[Twelve cases of monkeypox virus outbreak in Bangassou District (Central African Republic) in December 2015]

Understanding the infection severity and epidemiological characteristics of mpox in the UK

In May 2022, individuals infected with the monkeypox virus were detected in the UK without clear travel links to endemic areas. Understanding the clinical characteristics and infection severity of mpox is necessary for effective public health policy. The study period of this paper, from the 1st June 2022 to 30th September 2022, included 3,375 individuals that tested positive for the monkeypox virus. The posterior mean times from infection to hospital admission and length of hospital stay were 14.89 days (95% Credible Intervals (CrI): 13.60, 16.32) and 7.07 days (95% CrI: 6.07, 8.23), respectively. We estimated the modelled Infection Hospitalisation Risk to be 4.13% (95% CrI: 3.04, 5.02), compared to the overall sample Case Hospitalisation Risk (CHR) of 5.10% (95% CrI: 4.38, 5.86). The overall sample CHR was estimated to be 17.86% (95% CrI: 6.06, 33.11) for females and 4.99% (95% CrI: 4.27, 5.75) for males. A notable difference was observed between the CHRs that were estimated for each sex, which may be indicative of increased infection severity in females or a considerably lower infection ascertainment rate. It was estimated that 74.65% (95% CrI: 55.78, 86.85) of infections with the monkeypox virus in the UK were captured over the outbreak.

Molecular epidemiology, transmission and clinical features of 2022-mpox outbreak: A systematic review

Background and Aims

The 2022-mpox outbreak has spread worldwide in a short time. Integrated knowledge of the epidemiology, clinical characteristics, and transmission of mpox are limited. This systematic review of peer-reviewed articles and gray literature was conducted to shed light on the epidemiology, clinical features, and transmission of 2022-mpox outbreak.

Methods

We identified 45 peer-reviewed manuscripts for data analysis. The standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement and Cochrane Collaboration were followed for conducting the study.

Results

The case number of mpox has increased about 100 times worldwide. About 99% of the cases in 2022 outbreak was from non-endemic regions. Men (70%-98% cases) were mostly infected with homosexual and bisexual behavior (30%-60%). The ages of the infected people ranged between 30 and 40 years. The presence of HIV and sexually transmitted infections among 30%-60% of cases were reported. Human-to-human transmission via direct contact and different body fluids were involved in the majority of the cases (90%-100%). Lesions in genitals, perianal, and anogenital areas were more prevalent. Unusually, pharyngitis (15%-40%) and proctitis (20%-40%) were more common during 2022 outbreak than pre-2022 outbreaks. Brincidofovir is approved for the treatment of smallpox by FDA (USA). Two vaccines, including JYNNEOSTM and ACAM2000®, are approved and used for pre- and post-prophylaxis in cases. About 100% of the cases in non-endemic regions were associated with isolates of IIb clade with a divergence of 0.0018-0.0035. Isolates from B.1 lineage were the most predominant followed by B.1.2 and B.1.10.

Conclusion

This study will add integrated knowledge of the epidemiology, clinical features, and transmission of mpox.

The Changing Global Epidemiology of Re-emerging Human Monkeypox Virus Infection: A Systematic Review

Human monkeypox virus (MPVX) infection represents an emerging zoonotic disease caused by an orthopoxvirus, resulting in a condition reminiscent of smallpox. More recent developments have witnessed a notable surge in global MPVX outbreaks, eliciting significant concerns. We aimed to investigate the epidemiological factors of the emerging human monkeypox virus infection, including the number of suspected, confirmed, and fatal cases, as well as the risk factors for contracting monkeypox infection. We performed a systematic review of peer-reviewed literature by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic database search (PubMed, Wiley Online Library, and Science Direct) was undertaken. For monkeypox-related studies, we included 25 peer-reviewed articles from 2018 and 2022, and data were extracted on the current evidence on the cases and the risk factors for MPVX infection, to develop public health advisories. Our reports show a rapid rise of MPVX cases in the highly endemic African regions after the 1970s, spread to other countries, and an increase in the median age from young children to young adults. The cessation of smallpox vaccination might have been one of the factors responsible for these findings. As of 2022, the genomic sequences of ten MPVX strains associated with the recent countrywide outbreak have been determined. While the West African Clade has been primarily implicated in the recent viral surge, data were insufficient to determine which mutation contributed to increased transmissibility. In the Democratic Republic of the Congo (DRC), sleeping on the floor was significantly associated with contracting MPVX, while eating or processing of animal foods was not a significant risk factor. In the United States, cleaning the cages and bedding of sick animals, touching infected animals, and daily exposure to sick animals were associated with an increased probability of contracting the MPVX infection. Recent global outbreaks and the rising incidence of MPVX infections among young adults in the endemic zones might be a result of the cessation of the smallpox vaccine. The increased risk associated with exposure to sick animals or sleeping on the floor suggests high infectivity from animal excretions. Increasing awareness, strict surveillance, and contact tracing can help contain global outbreaks. The ring vaccination approach for exposed individuals is another potential disease containment strategy. Future studies should investigate measures for rapid laboratory diagnosis, maintaining lab safety, and transmissibility.

Investigation of a mpox outbreak in Central African Republic, 2021-2022

Human monkeypox virus is spreading globally, and more information is required about its epidemiological and clinical disease characteristics in endemic countries. We report the investigation of an outbreak in November 2021 in Central African Republic (CAR). The primary case, a hunter, fell ill after contact with a non-human primate at the frontier between forest and savannah. The ensuing investigation in a small nearby town concerned two families and four waves of inter-human transmission, with 14 confirmed cases, 11 suspected cases and 17 non-infected contacts, and a secondary attack rate of 59.5% (25/42). Complications were observed in 12 of the 19 (63.2%) confirmed and suspected cases with available clinical follow-up data: eight cases of bronchopneumonia, two of severe dehydration, one corneal ulcer, one abscess, two cutaneous superinfections, and six cutaneous sequelae (cheloid scars, or depigmentation). There was one death, giving a case fatality ratio of 1/25 (4.0%) for confirmed and suspected cases. This outbreak, with the largest number of confirmed cases ever described in CAR, confirms the potential severity of the disease associated with clade I monkeypox viruses, and highlights the need for rapid control over virus circulation to prevent the further national and international spread of infection.

Identifying the Most Probable Mammal Reservoir Hosts for Monkeypox Virus Based on Ecological Niche Comparisons

Previous human cases or epidemics have suggested that Monkeypox virus (MPXV) can be transmitted through contact with animals of African rainforests. Although MPXV has been identified in many mammal species, most are likely secondary hosts, and the reservoir host has yet to be discovered. In this study, we provide the full list of African mammal genera (and species) in which MPXV was previously detected, and predict the geographic distributions of all species of these genera based on museum specimens and an ecological niche modelling (ENM) method. Then, we reconstruct the ecological niche of MPXV using georeferenced data on animal MPXV sequences and human index cases, and conduct overlap analyses with the ecological niches inferred for 99 mammal species, in order to identify the most probable animal reservoir. Our results show that the MPXV niche covers three African rainforests: the Congo Basin, and Upper and Lower Guinean forests. The four mammal species showing the best niche overlap with MPXV are all arboreal rodents, including three squirrels: Funisciurus anerythrus, Funisciurus pyrropus, Heliosciurus rufobrachium, and Graphiurus lorraineus. We conclude that the most probable MPXV reservoir is F. anerythrus based on two niche overlap metrics, the areas of higher probabilities of occurrence, and available data on MPXV detection.

Monkeypox clinical disease: Literature review and a tool proposal for the monitoring of cases and contacts

The human monkeypox disease has mainly been described in Western and Central Africa. Since May 2022, the monkeypox virus has been spreading worldwide in a new epidemiological pattern, where cases result from person-to-person transmission, and develop clinically milder or less typical illness than during previous outbreaks in endemic areas. The newly-emerging monkeypox disease needs to be described over the long term, to improve cases definitions, to implement prompt control measures against epidemics, and to provide supportive care. Hence, we first conducted a review of historical and recent outbreaks to define the full clinical spectrum of the monkeypox disease and its course known so far. Then, we built a self-administrated questionnaire collecting daily symptoms of the monkeypox infection to follow cases and their contacts, even remotely. This tool will assist in the management of cases, the surveillance of contacts, and the conduct of clinical studies.

Knowledge and Attitude Regarding Monkeypox Virus among Physicians in Saudi Arabia: A Cross-Sectional Study

The growing incidence of human monkeypox cases emphasizes the significance of prevention, early detection, and prompt responses for healthcare providers. The aim of this study was to assess the knowledge and attitudes toward monkeypox infection among physicians, a frontline healthcare worker group, in Saudi Arabia. A cross-sectional survey assessing knowledge and attitudes towards monkeypox infection on multiple-item scales was sent to physicians in Saudi Arabia. The associations between independent factors and either knowledge or attitude were assessed. The final analysis included 398 participants. Approximately 55% of the surveyed participants had a "good knowledge" score about human monkeypox. The adjusted logistic regression analysis showed that being a female physician, working in the private sector, and having information on human monkeypox during medical school or residency years were the only factors associated with a good level of knowledge about human monkeypox. However, physicians' knowledge and attitudes regarding monkeypox infection are inadequate and influenced by various factors. There is a significant knowledge gap between the therapeutic management of monkeypox and its vaccination. Training and knowledge assessments are important, especially when studies show significant improvement in related and specific knowledge.

Monkeypox-What Pediatricians Need to Know

Monkeypox is a zoonotic disease, presenting with fever, lymphadenopathy and vesicular-pustular skin lesions, that historically has rarely been reported outside the endemic regions of Central and West Africa. It was previously thought that human-to-human transmission was too low to sustain spread. During 2022, the number of cases of monkeypox, caused by clade II, rose rapidly globally, predominantly among men who have sex with men. In previous outbreaks with monkeypox clade 1 in endemic areas, children were disproportionately more affected with higher morbidity and mortality. It is unclear whether children are at similarly higher risk from monkeypox clade II. Nonetheless, children and pregnant women are considered high-risk groups and antiviral treatment should be considered for those affected. While smallpox vaccination offers good protection against monkeypox, the duration of protection is unknown, and infection occurs in vaccinated individuals. Should the current outbreak spread to children, authorities should be prepared to rapidly implement vaccination for children. In this review, we summarize epidemiological and clinical features, as well as the pathogenesis, treatment, and prevention options for monkeypox with a focus on considerations for children.

The Global Human Monkeypox Outbreak and Management: A Comprehensive Literature Review

Monkeypox (MPX) belongs to the genus Orthopoxvirus (OPV), family Poxviridae, and sub-family Chordopoxvirinae. Human monkeypox (HMPX) is a viral zoonotic illness caused by the monkeypox virus (MPXV). Several non-endemic countries have confirmed MPX cases across the globe. Therefore, consider an outbreak to be a global health emergency. MPXV transmits from animals to humans via infected animals, and there is currently human-to-human transmission, notably among guys who have sexual relations with males. Healthcare interventions are required to stop outbreaks. These include strict isolation and care for MPX patients while they are still contagious or until the skin lesions dry out and crust over. JYNNEOS was approved as a vaccine for the prevention of MPXV. Tecovirimat is licensed to treat severe MPX or risk developing a serious disease. We should encourage international cooperation to conduct clinical trials investigating the effectiveness and safety of MPXV vaccines and antiviral medications. Precautions must be taken at the global level to prevent an MPXV outbreak.

Global monkeypox case hospitalisation rates: A rapid systematic review and meta-analysis

BACKGROUND

Estimates of the case hospitalization rate and case fatality rate when hospital care is available for monkeypox (MPX) infections have not been well defined. This rapid systematic review and meta-analysis aimed to estimate the case hospitalisation rate and case fatality rate where hospital care is available.

METHODS

We systematically searched PubMed, Embase, the Lancet Preprints, and MedRxiv for studies published between Jan 1, 1950 and Aug 2, 2022. We included documents which contained both the number of cases and associated hospitalisations of MPX infections. From eligible studies we extracted the country, the year of the study, the study design type, the clade of MPX, the participant characteristics, transmission type, any treatments used, number of cases (including suspected, probable, or laboratory confirmed diagnosis), number of hospitalizations, hospitalized patient outcomes, and case definition. Case hospitalization rate (CHR) was defined as the proportion of cases that were admitted to hospital care while case fatality rate (CFR) was defined as the proportion of cases that died. CHR and CFR were analysed in a fully Bayesian meta-analytic framework using random effects models, including sub-group analysis with heterogeneity assessed using I².

FINDINGS

Of the 259 unique documents identified, 19 studies were eligible for inclusion. Included studies represented 7553 reported cases among which there were 555 hospitalizations. Of the 7540 cases for which outcomes were available, there were 15 recorded deaths. The median age of cases was 35 years (interquartile range 28-38, n = 2010) and primarily male (7339/7489, 98%) in studies where age or sex were available. Combined CHR was estimated to be 14.1% (95% credible interval, 7.5-25.0, I² 97.4%), with a high degree of heterogeneity. Further analysis by outbreak period indicates CHRs of 49.8% (28.2-74.0, I² 81.4%), 21.7% (7.2-52.1, I² 57.7%), and 5.8% (3.2-9.4, I² 92.4%) during the pre-2017, 2017-2021, and 2022 outbreaks, respectively, again with high levels of heterogeneity. CFR was estimated to be 0.03% (0.0-0.44, I² 99.9%), with evidence of large heterogeneity between the studies.

INTERPRETATION

There is limited data for MPX hospitalization rates in countries where MPX has been traditionally non-endemic until the current outbreak. Due to substantial heterogeneity, caution is needed when interpreting these findings. Health care organizations should be cognizant of the potential increase in healthcare utilization. Rapid identification of infection and use of appropriate therapies such as antivirals play a role reducing the CHR and associated CFR.

FUNDING

None.

National Monkeypox Surveillance, Central African Republic, 2001-2021

We analyzed monkeypox disease surveillance in Central African Republic (CAR) during 2001-2021. Surveillance data show 95 suspected outbreaks, 40 of which were confirmed as monkeypox, comprising 99 confirmed and 61 suspected monkeypox cases. After 2018, CAR's annual rate of confirmed outbreaks increased, and 65% of outbreaks occurred in 2 forested regions bordering the Democratic Republic of the Congo. The median patient age for confirmed cases was 15.5 years. The overall case-fatality ratio was 7.5% (12/160) for confirmed and suspected cases, 9.6% (8/83) for children <16 years of age. Decreasing cross-protective immunity from smallpox vaccination and recent ecologic alterations likely contribute to increased monkeypox outbreaks in Central Africa. High fatality rates associated with monkeypox virus clade I also are a local and international concern. Ongoing investigations of zoonotic sources and environmental changes that increase human exposure could inform practices to prevent monkeypox expansion into local communities and beyond endemic areas.

Evolution, epidemiology, geographical distribution, and mutational landscape of newly emerging monkeypox virus

Recent monkeypox (MPX) outbreaks are major ones in non-endemic countries. The present study analyzed molecular phylogenetics, divergence, epidemiology, the geographical distribution, entropy diversity of genome, mutational landscape, and evolution of the monkeypox virus (MPXV) genome and the current MPXV is entitled "hMPXV1." We used different in-silico and statistical methods to study our objectives. The developed phylogram from molecular phylogenetics describes the origin and evolution of hMPXV1 of A, A.1, A.1.1, A.2, and B.1 lineages. The microevolution of B.1 lineage shows its evolution from May to August 2022. B.1 lineage is further adapting and showing more mutation and sub-lineages. The scatter plot of all lineages shows the clustering pattern of lineages and the divergence. We also developed two statistical models of confirmed cases and a diagram of the age-related pattern of infected cases to illustrate the epidemiology of the MPX outbreaks. The entropy diversity and mutational landscape of the hMPXV1 genome were analyzed in nucleotide and codon contexts. Our study has shown the in-depth evolution pattern of different lineages of the hMPXV1. We found B.1 lineage is associated with the current outbreaks. The mutational landscape informs about the slow mutation of the virus. Finally, the study might assists the new therapeutic development considering all the above points and would help the researcher to set up their future research directions.

Monkeypox: epidemiology, pathogenesis, treatment and prevention

Monkeypox is a zoonotic disease that was once endemic in west and central Africa caused by monkeypox virus. However, cases recently have been confirmed in many nonendemic countries outside of Africa. WHO declared the ongoing monkeypox outbreak to be a public health emergency of international concern on July 23, 2022, in the context of the COVID-19 pandemic. The rapidly increasing number of confirmed cases could pose a threat to the international community. Here, we review the epidemiology of monkeypox, monkeypox virus reservoirs, novel transmission patterns, mutations and mechanisms of viral infection, clinical characteristics, laboratory diagnosis and treatment measures. In addition, strategies for the prevention, such as vaccination of smallpox vaccine, is also included. Current epidemiological data indicate that high frequency of human-to-human transmission could lead to further outbreaks, especially among men who have sex with men. The development of antiviral drugs and vaccines against monkeypox virus is urgently needed, despite some therapeutic effects of currently used drugs in the clinic. We provide useful information to improve the understanding of monkeypox virus and give guidance for the government and relative agency to prevent and control the further spread of monkeypox virus.

Neurological and psychiatric presentations associated with human monkeypox virus infection: A systematic review and meta-analysis

Background

Neuropsychiatric presentations of monkeypox (MPX) infection have not been well characterised, despite evidence of nervous system involvement associated with the related smallpox infection.

Methods

In this pre-registered (PROSPERO ID 336649) systematic review and meta-analysis, we searched MEDLINE, EMBASE, PsycINFO, AMED and the preprint server MedRxiv up to 31/05/2022. Any study design of humans infected with MPX that reported a neurological or psychiatric presentation was included. For eligible symptoms, we calculated a pooled prevalence using an inverse variance approach and corresponding 95% confidence intervals. The degree of variability that could be explained by between-study heterogeneity was assessed using the I 2 statistic. Risk of bias was assessed with the Newcastle Ottawa Scale and the Joanna Briggs Institute quality assessment tool.

Findings

From 1705 unique studies, we extracted data on 19 eligible studies (1512 participants, 1031 with confirmed infection using CDC criteria or PCR testing) most of which were cohort studies and case series with no control groups. Study quality was generally moderate. Three clinical features were eligible for meta-analysis: seizure 2.7% (95% CI 0.7-10.2%, I2 0%), confusion 2.4% (95% CI 1.1-5.2%, I2 0%) and encephalitis 2.0% (95% 0.5-8.2%, I2 55.8%). Other frequently reported symptoms included myalgia, headache and fatigue, where heterogeneity was too high for estimation of pooled prevalences, possibly as a result of differences in viral clades and study methodology.

Interpretation

There is preliminary evidence for a range of neuropsychiatric presentations including severe neurological complications (encephalitis and seizure) and nonspecific neurological features (confusion, headache and myalgia). There is less evidence regarding the psychiatric presentations or sequelae of MPX. This may warrant surveillance within the current MPX outbreak, with prospective longitudinal studies evaluating the mid- to long-term sequelae of the virus. Robust methods to evaluate the potential causality of MPX with these clinical features are required. More evidence is necessary to explain heterogeneity in prevalence estimates.

Funding

UKRI/MRC (MR/V03605X/1), MRC-CSF (MR/V007181/1), MRC/AMED (MR/T028750/1) and the Wellcome Trust (102186/B/13/Z) and (102186/B/13/Z) and UCLH BRC.

Clinical features, hospitalisation and deaths associated with monkeypox: a systematic review and meta-analysis

Introduction

A multicountry monkeypox disease (MPX) outbreak began in May 2022 in Europe, leading to the assessment as a potential Public Health Emergency of International Concern (PHEIC) on June 23, 2022. Some observational studies have partially characterised clinical features, hospitalisations, and deaths. However, no systematic reviews of this MPX outbreak have been published.

Methods

We performed a systematic review with meta-analysis, using five databases to assess clinical features, hospitalisations, complications and deaths of MPX confirmed or probable cases. Observational studies, case reports and case series, were included. We performed a random-effects model meta-analysis to calculate the pooled prevalence and 95% confidence interval (95% CI). In addition, we carried out a subgroup analysis according to the continents and a sensitivity analysis excluding studies classified as having a high risk of bias.

Results

A total of 19 articles were included, using only 12 articles in the quantitative synthesis (meta-analysis). For 1958 patients, rash (93%, 95% CI 80–100%), fever (72%, 95% CI 30–99%), pruritus (65%, 95% CI 47–81%), and lymphadenopathy (62%, 47–76%), were the most prevalent manifestations. Among the patients, 35% (95% CI 14–59%) were hospitalised. Some 4% (95% CI 1–9%) of hospitalised patients had fatal outcomes (case fatality rate, CFR).

Conclusion

MPX is spreading rapidly, with a third of hospitalised patients, but less than 5% with fatal outcomes. As this zoonotic virus spreads globally, countries must urgently prepare human resources, infrastructure and facilities to treat patients according to the emerging guidelines and the most reliable clinical information.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12941-022-00527-1.

The changing epidemiology of human monkeypox-A potential threat? A systematic review

Monkeypox, a zoonotic disease caused by an orthopoxvirus, results in a smallpox-like disease in humans. Since monkeypox in humans was initially diagnosed in 1970 in the Democratic Republic of the Congo (DRC), it has spread to other regions of Africa (primarily West and Central), and cases outside Africa have emerged in recent years. We conducted a systematic review of peer-reviewed and grey literature on how monkeypox epidemiology has evolved, with particular emphasis on the number of confirmed, probable, and/or possible cases, age at presentation, mortality, and geographical spread. The review is registered with PROSPERO (CRD42020208269). We identified 48 peer-reviewed articles and 18 grey literature sources for data extraction. The number of human monkeypox cases has been on the rise since the 1970s, with the most dramatic increases occurring in the DRC. The median age at presentation has increased from 4 (1970s) to 21 years (2010-2019). There was an overall case fatality rate of 8.7%, with a significant difference between clades-Central African 10.6% (95% CI: 8.4%- 13.3%) vs. West African 3.6% (95% CI: 1.7%- 6.8%). Since 2003, import- and travel-related spread outside of Africa has occasionally resulted in outbreaks. Interactions/activities with infected animals or individuals are risk behaviors associated with acquiring monkeypox. Our review shows an escalation of monkeypox cases, especially in the highly endemic DRC, a spread to other countries, and a growing median age from young children to young adults. These findings may be related to the cessation of smallpox vaccination, which provided some cross-protection against monkeypox, leading to increased human-to-human transmission. The appearance of outbreaks beyond Africa highlights the global relevance of the disease. Increased surveillance and detection of monkeypox cases are essential tools for understanding the continuously changing epidemiology of this resurging disease.

Africa and the Nexus of poverty, malnutrition and diseases

This review examines the nexus of poverty, malnutrition and diseases in Africa, the challenges, implications and their mitigation. The paper takes a critical look at available literatures on the primary causes, modes, implications and solutions to the problems of poverty, malnutrition and diseases in Africa continent. Poverty and malnutrition are outcomes of uncontrolled rapid population growth, inefficient agricultural and industrial practices, high debt profile of many African countries due to poor governance and corruption, diseases such as AIDS epidemic, malaria, Ebola virus and COVID-19 pandemic, poor and inadequate health infrastructure and armed conflicts. African poverty scenario entails non-availability of basic human needs which makes many Africans to be very poor. Despite abundance of natural resources, the gross domestic product per capita of many African countries is among the lowest of list of nations of the world. According United Nation in 2009, 22 of 24 nations among the "Low Human Development" nations of the world on the UN's Human Development Index were found in sub-Saharan Africa. Out of the 50 countries on the United Nation list of least developed countries, 34 of them were in Africa. According to FAO data over 200 million people in sub-Saharan Africa were undernourished in 2014-2016. The prevalence of undernourishment in sub-Saharan Africa rose from 181 million in 2010 to 222 million in 2016. In 2016, Africa had the highest prevalence of undernourishment in the world and estimated to be 20% of the population. While this was alarming in Eastern Africa where one-third of the population is suspected to be undernourished. In a similar data, World Bank also found that sub-Saharan Africa Poverty and Equity Data was 47% with over 500 million people in abject poverty in 2012. Poverty is the major cause of hunger and malnutrition in Africa while hunger and malnutrition escalated the problem of diseases in African continent. Poverty has continued to torment Africa as a result of poor and harmful economic policies, conflict and war, environmental factors like drought and climate change and population growth, poor leadership and greed. With the advent of COVID-19, the problem of poverty, malnutrition and diseases has been escalated and in many African countries people find it difficult to make ends meet.

Politics of disease control in Africa and the critical role of global health diplomacy: A systematic review

Background: Africa is facing the triple burden of communicable diseases, non-communicable diseases (NCDs), and nutritional disorders. Multilateral institutions, bilateral arrangements, and philanthropies have historically privileged economic development over health concerns. That focus has resulted in weak health systems and inadequate preparedness when there are outbreaks of diseases. This review aims to understand the politics of disease control in Africa and global health diplomacy’s (GHD’s) critical role.

Methods: A literature review was done in Medline/PubMed, Web of Science, Scopus, Embase, and Google scholar search engines. Keywords included MeSH and common terms related to the topics: "Politics," "disease control," "epidemics/ endemics," and "global health diplomacy" in the "African" context. The resources also included reports of World Health Organization, United Nations and resolutions of the World Health Assembly (WHA).

Results: African countries continue to struggle in their attempts to build health systems for disease control that are robust enough to tackle the frequent epidemics that plague the continent. The politics of disease control requires the crafting of cooperative partnerships to accommodate the divergent interests of multiple actors. Recent outbreaks of COVID-19 and Ebola had a significant impact on African economies. It is extremely important to prioritize health in the African development agendas. The African Union (AU) should leverage the momentum of the rise of GHD to (i) navigate the politics of global health governance in an interconnected world(ii) develop robust preparedness and disease response strategies to tackle emerging and reemerging disease epidemics in the region (iii) address the linkages between health and broader human security issues driven by climate change-induced food, water, and other insecurities (iv) mobilize resources and capacities to train health officials in the craft of diplomacy.

Conclusion: The AU, Regional Economic Communities (RECs), and African Centres for Disease Control should harmonize their plans and strategies and align them towards a common goal that integrates health in African development agendas. The AU must innovatively harness the practice and tools of GHD towards developing the necessary partnerships with relevant actors in the global health arena to achieve the health targets of the Sustainable Development Goals.

Here, There, and Everywhere: The Wide Host Range and Geographic Distribution of Zoonotic Orthopoxviruses

The global emergence of zoonotic viruses, including poxviruses, poses one of the greatest threats to human and animal health. Forty years after the eradication of smallpox, emerging zoonotic orthopoxviruses, such as monkeypox, cowpox, and vaccinia viruses continue to infect humans as well as wild and domestic animals. Currently, the geographical distribution of poxviruses in a broad range of hosts worldwide raises concerns regarding the possibility of outbreaks or viral dissemination to new geographical regions. Here, we review the global host ranges and current epidemiological understanding of zoonotic orthopoxviruses while focusing on orthopoxviruses with epidemic potential, including monkeypox, cowpox, and vaccinia viruses.

Monkeypox re-emergence in Africa: a call to expand the concept and practice of One Health

INTRODUCTION

Monkeypox is a re-emerging viral zoonosis that occurs naturally in heavily forested regions of West and Central Africa. Inter-human transmission of monkeypox virus, although limited, drives outbreaks, particularly in household and health-care settings. But the available evidence suggests that without repeated zoonotic introductions, human infections would eventually cease to occur. Therefore, interrupting virus transmission from animals to humans is key to combating this disease. Areas covered: Herein we review laboratory and field studies examining the susceptibility of various animal taxa to monkeypox virus infection, and note the competence of various species to serve as reservoirs or transmission hosts. In addition, we discuss early socio-ecologic theories of monkeypox virus transmission in rural settings and review current modes of ecologic investigation - including ecologic niche modeling, and ecologic sampling - in light of their potential to identify specific animal species and features of the environment that are associated with heightened risk for human disease. Expert opinion: The role of disease ecology and scientific research in ongoing disease prevention efforts should be reinforced, particularly for wildlife-associated zoonoses such as monkeypox. Such efforts alongside those aimed at nurturing 'One Health' collaborations may ultimately hold the greatest promise for reducing human infections with this pathogen.

Emerging infectious diseases in Africa in the 21st century

Many infectious diseases have emerged or reemerged in Africa in the 21st century. Some of them are associated with newly discovered microorganisms such as Rickettsia felis and Tropheryma whipplei; others are known, historical diseases such as plague and cholera. In addition are diseases related to previously known microorganisms which recently have been involved for the first time in massive outbreaks with worldwide impacts (such as Ebola virus, Zika virus and Chikungunya virus). Research on emerging infectious diseases needs to be identified as a priority.

Emergence of Monkeypox as the Most Important Orthopoxvirus Infection in Humans

Monkeypox is an emerging zoonotic disease recognized as the most important orthopoxvirus infection in humans in the smallpox post-eradication era. The clinical presentation of monkeypox is similar to the one of smallpox. The case fatality rate of monkeypox (10%) lies between the case fatality rate of variola major (30%) and variola minor (1%). The disease is endemic in the Democratic Republic of the Congo, but other countries of Central and West Africa either reported cases of monkeypox in humans or circulation in wildlife. The disease was also imported once into the USA. The disease has always been considered rare and self-limiting, however recent sporadic reports suggest otherwise. Unfortunately, the collected data is limited, dispersed and often incomplete. Therefore, the objective of this review is to trace all reported human monkeypox outbreaks and relevant epidemiological information. The frequency and geographical spread of human monkeypox cases have increased in recent years, and there are huge gaps in our understanding of the disease's emergence, epidemiology, and ecology. The monkeypox virus is considered a high threat pathogen causing a disease of public health importance. Therefore, there is an urgent need to focus on building surveillance capacities which will provide valuable information for designing appropriate prevention, preparedness and response activities.

Investigation of an outbreak of monkeypox in an area occupied by armed groups, Central African Republic

BACKGROUND

Monkeypox is a zoonosis caused by an Orthopoxvirus of the Poxviridae family. Human infections are often severe and are a public health problem.

PATIENTS AND METHOD

We conducted a monkeypox outbreak investigation of suspected case patients in five villages of the Alindao-Mingala Health District following blood sample confirmation of the virus by the Institut Pasteur in Bangui. We aimed to determine disease characteristics, to describe the context and the risk factors, and to measure the incidence and case fatality. Patients were reported in the villages of Rehou 4, 5, Dalakere 1, Kongbo, and Pavika from August to October 2016. Data was collected on individual records when interviewing patients or parents.

RESULTS

A total of 26 patients were identified. The˂10 years and 21-30 years age groups were the most affected. The overall attack rate was 5 per 1000 inhabitants and the case fatality was 7.7%. Young age and the absence of smallpox vaccination were associated with severe presentations in 87.5% of cases.

CONCLUSION

The annual number of monkeypox outbreaks increases in the Central African Republic with severe presentations and a high case fatality especially in children. Reinforcing the surveillance and characterization of circulating strains will provide information on the need for vaccine production.

Understanding orthopoxvirus host range and evolution: from the enigmatic to the usual suspects

In general, orthopoxviruses can be considered as falling into one of three host-utilization categories: highly specialized, single-host; broad host range; or 'cryptic', the last encompassing those viruses about which very little is known. Single-host viruses tend to exploit abundant hosts that have consistent patterns of interaction. For these viruses, observed genome reduction and loss of presumptive host-range genes is thought to be a consequence of relaxed selection. In contrast, the large genome size retained among broad host range orthopoxviruses suggests these viruses may depend on multiple host species for persistence in nature. Our understanding of the ecologic requirements of orthopoxviruses is strongly influenced by geographic biases in data collection. This hinders our ability to predict potential sources for emergence of orthopoxvirus-associated infections.

Improving the Care and Treatment of Monkeypox Patients in Low-Resource Settings: Applying Evidence from Contemporary Biomedical and Smallpox Biodefense Research

Monkeypox is a smallpox-like illness that can be accompanied by a range of significant medical complications. To date there are no standard or optimized guidelines for the clinical management of monkeypox (MPX) patients, particularly in low-resource settings. Consequently, patients can experience protracted illness and poor outcomes. Improving care necessitates developing a better understanding of the range of clinical manifestations-including complications and sequelae-as well as of features of illness that may be predictive of illness severity and poor outcomes. Experimental and natural infection of non-human primates with monkeypox virus can inform the approach to improving patient care, and may suggest options for pharmaceutical intervention. These studies have traditionally been performed to address the threat of smallpox bioterrorism and were designed with the intent of using MPX as a disease surrogate for smallpox. In many cases this necessitated employing high-dose, inhalational or intravenous challenge to recapitulate the severe manifestations of illness seen with smallpox. Overall, these data-and data from biomedical research involving burns, superficial wounds, herpes, eczema vaccinatum, and so forth-suggest that MPX patients could benefit from clinical support to mitigate the consequences of compromised skin and mucosa. This should include prevention and treatment of secondary bacterial infections (and other complications), ensuring adequate hydration and nutrition, and protecting vulnerable anatomical locations such as the eyes and genitals. A standard of care that considers these factors should be developed and assessed in different settings, using clinical metrics specific for MPX alongside consideration of antiviral therapies.