program has created an ecologic gap whereby an increasing proportion of the population has either waning or nonexistent immunity to MPXV. This development will further increase the risk of both the animal-to-human and human-tohuman spread of the virus. Therefore, priority research and surveillance should 12 Petersen et al urgently be conducted through a joint “One-Human-Animal-Environmental Health” effort across Central and West Africa.83–85 ACKNOWLEDGMENTS The authors thank the NCDC staff for providing the clinical photographs from the ongoing 2019 monkeypox outbreak in Nigeria, and the patients who gave permission to have the photos taken. REFERENCES 1. WHO. Human monkeypox 2019. Available at: https://www.who.int/emergencies/ diseases/monkeypox/en/. Accessed February 22, 2019. 2. WHO. Smallpox 2019. Available at: https://www.who.int/biologicals/vaccines/ smallpox/en/. Accessed February 20, 2019. 3. CDC. Monkeypox. MMWR Morb Mortal Wkly Rep 2018;67:306–10. 4. Shchelkunov SN, Totmenin AV, Babkin IV, et al. Human monkeypox and smallpox viruses: genomic comparison. FEBS Lett 2001;509:66–70. 5. Pauli G, Blu¨mel J, Burger R, et al. Orthopox viruses: infections in humans. Transfus Med Hemother 2010;37:351–64. 6. Bera BC, Shanmugasundaram K, Barua S, et al. Zoonotic cases of camelpox infection in India. Vet Microbiol 2011;152:29–38. 7. Cook GC, Zumla A. Chapter 47. Cutaneous viral diseases. Monkeypox. In: Cook GC, Zumla A, editors. Manson’s tropical diseases. 22nd edition. London: Harcourt Brace Saunders, Publishing Group; 2009. p. 839–40. 8. Petersen E, Abubakar I, Ihekweazu C, et al. Monkeypox—Enhancing public health preparedness for an emerging lethal h 1. Introduction Monkeypox (MPX) is a viral zoonotic disease with symptoms similar to smallpox, although with less clinical severity. MPX was first discovered in 1958 in colonies of monkeys kept for research, hence the name ‘monkeypox.’ The first human case of monkeypox was reported from Democratic Republic of the Congo (DRC) in 1970. Monkeypox Virus primarily occurs in Central and West Africa. In 2003, the first monkeypox outbreak outside of Africa was reported in the United States of America which was linked to contact with infected pet prairie dogs. These pets had been housed with Gambian pouched rats and dormice that had been imported into the country from Ghana. 1.1 Global Scenario According to World Health Organization (WHO), in the present series of outbreaks being reported, this is the first time that chains of transmission are reported in Europe without known epidemiological links to West or Central Africa. Monkeypox has been reported as endemic in several other central and western African countries such as: Cameroon, Central African Republic, Cote d’Ivoire, Democratic Republic of the Congo, Gabon, Liberia, Nigeria, Republic of the Congo, and Sierra Leone. This has been also reported in certain non-endemic countries e.g. USA, UK Belgium, France, Germany, Italy, Netherlands, Portugal, Spain, Sweden, Australia, Canada, Austria, Canary Islands, Israel and Switzerland. There are no reported cases of monkeypox virus in India till date as on 31st May 2022. However, India needs to be prepared in view of the increasing reports of cases in non-endemic countries. 2. Epidemiology 2.1 Agent Monkeypox virus (MPXV) is an enveloped double-stranded DNA virus that belongs to the Orthopoxvirus genus of the Poxviridae family. There are two distinct genetic clades of the monkeypox virus – the Central African (Congo Basin) clade and the West African clade. The Congo Basin clade has historically caused more severe disease and was thought to be more transmissible. The geographical division between the two clades has so far been in Cameroon - the only country where both virus clades have been found. 3 2.2 Host: Natural reservoir is yet unknown. However, certain rodents (including rope squirrels, tree squirrels, Gambian pouched rats, dormice) and non-human primates are known to be naturally susceptible to monkeypox virus. 2.3 Incubation period: The incubation period (interval from infection to onset of symptoms) of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days. 2.4 Period of communicability: 1-2 days before the rash to until all the scabs fall off/gets subsided. 2.5 Mode of transmission: · Human-to-human transmission is known to occur primarily through large respiratory droplets generally requiring a prolonged close contact. It can also be transmitted through direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens of an infected person. · Animal-to-human transmission: may occur by bite or scratch of infected animals like small mammals including rodents (rats, squirrels) and non-human primates (monkeys, apes) or through bush meat preparation. 3. Case definition 3.1 Suspected case: A person of any age having history of travel to affected countries within last 21 days presenting with an unexplained acute rash AND one or more of the following signs or symptoms · Swollen lymph nodes · Fever · Headache · Body aches · profound weakness 4 3.2 Probable case: A person meeting the case definition for a suspected case, clinically compatible illness and has an