With more than 3,400 cases (22 June), the recent monkeypox outbreak in Europe and North America has become international news. The World Health Organization (WHO) has reacted by monitoring the progress of monkeypox globally, issuing guidelines regarding testing, and taking immediate measures. But WHO has not yet declared monkeypox a public health emergency.
As long as monkeypox was confined to Africa, where outbreaks have occurred in Central and Western countries for years, it raised little concern. But with monkeypox reaching rich countries, it has become an immediate media event with headlines and TV coverage.
Before we get into our response to monkeypox, what is it, and why has it appeared now?
Monkeypox is a misnomer; the disease is not endemic among monkeys but in rodent populations in Central and West Africa. It was wrongly named, as the initial case was of an infected monkey biting a child and transmitting the disease. The virus is from the Orthopoxvirus genus, which includes smallpox and cowpox.
From 1970 onwards, sporadic monkeypox outbreaks have occurred in Central and West Africa but drew tepid responses from the rest of the world. In the last ten years, the Democratic Republic of Congo has seen thousands of suspected cases and hundreds of suspected deaths. A significant outbreak occurred in Nigeria in 2017, with over 700 confirmed and suspected monkeypox cases. While the West African variant spreading in Europe and North America has a mortality rate of about 1%, mortality for the Central African variant is around 10% or ten times higher.
Genomic studies now show monkeypox has been circulating for quite some time in Africa. One major reason for its increase now, and not earlier, is the discontinuation of smallpox vaccination once it was eradicated. The smallpox vaccine also protected against monkeypox. As younger people are no longer vaccinated, the fraction of people who have no immunity against monkeypox has increased and, therefore, the threat of catching monkeypox. The only ones who still have immunity are people in the age group of 45 and above.
In 2017, Adesola Yinka-Ogunleye, an epidemiologist in Nigeria and others had warned that the virus was spreading in unfamiliar ways. Before the 2017 outbreak in the country, the virus seemed confined to rural areas, where hunters would come into contact with animals. After 2017, monkeypox appeared in urban settings. Infected people sometimes had genital lesions, suggesting the virus might also spread through sexual contact.
Once the virus spread from sparsely populated regions to more densely populated urban settings, the current rapid spread was an event waiting to happen. Monkeypox is no longer a zoonotic infection, meaning it no longer spreads from rodents to humans and then peters out after some cases. It is a human-to-human transmission that is now taking place in many countries, with large numbers infected in the United Kingdom, Germany, Spain, and Portugal.
Genomic studies show the virus probably circulated in east and north Africa from 2018 onwards. Even in Europe, it has probably been in community circulation for some time. Initially, cases would have been mistaken for a skin condition or allergies and not recognised as monkeypox. Currently, the transmission speed may appear more rapid, but that may be because monkeypox is getting recognized more quickly, also because public awareness has increased.
It will take a few more weeks before we work out its transmission rates. There are some advantages in combating this virus over the SARS-CoV-2, the virus that causes Covid-19. It appears to spread more by contact, and it is easier to isolate the infected. Even when patients shed dry skin, which carries the virus and is airborne, the virus is still much easier to contain than SARS-CoV-2 or the flu virus. We also have smallpox vaccines, which can quickly be deployed to contain the virus among health workers and those who have come in contact with the infected. Given early, it can even protect people from developing the disease.
In the recent cases of monkeypox, the infection seems to have spread among men who have sex with men. As the experts have explained, this is not a sexually transmitted disease and spreads through contact. It has spread among a certain section because they tend to be closed groups, and sex obviously provides close contact. The problem for health officials is how to warn high-risk groups without stigmatizing them, as happened with AIDS. During the initial period of the spread of AIDS, it was regarded as a disease of the gay population. This led to public health systems ignoring the problem and its subsequent much wider spread.
The current outbreak results from not addressing monkeypox in Africa when it was sporadic and could easily have been contained. If monkeypox is easy to detect and contain, why have we let the disease spread unhindered in Africa? Especially when monkeypox outbreaks have been taking place since the seventies, why does the global health system wake up only when the rich countries are affected?
Anthony Fauci, the well-known United States infectious disease expert, said the West believed antibiotics and vaccines had won them victory against the threat of infectious diseases. It is what molecular biologist Peter J Hotez wrote in his book, Forgotten People, Forgotten Diseases: The Neglected Tropical Diseases and Their Impact on Global Health and Development. The rich countries believe infectious diseases are only a problem of poor countries and all they have to do is restrict the entry of people from those countries. So it was of little concern to the rich that infectious diseases endemic in poor countries killed millions every year.
The West might have forgotten such diseases, but not the people at risk from tuberculosis, malaria, dengue, yellow fever, and other illnesses threatening more than 60% of the world’s population. Belief in ‘victory’ over infectious diseases led to collective amnesia in the West about a host of diseases that still plague the world. Their other mistake was believing microbes do not evolve and our defenses against them will hold for a long time. But diseases have a way of striking back. The AIDS epidemic was the first obvious breach. The Covid-19 pandemic proved we are always only one mutation away from a new infectious disease.
The West’s belief that it could keep infectious diseases outside its borders is what led to its unpreparedness for the Covid-19 pandemic. This is repeating for monkeypox.
Unless patients are immune-compromised or have ‘co-morbidities’, monkeypox is not life-threatening. An antiviral drug, Tecovirimat, authorized for use against smallpox, is also effective against monkeypox. It is a small-molecule drug, so easy to manufacture and scale-up production if required. Provided high-cost intellectual property rights do not cause an AIDS-like disaster again. Many countries have a stock of smallpox vaccines that can be rapidly deployed to vaccinate people who have come in contact with a possible monkeypox case. Old-fashioned epidemic control measures—test, isolate, and vaccinate all who have come in contact with a patient—should control this epidemic.
Why were such measures not taken for Africa? This neglect has led to a much larger spread of the disease. African health experts say that though countries have pledged 31 million doses of smallpox vaccine to the WHO for emergencies, no vaccine has been made available to Africa to address monkeypox. This needs to be addressed urgently and ramping up testing and antiviral use at prices people can afford. If we do not, we will see a repeat of the Covid-19 vaccine apartheid and a replay of Africa’s high-cost patented antiviral AIDS drugs disaster.