A recent article published in the pre-print server medRxiv * demonstrated the scarcity of appropriate clinical management guidelines for monkeypox (MPX) infections worldwide.
Study: Availability, Scope, and Quality of Monkeypox Clinical Management Guidelines Worldwide: A Systematic Review. Image credit: MIA Studio / Shutterstock
Fund
MPX is a zoonotic disease caused by a smallpox-related orthopoxvirus. In the Democratic Republic of the Congo (DRC), the first human MPX infection was discovered in 1970. Subsequently, human MPX has been documented mainly in the nations of West and Central Africa.
In non-endemic and endemic sites, there has been an increase in MPX cases and outbreaks in recent decades. With 257 confirmed cases of MPX in 23 nations on May 26, 2022, the continued outbreak of MPX in 2022 is the first known multinational outbreak among non-endemic countries. Contacts with infected people and animals are associated with an increased risk of infection. Antibody and antigen detection methods do not provide specific confirmation of MPX due to cross-serological reactivity of orthopoxviruses.
Smallpox vaccination is expected to be 85% effective against MPX. First-generation live smallpox vaccination is not recommended for pregnant women or immunosuppressed individuals. In some areas, new third-generation live vaccines that do not reproduce against smallpox and smallpox in adults have been approved. However, none are included in the standard vaccination programs and are not widely available for general use worldwide.
In addition, there are few therapeutic options available for MPX. In some nations, Tecovirimat is approved to treat smallpox in children and adults and MPX in outbreaks. In addition, in animal and in vitro trials, brincidofovir and cidofovir showed activity against MPX. However, there is a paucity of evidence of brincidofovir and cidofovir in treatment with MPX in humans, and they are only approved for use in some countries.
In addition, the increase in MPX cases in recent decades underscores the need for physicians around the world to have access to clinical management policies that can help guide treatment and improve patient care and outcomes.
About the study
In the present study, the scientists evaluated the scope, availability, inclusion, and quality of worldwide clinical management guidelines for MPX. The team scanned six databases (Ovid Embase, Ovid Medline, Ovid Global Health, Web of Science Core Collection, Scopus, and the World Health Organization’s (WHO) Global Medicus Index) from its inception to 14 from October 2021 and a search for gray literature until May. 17, 2022.
MPX guidelines incorporating supportive care and treatment recommendations were incorporated, without language exclusions. Two reviewers evaluated the guidelines. Quality was examined using the Research Guidelines for Evaluation and Evaluation (AGREE) 2 tool.
In addition, this research was part of a comprehensive systematic review of clinical management and supportive care guidelines for high-risk infectious diseases. The study was registered with PROSPERO, the prospective international registry for systematic reviews, and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) standards for conducting systematic reviews.
Results
The results of the study showed that among the 2026 records reviewed, 14 MPX guidelines were found. In general, most of the guidelines were of poor quality (with a score of two out of seven, ranging from one to seven), lacked detail, and dealt with a limited range of issues. Most of the guidelines focused on adults; however, five, or 36%, gave some advice to children, three, or 21%, to pregnant women, and three, or 21%, to people living with human immunodeficiency virus (HIV).
Treatment recommendations were mainly limited to antivirals. Seven guidelines recommended cidofovir, four of which were exclusively for severe MPX. In addition, 29%, ie four out of 14, recommended tecovirimat, and 7%, ie one out of 14, recommended brincidofovir. Only one guide included treatment recommendations and supportive care for complications.
Vaccination was suggested as post-exposure prophylaxis (PEP) in all guidelines. Three guidelines recommended vaccinia immunoglobulin as a PEP for severe cases in immunocompromised individuals.
The present review found a significant lack of guidance on treatment and PEP, as well as often conflicting advice, for many demographic groups, including pregnant women, children, and people living with immunosuppression, which could worsen their susceptibility. to the shoots. The researchers noticed a pattern of guidelines that was quickly established in response to outbreaks, which was rarely reviewed, but remained accessible to all public domains. Failure to review outdated recommendations as new evidence becomes available puts patient care at risk. In addition, some guidelines include tracking systems or updates.
Conclusions
Taken together, the current findings show that there was a global shortage of high-quality, up-to-date evidence-based MPX clinical management guidelines. The scientists described that as the number of cases and outbreaks of MPX increases, there is an immediate and obvious requirement for research on the prophylaxis and treatment of MPX infections, even for a variety of risk groups. .
The team found that most of the guidelines did not report the methodology used, which was reflected in the quality assessment, with most of the guidelines being described as low quality. The low scores observed by the rigor of the development are due to the scarcity of documentation, systematic methodologies and clear connections with the information that supports the suggestions.
In addition, the authors mentioned that the current outbreak of MPX offers an opportunity to accelerate this study by coordinating high-quality research. Newer tests should be integrated into the guidelines available worldwide to benefit patients and the outcome of the epidemic. In addition, the researchers suggested a system of living guidelines for the management of infectious diseases, including MPX.
* Important news
medRxiv publishes preliminary scientific reports that are not peer-reviewed and therefore should not be considered conclusive, guided by clinical practice or health-related behavior, or treated as established information.
Magazine reference:
- Eika Webb, Ishmeala Rigby, Melina Michelen, Andrew Dagens, Vincent Cheng, Amanda Rojek, Dania Dahmash, Susan Khader, Keerti Gedela, Alice Norton, Muge Cevik, Erhui Cai, Eli Harriss, Samuel Lipworth, Robert Nartowski, Helen Groves, Peter Hart , Lucille Blumberg, Tom Fletcher, Shevin T Jacob, Louise Sigfrid, Peter Horby. (2022). Worldwide availability, scope, and quality of monkeypox clinical management guidelines: a systematic review. medRxiv. two: