The World Health Organization (WHO) announced that it wants to clarify, with the help of the United Kingdom , the cases of monkeypox detected since the beginning of May. In turn , Spain and Portugal also reported patients under study and confirmed diagnoses.
Endemic in West Africa, this viral disease was identified in Portugal in "more than 20 suspected cases in the Lisbon region, five of which were confirmed," the Portuguese General Directorate of Health announced in a statement. "The cases, most of them young, all male, presented ulcerative lesions," said the health authority.
In the Madrid region, 23 suspicious cases were detected and the results of the analyzes are pending, announced the regional Ministry of Health. "Due to the characteristics of the 23 suspected cases of infection, it suggests that it was due to contact with mucous membranes during sexual relations," the ministry reported in a statement.
The United Kingdom has identified seven cases since May 6, including four in people who identify as "homosexuals, bisexuals or men who have sexual relations with men," according to the British Health Security Agency. acronym in English). To these were added two more cases, one in London and another in the southeast of England, bringing the total cases to 9. "The virus does not usually spread easily between people. The risk to the UK population remains low," the agency said.
With the exception of the first case - the infected person had recently traveled to Nigeria - the patients were infected in the United Kingdom, which leads to the assumption that the infections were due to community transmission.
According to the authorities of Spain and Portugal, who activated a national health alert, this rare disease is not very contagious among humans, has no treatment and generally heals on its own. Its symptoms include fever, headache, muscle aches, back pain, swollen lymph nodes, chills, and fatigue.
Rashes may also appear, especially on the face, and spread to other parts of the body.
Monkeypox is a viral infection generally associated with travel to West Africa, the British agency added on its Twitter account. And they added that generally, "it is a mild self-limiting disease, which is transmitted by very close contact" and "most people recover within a few weeks."
Description of monkeypox or monkeypox
Monkeypox is a rare viral zoonosis (disease caused by viruses transmitted from animals to people), which produces symptoms similar to those seen in smallpox patients in the past, although less severe. With the eradication of smallpox in 1980 and the subsequent cessation of vaccination against the disease, it has become the most important orthopoxvirus. This pathology continues to appear sporadically in some central and western parts of the African rainforest.
Monkeypox was first detected in humans in 1970 in the Democratic Republic of the Congo (then called Zaire) in a nine-year-old boy, in a region where smallpox had been eradicated in 1968.
In the spring of 2003, cases of monkeypox were confirmed in the United States of America. It was the first time the disease was detected outside the African continent. Most of the patients had had close contact with domestic prairie dogs that had been infected by African rodents imported into the country.
In early cases, infection occurs through direct contact with blood, body fluids, or lesions on the skin or mucous membranes of infected animals. Human infections resulting from handling infected monkeys, Gambian giant rats or squirrels have been described in Africa. Rodents are considered to be the main reservoir of the virus. A possible risk factor is inadequate cooking of meat from infected animals.
Secondary or person-to-person transmission can occur through close contact with infected respiratory tract secretions or skin lesions of an infected person, or with objects recently contaminated with the patient’s fluids or materials from the lesion. Transmission occurs mainly by respiratory droplets, generally after prolonged face-to-face contact with the patient, which exposes family members of active cases to an increased risk of infection. The infection is also transmitted by inoculation or through the placenta (congenital monkeypox).
The incubation period (interval between infection and the appearance of symptoms) of monkeypox is usually 6 to 16 days, although it can vary between 5 and 21 days.
The infection can be divided into two periods:
-The invasion period (between days 0 and 5), characterized by fever, intense headache, lymphadenopathy (inflammation of the lymph nodes), low back pain, myalgia (muscle pain) and intense asthenia (lack of energy);
- The period of skin rash (between 1 and 3 days after the onset of fever), when the different phases of the rash appear, which generally affects the face first and then spreads to the rest of the body. The most affected areas are the face (in 95% of cases), the palms of the hands and the soles of the feet (in 75% of cases). The evolution of the rash from maculopapules (flat-based lesions) to vesicles (fluid-filled blisters), pustules and subsequent scabs occurs in about 10 days. Complete removal of scabs may take up to three weeks.
The number of lesions varies from a few to several thousand, and they affect the mucous membranes of the mouth (70% of cases), the genitals (30%), the palpebral conjunctiva (20%) and the cornea (eyeball).
Some patients have severe lymphadenopathy (swelling of the lymph nodes) before the rash appears. This characteristic sign of monkeypox allows it to be differentiated from other similar diseases.
There are no specific treatments or vaccines against monkeypox virus infection, although outbreaks can be controlled. In the past, the smallpox vaccine was 85% effective in preventing monkeypox. However, the vaccine is no longer accessible to the public, since its production was suspended after the global eradication of smallpox. However, previous smallpox vaccination can contribute to a milder course of the disease.
European Center for Disease Prevention and Control (ECDC)
Monkeypox cases reported in the UK and Portugal
Several cases of monkeypox have been confirmed in Europe, including in one EU Member State (Portugal).
The first case was reported by the UK Health Security Agency (UKHSA) on May 7 and is believed to be imported. On 14 May 2022, two further cases were identified in the UK, both living in the same household, but with no recent travel history or contact with the case reported on 7 May. UKHSA confirmed a further four cases on 16 May, also with no history of recent travel to endemic areas, and were not contacts of the cases reported on 7 and 14 May. All cases reported on May 16 were men who identified themselves as men who have sex with men (MSM).
Additionally, on May 18, Portugal reported five confirmed cases of monkeypox and more than 20 suspected cases. All the cases were young men, and all in Lisbon and the Tagus Valley. Spain has also reported eight suspected cases.
Transmission and symptoms
Monkeypox is a viral disease. Transmission to humans can occur through contact with an infected animal or human, or with human body material containing the virus. Transmission between humans occurs primarily through large respiratory droplets. Since droplets cannot travel very far, prolonged face-to-face contact is needed. The virus can also enter the body through bodily fluids, injured material, or indirect contact with injured material.
Symptoms include fever, headache, muscle aches, back pain, swollen lymph nodes, chills, and exhaustion. Usually a rash develops. This often starts on the face and then spreads to other parts of the body, including the genitals. Of note, recently detected cases among MSM have reported a preponderance of lesions in the genital area.
The rash goes through different stages and may resemble chickenpox or syphilis, before eventually forming a scab, which then falls off. The difference in appearance from chickenpox or syphilis is the uniform evolution of the lesions. The incubation period is usually 6 to 16 days, but can be up to 21. When the scab falls off, the person is no longer infectious.
History of the disease
Since 2018, 7 cases of monkeypox have been reported in the UK (in 2021, 2019 and 2018), mainly with a history of travel to endemic countries. However, this is the first time that chains of transmission have been reported in Europe with no known epidemiological links to West and Central Africa. These are also the first cases reported worldwide among MSM. Monkeypox virus is considered to have moderate transmissibility between humans. In this case, transmission between sexual partners, due to intimate contact during sexual relations with infectious skin lesions, appears to be the likely mode of transmission among MSM.
Given the unusually high frequency of person-to-person transmission observed in this event, and the likely community transmission without a history of travel to endemic areas, the likelihood of further spread of the virus through close contact, for example during sexual activities , is considered high. The probability of transmission between individuals without close contact is considered low.
The extent of community transmission is currently unknown. However, trials targeting people with such clinical manifestations are starting in the affected EU/EEA countries.
The clinical manifestation of monkeypox is usually mild. The West African clade, which has so far been detected in cases reported in Europe, has been found to have a case fatality rate of 3.6% in studies conducted in African countries. Mortality is highest among children and young adults, and immunocompromised people are especially at risk for severe disease. Most people recover within weeks.
Immediate recommendations
Health professionals should consider monkeypox infection as a differential diagnosis for people presenting with compatible clinical symptoms and should contact specialized services.
Public health organizations and community organizations should take steps to raise awareness about the potential spread of monkeypox in communities of people who identify as MSM or who have casual sex or have multiple sexual partners.
People who present such symptoms should seek specialized care. People who have multiple sexual partners or have casual sex should be particularly vigilant.
Suspected cases should be isolated and examined and reported promptly. Backward and forward contact tracing should be initiated for positive cases. If smallpox vaccines are available in the country, vaccination of high-risk close contacts should be considered after a risk-benefit assessment. For severe cases, treatment with a registered antiviral may be considered, if available in the country.
Action
The ECDC is closely monitoring the situation and is in contact with EU Member States and participating countries of the Health Security Committee. A rapid risk assessment is being developed and will be published early next week.
