This is an integrative review conducted through the following stages: formulation of the research question, identification of relevant studies, selection of studies and extraction of data and, finally, presentation of a synthesis of the evidence^{8), (9}. This study followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ⁽¹⁰ guidelines. The dataset of this study was stored in the Mendeley Data¹¹ public repository.

The research question was formulated based on the PICO strategy (P: population - general population; I: interest - clinical aspects related to human mpox cases; C: context - world scenario). Thus, the following guiding question was delimited: What is the existing scientific evidence on the clinical aspects related to human mpox cases in the global scenario?

Five databases were accessed: SCOPUS, Web of Science, ScienceDirect, MEDLINE and PubMed from the National Library of Medicine and the National Institutes of Health, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The last database access was on October 3, 2024.

Regarding the inclusion criteria, we considered studies that addressed evidence on cases of human mpox in the world scenario and available in full text. In order to achieve a comprehensive survey of the literature and considering that human mpox is an old infection, whose repercussions are the focus of study worldwide, no time frame was set for publications. Editorials, letters to the editor, abstracts, case reports, case series, experience reports, non-systematic reviews and reflection articles were excluded.

For the search strategy, the descriptors indexed in the Medical Subject Headings (MeSH) were used: "Monkeypox," "Monkeypox virus" "Delivery of Health Care," "Epidemiology," and "Signs and Symptoms". Three search strategies were developed for the SCOPUS database, and were adapted to the other databases, considering their particularities (Table 1).

Table 1
Search strategies developed for SCOPUS database

The search was performed independently by two researchers, finding the same number of studies in each database. The publications found were stored and exported to the software Rayyan - Intelligent Systematic Review (https://rayyan.ai/). Duplicates were removed and studies were selected. The organization of the citations and reference list of this review were managed by the Mendeley reference management software.

After this process, the title and abstract of the studies found were read to analyze whether they answered ourguidingresearch question.The articlesincluded after theinitial readingweresubmitted for full reading. In order to reduce possible biases, two researchers independently performed a selection stage of studies for analysis, with a third researcher to resolve any discrepancies.

For data mapping and data extraction procedure, a structured tool was developed in Microsoft Excel 2019®, containing the following items: identification of studies, methodological aspects, items related to the clinical aspects of human mpox cases, and main conclusions of the studies.

An analytical framework was built for data analysis by compiling selected studies, allowing for gathering and synthesizing the main information of the articles. The results were analyzed and later synthesized descriptively with the characterization of the studies.

Regarding the level of evidence for analyzing the studies, we chose to follow the JBI guidelines, which present five levels of evidence, namely: level 1 - experimental studies; level 2 - quasi experimental studies; level 3 - analytical observational studies; level 4 - descriptive observational studies; and level 5 - expert opinions¹².

Regarding the MPXV incubation period, that is, the interval from infection to the onset of symptoms, most studies reported a period of 4 to 21 days, with a mean period of 8.5 days^{34), (37), (49), (55}. Before the 2022 outbreak, the mean incubation period of the infection was 5 to 13 days⁷⁰.

Patients typically present with symptoms such as fever, lymphadenopathy, proctitis, oral and/ or anogenital lesions, rash, headache, asthenia, myalgia, chills, malaise, fatigue and ocular complications^{51), (60), (61}, while odynophagia and cough are less common²⁰. Systemic symptoms are followed by the development of characteristic rashes. Generally, the rashes appear in the mouth and soon spread to the face and extremities, involving the palms of the hands and soles of the feet45. Lesions in the anogenital region, present in the anus, perianal region, scrotum and penis, were also reported in the studies^{16), (37), (42}.

Due to the systemic symptoms that occur initially, resembling those of flu-like syndrome, the initial diagnosis may be ignored. With the manifestation of rashes near the genitals, MPXV is often diagnosed as another Sexually Transmitted Infection (STI) ⁽⁷⁰. There is a need to identify and monitor symptoms for differential diagnosis by health professionals.

Furthermore, the findings show the possibility of complications resulting from MPXV infection, such as subsequent skin infections, pneumonia, sepsis, encephalitis and corneal infection leading to potential vision loss^{37), (46}. Immunocompromised individuals, pregnant women and children under eight years of age are more likely to have severe complications of the disease, with mortality rates ranging from 1 to 11%⁶⁶.

The MPXV can be transmitted from person to person, animal to animal, and animal to human. Human- to-human transmission has been associated with respiratory droplet transmission, contact with bodily fluids, contact with skin lesions of an infected person, and sexual transmission of an infected individual with groin and genital lesions. Furthermore, studies indicate that the environment or belongings of a contaminated patient, such as clothing and bed/bath linens, are capable of transmitting the virus^{35), (58}.

An interesting finding in this study was the transplacental passage of the virus, which may cross the placenta of the infected mother and contaminate the fetus. According to the guidelines, it is recommended that the monitoring of infected pregnant women include fetal monitoring through ultrasound in order to detect possible abnormalities, such as fetal hepatomegaly or dropsy⁴³.

Most studies indicate that males are the most frequently reported cases. In men, the observed age was between 20 and 67 years old, with a mean age of 35 years^{19), (20), (25), (55}. In the current mpox outbreak, men often self-identify as men who have sex with men, homosexuals and bisexuals^{32), (48}. Research confirms this finding, and this population requires greater attention^{71), (72}.

Another relevant finding relates to the frequent report of the occurrence of MPXV in patients with human immunodeficiency virus (HIV) ⁽⁴⁸. This may be related to the incidence rate in men, who are the main group affected by HIV infection.

A study points out that in relation to exposure rates, heterosexual men account for 49% of cases and homosexuals 38%. In specific populations, such as men who have sex with men, studies indicate a high prevalence of HIV, estimated at about 18.4%⁷³. In addition, risk factors were identified among young men, including engaging in risky behaviors and activities, such as condomless sex and being HIV positive^{48), (74}.

The diagnosis of MPXV infection was identified in the studies, preferably by reverse transcription followed by polymerase chain reaction (RT-PCR). Samples for RT-PCR tests are taken from blood, throat, anal region, skin vesicles and urine^{19), (52), (53), (56), (61}. However, optimal diagnostic samples come from rash, fluids, crusts, or, in some cases, a biopsy of the lesions⁴⁶.

When clinically suspecting an MPXV infection, health professionals should inquire about the patient’s travel and sexual history, as well as any close contact with people exhibiting a similar rash or with suspected or confirmed virus infection^{19), (38), (41}.

There are no vaccines specifically designed to protect against MPXV infection. However, numerous studies report that prior smallpox vaccination provides protection against human mpox and mitigates the severity of its clinical presentation, even though vaccine-induced immunity has progressively declined in older individuals^{20), (33), (41}. The smallpox vaccine is estimated to provide about 85% efficacy against human mpox⁶⁶.

For all cases, including suspected and confirmed contaminated patients, control measures should be implemented for patients and their contacts. It is recommended that patients be isolated at home and that surgical masks be worn by the affected patient and by the contact when sharing the same room. Personal objects, including clothes, towels and sheets should not be shared, and contact with domestic animals should be avoided. These measures should be maintained until the skin lesions have crusted over and all scabs have fallen off^{21), (45), (57), (61}.

Healthcare workers should wear specific Personal Protective Equipment (PPE) for droplet and contact isolation, such as an apron, gloves, eye protection and N95/PFF2 masks⁶².

The findings indicate that there is no clinically proven specific therapy for mpox. Treatment is based on symptoms and necessary clinical support, including the use of antipyretics and analgesics, maintenance of hydroelectrolytic balance, nutrition, early identification of secondary infections with prompt treatment with available antimicrobial agents^{37), (62}.

A medication called Tecovirimat, also known as TPOXX or ST-246, was approved for MPXV infection in early 2022. It is recommended for use in severe cases, such as pregnant women and children^{21), (25), (33}. However, it is not yet widely available and further studies are needed to prove its safety and efficacy.

For skin lesions, topical cidofovir at 1% has been identified as a potentially relevant therapy, but with mild systemic involvement. Its use should be evaluated based on a risk-benefit analysis^{25), (27}.

No studies were found that frequently and specifically addressed the care for the multidisciplinary team and, above all, the nursing team. Therefore, the results identified in this review may facilitate the management of patients with MPXV-related infection.

Strategies such as early recognition cases of MPXV infection cases through appropriate alert screening, isolation, and infection control protocols, and active case-finding in health facilities are effective in preventing and controlling widespread outbreaks and should be developed by health professionals. Additionally, possible symptoms such as fever, chills, rash, and lymphadenopathy should be monitored for a period of 21 days after the last exposure to a patient with confirmed infection or cases with characteristic rashes^{49), (56), (61}.

The interventions adopted by the team that provides care to patients with MPXV infection should be based mainly on treating symptoms, offering support to maintain adequate fluid balance(due to the possibility of increased insensitive fluid losses through the skin, decreased oral intake and vomiting or diarrhea) providing hemodynamic support, such as supplemental oxygen or other respiratory support, if necessary, and treating secondary bacterial infections of skin lesions when indicated^{26), (37), (56), (62}.

An important finding is related to management of eye infections and complications, since MPXV infection can specifically result in corneal scarring and/or vision loss. Approaches such as early ocular evaluation, application of lubricants, topical antibiotics, and possibly topical antivirals, such as trifluridine, can be used to avoid potential risks to the patient's vision^{35), (56}. In this context, nursing plays a fundamental role in providing direct care to patients, in order to avoid serious injuries and maintain ocular integrity.

Psychosocial support has also been reported in studies, where professionals must provide assistance according to the needs of the patient and family. Active listening and the transmission of supportive messages can be considered strategies for psychosocial support⁶⁰. Because mpox is a relatively current infection, with an increase in cases occurring in the last year, people may feel threatened and afraid of it, mainly due to the lack of information. Thus, psychosocial support is an intervention considered relevant for mpox patients care.

Thus, it is the responsibility of health professionals, especially the nursing team, who maintain closer contact with the patients, to establish interventions that promote progression of the patient's condition while considering their human responses resulting from infection with the MPXV.

This study has limitations that may relate to the databases selected identifying the studies, which may have contributed to concealing another relevant research on the topic. Regarding the level of evidence, most studies presented a low level, probably because this is a relatively current subject that has been studied little.

It is recommended that scientific studies with stronger levels of evidence, such as experimental or quasi-experimental studies, be developed to provide safer evidence for the care of these patients. It is important to note that the information contained in the results of this study may change as new studies on the subject are conducted.

*Correspondence. Ana Clara Dantas. E-mail: anaclaradaantas@yahoo.com.br