On 23 July 2022, the World Health Organisation (WHO) declared monkeypox a public health emergency of international concern. By 15 December, over 82 500 confirmed cases of human monkeypox across 110 countries had been identified, with 98% of cases emerging in 103 non-endemic countries. Notably, most patients present without clear epidemiological links and non-specific clinical characteristics. We offer an overview of human monkeypox and of the assessment, diagnosis, and management of confirmed cases and at-risk patients based primarily on guidance from the WHO and the UK Health Security Agency (UKHSA).
What is monkeypox?
The monkeypox virus is a zoonotic orthopoxvirus related to the variola virus that causes smallpox. Its main reservoirs are rodents, apes, and monkeys. It was first described in humans in 1970 in the Democratic Republic of Congo (DRC). The following 11 countries have historically reported cases of monkeypox (that is, considered endemic for monkeypox virus): Benin, Cameroon, Central African Republic, Congo, Côte d’Ivoire, DRC, Gabon, Liberia, Nigeria, Sierra Leone, and South Sudan. However, there are insufficient data to delineate the differences between endemic and non-endemic regions. Further, the mode of transmission, presentation, and management during the current outbreak is similar in all regions.
Key management points
- Consider coinfections with monkeypox and other sexually transmitted infections among patients presenting with an acute rash or skin lesions and systemic symptoms
- While it is safe to manage monkeypox patients virtually, they may need advice to maintain infection control measures and interventions to manage complications
- A specialist infectious disease unit with access to novel antivirals such as tecovirimat and cidofovir should manage high risk patients
- Healthcare workers should be aware of the stigma surrounding monkeypox, which may result in reduced health-seeking behaviours; healthcare staff should screen patients sensitively, using inclusive language to avoid alienating patients
Read more in our article in the British Medical Journal.
Our recent article in the Journal of the Royal Society of Medicine discuses the diagnosis and management of Monkeypox in UK primary care settings but is also relevant to primary care clinicians working in other countries outside West and Central Africa that have seen Monkeypox cases in 2022.
Since its discovery in 1958 in monkeys, the Monkeypox virus has been rarely found outside west and central Africa until the current global outbreak. The first human case of the virus was in an infant from the Democratic Republic of Congo (DRC) in 1970; the infection has since spread to other regions, primarily in Africa. The first case of the current outbreak was confirmed on 6 May 2022, in the UK and was linked to travel to Nigeria. Two subsequent UK cases were detected a week later; however, neither affected individuals reported contact with the primary case in the UK nor travel to Africa.
On 23 July 2022, the World Health Organization (WHO) declared the current Monkeypox outbreak a public health emergency of international concern, as the number of cases increased rapidly around the world. As of 9 September 2022, 57,016 cases have been confirmed in 96 non-endemic regions, with the UK having one of the highest number of cases worldwide (3484 cases).
As we understand more about the current outbreak, particularly the community transmission of the virus, primary care clinicians may be the first point of healthcare access. Therefore, awareness of the signs and symptoms of the disease and current management strategies is crucial to providing optimal care and advice to patients.
Earlier this month, a case of Monkeypox was reported in London, followed by reports of further cases in the UK and in many other countries. Understandably, people are anxious whenever an outbreak of an unusual infectious disease occurs, likely more so because of their experiences during the Covid-19 pandemic. Although we need to take the disease seriously, Monkeypox is much less of a threat to global health than Covid-19 and won’t have the same impact on societies or lead to the type of control measures we have seen for Covid-19 over the past two years.
The virus that causes Monkeypox is found primarily in small animals, like rodents, in parts of West and Central Africa – but was first identified in monkeys (hence the name). It can sometimes spread to humans and because of international travel, then spread to other parts of the world. But unlike Covid-19, which is easily transmissible and has caused huge waves of infection globally, Monkeypox spreads much more slowly, requiring close contact with an infected person or animal to spread.
Monkeypox outbreaks can generally be contained through conventional public health measures – like identifying and isolating cases early on, tracing contacts to identify people who are at risk of infection, and good infection control practices when dealing with people who are infected. We know that smallpox vaccines also provides some protection against infection and can be used if necessary in health care workers or in close contacts to reduce their risk of becoming infected. However, use of vaccination will be very limited and we won’t see it used widely in the UK.
Our public health agencies are well-placed to manage the Monkeypox outbreak in the UK. We now have much more experience in areas such as contact tracing and in isolating people with infections than we did before the Covid-19 pandemic. Although we will continue to see cases of Monkeypox in the UK and elsewhere, our public health system has the capacity to limit the outbreak and prevent it from having a major effect on our society.
The Monkeypox outbreak does however reinforce the need for the UK to maintain a strong infection control system so that we are prepared to deal with this and any future infectious diseases that may enter the country. Finally, although people should not become unduly anxious and have a very low risk of coming into contact with a person who has Monkeypox, everyone should remain vigilant and seek medical advice if they become unwell and develop an unusual skin rash.