CHENNAI: In the fourth week of September, a man in his early 30s, accompanied by his wife, came to the outpatient department (OPD) of the general medicine department at Rajagiri Hospital, Ernakulam. He had arrived from the UAE. He presented with symptoms resembling chickenpox—fever, chills, and rash. However, upon closer examination, the blisters did not match the typical appearance of chickenpox.
“The presentation was somewhere between smallpox and chickenpox, but we knew the lesions were something different,” said Dr Sunny P Orathel, the medical superintendent. The key clue that led the medical team to suspect mpox was the presence of swollen lymph nodes. This, combined with the patient’s unusual symptoms and travel history, pointed to a possible case of mpox, a viral infection that had recently been reported in the region.
The hospital had been on high alert after a confirmed case of mpox emerged in Malappuram just a week prior. The hospital’s epidemiology team had briefed doctors on global communicable diseases, and this knowledge helped them recognise the signs of the virus early. A dermatologist was consulted, and she too suspected mpox based on the clinical presentation. If confirmed, this would be the second case of mpox in Kerala and the third in India in the recent outbreak.
Before confirming the diagnosis, the doctors decided to take precautionary steps and immediately moved the patient and his wife to an isolation facility. She had recently visited her husband a week earlier in the UAE, but as she was asymptomatic, there was no need to place them in separate rooms. Her presence provided emotional support to the patient during his difficult ordeal, said Dr Orathel.
Swabs were collected for testing and sent to the National Institute of Virology (NIV) in Pune. While waiting for the test results, hospital authorities were proactive in alerting the health department, who immediately began contact tracing. They traced the flight the couple had taken to Kochi and started identifying anyone who may have been in close contact with them.
The test results came back 48 hours later, confirming that the patient had contracted mpox. While there is no specific antiviral treatment for mpox, the doctors focused on managing the patient’s symptoms. “We gave medicines to control the fever and prevent any complications,” said Dr Orathel.
The patient’s condition remained stable, and he was able to eat normally. His diagnosis was confirmed as clade 2b variant of mpox, which is considered more severe compared to other variants globally. However, another challenge doctors faced was in managing the discharge process.
Although the patient began feeling better after five days, complications arose when the follow-up tests showed that he was still testing positive for the virus. Even though he was asymptomatic, both he and his wife could still be infectious during the incubation period of up to 21 days, which delayed their discharge.
By the 10th day, a third test confirmed that the man was no longer infectious. He and his wife had spent nearly 20 days in isolation at the hospital. Even after discharge, the doctors set conditions. “We had to ensure that the infection was fully controlled before they were discharged. The disease may be mild, but our responsibility is to prevent its spread,” Dr Orathel explained.
Close contact transmission
Around 1.1 lakh cases of mpox were reported across the world affecting 123 countries since January 2022, of which, 236 patients died, according to the 42nd situation report for the multi-country outbreak of mpox published by the World Health Organisation (WHO) recently. But there is no need for worry in India, even though the first case in India was by the severe strain of the virus. Experts say that chances of an outbreak are slim in India, but caution that any virus always has the potential to change its virulence.
Dr Muhammed Niyas, department of infectious diseases, KIMSHEALTH, Thiruvananthapuram, who has been a consultant on many mpox cases, said the patient should be isolated till the lesions are crusted and new skin appears. Hospitalisation is not necessary as long as their isolation can be ensured. “The virus spreads only through close contact, and the possibility of airborne transmission is extremely rare. It is not as transmissible as diseases like Covid-19,” he said. He pointed out that the treatment remains same irrespective of the virus variants.
“Though it spreads through close physical contact, there is potential for infection in closed groups through used materials like bedsheets. However, as travel is open, we cannot completely say we are safe,” said Dr T S Selvavinaygam, Director of Public Health and Preventive Medicine, Tamil Nadu.
Mpox, also known as monkeypox, has been reported as endemic in African countries. It has also been reported in non-endemic countries like the US, UK, Belgium, France, Germany, Italy, Netherlands, Portugal, Spain, and Sweden.
On November 22 (Friday), WHO will convene the emergency committee on mpox to advise the director-general of WHO whether the disease continues to be a Public Health Emergency of International Concern.
Protocols in place
WHO had declared mpox as a Public Health Emergency of National Concern on August 14. A similar announcement was made in 2022. On September 26, Union Health Secretary Apurva Chandra issued a fresh advisory to states and union territories on mpox after the first clade 2b case was reported in Kerala.
He said robust diagnostic testing capabilities are already available, with 36 ICMR-supported labs across the country and three commercial PCR kits validated by ICMR and approved by the Central Drugs Standard Control Organisation.
States were directed to identify isolation facilities in hospitals for suspected and confirmed cases, equipped with logistics and trained staff. The advisory asked states and UTs to continue undertaking appropriate activities to make communities aware of the disease, its modes of spread, and the need for timely reporting and preventive measures.
In the last two years, Delhi’s Lok Nayak Jai Prakash (LNJP) Hospital, designated as the nodal facility for treating mpox cases, has managed 16 patients, with 90% of them being male, says Dr Suresh Kumar, the hospital’s medical director. “Nearly all the cases involved a travel history to African nations where mpox is endemic, except for one patient who arrived from England. Male-to-male sexual contact emerged as the primary transmission route in these cases,” he said.
LNJP Hospital follows the central government’s guidelines for managing and treating mpox patients. “A dedicated ward was repurposed for monkeypox treatment, equipped with beds and cubicles. Suspected cases were kept in a separate isolation unit. In-house tests were conducted, and samples which turn out positive were sent to the National Institute of Virology for genome analysis,” Dr Kumar added.
The hospital ensured thorough training for a multidisciplinary team of 18 members, including specialists and nurses from the dermatology, medicine, paediatrics, and gynaecology departments.
“Dermatology led the efforts since the disease spreads through skin-to-skin contact. The medicine department managed immunocompromised patients, while paediatricians and gynaecologists were involved when cases included children and women,” he added.
Healthcare workers adhered to stringent precautions, wore PPE kits and refrained from serving in other wards during the period. Treatment at LNJP was tailored to each patient’s symptoms. “The treatment was based on the symptoms patients exhibited. Dermatologists treated crusted skin and lesions with appropriate medications, while paracetamol and antibiotics were used for fever and pus. Despite the challenges, there were no fatalities, and all patients made full recoveries,” Dr Kumar said.
Chances of outbreak slim in India
The chances of a widespread outbreak in India are slim because of many reasons. Experts say factors including ethnicity, race, herd immunity, and exposure to animals might explain the high prevalence of mpox in African countries, where close contact with wildlife and other ecological conditions create an environment conducive for its transmission.
At present, there is no threat of any outbreak in the country. “It is not a big threat to India as it spreads with human-to-human skin contact. It is not a killer disease in normal people, and it is a self-limiting disease,” said Dr T Jacob John, an eminent virologist.
Vaccine is also available for mpox, says John, adding that the government should raise awareness on the disease to prevent misinformation among people, and also release bulletins on a weekly or monthly basis on the number of people tested and confirmed, if any. “This will keep the people informed about the status, like in developed countries. India has reported 32 mpox cases since July 2022,” he said.
Dr A Balaji, head of Department of community medicine at Arunai Medical College, said, “The severity and transmissibility of mpox are very low compared to other viral infections. Most individuals recover within five to seven days without specific treatment.”
However, Dr Balaji cautioned against complacency in this age of globalisation. “With increasing international travel, there is always the risk of diseases spreading to non-endemic regions. If a person with mpox lesions is identified, immediate isolation and appropriate measures should be undertaken to prevent further spread,” he said.
Covid-19 has heightened public awareness about personal hygiene and preventive practices, which are also effective in curbing the spread of mpox. Deaths are rare and occur primarily in vulnerable groups. “The fatalities are usually confined to pregnant mothers, children under five years of age, and individuals with weakened immune systems,” Dr Balaji added, stressing on the importance of protecting the high-risk population.
(With inputs from Unnikrishnan S at Thiruvananthapuram, Ashish Srivastava at New Delhi)