CME INDIA Presentation by Dr. S. K. Gupta, MBBS, MD(Med), CFM (France), Senior Consultant Physician, Delhi.

MPOX in India Confirmed

First Suspected Case of mpox reported from India in a person having travelled abroad: Now Confirmed.

• The resurgence of Mpox, along with the emergence of a new strain known as Clade 1b in the Democratic Republic of Congo (DRC), led the World Health Organization (WHO) to declare its highest level of international alert on August 14.
• India’s health ministry reported a suspected Mpox case on Sunday in a person who had recently returned from abroad and was placed in isolation. On Monday, the ministry confirmed that while the case was indeed Mpox, it was caused by the Clade 2 strain.
• “Laboratory testing has confirmed the presence of the Mpox virus of the West African Clade 2 in the patient,” the ministry stated. “This case is isolated and not related to the current public health emergency declared by the WHO, which involves Clade 1b of Mpox.”
• There have been no confirmed cases of the new Clade 1b strain in India, a country of 1.4 billion people. The individual, a young male who recently travelled from a country experiencing ongoing Mpox transmission, is currently isolated at a designated tertiary care facility.
• “Public health measures, including contact tracing and monitoring, are actively underway to contain the situation,” the statement added. “There is no indication of any widespread risk to the public at this time.”
• The Clade 1b strain was first detected among sex workers in eastern DRC in September 2023. Cases of Clade 1b have since been reported in neighbouring countries, including Burundi, Kenya, Rwanda, and Uganda – nations that had not previously recorded Mpox. The strain has also been detected in Asia and Europe.

No need to panic 

• Mpox (formerly known as monkeypox) is an infectious viral disease affecting humans and other animals.
• Mpox is caused by a DNA Virus unlike COVID virus which is an RNA virus (it’s important to know because RNA virus undergo rapid mutations)

Symptoms: 

• Symptoms include a rash -> blisters -> crusts over, *fever, and *swollen lymph nodes. Exhaustion, muscle aches, sore throat.
• In some people, the first symptom of mpox is a rash, while others may have fever, muscle aches or sore throat first.  
• The mpox rash often begins on the face and spreads over the body, extending to the palms of the hands and soles of the feet (It can also start on other parts of the body where contact was made, such as the genitals).
• Rash starts as a flat sore, which develops into a blister filled with liquid that may be itchy or painful. 
• As the rash heals, the lesions dry up, crust over and fall off. 
• Some people may have one or a few skin lesions and others have hundreds or more.
• These can appear anywhere on the body including: 

• Palms of hands and soles of feet 
• Face, mouth and throat 
• Groin and genital areas 
• Anus.

Note: Blisters are a feature of Chicken Pox but chicken pox is not usually associated with Swollen Lymph Nodes. Secondly, Mpox blisters are mainly on palms and soles.

Latent period:

• The time from exposure to the onset of symptoms ranges from 3 -17 day.

Duration:

• Symptoms last from 2-4 weeks.

Symptoms can be severe, especially in children, pregnant women, or people with suppressed immune systems.

Transmission:

• Close contact includes:

• Skin-to-skin (such as touching or sex).
• Mouth-to-mouth, or (lip kissing).
• Mouth-to-skin contact (such as kissing).
• Face-to-face with someone who has mpox (such as talking or breathing close to one another, which can generate infectious respiratory particles).

• Occasionally surface touch to abraded skin, mucus membranes (like nose, eyes); So washing hands is important. (Hand wash with Soap Water or Alcohol Based sanitizer.)

Avoid

Sharing Mobile Phones.

Sharing towels, beds linen etc.

Usually transmitted from one person to another through contact with *infectious lesion material or fluid on the skin, in the mouth or on the genitals; this includes touching, close contact, and during sex.

The disease is not known to spread by air respiratory route – for example, across rooms, in markets or classrooms, etc.

At Risk 

• Sex workers and their clients.
• Men having sex with Men.
• People with Multiple sex partners.
• Close contacts.
• Health workers (use PPE, hand washing, mask).

Period of infectivity:

• Until all their lesions have crusted over, the scabs have fallen off and a new layer of skin has formed underneath, and all the lesions on the eyes and in the body (in the mouth, throat, eyes, vagina and anus) have healed too, which usually takes from 2 to 4 weeks.

Diagnostic method

• Viral DNA PCR on blister Fluid/Scraping/Scab.

Differential diagnosis

• Chickenpox, smallpox, Scabies.

Prevention

• Smallpox vaccine, hand washing, covering rash, PPE, social distancing.

Vaccination: 

• Limited human studies and some animal studies have shown protection against Mpox following vaccination with Smallpox vaccines.
• MVA -BN or JYNNEOS (live attenuated nonreplicating vaccine given ID or SC).
• Only those with high risk of exposure are advised to have vaccine. 

FAQ

Does Chicken pox vaccination protect against Mpox?

• No. If someone has chickenpox vaccination or infection, it offers no cross protection against mpox because they are entirely different and unrelated viruses.
• However, the skin lesions look the same in both. In fact, one can be confused with the other. 

Does previous vaccination against Small pox provide any protection against mpox?

• Unlikely so.  
• Several cases of mpox have been reported in previously immunized persons with smallpox. Best is to take precautions.

Treatment

• Supportive treatment, pain fever management, nutrition, hydration Isolation. Prevention of secondary infection 

Medication

• Tecovirimat, not yet freely available but as trial enrolment.

Prognosis

• Most people recover.

Should we curtail foreign trips?

• No. Just observe safe sex practices and avoid contact with high-risk community.

Will mpox blow up like Covid?

• No. 

• Because it is DNA Virus which does not change so often.
• Vaccine already in place.
• Treatment already in place.
• High-risk community is limited.

Nevertheless, be informed and vigilant.

CME INDIA Learning Points

1. Resurgence and New Strain: Mpox has seen a resurgence, with the detection of a new strain, Clade 1b, in the Democratic Republic of Congo (DRC). This variant has led the World Health Organization (WHO) to declare its highest level of international alert as of August 14, 2024.

2. Global Spread: The Clade 1b strain was initially identified in sex workers in eastern DRC in September 2023. Since then, cases have been reported in Burundi, Kenya, Rwanda, Uganda, Asia, and Europe—areas that had not previously detected Mpox.

3. Clinical Presentation: Classic Symptoms: Patients typically present with fever, headache, muscle aches, back pain, swollen lymph nodes, and a characteristic rash that progresses through macules, papules, vesicles, and pustules before scabbing over.

Severe Cases: Immunocompromised individuals, including those with HIV, are at higher risk for severe disease.

Clade 1b Characteristics: This strain may present with atypical manifestations, and data suggest it may have increased transmissibility and severity compared to the West African Clade 2 strain.

4. Current Situation in India:

   – A suspected Mpox case in India was recently confirmed as Clade 2 (West African lineage), not the new Clade 1b strain.

   – The patient, who had traveled from a country with active Mpox transmission, is in isolation. Public health measures, including contact tracing and monitoring, are actively being enforced.

5. WHO Recommendations:

• Enhanced global surveillance is critical, especially in regions with new or increased transmission.
• Clinicians should consider Mpox in patients with compatible symptoms, especially those with recent travel to affected regions. Diagnosis is confirmed by PCR testing of lesion samples.
• Patients with suspected or confirmed Mpox should be isolated. Healthcare providers should use appropriate PPE to prevent transmission.
• Vaccination is recommended for high-risk individuals. Tecovirimat, an antiviral, is available under certain circumstances for severe cases or those at high risk of complications.

6. Management:

• Supportive care is the mainstay of treatment. Attention to pain management, hydration, and prevention of secondary bacterial infections is essential.
• In severe cases, particularly in immunocompromised patients, antiviral therapy may be considered under guidance.

7. Public Health Response:

• No widespread risk has been identified in India, but healthcare providers should remain vigilant.
• Early detection, isolation, and contact tracing are critical to containing outbreaks.

CME INDIA Tail-Piece

• Mpox continues to be a significant public health concern, especially with the emergence of the new Clade 1b strain. Clinicians should maintain a high index of suspicion in patients presenting with compatible symptoms, especially those with relevant travel history or epidemiologic links. Prompt diagnosis, isolation, and appropriate management are crucial in limiting transmission and protecting public health.
• The Union Health Ministry has confirmed that the previously suspected case of Mpox (monkeypox) in India is a travel-related infection caused by the West African Clade 2 strain of the virus. Laboratory testing verified the presence of this strain, which is distinct from the Clade 1 strain currently driving the public health emergency declared by the World Health Organization (WHO).
• This latest case mirrors the pattern of earlier cases reported in India, with 30 instances documented since July 2022, all involving the West African Clade 2 strain. These cases are not connected to the recent global concerns surrounding the Clade 1 strain.
• The patient, a young male who recently traveled from a country with ongoing Mpox transmission, is in isolation at a designated tertiary care facility. He remains clinically stable, without systemic illness or comorbidities.
• Public health measures, including contact tracing and monitoring, are underway to ensure the containment of the case. The ministry emphasized that there is no widespread risk to the public at this time.

References:

1. Bunge, E. M., Hoet, B., Chen, L., et al. (2022). The changing epidemiology of human monkeypox—A potential threat? A systematic review. PLOS Neglected Tropical Diseases, 16(2), e0010141.
2. Reynolds, M. G., McCollum, A. M., & Nguete, B. (2017). Improving the care and treatment of monkeypox patients in low-resource settings: Applying evidence from contemporary biomedical and smallpox biocontainment research. Viruses, 9(12), 380.
3. Yinka-Ogunleye, A., Aruna, O., Dalhat, M., et al. (2019). Outbreak of human monkeypox in Nigeria in 2017–18: A clinical and epidemiological report. The Lancet Infectious Diseases, 19(8), 872-879.
4. https://www.who.int/news/item/14-08-2024-who-director-general-declares-mpox-outbreak-a-public-health-emergency-of-international-concern.

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