Knowing the unknown: The underestimation of monkeypox cases. Insights and implications from an integrative review of the literature

Abstract

Monkeypox is an emerging zoonotic disease caused by the monkeypox virus, which is an infectious agent belonging to the genus Orthopoxvirus. Currently, commencing from the end of April 2022, an outbreak of monkeypox is ongoing, with more than 43,000 cases reported as of 23 August 2022, involving 99 countries and territories across all the six World Health Organization (WHO) regions. On 23 July 2022, the Director-General of the WHO declared monkeypox a global public health emergency of international concern (PHEIC), since the outbreak represents an extraordinary, unusual, and unexpected event that poses a significant risk for international spread, requiring an immediate, coordinated international response. However, the real magnitude of the burden of disease could be masked by failures in ascertainment and under-detection. As such, underestimation affects the efficiency and reliability of surveillance and notification systems and compromises the possibility of making informed and evidence-based policy decisions in terms of the adoption and implementation of ad hoc adequate preventive measures. In this review, synthesizing 53 papers, we summarize the determinants of the underestimation of sexually transmitted diseases, in general, and, in particular, monkeypox, in terms of all their various components and dimensions (under-ascertainment, underreporting, under-detection, under-diagnosis, misdiagnosis/misclassification, and under-notification).

Knowledge on Monkeypox Among Community in Southern Malaysia: Are We Prepared for The Next Battle?

“…72% of responders demonstrated a lack of understanding towards monkeypox infection. The infection of monkeypox, which is abundant in the tropical rainforest region, is not endemic in Malaysia (Luigi Bragazzi et al, 2022). Therefore, the population of Malaysia is not accustomed to it, which might explain why majority of the respondents had lower knowledge towards monkeypox infection.…”

Mpox: Risks and approaches to prevention

“…Cases, including immunosuppressed patients, may show prolonged viral shedding from the upper respiratory tract and may be re-evaluated to decide when isolation precautions can be terminated [2] . The infectivity of patients with positive upper respiratory tract swabs and crusted skin lesions remains doubtful, an area calling for further study [6] .…”

“…The rash may appear first, or sometimes flu-like symptoms may be evident before the rash [1] . The spectrum of the disease ranges from mild to severe and can be fatal depending on the initial health status of the patient, their immune response, previous vaccination, the presence of comorbidities, and the route of exposure [6] . In addition to the clinical picture and history of contact with a suspected or confirmed case, the laboratory diagnosis of Mpox is confirmed by two-stage testing, first with a panorthopox polymerase chain reaction (PCR) followed by a specific Mpox PCR test.…”

Insights on Mpox virus infection immunopathogenesis

“…Meta‐analysis confirms this changing epidemiology that between 1970 and 2009, MPXV mainly affected young children aged less than 10 years, 6 while it is now considered a disease of young adults. MPXV has been particularly concentrated among men who have sex with men (MSM) 7–10 . Of note, among MSM people, immunocompromised people have more odds of progressing to severe disease and even death 11 .…”