Monkeypox is rare but it has recently been in the news for its increase. It affects everyone, especially kids under the age of 15. A major study has found that the monkeypox virus outbreak is more predominant in men who have sex with men.
The World Health Organization declared the monkeypox outbreak a global health emergency on Saturday, July 23, 2022. The determination of this status is the highest warning issued by WHO due to the increase in monkeypox cases throughout the world.
The monkeypox virus was first discovered in Central Africa in the 1950s. Even though it was discovered decades ago, this disease never spread and sparked an outbreak outside the continent. However, in May 2022, authorities detected dozens of epidemics in Europe, North America and several other places.
Mpox, formerly known as monkeypox, has emerged as a global health concern in 2023 with an unprecedented rise in cases outside of its endemic regions in Central and West Africa.
This comprehensive review explores the current understanding of Mpox, focusing on its virology, epidemiology, clinical manifestations, diagnosis, treatment, and prevention strategies. The article specifically analyzes the situation in Indonesia, comparing it to the global landscape. It also delves into the recent emergence of Mpox cases in Europe among men who have sex with men (MSM) and its implications for public health responses. Finally, the article emphasizes the need for vigilance and preparedness in Indonesia, outlining potential control measures and highlighting areas for further research.
Mpox: A Re-emerging Zoonotic Threat
Mpox, a viral zoonotic disease caused by the Monkeypox virus (MPXV), has traditionally been confined to Central and West Africa. However, 2023 witnessed a significant surge in Mpox cases globally, raising concerns about its potential for further international spread. This resurgence underscores the dynamic nature of infectious diseases and the need for proactive public health interventions. This review aims to provide a comprehensive analysis of Mpox, focusing on its virological characteristics, epidemiology, clinical manifestations, diagnosis, treatment, and prevention strategies.
The global Mpox outbreak poses a significant public health challenge for Indonesia. The Indonesian Ministry of Health also highlighted the results of a report regarding the increasing lifestyle of male sex groups (gay), which is the cause of the increase in monkeypox and HIV. Nevertheless, the Ministry of Health is moving to overcome the spread of monkeypox cases by providing treatment and vaccines.
The following discussion, in general, is to explain some and aims to:
- Analyze the current understanding of Mpox, including its virology, epidemiology, and clinical presentation.
- Compare the global Mpox situation with the specific context of Indonesia, highlighting potential risks and vulnerabilities.
- Evaluate available diagnostic and treatment options for Mpox.
- Explore the role of public health interventions in mitigating Mpox spread, focusing on prevention, surveillance, and vaccination strategies.
- Identify areas for further research to optimize Mpox control measures in Southeast Asia.
Virological Characteristics of Mpox
Classification and Genome
MPXV belongs to the Orthopoxvirus genus within the Poxviridae family. It is a double-stranded DNA virus with a complex genome encoding for various proteins involved in viral replication, host interaction, and immune evasion. MPXV shares a close genetic relationship with the Variola virus (VARV), the causative agent of smallpox, which was eradicated in 1980. This genetic similarity explains the cross-protective efficacy of smallpox vaccines against Mpox.
Phylogenetic Lineages and Variants
MPXV exists in two distinct clades: the Central African (CA) clade and the West African (WA) clade [6]. The CA clade is associated with a higher case fatality rate (CFR) compared to the WA clade, which is responsible for the majority of the recent global cases. Within these clades, further genetic variations exist. Understanding these variations is crucial for epidemiological surveillance and potential development of targeted diagnostics and therapeutics.
Epidemiology of Mpox
Historical Context
The first human case of Mpox was identified in the Democratic Republic of Congo (DRC) in 1970 [7]. Subsequently, sporadic cases were reported primarily in Central and West African countries, often linked to zoonotic transmission from infected rodents. However, the recent global outbreak represents a significant shift in the epidemiological landscape of Mpox.
Global Outbreak in 2023
In May 2023, an unprecedented rise in Mpox cases was reported outside of endemic regions in Central and West Africa. The initial cases were identified in travelers returning from these areas. However, subsequent cases lacked travel history, indicating ongoing community transmission. The outbreak primarily affected men who have sex with men (MSM), raising concerns about potential modes of transmission beyond established zoonotic routes.
On 14 August 2024, WHO reassigned Public Health Emergency of International Concern (PHEIC) status to Mpox.
Based on a CNBC Indonesia report, 7th September 2024, the Mpox virus continues to spread rapidly in the Democratic Republic of Congo (CDR), cases have increased for several decades. Official figures from WHO show that this year there were almost 8,000 cases, including 384 deaths, almost half of which occurred in children under 15 years old.
Mpox in Indonesia
The first case of monkeypox in Indonesia was discovered in the Jakarta area in August 2022. As of September 2022, there were around 75 suspected cases of monkeypox, consisting of 1 confirmed case, 1 suspect and 73 discarded cases.
Based on data from the Indonesian Ministry of Health, which was published on August 17, 2024, there were 88 confirmed cases of Mpox. The most cases, 59 cases occurred in Jakarta and the others were spread across the provinces of West Java, Banten, Yogyakarta and the Riau Islands. Of this number, 87 cases have been declared cured. If we look at the weekly trend of Mpox confirmed case in Indonesia from 2022 to 2024, the period with the most cases occurred in October 2023.
The Indonesian Ministry of Health also highlighted the results of a report regarding the increasing lifestyle of male sex groups (gay), which is the cause of the increase in monkeypox and HIV. Nevertheless, the Ministry of Health is moving to overcome the spread of monkeypox cases by providing treatment and vaccines.
However, the lack of reported cases may happen, but it does not necessarily equate to complete absence of the virus. Limited testing availability, underreporting, and potential misdiagnosis could contribute to this gap. Additionally, Indonesia’s position as a major travel hub increases its vulnerability to Mpox introduction through international travel routes.
Comparative Epidemiology
The global Mpox outbreak differs significantly from the historical pattern observed in Central and West Africa. The current outbreak primarily affects MSM, suggesting a potential role for sexual transmission in this population group. 1 Further research is needed to elucidate the specific modes of transmission in the context of the ongoing outbreak. Additionally, the geographic distribution of cases
Clinical Manifestations of Mpox
Early Symptoms
Mpox typically presents with a non-specific prodromal phase characterized by fever, headache, muscle aches, backache, swollen lymph nodes, chills, and exhaustion. These symptoms may last for several days before the onset of a rash.
Skin Rash
The rash is a distinctive feature of Mpox and typically begins on the face, then spreads to other parts of the body, including the genitals. The rash progresses through several stages, including macules, papules, vesicles, pustules, and crusts. The lesions are often painful and may be accompanied by itching.
Complications
While most Mpox cases resolve without complications, severe illness can occur, particularly in young children, pregnant women, and immunocompromised individuals. Complications may include pneumonia, encephalitis, sepsis, and death.
Diagnosis of Mpox:
Clinical Evaluation
The diagnosis of Mpox is primarily based on clinical presentation, including the characteristic rash and prodromal symptoms. However, it is essential to consider other differential diagnoses, such as smallpox, chickenpox, and other viral exanthems.
Laboratory Testing
Confirmation of Mpox diagnosis requires laboratory testing. Polymerase chain reaction (PCR) is the most sensitive and specific method for detecting MPXV DNA in clinical specimens, such as skin lesions, respiratory secretions, or blood [10]. Other diagnostic tests, such as enzyme-linked immunosorbent assay (ELISA) and immunofluorescence assay (IFA), can be used to detect MPXV antibodies in serum.
Treatment of Mpox
Supportive Care
Currently, there is no specific antiviral treatment for Mpox. Management focuses on supportive care to alleviate symptoms and prevent complications. This includes pain management, fluid hydration, and treatment of secondary infections.
Antiviral Medications
Antiviral medications developed for smallpox, such as tecovirimat, brincidofovir, and cidofovir, have shown potential activity against MPXV in animal models. However, their efficacy in humans remains to be fully established. These medications may be considered in severe cases, particularly in immunocompromised individuals, but their use should be guided by clinical judgment and available evidence.
Prevention and Control of Mpox
Public Health Measures
Effective prevention and control of Mpox require a multi-faceted approach, including:
- Raising awareness among healthcare providers and the public about the signs and symptoms of Mpox, transmission routes, and preventive measures.
- Contact tracing and isolation of infected individuals to prevent further transmission.
- Strengthening surveillance systems to detect and monitor Mpox cases.
- Promoting safe hygiene practices, including handwashing and respiratory etiquette.
- Promoting vaccination against smallpox, which offers cross-protection against Mpox.
Vaccination
The Jynneos vaccine, originally developed for smallpox, has been shown to be effective against Mpox in animal models and has been approved for use in humans in the United States. However, vaccine availability remains limited in many countries, including Indonesia. Vaccination strategies should prioritize healthcare workers, laboratory personnel, and individuals at high risk of exposure, such as those with close contact with infected animals or persons.
Research and Development
Further research is needed to address critical knowledge gaps in Mpox, including:
- Understanding the natural history of Mpox and its transmission dynamics.
- Developing more effective antiviral drugs specifically targeting MPXV.
- Improving access to vaccines and ensuring equitable distribution.
- Investigating the role of animal reservoirs in Mpox transmission.
Mpox in Indonesia: A Comparative Analysis
Risk Factors and Vulnerabilities
Indonesia’s vulnerability to Mpox introduction stems from several factors, including:
- International travel and trade: The country’s position as a major travel hub increases the risk of Mpox importation from affected regions.
- Zoonotic transmission: Indonesia’s diverse ecosystems and close human-animal interactions create opportunities for zoonotic transmission of Mpox.
- Limited surveillance and diagnostic capacity: The country’s ability to detect and respond to Mpox outbreaks may be constrained by limited resources and infrastructure.
Preparedness and Response
To mitigate the risk of Mpox in Indonesia, it is essential to strengthen public health preparedness and response efforts. This includes:
- Developing a comprehensive Mpox surveillance plan, including case definitions, reporting mechanisms, and laboratory capacity.
- Training healthcare providers on the diagnosis, management, and prevention of Mpox.
- Establishing a system for early detection and response to potential outbreaks.
- Ensuring adequate supplies of diagnostic tests, personal protective equipment, and essential medical supplies.
- Coordinating with international health organizations to share information and best practices.
Conclusion
The global Mpox outbreak represents a significant public health challenge that requires a coordinated international response. Indonesia, despite having small numbers of confirmed cases as of October 2024, is at risk of introduction due to its geographic location and international connectivity. Strengthening public health preparedness, enhancing surveillance, and implementing effective prevention measures are crucial to mitigate the potential impact of Mpox in Indonesia. Further research is needed to address the evolving nature of this virus and inform evidence-based control strategies.
Future Directions and Research Priorities
Surveillance and Epidemiology
- Strengthening surveillance systems to detect and monitor Mpox cases, including the establishment of sentinel sites and the use of advanced diagnostic techniques.
- Investigating the role of different modes of transmission, including sexual transmission and zoonotic transmission.
- Studying the factors associated with disease severity and outcomes.
- Conducting epidemiological modeling to predict the potential spread of Mpox and inform control measures.
Virology and Pathogenesis
- Investigating the genetic diversity of MPXV and its implications for disease severity and vaccine effectiveness.
- Understanding the mechanisms of MPXV entry into cells and replication.
- Identifying the viral proteins involved in immune evasion and pathogenesis.
- Studying the interaction between MPXV and the host immune response.
Therapeutics and Vaccines
- Developing novel antiviral drugs with improved potency and specificity against MPXV.
- Evaluating the efficacy and safety of existing smallpox vaccines against Mpox in different populations.
- Investigating the potential for passive immunization using monoclonal antibodies against MPXV.
- Exploring the development of live attenuated or recombinant Mpox vaccines.
Public Health and Social Sciences
- Conducting social science research to understand the impact of Mpox on individuals, communities, and healthcare systems.
- Developing effective communication strategies to raise awareness and promote behavioral changes.
- Addressing stigma and discrimination associated with Mpox.
- Evaluating the effectiveness of public health interventions and identifying areas for improvement.
Conclusion
The emergence of Mpox as a global health threat highlights the importance of preparedness and response for emerging infectious diseases. While no confirmed cases have been reported in Indonesia, the country’s vulnerability to Mpox introduction necessitates a proactive approach. Strengthening public health surveillance, enhancing diagnostic capabilities, and implementing effective prevention measures are crucial to mitigate the potential impact of Mpox in Indonesia. Further research is needed to address the evolving nature of this virus, inform evidence-based control strategies, and ensure the long-term well-being of populations worldwide.
Additional Considerations
- Climate Change and Mpox: Climate change may influence the geographic distribution and transmission dynamics of Mpox. Changes in temperature, precipitation, and land use patterns can affect the habitats of rodents and other potential reservoirs of the virus.
- Emerging Variants: The ongoing evolution of MPXV may lead to the emergence of new variants with different characteristics, potentially affecting disease severity, transmissibility, and vaccine effectiveness.
- Global Health Governance: International collaboration and cooperation are essential for effective Mpox control. Strengthening global health governance mechanisms, including the World Health Organization (WHO), can facilitate information sharing, resource mobilization, and coordinated responses.
- Equity and Access: Ensuring equitable access to Mpox prevention, diagnosis, and treatment is crucial for addressing health disparities and preventing the virus from disproportionately affecting marginalized populations.
- One Health Approach: A One Health approach, which recognizes the interconnectedness of human, animal, and environmental health, is essential for understanding and addressing the complex factors that influence Mpox transmission and emergence.
Future Outlook
The global Mpox outbreak represents a significant public health challenge that requires sustained attention and coordinated action. While the current situation is evolving, the future outlook for Mpox control depends on several factors, including:
- The effectiveness of public health interventions and the availability of resources.
- The emergence of new variants or changes in the virus’s characteristics.
- The development of more effective vaccines and therapeutics.
- The ability of countries to strengthen their surveillance systems and respond effectively to outbreaks.
By addressing these challenges and implementing comprehensive control measures, it is possible to mitigate the impact of Mpox and prevent future outbreaks. However, ongoing vigilance and international cooperation are essential to ensure the long-term health and well-being of populations worldwide.