Why is there a surge in monkeypox cases in China in July? Zhang Wenhong's team releases the "Monkeypox Public Protection Guidelines" for patients | infected | China

Introduction: The monkeypox epidemic has hidden sexual transmission among men who have sex with men, and the source of infection is unclear, making prevention and control difficult. The overseas epidemic continues to enter China, and the risk of importation still persists.

Author | childlike innocence of money from first Finance and Economics

On August 10th, Professor Zhang Wenhong's team from the National Center for Infectious Diseases, Huashan Hospital affiliated with Fudan University, and Gao Zhiliang's team from the Department of Infectious Diseases at the Third Affiliated Hospital of Sun Yat sen University released the "Guidelines for Public Protection against Monkeypox" in the Chinese Journal of Infectious Diseases, answering 12 clinical questions about monkeypox.

Recently, the China Center for Disease Control and Prevention released the "Monitoring of Monkeypox Epidemic in July 2023". In July of this year, 23 provinces in mainland China reported 491 new confirmed cases of monkeypox, a significant increase from 106 cases in June. Among them, 115 cases were reported in Guangdong, 81 cases in Beijing, 49 cases in Sichuan, 40 cases in Zhejiang, 33 cases in Hunan, 31 cases in Jiangsu, and 25 cases in Shanghai, with no severe cases or deaths.

Regarding why there was a surge in cases in July, disease control experts explained that the main reason is that the monkeypox epidemic has hidden sexual transmission among men who have sex with men, and the source of infection is unclear, making prevention and control difficult; Secondly, with the promotion and education, the number of active medical cases among key populations has increased. In addition to close contact screening, cases have also been discovered through active reporting and screening of key populations; The third is that the overseas epidemic continues to enter China, and the risk of importation still exists.

Epidemiological investigation and analysis show that the monkeypox epidemic in China presents several major characteristics: firstly, all cases are male, and 96.3% of cases are clearly male behavioral groups; Secondly, there is a low risk of transmission through other forms of contact, and close contacts other than same-sex contact have not been infected; Thirdly, 89.2% of cases were discovered through active medical consultations, and 80% of cases were single cases. The source of infection is unclear, making prevention and control difficult; The fourth is that the vast majority of cases have typical clinical manifestations, mainly symptoms such as fever, herpes, and lymph node enlargement, with no severe cases or deaths.

At present, the general population does not need to be vaccinated

The latest guidelines point out that the interpersonal transmission of monkeypox is mainly due to direct contact with the skin or mucous membrane damage of monkeypox patients, oral secretions, and items contaminated by the virus. It can also be transmitted through long-term close inhalation of respiratory droplets from patients, or through sexual contact. In addition, there is also a possibility of vertical and intra hospital transmission.

Symptoms usually appear within 5-21 days after infection with monkeypox virus, with the majority lasting 6-13 days.

The high-risk population for monkeypox infection includes people who live with or have close contact with monkeypox patients, such as men who engage in male sexual activity; People who come into contact with monkeypox patients, including health workers infected with the monkeypox virus; Children, pregnant women, and people with weakened immunity.

The most common clinical manifestations of monkeypox include fever, rash, and enlarged lymph nodes, and may also include headaches, itching, fatigue, muscle soreness, back pain, sore throat, and oral ulcers. Among them, lymph node enlargement is a characteristic that distinguishes monkeypox from chickenpox.

The mortality rate of monkeypox infection is related to the infected virus branch, location, and the host's own health status. Since 2022, the virus has originated from Branch II, with a mortality rate of approximately 0.13%.

How can ordinary people prevent monkeypox? The Guidelines point out that the main goal is to avoid close contact with confirmed cases of monkeypox; Avoid contact with animals that may carry monkeypox virus, such as rodents, primates, and marsupials. But at present, the general population does not need to be vaccinated.

Due to the lack of large-scale sample based studies on the efficacy of monkeypox vaccines, according to the Interim Guidelines for Monkeypox Vaccination and Immunization issued by the World Health Organization, it is not recommended to conduct large-scale vaccination in the general population. In addition, due to the presence of cross immunity, smallpox vaccination can also prevent monkeypox. Research has shown that after receiving the smallpox vaccine, individuals can have a high immunity against monkeypox virus, with a protective effect of up to 85%.

At present, the main vaccines available globally for combating monkeypox are OrthopoxVac, MVA-BN, and LC16m8. These three vaccines were originally developed to prevent smallpox and have now been used for pre - and post exposure prevention of monkeypox virus. Non replicative vaccines are currently being developed domestically.

The Guidelines state that when suspected of having monkeypox, one should promptly go to the hospital for a clear diagnosis. Although monkeypox may cause rash and mucosal damage, distinguishing it solely based on clinical manifestations of the skin and mucosa can be challenging, especially for cases with atypical manifestations. Therefore, based on the combination of clinical manifestations and epidemiological investigations, when there is a high suspicion of infection with monkeypox, pathogen testing should be carried out as soon as possible.

The treatment of monkeypox virus infected patients mainly involves isolation observation and symptomatic support in designated infectious disease professional institutions, including pain relief and fever reduction, rash management, and nutritional support.

The long-term sequelae of monkeypox are not yet clear

Monkeypox is a self limiting disease with generally mild symptoms. Treatment focuses on symptomatic support. The World Health Organization's Interim Guidelines for Clinical Management and Infection Prevention and Control of Monkeypox suggest that acetaminophen can be used for treatment of fever and mild pain. If pain is intolerable, tramadol or opioid drugs can be used; For oral injuries, rinse daily with diluted saline solution. Monkeypox patients should be given sufficient nutrition.

At present, there are no clinically validated specific antiviral drugs for monkeypox. Antiviral drugs used for the treatment of smallpox may be beneficial for monkeypox infections, including terclovir, budoxifovir, and cilidofovir. The benefits of cowpox immunoglobulin are currently unclear.

What are the sequelae of monkeypox? The Guidelines state that only about one in ten monkeypox patients will experience sequelae, with the most common being facial scars and visual impairment, as well as possible neurological symptoms. However, there is currently limited research evidence, and the medium to long-term effects caused by monkeypox are not yet clear.

Currently, some studies have shown that monkeypox may cause neurological and psychiatric symptoms. A systematic review included 19 related studies, and the results showed that the incidence of epilepsy in monkeypox patients was 2.7%, mental disorder was 2.4%, and encephalitis was 2.0%. This result suggests that monkeypox may cause neurological and psychiatric symptoms, including severe neurological complications and non-specific neurological symptoms. However, it should be noted that due to the lack of relevant research at present, the causal relationship between the two still needs to be verified through long-term follow-up studies.

Monkeypox infection is mainly treated with symptomatic support, including relieving symptoms, managing complications, and preventing long-term sequelae. The Guidelines specifically point out the relevant management of special populations, including pregnant women, children, and HIV infected patients.

How to manage children who are infected with monkeypox? The Guidelines state that if a mother suffers from monkeypox, close monitoring of the newborn should be carried out to identify potential congenital or perinatal infections in a timely manner; For suspected infected children, timely epidemiological investigations should be carried out and they should be isolated, observed, and treated at corresponding medical institutions; The diagnosed child should be immediately isolated until the rash and scab subside.

The Interim Guidelines for Monkeypox Vaccination and Immunization released by the World Health Organization point out that although children are more prone to worsening of the disease after contracting monkeypox compared to other populations, it is still not recommended to vaccinate children before virus exposure.

How should pregnant patients with monkeypox be managed? The Guidelines suggest that pregnant patients diagnosed with monkeypox should be accompanied by epidemic prevention personnel to designated professional infectious disease treatment institutions for a period of 3 weeks of isolation observation and treatment. Simultaneously monitor the health status of the fetus.

For HIV patients with monkeypox, the Guidelines state that for known HIV patients diagnosed with monkeypox, antiretroviral therapy should continue and opportunistic infection prevention should be carried out as needed. For patients infected with monkeypox and newly diagnosed with HIV, antiretroviral therapy should be started as soon as possible.