Monkeypox

 

Monkeypox

Monkeypox is an infectious viral disease that can occur in humans and some other animals. Symptoms include fever, swollen lymph nodes, and a rash that forms blisters and then crusts over. The time from exposure to onset of symptoms ranges from 5 to 21 days. The duration of symptoms is typically 2 to 4 weeks. There may be mild symptoms, but to what extent it may occur without any symptoms is not known. The classic presentation of fever and muscle pains, followed by swollen glands, with lesions all at the same stage, has not been found to be common to all outbreaks. Cases may be severe, especially in children, pregnant women or people with suppressed immune systems.

The disease is caused by monkeypox virus, a zoonotic virus in the genus Orthopoxvirus. The variola virus, the causative agent of smallpox, was also in this genus. Of the two types in humans, the West African type causes a less severe disease than the Central African (Congo Basin) type. It may spread from handling bushmeat, animal bites or scratches, body fluids, contaminated objects, or other close contact with an infected person. Spread can occur by small droplets and possibly the airborne route. People can spread the virus from the onset of symptoms until all the lesions have scabbed and fallen off; with some evidence of spread for more than a week after lesions have crusted. The virus is believed to normally spread among certain rodents in Africa. Diagnosis can be confirmed by testing a lesion for the virus's DNA. The disease can appear similar to chickenpox.

There is no known cure. The smallpox vaccine was found to be around 85% protective in preventing infection in close contacts and in lessening the severity of the disease. A newer smallpox and monkeypox vaccine based on modified vaccinia Ankara has been approved, but with limited availability. Other measures include regular hand washing and avoiding sick people and other animals. Antiviral drugs, cidofovir and tecovirimat, vaccinia immune globulin and the smallpox vaccine may be used during outbreaks. The risk of death has varied from 0% to 11%. Most people recover.

The disease is no longer believed to be as rare as previously thought; possibly as a result of waning immunity since the stopping of routine smallpox vaccination. Cases have significantly increased since the 1980s. Sporadic cases occur frequently in Central and West Africa, and it is highly endemic in the Democratic Republic of the Congo (DRC). Hunters in the tropical forests of Central and West Africa are most at risk. It was first identified as a distinct illness in 1958 among laboratory monkeys in Copenhagen, Denmark. Monkeys are not a natural reservoir of the virus. The first cases in humans were found in 1970 in the DRC. An outbreak that occurred in the United States in 2003 was traced to a pet store where rodents imported from Ghana were sold. Since 2017, a large outbreak has been occurring in Nigeria. The 2022 monkeypox outbreak represents the first incidence of widespread community transmission outside of Africa, which was initially identified in the United Kingdom in May 2022, with subsequent cases confirmed in at least 20 countries in Europe, North America, South America, Asia, Africa, and Australia.

Definition and types

Monkeypox is a zoonotic poxvirus infection that can occur in both humans and some other animals. Two recognized distinct types are described as the Congo Basin clade and the milder West African clade.

Signs and symptoms

Stages of monkeypox lesion development

Early symptoms include headache, muscle pains, fever and fatigue. It may initially appear like influenza. The disease can resemble chickenpox, measles and smallpox but is distinguished by the presence of swollen glands. These characteristically appear behind the ear, below the jaw, in the neck or in the groin, before the onset of the rash. Within a few days of the fever, lesions characteristically appear on the face before appearing elsewhere such as palms of the hands and soles of the feet in a centrifugal distribution. Symptoms may vary in people with HIV. Many cases in the 2022 monkeypox outbreak presented with genital and peri-anal lesions, fever, swollen lymph nodes, and pain when swallowing.

Three-quarters of affected people have lesions on the palms and soles, more than two-thirds in the mouth, a third on the genitals and one in five have lesions in the eyes. They begin as small flat spots, before becoming small bumps which then fill with at first clear fluid and then yellow fluid, which subsequently burst and scab over. There may be a few lesions or several thousand, sometimes merging to produce large lesions.

In each affected part of the body, the lesions evolve in the same stage. It looks identical to the rash of smallpox. The rash typically lasts around ten days. An unwell person may remain so for two to four weeks. After healing, the lesions may leave pale marks before becoming dark scars.

Limited person-to-person spread of infection has been reported in disease-endemic areas in Africa.

Complications

Complications include secondary infections, pneumonia, sepsis, encephalitis, and loss of vision if severe eye infection. If infection occurs during pregnancy, still birth or birth defects may occur. The disease may be milder in people vaccinated against smallpox in childhood.

Causes

Monkeypox in both humans and animals is caused by infection with the monkeypox virus – a double-stranded DNA virus in the genus Orthopoxvirus, family Poxviridae. The virus is found mainly in tropical rainforest regions of Central and West Africa. The virus is split into Congo Basin and West African clades, matching the geographical areas.

Most human cases of monkeypox are acquired from an infected animal, though the route of transmission remains unknown. The virus is thought to enter the body through broken skin, the respiratory tract, or the mucous membranes of the eyes, nose, or mouth. Once a human is infected, transmission to other humans is common, with family members and hospital staff at particularly high risk of infection.

Human-to-human transmission is thought to occur primarily through close contact with an infected subject. There are indications that transmission occurs during sexual intercourse. Animal-to-human transmission may occur by bite or scratch, bush meat preparation, direct contact with body fluids or lesion material, or indirect contact with lesion material, such as through contaminated bedding.

Humans can be infected by an animal via a bite, or by direct contact with an infected animal’s bodily fluids. The virus can also spread from human to human, by respiratory (airborne) contact or by contact with an infected person's bodily fluids. Risk factors for transmission include sharing a bed or room, or using the same utensils as an infected person. Increased transmission risk is associated with factors involving the introduction of virus to the oral mucosa.

Monkeypox symptoms tend to begin 5 to 21 days after infection. Further research about the transmission of the strain responsible for the 2022 outbreak is ongoing, but it is not thought to be different to other strains of the West African clade.

Reservoir

In addition to monkeys, the virus is found in Gambian pouched rats (Cricetomys gambianus), dormice (Graphiurus spp.) and African squirrels (Heliosciurus, and Funisciurus). The use of these animals as food may be an important source of transmission to humans.

No specific reservoir for monkeypox has been found. Monkeys are not a main reservoir, contrary to the name. It is believed African rodents, such as the ones listed above, serve as the actual reservoir.

Diagnosis

Clinical differential diagnosis must consider other rash illnesses, such as chickenpox, measles, bacterial skin infections, scabies, syphilis and medication-associated allergies. Lymphadenopathy during the prodromal stage of illness can distinguish monkeypox from chickenpox or smallpox. Diagnosis can be verified by testing for the virus.

Polymerase chain reaction (PCR) testing of samples from skin lesions is the preferred laboratory test. PCR blood tests are usually inconclusive because the virus does not remain very long in the blood. To interpret test results, information is required on date of onset of fever, date of onset of rash, date of specimen collection, current stage of rash, and patient age.

Prevention

Vaccination against smallpox is assumed to provide protection against human monkeypox infection because they are closely related viruses and the vaccine protects animals from experimental lethal monkeypox challenges. This has not been conclusively demonstrated in humans because routine smallpox vaccination was discontinued following the eradication of smallpox.

Smallpox vaccine has been reported to reduce the risk of monkeypox among previously vaccinated persons in Africa. The decrease in immunity to poxviruses in exposed populations is a factor in the prevalence of monkeypox. It is attributed both to waning cross-protective immunity among those vaccinated before 1980 when mass smallpox vaccinations were discontinued, and to the gradually increasing proportion of unvaccinated individuals.

The United States Centers for Disease Control and Prevention (CDC) recommends that persons investigating monkeypox outbreaks and involved in caring for infected individuals or animals should receive a smallpox vaccination to protect against monkeypox. Persons who have had close or intimate contact with individuals or animals confirmed to have monkeypox should also be vaccinated.

The CDC does not recommend pre-exposure vaccination for unexposed veterinarians, veterinary staff, or animal control officers, unless such persons are involved in field investigations.

The CDC recommends that healthcare providers don a full set of personal protective equipment (PPE) before caring for an infected person. This includes a gown, mask, goggles, and a filtering disposable respirator (such as an N95). An infected person should be isolated in preferably a negative air pressure room or at least a private exam room to keep others from possible contact.

Treatment

In the European Union and the United States, tecovirimat is approved for the treatment of several poxviruses, including monkeypox.[55] BMJ Best Practice recommends tecovirimat or the smallpox treatment brincidofovir as the first line antiviral treatment if required, alongside supportive care (including antipyretic, fluid balance and oxygenation). Empirical antibiotic therapy or aciclovir may be used if secondary bacterial or varicella zoster infection is suspected, respectively.

Outcome

After healing, the scabs may leave pale marks before becoming darker scars. The risk of death in those infected ranges from 0% to 11%, depending on the type of monkeypox and location in the world. Fatality rates have been reported as around 3.6% in West Africa and 10.6% in Central Africa. Most reported deaths have occurred in young children and people with HIV.

Dried fruit

 Dried fruit

Dried fruit is fruit from which the majority of the original water content has been removed either naturally, through sun drying, or through the use of specialized dryers or dehydrators. Dried fruit has a long tradition of use dating back to the fourth millennium BC in Mesopotamia, and is prized because of its sweet taste, nutritive value, and long shelf life.

Today, dried fruit consumption is widespread. Nearly half of the dried fruits sold are raisins, followed by dates, prunes, figs, apricots, peaches, apples, and pears. These are referred to as "conventional" or "traditional" dried fruits: fruits that have been dried in the sun or in heated wind tunnel dryers. Many fruits such as cranberries, blueberries, cherries, strawberries, and mango are infused with a sweetener (e.g. sucrose syrup) prior to drying. Some products sold as dried fruit, like papaya, kiwifruit and pineapple, are most often candied fruit.

Dried fruits retain most of the nutritional value of fresh fruits. The specific nutrient content of the different dried fruits reflects their fresh counterpart and the processing method.

History

Traditional dried fruit such as raisins, figs, dates, apricots and apples have been a staple of Mediterranean diets for millennia. This is due partly to their early cultivation in the Middle Eastern region known as the Fertile Crescent, made up by parts of modern Iran, Iraq, southwest Turkey, Syria, Lebanon, Palestine, Israel, and northern Egypt. Drying or dehydration also happened to be the earliest form of food preservation: grapes, dates, and figs that fell from the tree or vine would dry in the hot sun. Early hunter-gatherers observed that these fallen fruit took on an edible form, and valued them for their stability as well as their concentrated sweetness.The earliest recorded mention of dried fruits can be found in Mesopotamian tablets dating to about 1500 BC, which contain what are probably the oldest known written recipes. These clay slabs, written in Akkadian, the daily language of Babylonia, were inscribed in cuneiform and tell of diets based on grains (barley, millet, wheat), vegetables and fruits such as dates, figs, apples, pomegranates, and grapes. These early civilizations used dates, date juice evaporated into syrup and raisins as sweeteners. They included dried fruits in their breads for which they had more than 300 recipes, from simple barley bread for the workers to very elaborate, spiced cakes with honey for the palaces and temples.The date palm was one of the first cultivated trees. It was domesticated in Mesopotamia more than 5,000 years ago. It grew abundantly in the Fertile Crescent and it was so productive (an average date palm produces 50 kg (100 lbs) of fruit a year for 60 years or more) that dates were the cheapest of staple foods. Because they were so valuable, they were well recorded in Assyrian and Babylonian monuments and temples. The villagers in Mesopotamia dried them and ate them as sweets. Whether fresh, soft-dried or hard-dried, they helped to give character to meat dishes and grain pies. They were valued by travelers for their energy and were recommended as stimulants against fatigue.Figs were also prized in early Mesopotamia, Palestine and Egypt where their daily use was probably greater than or equal to that of dates. As well as appearing in wall paintings, many specimens have been found in Egyptian tombs as funerary offerings. In Greece and Crete, figs grew very readily and they were the staple of poor and rich alike, particularly in their dried form.

Grape cultivation first began in Armenia and the eastern regions of the Mediterranean in the 4th century BC. Raisins were produced by drying grapes in the hot desert sun. Very quickly, viticulture and raisin production spread across northern Africa including Morocco and Tunisia. The Phoenicians and the Egyptians popularized the production of raisins, probably due to the perfect arid environment for sun drying. They put them in jars for storage and allotted them to the different temples by the thousands. They also added them to breads and various pastries, some made with honey, some with milk and eggs.

From the Middle East, these fruits spread through Greece to Italy where they became a major part of the diet. Ancient Romans consumed raisins in spectacular quantities and at all levels of society, including them as a key part of their common meals, along with olives and fresh fruits. Raisined breads were common for breakfast and were consumed with their grains, beans and cultured milks. Raisins were so valued that they transcended the food realm and became rewards for successful athletes, as well as premium barterHaving dried fruits was essential in ancient Rome as these instructions for housekeepers around 100 BC tell: "She must keep a supply of cooked food on hand for you and the servants. She must keep many hens and have plenty of eggs. She must have a large store of dried pears, sorbs, figs, raisins, sorbs in must, preserved pears and grapes and quinces. She must also keep preserved grapes in grape-pulp and in pots buried in the ground, as well as fresh Praenestine nuts kept in the same way, and Scantian quinces in jars, and other fruits that are usually preserved, as well as wild fruits. All these she must store away diligently every year."

Figs were also extremely popular in Rome. Dried figs were added to bread and formed a major part of the winter food of country people. They were rubbed with spices such as cumin, anise and fennel seeds, or toasted sesame, wrapped in fig leaves and stored in jars. Today, major producing regions include Israel, Jerusalem, Gaza and many other Arabic countries. Dried figs are rich in vitamins, phosphorus and the various other important minerals .

Plums, apricots and peaches had their origins in Asia. They were domesticated in China in the 3rd millennium BC and spread to the Fertile Crescent where they were also very popular, fresh and dried alike. They arrived in Greece and Italy much later and were very expensive but valued in the preparation of gourmet dishes with port or stewed with honey and spices.

Production

Today, dried fruit is produced in most regions of the world, and consumption occurs in all cultures and demographic segments. In the United States, Americans consumed an average of 2.18 lb (1 kg) (processed weight) of dried fruit in 2006. Raisins accounted for about two thirds of this.[10] California produces the largest percentage of the US and the world's[citation needed] dried fruit crop. It accounts for over 99% of the US crop of raisins and dried plums, 98% of dried figs, 96% of dried peaches, 92% of apricots and over 90% of dates. Most of California dried fruit production is centered in the San Joaquin Valley where the soil and climate, especially the hot, dry summers, provide ideal growing conditions. While these fruits were commonly dried in the sun in the past, now only raisins are almost entirely naturally sun-dried.

Fruits can be dried whole (e.g., grapes, berries, apricot, plum), in halves, or as slices, (e.g., mango, papaya, kiwi). Alternatively they can be chopped after drying (e.g., dates), made into pastes, or concentrated juices. The residual moisture content can vary from small (3 – 8%) to substantial (16 – 18%), depending on the type of fruit. Fruits can also be dried in puree form, as leather, or as a powder, by spray or drum drying. They can be freeze dried. Fresh fruit is frozen and placed in a drying chamber under vacuum. Heat is applied and water evaporates from the fruit while still frozen". The fruit becomes very light and crispy and retains much of its original flavor. Dried fruit is widely used by the confectionery, baking, and sweets industries. Food manufacturing plants use dried fruits in various sauces, soups, marinades, garnishes, puddings, and food for infants and children

As ingredients in prepared food, dried fruit juices, purées, and pastes impart sensory and functional characteristics to recipes:

Dozens of types of dried fruit and fruit leather at a market in Yerevan

The high fiber content provides water-absorbing and water-binding capabilities, tenderization, and nutritional enhancement.

Organic acids such as sorbitol act as humectants, provide dough and batter stability, and control water activity.

Fruit sugars add sweetness, humectancy, and surface browning, and control water activity.

Fruit acids, such as malic acid and tartaric acid, contribute to flavor enhancement and act as anti-microbial agents (suppress mold and bacterial growth).

Vitamins and minerals increase nutritional value and label appeal.

Phenolic compounds slow down lipid oxidation in meats. They add a natural caramel color.

The high drying and processing temperatures, the intrinsic low pH of the fruit, the low water activity (moisture content) and the presence of natural antimicrobial compounds in dried fruit make them a stable food. Incident of a food-borne illness related to dried fruit are not known.

Traditional medicine

 

Traditional medicine

Traditional medicine also known as indigenous or folk medicine comprises medical aspects of traditional knowledge that developed over generations within the folk beliefs of various societies, before the era of modern medicine. The World Health Organization (WHO) defines traditional medicine as "the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness". Traditional medicine is often contrasted with scientific medicine.

Botánicas such as this one in Jamaica Plain, Boston, cater to the Latino community and sell folk medicine alongside statues of saints, candles decorated with prayers, lucky bamboo, and other items.

In some Asian and African countries, up to 80% of the population relies on traditional medicine for their primary health care needs. When adopted outside its traditional culture, traditional medicine is often considered a form of alternative medicine. Practices known as traditional medicines include traditional European medicine, traditional Chinese medicine, traditional Korean medicine, traditional African medicine, Ayurveda, Siddha medicine, Unani, ancient Iranian medicine, traditional Iranian medicine, medieval Islamic medicine, Muti, and Ifá. Scientific disciplines that study traditional medicine include herbalism, ethnomedicine, ethnobotany, and medical anthropology.

The WHO notes, however, that "inappropriate use of traditional medicines or practices can have negative or dangerous effects" and that "further research is needed to ascertain the efficacy and safety" of such practices and medicinal plants used by traditional medicine systems. As a result, the WHO has implemented a nine-year strategy to "support Member States in developing proactive policies and implementing action plans that will strengthen the role traditional medicine plays in keeping populations healthy."

Health Care Card

 Health Care Card

The Australian Health Care Card is a card issued by the Australian Government which evidences the entitlement of the cardholder to concessions, such as the cost of some prescription medicines, medical services, and other government concessions. Eligibility for the card is determined by the eligibility (and registration) for various federal government welfare payments (see Centrelink). The benefits are clearly shown on the card. Some benefits (most notably public transport ones in some areas) are only available to recipients of certain Centrelink benefits.

The card is issued after an applicant has successfully applied for one or more of the associated payments. The card is valid for six months, after which time it is renewed if the holder continues to be in receipt of the payment for which the card was granted. This includes periods in which the holder received a "zero rate" of payment due to income reported.

Eligibility

A person may be eligible for a Low Income Health Care Card if they are not eligible to a Pensioner Concession Card. This is assessed through a separate claim to a health care card, based on the average weekly income received by the claimant (and their partner, if applicable) in the eight weeks prior to claiming the card. Income thresholds for the card vary depending on the claimant's circumstances (i.e.: if single, a member of a couple, and a member of a couple with children), which the threshold increasing based on the number of children in care. Eligibility for the card is reassessed every six months.

A claim may be made for a Health Care Card from the age of 16 onwards. Eligibility criteria vary depending on the age and circumstances of the claimant.

Benefits

A health care card will general cover the cardholder's family (cardholder, partner and children). An exception to this may be where a partner does not meet residency requirements for a health care card, or where the health care card has been issued in conjunction with a claim for Carer Allowance (in which case the card will be in the name of the person being cared for, and not the payment recipient).

Advantages of holding the card can include reduced:

health care costs including PBS medicines, ambulance transportation, dental care and eye care

public transport costs in many areas (excluding Queensland)

water rates

gas and electricity bills.

Some private businesses may also give discounts to cardholders, which are subject to the discretion of the provider, and are not administered by Centrelink.