We live in the era of Pandemics, yet another threat has knocked our doors.
Monkey pox has finally landed our land with two cases notified as of now.
Though far less dangerous than COVID-19, SARS, Zika and Ebola virus, yet this is a public health hazard and calls for prompt activation of “health Security” apparatus.
In July 2022 WHO announced Monkeypox as “Public health emergency of international concern”. This followed a global call from the public health community amidst a rapid surge in cases from different countries.
This new outbreak started with a case on 7th May 2022 in the UK in a traveller from Nigeria, gradually spreading to many countries.
Since January 2022, cases of Monkeypox have been reported to WHO from 110 member states across all 6 WHO regions.
As of April 25th 2023, a total of 87,113 laboratory-confirmed cases and 130 deaths, have been reported to WHO.
“Monkeypox” is a viral zoonosis (a virus transmitted to humans from animals) disease with symptoms very similar to those seen in smallpox patients, although it is clinically less severe.
Various animal species have been identified as susceptible to the monkeypox virus.
This includes rope squirrels, tree squirrels, pets, Gambian pouched rats, dormice, non-human primates and other species.
History goes back to 1970 when smallpox was near eradication, a previously unrecognized virus named “Monkeypox” was identified in humans.
The first known human case was notified in the Democratic Republic of Congo when a 9-year-old boy was confirmed as human monkeypox case by the World Health Organization.
Retrospectively, similar cases occurring in 1970-1971 from the Ivory Coast, Liberia, Nigeria, and Sierra Leone were then attributed to monkeypox infection.
Monkeypox was then confined to the rain forests of central and western Africa until the late spring of 2003.
In 2003, the first monkeypox outbreak outside of Africa was in the United States of America and was linked to contact with infected pet prairie dogs.
Monkeypox has also been reported in travellers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, to Singapore in May 2019, and to the United States of America in July and November 2021.
Transmission of this disease can occur from direct contact with the blood, bodily fluids, or cutaneous or mucosal lesions of infected animals.
Human-to-human transmission can result from close contact with respiratory secretions, sexual intercourse, skin lesions of an infected person or recently contaminated objects. Transmission via droplet respiratory particles- less often- usually requires prolonged face-to-face contact, which puts health workers, and household members of active cases at greater risk.
Eating inadequately cooked meat and other animal products of infected animals is a possible risk factor.
People living in or near forested areas may have indirect or low-level exposure to infected animals.
The current episode depicts predominantly the transmission through sexual transmission routes, – men-men sexual contact- being the primary one. 99.5 % of these cases are among men averaging 37 years of age, 95 % of which are in men sex with men, gays, bisexuals, and interconnected mobile individuals.
The incubation period of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days.
Early signs of the disease is characterised by fever, intense headache, lymphadenopathy (swelling of the lymph nodes), back pain, muscle aches and intense asthenia (lack of energy).
The skin eruption usually begins within 1-3 days of the appearance of rash which concentrate more on the face and extremities rather than on the trunk. The oral mucous membranes, genitalia, conjunctivae can also be affected.
Complications of monkeypox can include secondary infections, bronchopneumonia, sepsis, encephalitis, and infection of the cornea with ensuing loss of vision.
The case fatality ratio of monkeypox has historically ranged from 0 to 11 % in the general population and has been higher among young children. In recent times, the case fatality ratio has been around 3-6%.
Monkeypox is usually a self-limited disease with symptoms lasting from 2 to 4 weeks. Severe cases occur more commonly among children and are related to the extent of virus exposure, patient health status and nature of complications. Underlying immune deficiencies may lead to worse outcomes.
Although vaccination against smallpox was protective in the past, today persons younger than 40 to 50 years of age may be more susceptible to monkeypox due to the cessation of smallpox vaccination campaigns globally after the eradication of the disease.
If monkeypox is suspected, health workers should collect an appropriate sample and have it transported safely to a recognised lab.
Polymerase chain reaction (PCR) is the preferred laboratory test, given its accuracy and sensitivity.
Where feasible, a biopsy could be another option.
Clinical care for monkeypox should be fully optimized to alleviate symptoms, manage complications and prevent long-term sequelae.
Patients should be offered fluids and food to maintain adequate nutritional status. Secondary bacterial infections should be treated as indicated.
To prevent transmission, the same standards public health measures of, Airports/seaports/borders screening, active surveillance, health education, contact tracing, prompt testing and case isolation apply.
Raising awareness of risk factors and educating community about the measures they can take to reduce exposure to the virus – especially safe sex practices- is the main prevention strategy.
A sensitive surveillance system and rapid identification of new cases is critical for outbreak containment.
An antiviral agent known as “tecovirimat” then developed for smallpox was licensed by the European Medical Association for monkeypox in 2022, based on data in animal and human studies.
Vaccination against smallpox was demonstrated through several observational studies to be about 85% effective in preventing monkeypox. Thus, prior smallpox vaccination may result in milder illness.
At present, a newer vaccine based on a modified attenuated vaccine virus has been approved for the prevention of monkeypox as risks dictate. This is a two-dose vaccine for which availability remains limited.
It’s reassuring that the essential health security measures like Airport/ seaport screening and contact tracing have already been implemented.
Strengthening the lab capacity and the surveillance system are critical for a potential outbreak response.
Pakistan has an already well-functioning platform-NCOC- that can be optimally utilised for a coordinated preparedness, response and integration.
The author is an internationally recognised public policy, national security & health expert, who has had an illustrious career with the UN, USAID, Bill Gates foundation, The World Bank and various Governments.
He tweets at @DrNadeemjan
