JURNAL KEDOKTERAN DIPONEGORO

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Meiriani Sari, Nany Hairunisa

A REVIEW OF THE MONKEYPOX OUTBREAK IN INDONESIA IN 2022

Meiriani Sari1*, Nany Hairunisa2

1
Department of Pediatrics, Faculty of Medicine,Universitas Trisakti, Jakarta, Indonesia
2
Department of Occupational Medicine, Faculty of Medicine, Universitas Trisakti, Jakarta. Indonesia
* Corresponding Author : E-mail : [email protected]

ABSTRACT
Monkeypox disease (monkey smallpox) is a disease that has never been found in Indonesia since it was first discovered in
humans in the Congo in 1970. So if there is one positive confirmed event, then the disease is an Extraordinary Event
(KLB). This disease has become a global concern because since May 13, 2022, WHO has received reports of Monkeypox
cases from non-endemic countries. It has expanded to 4 WHO regions: Europe, America, Eastern Mediterranean, and
Western Pacific. Until now, further investigations and studies are still being carried out to understand more about the
epidemiology, sources of infection, and transmission patterns in non-endemic countries that have reported new cases, such
as Indonesia. Until now, no specific treatment has been proven to treat Monkeypox infection. Currently, the therapy used
is symptomatic support. The antiviral tecovirimat, or TPOXX, developed by the European Medicines Agency (EMA) as a
Monkeypox therapy in 2022 based on research, has not been marketed freely. In addition, antivirals such as cidofovir and
brincidofovir have been shown to be effective against orthopox virus in vitro and in animal studies. However, the
effectiveness of this drug against monkeypox in humans is not yet known. However, this disease can be prevented by
vaccination. In Indonesia, the Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN) vaccine is recommended to prevent
Monkeypox disease. The existence of the outbreak report is important to discuss, explore, and understand more about the
disease and its management and prevention.
Keywords: Antivirus, Outbreaks, Monkeypox, Vaccination

INTRODUCTION public health concern, as it was reported in

Monkeypox disease has never been found in previously non-endemic countries. Since May 13,
Indonesia since it was first discovered in humans in 2022, WHO has received reports of Monkeypox
the Congo in 1970, caused by the Monkeypox virus. cases originating from non-endemic countries, and
On August 19th, 2022, one positive case was found in currently, it has expanded to 4 WHO regions, namely
a 27-year-old male patient in Jakarta. As of Europe, America, Eastern Mediterranean, and
September 15th, 2022, 2 suspects and 63 were Western Pacific. 7–10
discarded. From the distribution of 63 patients with Until now, further investigations and studies
discarded status covering ten provinces in Indonesia.1 are still being carried out to understand better the
Monkeypox itself was first discovered in epidemiology, sources of infection, and transmission
1958 when an outbreak of diseases such as smallpox patterns in non-endemic countries that have reported
occurred in a group of monkeys that were kept for new cases, such as Indonesia. There are reports of
research.2,3,4 Common symptoms such as fever, human-to-human transmission, considering the
headache, enlarged lymph nodes, and skin lesions importance of cases in infected countries. In addition
can cause severe pain.5 This disease has clinical to the possibility of infectious animals in Indonesia,
relevance in endemic areas of Africa, with outbreaks it is important to discuss, explore, and understand
in the west due to international travel. 6 how to deal with this disease.1,2
According to the WHO, around 3-6% of
cases can be fatal; unfortunately, the data on deaths About Monkeypox
based on cases in Africa before 2022 do not have Monkeypox is a rare zoonotic disease caused
data that is too representative. Monkeypox virus can by the Monkeypox virus.3 This virus is in the same
heal itself without getting special treatment within a family as viruses such as the variola virus that causes
few weeks. As of August 2, 2022, 80 countries have smallpox. Monkeypox virus contains double-
reported approximately 24,000 cases of Monkeypox stranded DNA and has a 200-250 nm brick-shaped
and five deaths have occurred since May 2022. envelope. This virus belongs to Poxviridae,
Monkeypox has since become a disease of global subfamily Chordopoxvirinae, and genus

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Orthopoxvirus. Monkeypox symptoms are similar to (eyes, nose, or mouth). Airborne transmission is rare.
those of smallpox but are usually milder. Although Transmission through droplets usually requires
named Monkeypox, the main cause of this disease is prolonged contact, so family members who live in
not known with certainty. However, African rodents the same household or are in close contact with cases
and primates (such as monkeys) may harbor the virus are at greater risk of infection. People with
and transmit it to humans.3,11–16 Monkeypox are contagious when symptomatic
(usually between two to four weeks). Rashes, body
fluids (such as fluid, pus or blood from skin lesions)
and scabs are highly contagious. Clothes, bedding,
towels or eating utensils/plates contaminated with the
virus from an infected person can also infect others.14
In addition, animal-to-person transmission
can also occur. Contact with blood, body fluids or
skin lesions of infected animals can transmit
Monkeypox. Monkeypox's natural reservoir has not
been determined, but it is most likely in rodents.
Monkeypox infection in Africa has been found in
many animal species: tree squirrels, Gambian giant
Figure 1. Some forms of Monkeypox virus1 rats, striped rats, dormice and primates. In the case
that occurred in the United States, the first case was
Epidemiology and Risk Factors (Vulnerable infected by a prairie dog. 4,21,22
Group)
Fatal cases of Monkeypox are more common Pathophysiology
in children and are often related to exposure to the The entry of the virus from various places of
virus, the patient's health status and complications. entry, such as the oropharynx, nasopharynx and
The presence of immune deficiency can worsen the intradermal; Monkeypox virus will then replicate at
prognosis. Smallpox vaccination can reduce the the inoculation site and then spread through the
incidence of this disease. Individuals under 40-50 lymph nodes. Initial viremia will trigger the viral
years old seem more easily infected with spread of the infection and focus on other organs.
Monkeypox. This is thought to occur due to the This phase describes the incubation period. This
decreasing number of smallpox vaccines as the period lasts 7-14 days with a deadline of 21 days.
disease is eradicated in several countries. 9,12,14,17,18 The onset of symptoms correlates with secondary
Some groups included in the vulnerable group viremia lasting 1-2 days of prodromal symptoms
are pregnant women, children, and such as fever and lymphadenopathy before the
immunocompromised patients. Research conducted appearance of the lesions. Infected patients are highly
by the New England Journal of Medicine recently contagious during this period. Lesions begin in the
showed that 98% of monkeypox cases diagnosed in oropharynx and then on the skin. Serum antibodies
16 countries between April and June occurred in men can be detected when lesions appear. 2,4,5,9,12
who had sex with other men. This raises concerns
about the stigma of the LGBT community toward Sign and Symptoms
Monkeypox.19,20 Monkeypox symptoms vary. Some people can
have moderate symptoms, while some can be more
Transmission severe and require health facilities. The most
Monkeypox is usually passed from person to common symptoms include fever, headache,
person through close contact with an infected person. myalgia, backache, malaise and enlarged lymph
Contact from person to person, such as direct contact, nodes. These symptoms can be followed or
contact with droplets, contact with infectious body accompanied by a rash lasting two to three weeks.23
fluids or through media (linen). The virus enters the This rash is commonly found on the face,
body through broken/open skin (even if it is not palms, soles of the feet, eyes, mouth, throat, and
visible), the respiratory tract, or mucous membranes

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genital areas such as the penis, vulva, and anus. The often form an umbilical cord (a point at the apex of
number of these rash lesions varies from one to the lesion). These lesions are typically painful to the
thousands. The evolution of these lesions usually point that they become itchy during the healing
begins with the appearance of macular lesions and process. The patient will remain infectious until all
then becomes papules, vesicular, pustular to lesions heal.1,3,5,7,12,14,23,24
desquamated. These lesions are usually firm and

Figure 2. Lesions on Monkeypox 1

In addition, Monkeypox can also be the skin. The number of lesions varies from a few to
accompanied by rectal symptoms. Purulent or bloody several thousand. In severe cases, the lesions may
stools, rectal pain or bleeding from the rectum may coalesce and cause large patches of skin to peel.1,2,8
be seen in patients with Monkeypox. Respiratory
symptoms such as sore throat, nasal congestion, and Table 1. Monkeypox lesion progression2
cough can be found in sufferers.1,2,8 Stadium Duration Characteristic
Monkeypox infection can be divided into Enatem Lesions sometimes appear first on
two periods:2 The invasion period (lasting 0-5 days) the tongue and in the mouth
is characterized by fever, severe headache, Macula 1-2 days Macular lesions appear
Papule 1-2 days The lesion progresses from a
lymphadenopathy, back pain, myalgia, and severe
macula (flat) to a papule (there is
asthenia. Lymphadenopathy is a distinctive feature of an elevation)
Monkeypox compared to similar diseases. Vesicle 1-2 days The lesion will become a vesicle,
Lymphadenopathy can be felt in the neck, armpit or an elevated lesion with elevation
groin.2 The skin eruption usually begins within 1-3 and filled with clear fluid
days of the onset of fever. The rash tends to appear Pustule 5-7 days The lesion becomes a pustule
on the face and extremities rather than the trunk. filled with opaque fluid, elevates,
Involves the face in 95% of cases, palms and soles in is round and hard on pressure
75% of cases, genitalia in 30% of cases and the Crust 7-14 days At the end of the second week,
conjunctiva in 20% of cases, including the cornea. the pustules become crusty and
will last up to 1 week and then
Lesions develop from macules to papules then
peel off
vesicles and pustules to crust over and detach from

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Figure 3. Clinical Manifestations in Monkeypox2

Diagnosis and Differential Diagnosis Clinically, Monkeypox's differential

In addition to signs and symptoms, diagnosis can account for diseases with other rashes,
Monkeypox's diagnosis is based on real-time such as smallpox, chickenpox, measles, bacterial skin
polymerase chain reaction (PCR) examination of dry infections, scabies, syphilis, and specific drug-related
swab samples of lesions or ulcers. Samples from allergies. In addition, lymphadenopathy during the
nasopharyngeal swabs, serum samples, scabs, and prodromal phase can be a typical clinical feature to
tissue samples can also be used for PCR or distinguish Monkeypox from other similar smallpox
pathological examination. The differential diagnosis diseases, such as smallpox, chickenpox/varicella
includes syphilis, cancroid, varicella zoster, herpes (chickenpox), and others.8
simplex, hand-foot-and-mouth disease, molluscum
contagious and cryptococcus. 1,3,5,6,8,12,14
The definition of Monkeypox cases can be
divided into four classifications of suspected
(suspected), confirmed, probable and possible
diagnoses. The Monkeypox case definitions are
divided into four classifications: suspected,
confirmed, probable and possible diagnoses.
Suspected cases are patients with sudden onset of Figure 4. Lymphadenopathy in children with monkeypox8
fever followed by vesicular-pustular eruptions
predominantly on the face, palms, soles of the feet, Table 2. Comparison of Monkeypox Symptoms and Signs
and the discovery of at least five smallpox-type and Differential Diagnosis2
crusts. Recent WHO guidelines add the presence of a Symptoms Monkeypox Chickenpox Measles
and Signs (Varicella)
mucosal lesion as the definition of a suspected case.
Fever Fever >38°C, Fever up to High fever
Confirmed cases are suspected cases that have been rash after 1-3 39°C, rash 40.5°C, rash
confirmed by the laboratory, such as positive IgA days after 0-2 days after 2-4 days
antibodies, PCR or virus isolation. A probable case is Rash Macules, Macules, Non-vesicular
a suspected case with appropriate epidemiology but papules, papules, rash in
vesicles, vesicles. various
no laboratory confirmation access. Cases may be pustules. The There are phases
established in patients with vesicular lesions, type of rash is various
pustules or crusts who have not been diagnosed with the same in phases
measles, have a history of fever with vesicles or have every phase in
a crusted rash. This individual also meets all areas of
the body
epidemiological criteria, has an orthopoxvirus- Rash Slow, 3-4 Fast, crops Fast, 5-7 days
specific IgM elevation, and has an unexplained development weeks appear for a
febrile rash. 1,3,5,6,8,12,14 few days

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Rash Starting at the Start at the Starts in the as cidofovir and brincidofovir have been shown to be
Duration head, denser head; denser head and effective against orthopoxvirus in in-vitro and animal
on the face on the body; spreads; can
and limbs; not on the reach hands studies. The effectiveness of this drug against
appears on the palms of the and feet monkeypox in humans is unknown. 2,3,5,8,24–26
palms of the hands and However, there are also precautions that can
hands and soles of the be taken to prevent an outbreak from occurring. For
soles of the feet
example, vaccines used during smallpox (smallpox)
feet
Distinctive Lymphadenop Itchy rash Koplik spots eradication programs protect{ }Monkeypox. Based
appearance athy on several observational studies, the smallpox
Mortality 3-6% Rare Varies vaccine has an effectiveness of 85% for preventing
Monkeypox. In addition, receiving this vaccine will
2022 Monkeypox Outbreak result in milder symptoms. A new vaccine developed
Monkeypox was first discovered in 1958 for smallpox was approved in 2019 to prevent
when a disease such as the smallpox outbreak Monkeypox, but global availability is limited.2,8,27–29
occurred in a group of Singaporean monkeys sent to The recommended vaccination in Indonesia
Denmark for research. The first human case of to reduce the incidence of Monkeypox is the
Monkeypox was discovered in 1970 in Congo in a 9- Modified Vaccinia Ankara-Bavarian Nordic (MVA-
month-old child. As of June 2022, 86% of cases BN) vaccine. The MVA-BN that will be used as the
reported to WHO were from the European region. third generation of smallpox vaccine is effective and
Other regions such as Africa 2%, America 11%, safe to give to monkeypox patients with
Eastern Mediterranean <1%, and West Pacific region immunocompromised conditions or those with innate
<1%.3,5,8–14 immune disorders. In addition, MVA-BN is also safe
Since May 2022, Monkeypox cases have been to use for patients over 18 years, children and also
reported from non-endemic countries and forwarded pregnant woman. , .1,2
to reports from endemic countries. Most confirmed
cases had a history of travelling to European and Complications and Prognosis
North American countries, compared to Central and There are data on the relationship between
South Africa, where Monkeypox is endemic. This is Monkeypox in children. However, based on reports
the first time that Monkeypox cases have been found of patients infected with Monkeypox, this disease
in both endemic and non-endemic countries. Of the tends to be more severe in children. Rarely,
cases reported to WHO, most were identified as Monkeypox can cause complications, including
being transmitted through sexual intercourse or encephalitis, cellulitis, pneumonia, sepsis, abscess,
health facilities related to but not exclusively with airway obstruction due to severe lymphadenopathy,
men who have sex with men.2,4,8,17,20,22 keratitis, hyperpigmentation, pneumonia, and corneal
On August 19, 2022, one positive case was scarring. 2,8,30,31
found in a 27-year-old male patient in Jakarta. As of
September 15, 2022, there are 2 suspects and 63 Conclusions
discarded. From the distribution of 63 patients with With the outbreak report, it is important to
discarded status covering 10 provinces in Indonesia.1 discuss, explore, and understand more about the
disease and its management and prevention.
Management and Vaccination Unfortunately, there is currently no specific
Currently, no specific treatment has been treatment for Monkeypox. However, this disease can
proven to treat Monkeypox infection. Like other viral be prevented by vaccination. In Indonesia, the
diseases, Monkeypox therapy is symptomatic Modified Vaccinia Ankara-Bavarian Nordic (MVA-
supportive therapy. An antiviral tecovirimat or BN) vaccine is recommended to prevent Monkeypox
TPOXX was developed by the European Medicines disease.
Agency (EMA) as a monkeypox therapy in 2022
based on animal and human studies. This drug has
not been marketed freely. In addition, antivirals such

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Meiriani Sari, Nany Hairunisa

CONFLICTS OF INTEREST outbreak strategy. PLoS Negl Trop Dis.

The authors declare no conflict of interest in 2019;13(10).
this article. 10. European Centre for Disease Prevention and
Control. Monkeypox multi-country outbreak
FUNDING Key messages. 2022.
No specific funding was provided for this 11. Oladoye MJ. Monkeypox: A Neglected Viral
review. Zoonotic Disease. European Journal of
AUTHORS CONTRIBUTIONS Medical and Educational Technologies. 2021
The authors contributions to this review are May 15;14(2):em2108.
as follows: conceptualization, collecting literature, 12. Petersen E, Kantele A, Koopmans M, et al.
and writing draft: Meiriani Sari; supervision, review Human Monkeypox epidemiologic and
and editing: Nany Hairunisa. clinical characteristic, diagnosis and
prevention Elsevier Enhanced Reader. Infect
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