Monkeypox: How Concerned Should We Be?

As the world continues to fight COVID-19 and many countries look for ways to recover from the pandemic, a new virus is making headlines worldwide.

The monkeypox virus is now estimated to have nearly 100 cases in 12 countries, with more expected as surveillance is stepped up. The first case of this current outbreak was discovered on May 7 in the United Kingdom (UK) and so far infections have been confirmed in nine European countries: the UK, Spain, Portugal, Germany, Belgium, France, the Netherlands, Italy and Sweden, as well as the United States (US), Canada and Australia.

While the first case discovered in the UK was linked to travel to Nigeria – which reports about 3,000 cases of monkey pox each year – later cases have not been traced back to Africa, confusing many scientists and doctors.

What is unusual about the current outbreak is that cases are diagnosed in countries where monkeypox is rare, and the fact that many cases identified are unrelated to West and Central Africa makes this outbreak unprecedented.

What is Monkeypox?

Monkeypox is caused by a virus endemic to tropical parts of Africa. Despite its name, monkeypox is rarely spread through infected monkeys, but is more common in rodents such as squirrels, rats, and mice. The virus is known as zoonotic – meaning it is transmitted to humans from infected animals through blood, infected fluids or lesions on the animal.

Human-to-human transmission can result from close contact with respiratory secretions, skin lesions from an infected person, or recently contaminated objects. Transmission via droplet-shaped respiratory particles usually requires prolonged face-to-face contact, putting health professionals, household members, and other close contacts of active cases at greater risk. Whether the virus can spread through the airways is currently under investigation, although there is currently no evidence to support this.

Although monkeypox was first identified in laboratory monkeys in 1958, it was first identified in a human in 1970 and is a disease commonly restricted to parts of Africa, most prevalent in rural parts of the Democratic Republic of the Congo, although Outbreaks have been reported in Gabon, Ivory Coast, Liberia, Nigeria, Benin, Cameroon, Sierra Leone and South Sudan.

The first outbreak outside Africa occurred in 2003 and affected people in the US; it was linked to infected prairie dogs imported from Ghana and housed with infected rodents. Since then, small numbers related to travel have been reported around the world.

The first symptoms of monkey pox are fever, headache, muscle aches, back pain, swollen lymph nodes, chills and exhaustion. A rash can develop, often starting on the face and then spreading to other parts of the body, including the genitals. The rash changes and goes through several stages – initially it may be a fluid-filled blistering rash similar to chickenpox or syphilis, before eventually forming a scab that later falls off. Most people recover from monkeypox within a few weeks without treatment.

The diagnosis is usually a clinical one, meaning the signs and symptoms are enough for clinicians to make the diagnosis without the need for testing. However, if monkeypox is suspected, clinicians should take a fluid sample from one of the lesions and send it to the lab for a polymerase chain reaction (PCR) test to confirm the diagnosis. Blood tests are not considered as accurate and should not be used routinely.

The monkeypox virus is part of a family of viruses known as “DNA viruses”. Unlike the SARS-CoV-2 virus that causes COVID-19, which is an RNA virus, DNA viruses mutate at a much slower rate because they can better identify and correct errors in their genetic makeup during the replication process. This is important because it will help scientists better understand why the current monkeypox outbreak is happening – has the virus itself changed or is it just in the right place at the right time?

It’s too early to be sure. The current species is thought to be related to a species commonly found in West Africa, which is associated with mild symptoms and a low mortality rate, about one percent.

Who gets infected?

This outbreak certainly feels different from previous outbreaks outside Africa.

Other than the first cases, many of the infected people have no ties to travel or to anyone from Africa. What is remarkable is that the virus has been found in a disproportionate number of men who have sex with men. Monkeypox is not known to be a sexually transmitted virus, but sexual contact would be considered close contact, one of the main routes the virus is known to spread.

Members of the LGBTQ community may be better at getting sexual health checks, so the virus is just being picked up more here than in the heterosexual community. Whatever the reason, it remains important that no one who is infected is stigmatized, both for their well-being and for continued monitoring of cases and outbreaks.

More travel after a period of travel restrictions during the COVID pandemic could also be a factor.

What is worrying is that the cases found across Europe and the world are not linked, meaning there is a missing piece of the puzzle in how this virus is spread.

The monkeypox virus is part of the same family that the smallpox virus comes from. Older generations will have been vaccinated against smallpox, eradicating the disease and giving them some protection against monkeypox. It may be that now that most younger generations have not been vaccinated against smallpox, the monkeypox virus has been able to spread more easily.

Is there a treatment or vaccine available?

For the vast majority of people, signs and symptoms of monkeypox will go away on their own, without any treatment. Rest, adequate fluids and good nutrition are usually all that is needed.

The risk of serious illness may be higher in pregnant women, children, and people with weaker immune systems. Currently, there is no specific vaccine available for monkeypox, but the smallpox vaccine has been shown to provide 85 percent protection against monkeypox.

At this time, the original (first generation) smallpox vaccines are no longer available to the general public. Scientific studies are now underway to assess the feasibility and suitability of vaccination for the prevention and control of monkeypox. Some countries have or are developing policies to offer vaccines to people who may be at risk, such as laboratory personnel, rapid response teams and health professionals.

An antiviral drug known as tecovirimat, which was developed for smallpox, was licensed by the European Medical Association (EMA) in 2022 for monkeypox based on data in animal and human studies. It is not yet widely available.

Understanding how this current outbreak is spreading will be key to breaking the chain of transmission and getting the numbers under control. In the future, our relationship with animals should be evaluated. Zoonotic spread of viruses will continue to be a concern as we invade wildlife environments and treat them as part of science, food and the pet trade.

How concerned should we be?

Most scientists agree that this current monkeypox outbreak, while important to understand, is unlikely to trigger another pandemic akin to SARS-CoV-2.

This is not a new virus; we have known it for many years and have a good understanding of its structure and replication process. We already have a good vaccine available in the form of the smallpox vaccine and treatment options should we need them. The virus spreads more slowly than the COVID virus, and most people show symptoms, including a signature rash that is easier to spot than some of the vague symptoms that COVID causes. This means that we can identify the infected persons and if necessary vaccinate or isolate their close contacts.

However, there is some concern that as summer approaches and large gatherings such as festivals and conventions become more frequent, close contact will occur and the virus could spread.

But even with the virus showing new behavior and the high probability that more cases will be identified in the coming weeks and months, there is no need to panic.

The World Health Organization (WHO) has started holding emergency daily meetings about the infection and continues to monitor the situation worldwide. Much more remains to be understood about this current outbreak and while this is not new COVID, more research and subsequent prevention strategies need to be put in place to prevent the virus from gaining a foothold.


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