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REVIEW: AN ANALYSIS OF MONKEYPOX DISEASE AND CURRENT SCENARIO IN

MALAYSIA

Article · September 2019

DOI: 10.5281/zenodo.3464386

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[Mustaffa et. al., Vol.7 (Iss.9): September 2019] ISSN- 2350-0530(O), ISSN- 2394-3629(P)
DOI: 10.5281/zenodo.3464386

Science

REVIEW: AN ANALYSIS OF MONKEYPOX DISEASE AND CURRENT

SCENARIO IN MALAYSIA

Fazlina Mustaffa *1, Nur Adilla Zaini 2, Komathi Selvarajah 2

*1
Department of Pharmacology, Faculty of Pharmacy, Asian Institute of Medical Sciences and
Technology (AIMST) University -Kedah, Malaysia
2
Department of Microbiology, Faculty of Medicine, Asian Institute of Medical Sciences and
Technology (AIMST) University -Kedah, Malaysia

Abstract
Recently, there is large outbreak of monkeypox virus in Central Africa and this remains as a
growing public health threat. The last confirmed case of monkeypox was in 1978 at Nigeria.
Monkeypox is now a major threat to global health security, requiring an urgent multidisciplinary
approach including virologists, veterinarians, physicians, and public health experts to fast‐track
the development of diagnostic assays, vaccines, antivirals, and other control strategies. This aim
of this manuscript is to provide information on the current state of knowledge about human
monkeypox, with emphasis on epidemiologic characteristics, clinical features, diagnosis,
treatment, and prevention.

Keywords: Monkeypox; Malaysia; Treatment.

Cite This Article: Fazlina Mustaffa, Nur Adilla Zaini, and Komathi Selvarajah. (2019).
“REVIEW: AN ANALYSIS OF MONKEYPOX DISEASE AND CURRENT SCENARIO IN
MALAYSIA.” International Journal of Research - Granthaalayah, 7(9), 82-87.
https://doi.org/10.5281/zenodo.3464386.

1. Introduction

The first case of monkeypox was first reported in a 9-month-old child from Zaire in 1970 (1, 15).
Poxvirus infections are a common cause of cutaneous signs. Monkeypox is regarded as the most
important orthopoxvirus infection in human beings since the eradication of smallpox. Monkeypox
is a rare zoonotic viral disease caused by the monkeypox virus belonging to the Orthopox virus
genus. Other notable members of this group include smallpox, vaccinia, cowpox, camelpox,
ectromelia (mousepox) and other viruses (2, 16). There is no evidence to date that person-to-person
transmission alone can sustain monkeypox in the human population. After smallpox eradication in
1980 and consequent to the cessation of smallpox vaccination, monkeypox emerged as the most
prevalent orthopoxvirus infection in humans (3). The high risk of dissemination of this virus is due
to the increase in international transport as well as loss of vaccinal protection against smallpox (4).
Furthermore, trends for new animals as pets also increase the risk of monkeypox transmission

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among public. Monkeypox has a wide range of hosts, 4 which has allowed it to maintain a reservoir
in wild animals while sporadically causing human disease, and has precluded global eradication
by human vaccination (5). Effective prevention relies on limiting the contact with infected patients
or animals and limiting the respiratory exposure to infected patients.

2. Prevalence of Monkeypox Infection Cases

Monkeypox has been reported in the tropical rainforest region of Central and West Africa. The
central and Western Africa includes the region of Democratic Republic of Congo, Cameroon,
Central African Republic, Nigeria, Ivory Coast, Liberia, Sierra Leone, Gabon and South Sudan. It
is considered endemic in Democratic Republic of Congo with more than 1000 suspected cases per
year since 2005. Nigeria reported a large multistate outbreak in 2017 to 2018. In 2003, the Centres
for Disease Control (CDC) reported 47 confirmed and probably human monkeypox cases in six
(6) states (6,17). Cases were infected after contact with prairie dogs purchased as pet, which was
earlier kept in proximity with small mammals imported from Ghana. Investigation revealed some
patients get infected after touching sick animals, being bitten or scratched, and cleaning cage and
the animal’s bedding. No cases attributed to human-to-human transmission. In September 2018,
the UK reported two imported cases in travellers returning from Nigeria. iii. On 12 October 2018,
Israel reported a case, a 38-year-old Israeli man who was working in Nigeria and came back to
Israel who had history of contact with dead rodents. Recently, on 9 May 2019, Singapore reported
one case, a Nigerian who entered Singapore on 28 April 2019 and had history of consuming bush
meat in Nigeria.

3. Mode of Virus Transmission

The monkeypox virus is transmitted to humans through a bite or direct contact with an infected
animal’s blood, body fluids or cutaneous/mucosal lesions. Monkeypox virus transmission occurs
when a person comes into contact with the virus from human, animal or materials contaminated
with the virus. It was postulated that the virus enters the body through broken skin, mucous
membrane or respiratory tract. Animal to human transmission is possible by bite or scratch, bush
meat preparation or direct contact with body fluids or lesion material. Indirect contact with lesion
material such as through contaminated bedding may also cause the virus transmission (7). Human
to human virus transmission is thought to occur mainly through large respiratory droplets.
Respiratory droplets generally cannot travel more than a few feet, hence prolonged face toface
contact is required for the virus transmission. Other human to human methods of transmission
include direct or indirect contact with lesion material or body fluids (8).

The reservoir host (main disease carrier) of monkeypox is still unknown although African rodents
are suspected to play a part in transmission. The virus that causes monkeypox has only been
recovered (isolated) twice from an animal in nature. In the first instance (1985), the virus was
recovered from an apparently ill African rodent (rope squirrel) in the Equateur Region of the
Democratic Republic of Congo. In the second (2012), the virus was recovered from a dead infant
mangabey found in the Tai National Park, Cote d’Ivoire. Human to human transmission is rare and
likely to occur by close contact or airborne routes (9).

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4. Symptoms of Illness

The incubation period is usually 6 to 21 days. The illness typically lasts for two to four weeks. It
is characterised by fever, myalgia, headache, lymphadenopathy and rash. The rash which is first
seen about two days after fever onset usually starts in the trunk and spreads peripherally to involve
the palms and soles. The rash starts as a macules and papules and then progresses to become
vesicles and pustules before scabbing and desquamation over a 2-3 week period. Unlike in
chickenpox where lesions at various stages of development and healing are seen, in monkeypox
all the lesions are generally at the same stage. Lymphadenopathy is observed prior to and
concomitant with the rash, which helps differentiate it from smallpox or varicella (10).

5. Risk of Infection in Malaysia

Introduction of monkeypox case might be related to importation. The risk of its spread in Malaysia
is very low due to the limited human-to-human transmission. lf there is any, early identification of
cases is vital for early case management including isolation and contacts tracing.

6. Identification of New Cases

Case will present with maculopapular or vesicular rash or pustular, generalised or localised,
discrete or confluent with one or more of the symptoms such as chilling, sweating, headache,
backache, lymphadenopathy, sore throat, cough, shortness of breath with epidemiologic criteria as
exposure to a suspect, probable or confirmed human case of monkeypox within the incubation
period or exposure to wild, captive or pet mammal from or in the African monkeypox endemic
countries within the incubation period (11,18).

7. Diagnosis of Monkeypox Infection in Malaysia

National Public Health Laboratory (NPHL) and Institute for Medical Research (IMR) have the
capacity to do test for monkeypox virus. Optimal diagnostic specimens are from lesion i.e.
vesicular swabs of lesion exudate or crust, stored in a dry sterile tube (without any viral transport
media) and send on ice. Blood and serum is useful if taken at the viremia phase. Monkeypox
infection is confirmed via isolation of monkeypox virus in culture or demonstration of the virus
DNA by PCR test. Probable case of monkeypox is when there is a demonstration of virus
morphology under electron microscope or presence of orthopoxvirus in tissue using
immunohistochemical test; in the absence of exposure to another orthopoxvirus. Monkeypox cases
are classified into three different categories as below.
1) Suspect: a clinically compatible case that meets epidemiologic criteria that is awaiting
laboratory test result.
2) Probable: a clinically compatible case that meets epidemiologic criteria and probable
laboratory criteria for monkeypox.
3) Confirmed: a clinically compatible case with laboratory confirmed for monkeypox
infection.

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8. Treatment for Monkeypox Infection

There is no specific treatment or vaccine for monkeypox infection. Monkeypox is usually a self-
limited disease with the symptoms lasting from 2 to 3 weeks. Severe symptoms common among
children and is related to extent of virus exposure and patient’s health status. McSharry JJ et al
(2009) reported on an investigational new-drug cidofovir for treatment of variola infection. The
use of an acyclic nucleoside phosphonate analogue (ANPA) was also being studied in animal
infected with variola virus. A registered ANPA in Malaysia is Tenofovir®. However, no further
studies or articles found to support the effectiveness of these drugs in treating monkeypox. CDC
Atlanta reported that monkeypox outbreak can be controlled with smallpox vaccine, antiviral
cidofovir, ST-246 (tecovirimat) and vaccinia immune globulin (VIG).

9. Management of Monkeypox Spreading

Even though human-to-human infection is limited, health care workers attending to monkeypox
patient must implement standard contact and airborne infection control precautions (12,19). A
monkeypox case should be isolated until all lesions have resolved and scabs separate. Close contact
includes of anyone who provided care for the patient including a health care worker or family
member, or had other similarly close physical contact should also be isolated. Anyone who stayed
at the same place (e.g. lived with, visited) is identified as a probable or confirmed case while the
case was symptomatic. Contacts with high risk of infections need to be quarantined and monitored
for 21 days from the date of last exposure to the confirmed case; for monkeypox symptoms and
signs surveillance. Contacts with low risk of being infected are to be placed under active
surveillance with twice daily monitoring of their health status. Asymptomatic contacts should not
donate blood, cells, tissue, organs, breast milk or semen while they are under symptom
surveillance.

Monkeypox is not in the list of notifiable disease under the Prevention and Control of Infectious
Disease Act 1988. However, as it is a new and emerging disease, all suspected or probable or
confirmed monkeypox cases must be notified via phone or fax or email to nearest district health
office within 24 hours.

10. Who Recommendation of Travel or Trade Restrictions Related to Monkeypox

At this point of time, based on available information, WHO does not recommend any restriction
for travel to and trade with Singapore or Nigeria.

11. Precautions While Travelling to Monkeypox Endemic Countries

Travelers to monkeypox endemic countries should avoid contact with sick, dead or live animals
(rodents, marsupials, primates) that could harbor the virus (13). Do not eat or handle bush meat.
Travellers must always practice good self-hygiene including proper hand hygiene using soap and
water. Travellers must practice the use alcohol-based sanitizer when water and soap is no available.
Any illness during travel or upon return should be reported to a health professional. Tell the doctor
about all recent travel (19, 20).

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*Corresponding author.
E-mail address: fazlina_mustaffa@ yahoo.com

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