.4 Conjunctivitis 7.2 Abdominal 21.8 Vomiting or Nausea 28.4 Myalgia 65.4 Chills 71.8
  47. 47. DIFFERENTIAL DIAGNOSIS Hand-foot-mouth disease Molluscum contagiosum Secondary syphillis Herpes Zoster Infectious mononucleosis Measles Chicken pox
  48. 48. Comparison- MONKEYPOX CHICKENPOX MEASLES Rash after 1-3 days Rash after 0-2 days Rash after 3-5 days Lesions are in one stage of development Lesions in multiple stages of development Lesions in multiple stages of development Slow, 3-4 weeks Rapid, appear in crops Rapid, 5-7 days More dense on face; appears in palms and soles More dense on trunk; absent in palms and soles Starts on face; sometimes reaching hands and feet Lymphadenopathy Rash after 1-3 days Rash after 1-3 days Rash after 1-3 days Itchy rash Koplik spots Fever: Rash Development: Classic Feature: Death:
  49. 49. ARDS Sepsis Viral encephalitis Corneal ulceration Bronchopneumonia Secondary bacterial infections COMPLICATIONS
  50. 50. • Mortality rates ranging from 1-10% have been reported in Africa, but no fatalities occurred in the United States 2003 outbreak. • Death rates are disproportionately high in African children. • Health status, comorbidities, vaccination status, and severity of complications and the amount of exposure to the virus influence the prognosis. • Uncomplicated cases resolve in 2-4 weeks, with only pock scars remaining. PROGNOSIS
  51. 51. ASYMPTOMATIC Observe for the development of any signs and symptoms for 21 days’ post exposure If signs and symptoms develop, collect specimens as per the duration of illness as mentioned below Samples to be collected PPE to be donned before collecting the specimens should include- Coveralls/Gowns, N-95 mask, Face shield/safety goggles, double pair of gloves.
  52. 52. S Y M P T O M A T I C **RASH PHASE RECOVERY PHASE *Lesion roof- with scalpel or plastic scrapper collected in plain tube *Lesion fluid with intradermal syringe *Lesion base scrapings with sterile polyester swab collected in plain tube *Lesion crust in plain tube NPS/OPS in dry plain tube [without VTM] Blood collected in SSGT (4-5 ml) Blood collected in EDTA (2-3ml) Urine in sterile urine container (3-5ml) Blood collected in SSGT (4-5 ml) Urine in sterile urine container (3-5ml) *The specimens from lesion should be collected from multiple sites ** A clear lesion images should be sent along with the case record form
  53. 53. 5-21 days 1-4 days 2-4 weeks Days to weeks No sample collected Nasopharyngeal / oropharyngeal swab Lesion fluid, lesion roof or lesion crust Serum MONKEYPOX: When and which specimens to collect? Incubation period Febrile stage Rash stage Recovery
  54. 54. Clinical specimen (Lesion, EDTA, Serum, Urine, OPS/NPS) PCR for Orthopoxvirus genus [Cowpox, Buffalopox, Camelpox, Monkeypox] PCR specific for Monkeypox Real time PCR for Monkeypox DNA Report POSITIVE for Monkeypox (Or) Investigate for other causes If positive If negative DIAGNOSTIC MODALITY (ICMR NIV Pune)
  55. 55. MANAGEMENT OF
  56. 56. • 1980: WHO declared that smallpox was eradicated (the last known natural case was in Somalia in 1977) • Strategies & tools: Disease surveillance, Health promotion and Ring vaccination • Vaccinate all the vulnerable population SMALL POX ERADICATION: LESSONS LEARNT
  57. 57. 1. Patient Isolation 2. Protection of compromised skin & mucous membrane 3. Rehydration & Nutritional support 4. Symptom alleviation 5. Management of complications Management of PRINCIPLES
  58. 58. • Isolation room in hospital / home isolation with separate ventilation • Triple layer mask – source containment • Cover skin lesions to the best extent possible (e.g. long sleeves, long pants) to minimize risk of contact with others • Isolation to be continued until all lesions have resolved and scabs have completely fallen off PATIENT ISOLATION
  59. 59. COMPONENT SYMPTOM/SIGNS MANAGEMENT Protection of compromised skin and mucous membranes Skin rash  Clean with simple antiseptic  Mupironic Acid/Fucidin  Cover with light dressing if extensive lesion present  Do not touch/ scratch the lesions  Systemic antibiotics In case of secondary infection Genital ulcers  Sitz bath Oral ulcers  Warm saline gargles/ oral topical anti-inflammatorygel Conjunctivitis  Usually, self-limiting  Consult Ophthalmologist if symptoms persist or there are pain/ visual disturbances
  60. 60. COMPONENT SYMPTOM/SIGNS MANAGEMENT Rehydration therapy and nutritional support Dehydration Encourage ORS or oral fluids Intravenous fluids if indicated Encourage nutritious and adequate diet Symptom alleviation Fever Tepid sponging Paracetamol as required Itching/Pruritus Topical Calamine lotion Antihistaminics Nausea and vomiting Consider anti-emetics Headache/ malaise Paracetamol and adequate hydration
  61. 61. • Pain in eye or blurring of vision • Shortness of breath, chest pain • Altered consciousness, seizure • Decrease in urine output • Poor oral intake • Lethargy Monitoring and treatment of complications The patient should closely monitor for appearance of any of the following symptoms during the period of isolation: In case any of the above symptoms appear, the patient should immediately contact nearby healthcare facility/ specialist
  62. 62. Currently there is no treatment approved specifically for monkeypox virus infections. Antivirals developed for use in patients with smallpox may prove beneficial against monkeypox. Medical Countermeasures for the Treatment of Monkeypox The following medical countermeasures are currently available from the Strategic National Stockpile (SNS) as options for the treatment of monkeypox: TECOVIRIMAT CIDOFOVIR BRINCIDOFOVIR Vaccinia Immune Globulin Intravenous (VIGIV) https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
  63. 63. TECOVIRIMAT CIDOFOVIR BRINCIDOFOVIR Vaccinia Immune Globulin Intravenous (VIGIV)
  64. 64. CDC holds a non-research expanded access Investigational New Drug (EA-IND) protocol (Compassionate use) that allows for the use of tecovirimat for primary or early empiric treatment of non-variola orthopoxvirus infections, including monkeypox, in adults and children of all ages. TECOVIRIMAT (also known as TPOXX or ST-246) FDA-approved for the treatment of human smallpox disease caused by Variola virus in adults and children Its use for other orthopoxvirus infections, including monkeypox, is not approved by the FDA https://www.cdc.gov/poxvirus/monkeypox/pdf/tecovirimat-ind-protocol-cdc-irb.pdf
  65. 65. VACCINES
  66. 66. JYNNEOS
  67. 67. A one-dose vial of medication can be divided into five doses by intradermal delivery.  JYNNEOS vaccine is approved for prevention of smallpox and monkeypox (>18 years age group)  It is the primary vaccine being used in the U.S. during this outbreak.  The JYNNEOS vaccine is given as a two-dose series 28 days apart.  CDC recommends second dose on time preferably within 35 days after the first dose.  Considered vaccinated against monkeypox 14 days after you receive your second vaccine dose 0.5ml subcutaneously x 2 doses (4 weeks apart)
  68. 68. •ACAM2000 vaccine is approved to help protect against smallpox and has been made available to prevent monkeypox. •It is an alternative to the JYNNEOS vaccine. •Vaccine is recommended as a single dose given by multiple pricks to the skin using a special needle. (Percutaneous route_Scarification) •A droplet of ACAM2000 is administered by the percutaneous route (scarification) using 15 jabs of a bifurcated needle. ACAM2000
  69. 69. •ACAM2000 vaccine vial has approximately 100 doses of 0.0025 mL of live vaccinia virus •Following vaccination, a lesion or sore (known as a “take”) will form at the site of the vaccination. The lesion may take up to several weeks or more to heal. •Considered vaccinated against monkeypox 28 days after getting the single vaccine dose.
  70. 70.  MVA-BN® is approved as a smallpox vaccine in Canada and the EU (under the trade names IMVAMUNE® and IMVANEX® respectively).  Approved against monkeypox in 2019.  A major advantage of MVA-BN is the virus’ inability to replicate in a vaccinated individual, in contrast to the original smallpox vaccines.  Can be used in pregnant and breastfeeding women.  0.5ml subcutaneously  2 doses (4 weeks apart) Modified Vaccinia Ankara - Bavarian Nordic (MVA-BN)
  71. 71. LC16 KMB Monkeypox Vaccine (LC16m8)  It is formulated as a freeze-dried cell culture smallpox and monkeypox vaccine.  Live attenuated vaccine containing live vaccinia virus (LC16m8 strain)  Only approved vaccine for infants and children.  0.01 mL was inoculated into the skin by using designated bifurcated needles  Pricking (puncture) was done 5 times for primary vaccinees (without previous smallpox vaccination) and 10 times for re-vaccinees  It can replicate at the inoculation site, producing a "take lesion" in vaccinees.
  72. 72. Other preventive measures • Raising awareness of risk factors and educating people. • Infection prevention & Control measures • Isolating the suspects until monkeypox is ruled out • Hand hygiene, cover skin lesions, source control • Use of PPE by the health care provider • Proper biomedical waste management • Avoid contact with animals
  73. 73. A person who has had one or more of the following exposures with a probable or confirmed case of monkey pox, in the period beginning with the onset of the source case’s first symptoms, and ending when all scabs have fallen off. CONTACT TRACING Definition of a contact: • Face-to-face exposure • Direct physical contact • Contact with contaminated materials
  74. 74. a) Contacts should be monitored daily for the onset of signs/symptoms for a period of 21 days from the last contact with a patient or their contaminated materials during the infectious period. In case of occurrence of fever clinical/lab evaluation is warranted. b) Asymptomatic contacts should not donate blood, cells, tissue, organs or semen while they are under surveillance. c) Pre-school children may be excluded from day care, nursery, or other group settings. d) Health workers who have unprotected exposures to patients with monkeypox or possibly contaminated materials do not need to be excluded from work duty if asymptomatic, but should undergo active surveillance for symptoms for 21 days. CONTACT MONITORING
  75. 75. RISK COMMUNICATION This includes providing public health advice through the channels that target audiences use on how the disease transmits, its symptoms, preventive measures and what to do in case of suspect or confirmed infection. This should be combined with targeting community engagement to the population groups who are most at risk, working closely with health care providers, including STD clinics, and civil society organizations.
  76. 76. Risk communication should be informed by insights from social listening detecting public sentiment and should timely address possible rumours and misinformation. Health information and advice should be provided avoiding any form of stigmatization of certain groups such as men who have sex with men (MSM).
  77. 77. • Modes of spread • Period of infectivity • Vaccine doses, efficacy, adv effects, indications • Antivirals KNOWLEDGE GAPS
  78. 78. THANK YOU…!!! Email ID: immanuel2346@gmail.com Instagram: @immanuel_josh WhatsApp: 7904632794

Notas del editor

  • July 23
  • And humans
  • Bushmeat is of wild animals. It is often smoked, dried, or salted (these procedures are not sufficient to render the meat noninfectious)
  • ARDS
    Sepsis
    Viral encephalitis
    Corneal ulceration
    Bronchopneumonia
    Secondary bacterial infections
  • Vaccination upto 14 days after exposure and 4 days before appearance of symptoms are effective as PEP

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