Monkeypox

Monkeypox is a viral zoonotic disease that has historically occurred in tropical rainforest areas of central and west Africa. Cases of monkeypox have also been reported in non-endemic regions including Europe, United States and Australia. The monkeypox virus is a double-stranded DNA enveloped virus and can be transmitted from animal-to-human, human-to-human and via contaminated surfaces. 

WHAT IS MONKEYPOX?

Monkeypox is a viral zoonotic disease caused by infection with monkeypox virus. It is an enveloped double-stranded DNA virus in the genus Orthopoxvirus within the family Poxviridae1,2. Other members of the genus are variola virus (smallpox), vaccinia virus (used in the smallpox vaccine), and cowpox virus. Monkeypox was first discovered in 1958 in colonies of research monkeys following two outbreaks of pox-like disease. In 1970 the first human case of monkeypox occurred in the Democratic Republic of Congo and continues to occur primarily in tropical rainforest areas of central and west Africa. Since 2017, Nigeria has experienced a large outbreak, with over 500 suspected cases and over 200 confirmed cases and a case fatality ratio of approximately 3%1. It is occasionally reported in other regions. In 2003, the first monkeypox outbreak outside of Africa occurred in the United States of America, with over 70 cases that were linked to contact with infected pet prairie dogs. Monkeypox has been reported in travelers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, to Singapore in May 2019, and to the United States of America in July and November 2021. In May 2022, multiple cases of monkeypox were identified in several non-endemic countries. Studies are currently underway to further understand the epidemiology, sources of infection, and transmission patterns1.

WHAT ARE THE SYMPTOMS?

Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. Monkeypox is less contagious than smallpox and causes less severe illness. It typically presents clinically with fever, rash and swollen lymph nodes. Severe cases occur more commonly among children and are related to the extent of virus exposure, patient health status, and nature of complications. Underlying immune deficiencies may lead to worse outcomes. In recent times, the case fatality ratio has been around 3–6%1. Very few deaths have been reported in the 2022 outbreak.

HOW IS IT TRANSMITTED?

Transmission of monkeypox virus can occur when a person comes into contact with the virus from an infected animal, human, or materials/surfaces contaminated with the virus. The virus can enter the body through broken skin, respiratory tract, or the mucous membranes (eyes, nose, or mouth). Zoonotic or animal-to-human transmission may occur through a bite or scratch, bush meat preparation, direct contact with body fluids or lesion material, or indirect contact with lesion material, such as through contaminated bedding. Human-to-human transmission can occur through large respiratory droplets, for example if engaging in prolonged face-to-face contact with an infected individual. Other human-to-human methods of transmission include via the placenta from mother to fetus, direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens1. The main mode of transmission in the 2022 outbreak is reported to be intimate or skin-to-skin contact with individuals who have monkeypox2. Anyone in close or intimate contact with someone who has monkeypox is at risk, including caregivers, family members or others.

The reservoir host (main disease carrier) of monkeypox is still unknown but African rodents are suspected to play a part in transmission3.

HOW IS IT CONTROLLED?

Surveillance, rapid detection, raising awareness of risk factors and educating people about measures they can take to reduce exposure are the main ways to control Monkeypox. Vaccines and antiviral treatment options are available through healthcare providers. There are several measures that can be taken to prevent the spread of monkeypox virus: 

  • Practice enhanced precautions when traveling in areas experiencing outbreaks of Monkeypox
  • Avoid close, skin-to-skin contact with people who have a rash. 
  • Wash hands frequently with soap and water or use an alcohol-based hand sanitizer.  
  • If hands are visibly soiled, use soap and water before applying alcohol-based hand sanitizer. 
  • Ensure hand hygiene supplies are readily available at the point of use in pertinent locations (e.g., restrooms, kitchen or food preparation areas, high-traffic areas such as entrances and exits). 
  • Wear appropriate personal protective equipment (PPE) such as disposable gloves and a well-fitting mask when cleaning or handling linen, particularly in regions known to be higher risk for monkeypox or when a person suspected or confirmed to have monkeypox has occupied the area. 
  • Disinfect high touch hard, non-porous surfaces (e.g., doorknobs, light switches, railings) using an EPA registered disinfectant with an Emerging Viral Pathogen (EVP) claim4. Follow product label directions to ensure proper use concentration, wet contact time, and handling.
  • Ensure soiled linens are contained in a laundry bag or other receptacle and avoid shaking or handling in a manner that may disperse infectious material.  
  • Launder linens (e.g., towels, sheets, clothing) following standard laundry protocols5 including existing Ecolab products (e.g., detergent, etc.) and wash formulas. 
  • Avoid sharing dishes and eating utensils and wash these items following standard warewashing protocols.
  • Avoid activities (e.g., dry dusting, sweeping, use of fans) that could spread infectious particles in areas where a person with monkeypox has spent time6.

CONTROL IN A HEALTHCARE SETTING  

During an outbreak in a healthcare setting a combination of standard, contact, and droplet precautions should be applied for Monkeypox patients in addition to the following to control the spread of the virus7

  • Proper hand hygiene after all contact with an infected patient and/or their environment during care. 
  • Correct containment and disposal of contaminated waste (e.g., dressings) in accordance with facility-specific guidelines for infectious waste or local regulations pertaining to household waste.
  • Care when handling soiled laundry i.e. bedding, towels, personal clothing etc. from a patient suspected or confirmed to have monkeypox, to avoid contact with lesion material. 
    • Soiled laundry should never be shaken or handled in manner that may disperse infectious particles. 
    • Soiled linens can be disinfected using an EPA-registered laundry disinfectant with an Emerging Viral Pathogen claim 
  • Care when handling used patient-care equipment in a manner that prevents contamination of skin and clothing. 
    • Ensure that used equipment has been cleaned and reprocessed appropriately. 
  • Ensure procedures are in place for cleaning and disinfecting environmental surfaces in the patient care environment. 
    • An EPA-registered hospital disinfectant with an Emerging Viral Pathogen claim, currently used by healthcare facilities for environmental disinfection, may be used8. Follow the manufacturer’s recommendations for concentration, contact time, and care in handling.

REFERENCES AND FURTHER INFORMATION

  1. Monkeypox (who.int)
  2. Monkeypox outbreak 2022 - Global (who.int)
  3. Monkeypox | Poxvirus | CDC
  4. Disinfectants for Emerging Viral Pathogens (EVPs): List Q | US EPA
  5. Disinfecting Home and Other Non-Healthcare Settings | Monkeypox | Poxvirus | CDC
  6. Congregate Living Settings | Monkeypox | Poxvirus | CDC
  7. Infection Control: Hospital | Monkeypox | Poxvirus | CDC
  8. Disinfectants for Emerging Viral Pathogens (EVPs): List Q | US EPA