About Monkey Pox

On 23 July 2022, the World Health Organization (WHO) declared monkeypox a public health emergency of international concern (PHEIC).

This article will shed light on the disease in terms of its epidemiology, treatment, and prevention.

Monkeypox is actually not a new disease. It was first discovered in monkeys in 1958, caused by a virus different from the one that causes smallpox in humans, but genetically very similar.

Human cases of monkeypox were first reported in 1970 in the West and Central African regions, and the disease was declared an endemic. Only in 2022 was human-to-human transmission detected in many countries, almost simultaneously. This disease spreads very fast. More than 75 countries have reported cases this year to total more than 16,000. Most cases have occurred in continental Europe, followed by the United States.

The US reported 5,189 cases on 1 Aug., a huge jump from 113 cases on 18 July. An escalation of the caseload was also reported in Germany, from 80 cases on 7 June to 2,459 cases on 27 July. France detected its first cases on 20 May, and recorded an increase from 912 cases on 12 July to 1,955 cases on 28 July, or up 200 percent in two weeks. Spain reported 3,536 cases across several regions, including Madrid, Catalonia and Andalusia.

So, it is obvious that has been a rapid and simultaneous increase in many countries. Until now, Indonesia has not reported any cases of monkeypox. However, given the speed of transmission and the vastness of our country, as well as knowledge about how the Covid-19 pandemic began to unfold, we must take full care, continue to heighten surveillance and increase vigilance.

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In Australia, which is relatively close to Indonesia, monkeypox was first detected in May. There have so far been 41 confirmed or suspected cases across several states, including New South Wales, Victoria, the Australian Capital Territory, Queensland, and South Australia.

In the United Kingdom, 2,367 cases have been confirmed as of 25 July. Occurring primarily in London, the cases were dominated by men (99.3 percent), with the median patient age relatively young (37). The situation in the US has been no better with 5,189 confirmed cases as of 1 Aug., with the patient profile roughly the same as in the UK.

The UK health department has classified the outbreak into four potential levels of transmission: Level 1 is disease emergence in a country, followed by imported cases with limited transmission. Level 2 is transmission within a particular subpopulation. Level 3 is transmission within multiple subpopulations, or widespread transmission in a subpopulation. Level 4 is widespread transmission in the population with the potential to become an epizootic endemic disease. Based on these classifications, the UK government has declared a Level 2 alert for the entire country, with the possibility of elevating to level 3.

Risk factors

Data shows that 99 percent of monkeypox cases are found in men. Most patients are men who have sex with men (MSM) and/or men who have more than one male sexual partner. However, this does not mean that only MSM with more than one sexual partner can contract monkeypox.

The US Centers for Disease Control (CDC) reported that two children have contracted monkeypox, while the UK has detected the disease in 13 women and three health workers who contracted it while treating monkeypox patients. Pregnant women who contract the monkeypox virus can potentially transmit it through the placenta to the fetus they are carrying. The increasing number of cases among women still needs further observation and surveillance.

Human-to-human infections are transmitted through direct contact with the blisters or bodily fluids of people who are ill, especially through prolonged and intimate contact, such as hugging and having sex, as well as touching objects that a patient has used. Although the virus is mainly spread through close contact, including sex, further observations have shown that the virus persists in the air and on various materials in the room used to extract samples from monkeypox patients.

Symptoms, treatment & prevention

The disease generally begins with fever, muscle aches, headache, backache, swollen lymph nodes, chills, tiredness and fatigue, rashes on the skin that develop blisters on the left and right sides of the body that resemble herpes. Blisters can appear on the face, mouth, hands, feet, and genitalia (anus). In some people, it can progress and develop into more severe symptoms and complications, such as inflammation of the lungs (pneumonitis), inflammation of the brain (encephalitis), inflammation of the cornea (keratitis), and some types of secondary bacterial infections.

The New England Journal of Medicine reported last week that immunocompromised children and adults, such as people with HIV, are at risk of developing serious problems from contracting the virus. It is unknown whether antiretroviral therapy (ART) can reduce the disease symptoms or not. Although it is known to be a self-limiting disease, some cases have led to the patient being hospitalized to undergo treatment to alleviate excruciating pain around the blisters, or acute disorders of the kidneys and the membranes of the heart.

There are several measures that can help prevent transmission, including avoiding contact with animals suspected or known to be positive for the monkeypox virus. If you travel to Africa, avoid rats, monkeys, and roadkill. Fully cook meat and other animal parts before consuming.

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Avoid close contact with people presenting symptoms resembling chickenpox or herpes zoster, such as a rash or other skin disorder, because both diseases have symptoms that are similar to monkeypox. Do not touch the affected skin. Do not kiss, hug, or have sex with people who exhibit these symptoms, especially if that person is confirmed to have monkeypox.

Do not share utensils with others, such as plates, spoons, glasses, and cups. Do not touch the towels, clothes, mattresses, bed covers used by monkeypox patients. Wash hands frequently with soap and water and use hand sanitizer. Make sure monkeypox patients self-isolate at home to recover. For medical workers treating monkeypox patients, always use standard personal protective equipment (PPE).

If you experience the symptoms mentioned above, mind the following points. Avoid close contact, let alone sex, with anyone until a doctor has checked you and ascertained that you don't have monkeypox or other viral diseases. If you don't have access to a private doctor, go to the nearest Puskesmas (community health center) and use a BPJS (government health insurance) card. Always wear a mask while visiting a doctor. Be open with the doctor and other health workers that you may have contracted a highly contagious virus. Remember, doctors and health workers are also people who can let their guard down.

The European Medicines Agency has approved the use of Imvanex as a monkeypox vaccine to prevent transmission in adults. This vaccine has been in use since 2013 and contains an attenuated virus called the modified vaccinia virus Ankara (MVA), which is related to the virus that causes monkeypox. With the similarity between these two viruses, scientists believe Imvanex is effective against monkeypox. The company Bavarian Nordic holds the marketing license for Imvanex.

In addition to Europe, Imvanex is also used in the US under the trade name Imvamune (JYNNEOS) along with other vaccines, such as ACAM200. Another vaccine is likely to be produced soon to deal with the monkeypox pandemic.

The vaccine is recommended for people who have been exposed or are at high risk of exposure to the disease, including those people identified by health workers as having been in close contact with someone who has tested positive for monkeypox. Vaccination is also recommended for people whose partners have been diagnosed with monkeypox in the last two weeks, or those who have had sex with more than one partner in areas where monkeypox has been found.

Other groups of people may also be prone to orthopoxviruses exposure, due to the nature of their work, such as (1) laboratory workers who run tests for orthopoxviruses, (2) laboratory workers who culture or treat animals with orthopoxviruses, (3) health workers assigned to handle a monkeypox outbreak.

As the monkeypox and smallpox viruses are genetically similar, smallpox drugs and vaccines can be used for the curative and preventive treatment of monkeypox. Antiviral drugs, such as tecovirimat (TPOXX), can be given to monkeypox patients who are at risk of health deterioration, such as patients with weak immune systems. In addition to tecovirimat, another option is brincidofovir. Both are believed to be effective in curing monkeypox in animals.

Monkeypox cases are classified into the three stages of possible infection, probable infection, highly probable (highly likely) infection, and confirmed infection. A case is classified as possible if a doctor finds genital and urogenital ulcers or nodules, or proctitis, which is unknown inflammation or bleeding in the lining of the rectum (UK NHS criteria) on a patient. A possible case may also arise from the discovery of skin disorders (similar to smallpox, chickenpox, or herpes symptoms) on the left and right sides of the body, accompanied by swollen lymph nodes.

A possible case becomes probable if: (a) the patient has had contact with a confirmed case in the last 21 days, even before symptoms appear; (b) if the patient is an MSM or bisexual; (c) the patient has a history of sexual intercourse with one or more partners 21 days before the onset of symptoms; (d) the patient has a history of traveling to Central or West Africa 21 days before the symptoms appeared.

The symptoms of monkeypox are fever over 38 degrees Celsius, chills, headache, muscle aches, joint aches, lumbago and swelling lymph nodes.

With this diagnostic classification, it is very possible for us in Indonesia to identify possible, probable and highly probable cases before arriving at confirmed cases.

Mitigation measures

To date, it is believed that monkeypox will not develop into such an adverse magnitude to become pandemic like Covid-19, because spreading it requires close contact. However, the WHO has taken the disease seriously because its potential for spreading on an unforeseen scale. The WHO has based it serious response on the grounds that after decades since it was detected and deemed dormant, the virus has spread very quickly in a matter of months. So, there is nothing wrong if we in Indonesia get ready from now in as serious a manner.

Given that Indonesia is the fourth most populous country in the world after China, India and the US, and a total of more than 16,000 reported cases in 75 countries, it seems unlikely that the country will be free from monkeypox. Moreover, our large population (around 270 million people) is highly mobile, and the country also has many points of entry.

With our neighbor Singapore reporting 12 cases, a case is likely to already exist in Indonesia. It may be that it has not been detected yet. In this case, the government, medical workers, and all relevant circles, including the public, must work together.

Given that Indonesia is the fourth most populous country in the world and a total of more than 16,000 reported cases in 75 countries, it seems unlikely that the country will be free from monkeypox.

Here are several things we can do to mitigate the spread of monkeypox.

First, if any friends or relatives show abnormalities in the skin (blisters or lesions) on both sides of the body, they should be referred to a doctor. The doctor must then report the case to their superior so that the hospital administrator will report it to the health office for further examination.

Second, increase knowledge and awareness about the disease among surveillance officers on duty at the entry points to Indonesia, including international airports and seaports. In the event that people with skin disorders on the face and hands – the parts of the body that are immediately visible – they should be immediately referred to the Puskesmas at the airport or seaport. So, case detection must start domestically at the country’s entry points.

Third, communities and groups at high risk need to be encouraged to educate their peers. They must be aware of the symptoms and take any people who show the symptoms to a doctor to check if it is monkeypox or not.

Fourth, regarding medical human resources, the Health Ministry and the Indonesian Medical Association (IDI), other health organizations, hospitals, and the Medical Services Development Council must coordinate in preparing a special area in hospitals for treating monkeypox patients. In addition to improving the knowledge of their staff, hospitals must equip their staff with adequate PPE.

Zubairi Djoerban, Professor of internal medicine and discoverer of first HIV/AIDS case in Indonesia.

This article was translated by Musthofid.