With the rapid transmission of monkeypox outside Africa, the disease finally receives the attention and resources required to address it.

Vol 2, No. 5 , 09 August 2022.

Cover Story

By Apoorva Sudhakar

In July 2022, the World Health Organization issued its highest alert by declaring monkeypox a “public health emergency of international concern” (PHEIC). However, the WHO assessed that the risk is moderate, except in Europe, and said that despite a risk of further international spread, the threat to international traffic is low.

I

Monkeypox outbreak 2022: A brief timeline

The first monkeypox case in 2022 was confirmed in May in a non-endemic country.

On 7 May, the United Kingdom confirmed a case of monkeypox in a person who had travelled to and returned from Nigeria. On 12 May, the UK Health Security Agency (UKHSA) confirmed two more cases; on 17 May, four more were confirmed. By 6 June, the UKHSA said the UK had 302 confirmed cases - 287 in England, ten in Scotland, three in Wales and two in Northern Ireland. On 5 August, the UKHSA said the spread had slowed down with 2,589 confirmed cases since May.

In the rest of Europe, monkeypox was detected immediately after the UK. On 25 May, the European Centre for Disease Prevention and Control (ECDC) said: “This is the first time that chains of transmission are reported in Europe without known epidemiological links to West or Central Africa, where this disease is endemic.” At the time, the confirmed number of cases stood at 71 in the UK, 51 in Spain and 37 in Portugal.

On 18 May, the United States confirmed its first case after the Massachusetts Department of Public Health completed tests on a man who had travelled to Canada. By 26 May, the Centers for Disease Control and Prevention (CDC) confirmed 19 cases across 10 states in the US; the CDC Director said it could be presumed that a certain degree of community spread was prevalent and therefore, not all patients had travelled to places which had monkeypox cases. On 5 August, the US, with 7,100 confirmed cases, declared monkeypox a public health emergency.

On 15 July, India recorded its first monkeypox case in a man who arrived from the Middle East, making it the first one in the WHO South-East Asia Region. On 24 July, the South-East Asia Region had four cases - three from India and one from Thailand.

As of 5 August, the CDC’s 2022 Monkeypox Outbreak Global Map shows there are 28,220 confirmed cases globally; of these, 27,875 cases are in 81 countries that have not reported monkeypox previously, and 345 in seven countries which have had monkeypox cases earlier. The countries with the highest number of cases are the US (7,509), followed by Spain (4,942), Germany (2,887), the UK (2,859), and France (2,423). As of 2 August, four people had died from the disease - one in India, two in Spain and one in Brazil.

II

Tracing monkeypox

What is monkeypox?

Monkeypox is a zoonotic disease, transmitted from animals to humans, caused by the monkeypox virus (MPXV), a part of the Orthopoxvirus genus of the Poxviridae family, that also causes smallpox. It was first observed among colonies of monkeys under research in the Statens Serum Institute, Copenhagen. Later research on African animals showed that several rodents were infected with monkeypox. The disease was commonly detected in the tropical rainforests in the region, especially in the Congo Basin, and among people who are vulnerable to being exposed to infected animals.

There are two clades of MPXV, the West African clade and the Congo Basin (Central African) clade; a clade is defined as “a group of organisms that all originate from a common ancestor.” The Congo Basin clade has a high case fatality ratio (CFR) estimated at 10 per cent. The West African clade has a lower CFR estimated at one per cent. The 2022 outbreak is classified under the West African clade, common in Cameroon and Sierra Leone.

Where is monkeypox commonly detected?

In 1970, the first human case was detected in the Democratic Republic of the Congo (DRC, then known as Zaire) in a child. Historically, monkeypox has been endemic to central and west African countries. Several cases were documented between 1981 and 1986; the largest outbreak in the region spanned from 1996 to 1997 with 71 cases recorded between February to August 1996, including six deaths, and 170 cases between March and May 1997. In a 1997 study sponsored by the WHO and Zaire’s Ministry of Health, revealed that the strain collected from a 1996 patient was not different from the strains studied between 1970 and 1979. However, there was an increase in infection through secondary contact in the 1996-97 epidemic, compared to the outbreak between 1981 and 1986.

Globally, between 1970 and 2018, monkeypox had been detected in the DRC, Cameroon, Central African Republic, Nigeria, Ivory Coast, Liberia, Sierra Leone, Gabon, Republic of Congo and the US. In the US, the first monkeypox case was detected in 2003 in a three-year-old child and 71 cases were reported during the outbreak. The outbreak was linked to prairie dogs in Illinois who were likely infected by Gambian giant rats and dormice purchased from Ghana. Meanwhile, Nigeria has reported frequent outbreaks of monkeypox since 2017 with about 200 cases. In 2018, 2019 and 2021, cases were recorded in travelers from Nigeria to Israel, the UK, Singapore and the US.

How common are monkeypox deaths?

Listed below are the CFRs over the years from Africa.

*The above data are tabulated from multiple studies quoted in a journal article.

Source: Africa Centres for Disease Control and Prevention

III

Transmission, Symptoms and Vaccination

Monkeypox is transmitted from animals to humans by direct contact with an infected animal’s blood, bodily fluids, and cutaneous or mucosal lesions. The transmission also takes place during the consumption of inadequately cooked meat or other products of the infected animal.

Among humans, the transmission occurs through close contact with an infected person’s respiratory secretions, skin lesions or any other contaminated object. The virus can also be transmitted from the mother to a fetus through the placenta, or by being in contact immediately after giving birth.

Once infected, the symptoms displayed by a person can be divided into two phases. The first phase lasts between zero to five days. This phase includes fever, severe headaches, swelling of lymph nodes, back pain, muscle aches and an overpowering lack of energy. The second phase begins once the fever sets in. This phase is characterised by the increasing severity of rashes on the face, palms and soles; it could also infect the oral mucous membranes, genital organs and the cornea. The symptoms span from two to four weeks. Suspected cases of monkeypox are confirmed through a polymerase chain reaction (PCR) of the samples collected from the skin lesions.

Apart from the treatment of symptoms, there is no cure for monkeypox; most people recover without treatment in a few weeks. Traditionally, smallpox vaccines have been effectively administered for monkeypox cases. However, the eradication of smallpox in the late 1970s and the cessation of vaccination against the same resulted in a fall in immunity against the Orthopoxviruses.

Currently, the WHO has urged suspected patients and close contacts to be administered the vaccine for the prevention of monkeypox. This vaccine is drawn from the strain of vaccinia virus, also known as the modified vaccinia Ankara Bavarian Nordic strain (MVA-BN). In 2013, the MVA-BN was approved as a smallpox vaccine in Europe and Canada; in 2019, the same was approved as the smallpox and monkeypox vaccine in the US. Different countries have different names for the vaccine - Jynneos in the US, Imvamune in Canada. Imvanex in the UK and Europe. These vaccines are also bought globally by India, Brazil, the DRC and so on.

IV

Misconceptions about monkeypox

Shortly after the initial few cases were confirmed in non-endemic countries, the United Nations noted reporting on the outbreak was stigmatised. For example, pictures of African children with monkeypox were frequently used in media reports; Foreign Press Association, Africa (FPAA) condemned the same saying the stereotype “assigns calamity to the African race and privilege or immunity to other races.” Similarly, it was widely speculated that monkeypox was common among men who had sex with men (MSM). The UNAIDS Deputy Executive Director called for rights and evidence-based approach to addressing the outbreak, saying: “Stigma and blame undermine trust and capacity to respond effectively during outbreaks like this one.”

Scientists also noted the need for a “non-discriminatory and non-stigmatizing” name for MPXV stating that the current outbreak is sustained by human-to-human transmission, unlike the previous outbreaks in Africa caused by spillover events to humans from infection among animals. Therefore, the scientists believed “a continued reference to, and nomenclature of this virus being African is not only inaccurate but is also discriminatory and stigmatizing.” The WHO agreed with the above; in June, the WHO Director-General said the organisation was working on changing the name and the clades of the disease.

Experts at the International Aids Conference 2022 observed that monkeypox was not a health issue of concern when it was confined to Africa. The WHO Assistant Director-Deneral for Emergencies said: “We have been working on monkeypox in Africa for several years, but nobody was interested.” The declaration of PHEIC testifies this claim; since the COVID-19 outbreak in 2020, the death of 365 Africans in three years and hundreds more since 1970 did not instil the urgency to address monkeypox as a global threat.

The above misconceptions are similar to the ones propagated about Zika and the HIV-AIDS cases in the late 20th century. It took decades of education to address these misconceptions; the world may have to do the same again, with monkeypox.

References

“More than 300 monkeypox cases now found in UK,” BBC, 6 June 2022

Aria Bendix, “19 monkeypox cases identified in U.S.: What we know about the patients,” NBC News, 26 May 2022

“More than 215 confirmed monekypox cases worldwide, says EU's disease agency; know symptoms here,” Firstpost, 26 May 2022

“2022 Monkeypox Outbreak Global Map,” Centers for Disease Control and Prevention, 2022

Jose Devasia and Chris Thomas, “India confirms Asia's first monkeypox death,” Reuters, 2 August 2022

Lois Zoppi, “Viral Clades of SARS-CoV-2,” News Medical & Life Sciences, 3 June 2021

“Update: Multistate Outbreak of Monkeypox --- Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003,”  Centers for Disease Control and Prevention, 11 July 2003

“Multi-country monkeypox outbreak in non-endemic countries: Update,” World Health Organization, 29 May 2022

“Monkeypox: waiting for your vaccination,” UK Health Security Agency, 1 August 2022

Nikola Sklenovská and Marc Van Ranst, “Emergence of Monkeypox as the Most Important Orthopoxvirus Infection in Humans,” Front Public Health. September 2018

Scott Parker and R Mark Buller, “A review of experimental and natural infections of animals with monkeypox virus between 1958 and 2012,”  Future Virol, February 2013

“Monkeypox,” World Health Organization, 19 May 2022

Apoorva Mandavilli, “Three Pressing Questions About Monkeypox: Spread, Vaccination, Treatment,” The New York Times, 29 July 2022

Ian Sample, “WHO to rename monkeypox virus to avoid discrimination,” The Guardian, 15 June 2022

Rachel Treisman, “As monkeypox spreads, know the difference between warning and stigmatizing people,” NPR, 26 July 2022

“Monkeypox: When it was an African problem nobody cared, say experts,” News24, 4 August 2022

“Multi-country monkeypox outbreak declared a global Public Health Emergency of International Concern,” Africa Centres for Disease Control and Prevention, 25 July 2022)

About the author

Apoorva Sudhakar is a Project Associate at the School of Conflict and Security Studies at the National Institute of Advanced Studies.

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