Changing epidemiology of monkeypox and risk for wide-scale outbreak : Al-Azhar Assiut Medical Journal

Secondary Logo

Journal Logo

Review Article

Changing epidemiology of monkeypox and risk for wide-scale outbreak

Yasri, Soraa,; Wiwanitkit, Virojb

Author Information
Al-Azhar Assiut Medical Journal 20(4):p 311-313, Oct–Dec 2022. | DOI: 10.4103/azmj.azmj_33_22
  • Open



Pox is a dangerous infection that can cause an acute illness with skin signs. The most well-known human pox infections are pox, smallpox, and chickenpox. In addition to the well-known pox infections, emergent zoonotic pox infections have become an interesting new issue in infectious medicine [1]. Monkeypox is a zoonotic illness caused by the monkeypox virus, an orthopoxvirus member. The spread of monkeypox to nonendemic areas has become a major public health concern [2]. Monkeypox is an unusual pox illness that has resurfaced, and zoonosis is assumed to be the cause [1].

Human monkeypox is a virus that was very recently discovered [3]. Africa is the endemic region for the disease. Visiting a forest is the main source of infection [4]. The zoonotic illness Human MonkeyPox Virus is endemic in the Congo basin and West Africa [1]. Its public health importance is underscored by its similarities to smallpox infection, increased susceptibility to infection in human populations, absence of a definitive cure, and potential for use as a bioterrorism agent [1].

Coinfection with monkeypox and varicella has also been described [5]. According to clinical features, patients with human monkeypox infection typically develop acute illness. According to Kalthan et al. [6], the main symptoms of the illness were fever and rash. Overall, 54.5% of the participants experienced lymphadenopathy. A new diagnostic test kit is now available to aid in the confirmation and identification of infections [7]. The recent discovery of extended human-to-human transmission of monkeypox infection [8] is causing widespread worry.

Current concern on monkeypox outbreak from imported cases

A zoonotic illness produced by an orthopoxvirus, monkeypox, causes a smallpox-like condition in humans. Since the first human cases of monkeypox were discovered in the Democratic Republic of the Congo (DRC) in 1970, the disease has spread to other parts of Africa (mainly West and Central), with cases outside of Africa emerging in recent years [9]. Bunge and colleagues found an increase in monkeypox cases, particularly in highly endemic areas, as well as a spread to neighboring countries and a median age shift from young children to young adults. These findings could be linked to the end of smallpox immunization, which gave some cross-protection against monkeypox, resulting in greater human-to-human transmission [9], according to Bunge and colleagues. A combination of population increase, accumulation of unprotected cohorts, and decrease in smallpox vaccine protection appears to have triggered the significant recurrence of monkeypox in Nigeria in 2017 [10]. According to Nguyen et al. [10], the growing unvaccinated population means that entire households, not just children, are now more vulnerable to monkeypox, raising the likelihood of human-to-human transmission.

The advent of epidemics outside of Africa, according to Bunge and colleagues, emphasizes the disease’s worldwide significance. Increased surveillance and detection of monkeypox cases are critical tools for gaining a better knowledge of the disease’s ever-changing epidemiology [9]. The medical community has been alerted by an increasing number of reported cases in several nations [2,11,12]. Between September 2018 and May 2021, six unrelated Nigerians were diagnosed with monkeypox in non-African nations in the United States: four in the United Kingdom and one each in Israel and Singapore [11]. A person traveling from Lagos, Nigeria, to Texas in July 2021 became the sixth non-African to be diagnosed with monkeypox [11]. Flying contacts accounted for up to 74% of the interactions observed [11]. The patient was given tecovirimat, an antiviral drug used to treat orthopoxvirus infections, and his home had to be thoroughly decontaminated [11]. On March 9, 2022, a case of monkeypox was discovered in a returning tourist from Nigeria to Maryland [12]. Costello advocated that public health systems be informed of possible measures to prevent the spread of monkeypox because of the global health implications [12]. Seven cases of monkeypox have already been verified in Europe [2]. These cases of imported monkeypox in the United States and Europe suggest that the disease may reemerge in other parts of the world.

How to manage the current situation

Human-to-human transmission is now being monitored. A growing number of reported instances in numerous countries has drawn the attention of the medical community. COVID-19 taught us that in the event of an outbreak, we must respond quickly, thoroughly investigate, and take action quickly. Although monkeypox is an old disease, it may have a new genetic mutation that causes a more severe illness and a broad epidemic. According to a recent report from Congo, estimations of molecular dating imply that periods of significant political instability resulting in population movements throughout the country, frequently accompanied with increasing poverty, may have resulted in more frequent contact with host wild animals [13]. The Congo’s socioeconomic status, military conflicts, and ecological changes, according to Berthet et al. [13], will likely encourage populations to engage more with wild animals, increasing the danger of zoonotic spillover.

As a result, it is vital to prepare for the likely reemergence of the pandemic. Isolation of diseased individuals in the human population helps to limit disease transmission, according to a mathematical model research [14]. Clinical investigation of newly emerging cases, including in-depth pathogen molecular analysis, disease control system implementation, including good case screening to prevent disease importation from endemic areas, and readiness for possible large-scale outbreak correspondence are all possible needs right now. The current consensus topic is the usage of an ancient vaccine to prevent sickness. As proven by monkeypox and buffalopox epidemics, declining smallpox immunity may increase the possibility for animal-to-human transmission, followed by community transmission person-to-person and through contact with fomites (as demonstrated by camelpox, cowpox, and potentially Alaskapox) [15]. The small pox vaccine could be reintroduced to help control the epidemic. The vaccination should be given to at least one disease contact individual [15].

Additionally, it is important to consider the likelihood of a concomitant infection with monkeypox or another disease, which could result in misdiagnosis and a delay in disease control. The combination of monkeypox and varicella zoster is a good example [16]. If no recognition is made, a missed diagnosis may occur, resulting in an unexpected breakout of monkeypox in new settings. PCR testing of samples from cutaneous lesions and blood are currently the gold standard for diagnosis.

If the monkeypox does eventually appear in a new setting, a good medical care system must be in place. As previously stated, no standard treatment for this disease exists. Most infected cases in African countries are treated with supportive and symptomatic therapy. Antibiotics, antihistamines, NSAIDs, and multivitamins may be prescribed, and universal precautions are required in the care center [17].


Monkeypox is an ancient viral disease that has been recorded in Africa on a sporadic basis. The recent influx of additional cases into Europe and the United States highlights the need for quick response in the event of a large-scale outbreak of this re-emerging illness.

Financial support and sponsorship


Conflicts of interest

There is nothing to declare.


1. Wiwanitkit S, Wiwanitkit V. Atypical zoonotic pox: acute merging illness that can be easily forgotten J Acute Dis. 2018;7:88–89
2. Mahase E. Seven monkeypox cases are confirmed in England BMJ. 2022;377:o1239
3. Di Giulio DB, Eckburg PB. Human monkeypox: an emerging zoonosis Lancet Infect Dis. 2004;4:15–25
4. Quiner CA, Moses C, Monroe BP, Nakazawa Y, Doty JB, Hughes CM, et al Presumptive risk factors for monkeypox in rural communities in the Democratic Republic of the Congo PLoS ONE. 2017;12:e0168664
5. Hoff NA, Morier DS, Kisalu NK, Johnston SC, Doshi RH, Hensley LE, et al Varicella coinfection in patients with active monkeypox in the Democratic Republic of the Congo Ecohealth. 2017;14(3):564–574
6. Kalthan E, Dondo-Fongbia JP, Yambele S, Dieu-Creer LR, Zepio R, Pamatika CM. Twelve cases of monkeypox virus outbreak in Bangassou District (Central African Republic) in December 2015 Bull Soc PatholExot. 2016;109:358–363
7. Li D, Wilkins K, McCollum AM, Osadebe L, Kabamba J, Nguete B, et al Evaluation of the geneXpert for human monkeypox diagnosis Am J Trop Med Hyg. 2017;96:405–410
8. Nolen LD, Osadebe L, Katomba J, Likofata J, Mukadi D, Monroe B, et al Extended human-to-human transmission during a monkeypox outbreak in the Democratic Republic of the Congo Emerg Infect Dis. 2016;22:1014–1021
9. Bunge EM, Hoet B, Chen L, Lienert F, Weidenthaler H, Baer LR, Steffen R. The changing epidemiology of human monkeypox − a potential threat? A systematic review PloS Negl Trop Dis. 2022;16:e0010141
10. Nguyen PY, Ajisegiri WS, Costantino V, Chughtai AA, MacIntyre CR. Reemergence of human monkeypox and declining population immunity in the context of urbanization, Nigeria, 2017–2020 Emerg Infect Dis. 2021;27:1007–1014
11. Rao AK, Schulte J, Chen TH, Hughes CM, Davidson W, Neff JM, et al July 2021 monkeypox response team. monkeypox in a traveler returning from Nigeria − Dallas, Texas, July 2021 Morb Mortal Wkly Rep. 2022;71:509–516
12. Costello V, Sowash M, Gaur A, Cardis M, Pasieka H, Wortmann G, Ramdeen S. Imported Monkeypox from International Traveler, Maryland, USA, 2021 Emerg Infect Dis. 2022;28:1002–1005
13. Berthet N, Descorps-Declère S, Besombes C, Curaudeau M, NkiliMeyong AA, Selekon B, et al Genomic history of human monkey pox infections in the Central African Republic between 2001 and 2018 Sci Rep. 2021;11:13085
14. Peter OJ, Kumar S, Kumari N, Oguntolu FA, Oshinubi K, Musa R. Transmission dynamics of Monkeypox virus: a mathematical modelling approach Model Earth Syst Environ. 2021;15:1–12
15. Diaz JH. The disease ecology, epidemiology, clinical manifestations, management, prevention, and control of increasing human infections with animal orthopoxviruses Wilderness Environ Med. 2021;32:528–536
16. Hughes CM, Liu L, Davidson WB, Radford KW, Wilkins K, Monroe B, et al A tale of two viruses: coinfections of monkeypox and varicella zoster virus in the Democratic Republic of Congo Am J Trop Med Hyg. 2020;104:604–611
17. Eseigbe EE, Akude C, Osagie IA, Eseigbe P. Human monkey pox virus infection in plateau state, North Central Nigeria: a report of two cases West Afr J Med. 2021;38:1242–1246

emergence; monkeypox; outbreak

© 2022 Al-Azhar Assiut Medical Journal | Published by Wolters Kluwer – Medknow