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Table of Contents
EDITORIAL
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 1-2

A pandemic 'to be or not to be'- we should still be ready for monkeypox


Department of Community and Family Medicine, AIIMS, Bhubaneswar, Odisha, India

Date of Web Publication30-Jun-2022

Correspondence Address:
Sonu Hangma Subba
Department of Community and Family Medicine, AIIMS, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcfm.ijcfm_39_22

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How to cite this article:
Subba SH. A pandemic 'to be or not to be'- we should still be ready for monkeypox. Indian J Community Fam Med 2022;8:1-2

How to cite this URL:
Subba SH. A pandemic 'to be or not to be'- we should still be ready for monkeypox. Indian J Community Fam Med [serial online] 2022 [cited 2022 Oct 4];8:1-2. Available from: https://www.ijcfm.org/text.asp?2022/8/1/1/349382



The world had barely come out of the COVID-19 pandemic when another disease, primarily restricted to Africa, appeared in the West, almost explosively. Even though monkeypox had occurred outside Africa since 2003, it had not affected multiple countries in the way it has been seen recently.[1] The previous occurrences in the west had a clear history of travel to endemic African countries or exposure to animals imported from Africa.[2],[3] The recent occurrences in Europe were unusual, with human-to-human transmission, absence of travel history, and a lack of contact with travelers or animals from endemic countries. This shows that the zoonotic infection, which was supposed to be limited to the tropical rainforest areas of Central and West Africa, is now adapted to survive and transmit beyond the traditional milieu. In the way it has suddenly appeared simultaneously in several countries, monkeypox may be another disease of concern for public health. The World Health Organization (WHO) is rightly deliberating whether to declare monkeypox as public health emergency of international concern.[4]

Monkeypox is a viral disease caused by orthomyxovirus that closely resembles smallpox. The reservoirs for the virus are known to be monkeys, rodents, squirrels, etc., It is transmitted through eating improperly cooked meat and contact with or bites of animals. From the cases, it transmits via respiratory droplets and fluids and scabs of the skin lesions. The incubation period ranges from 5 to 21 days, and the smallpox like rash is preceded by a prodrome of about 1–4 days. The rash predominantly occur on the face and limbs. They take 2–4 weeks to resolve. Complications can be varied from secondary bacterial infection of the lesions to bronchopneumonia and encephalitis. Treatment is mainly supportive, but Tecovirimat (ST-264), which has FDA approval for the treatment of smallpox, is also being used for monkeypox. Smallpox vaccine with new vaccinia virus has been approved for the prevention of monkeypox.[5]

As of June 17, 2022, from the beginning of the year, there were 2103 confirmed, one probable case, and one death reported to the WHO from 42 countries.[6] The cases predominantly occurred among men who self-reported having sex with men. Only one death was reported. The cases have resulted from human-to-human transmission. This contrasts with how the cases started and were transmitted in the African countries from 1970 onward. The first case of monkeypox was in a 9-month-old boy in Zaire.[7] From 1970 to 1979, there were only 48 cases of monkeypox in Africa and eight deaths in children aged 7 months to 7 years. There were only four person-to-person transmissions among the 48 cases. At the time, two clades were reported to exist, the West African clade and the Congo Basin (CB) clade. The latter has been known to be more severe and caused around a 10% case-fatality rate compared to the west African clade, which is less severe and showed 3% mortality.[1] The recent outbreak in the western hemisphere is attributed to the West African clade. The occurrence of the first and the subsequent cases in Africa was attributed to the cessation of smallpox vaccination, which led young children to be susceptible to monkeypox as they were born after smallpox was eradicated. It was correctly postulated that as the immunity to smallpox wanes in the population, the susceptibility to monkeypox and its occurrence would increase, which is being witnessed at present.

Whether monkeypox will be another milestone in the world health scenario is yet to be established. However, one can observe that the epidemiology of the disease has shifted enough to cause outbreaks with the sustained human-to-human transmission in the erstwhile naïve countries. And with the reproduction number of 2.13, the possibility of a widespread disease cannot be ruled out. The change in the pattern of occurrence due to reasons hitherto unknown, the virus has started affecting the specific demographic group resulting in human-to-human transmission. This raises the possibility that the disease may transmit to more countries, which will be amplified by air travel and lack of evidence to know if the person may be in the incubation period. Currently, the disease is primarily in the African continent, Europe, and North America. However, if it manages to enter the developing countries in Asia, the Middle East, and Western Pacific regions, the cases may rise alarmingly. Infection control measures may not be enough, and the vaccination is not available readily. Vaccine production at only a few places may not be feasible enough to supply such countries. In developing countries where chickenpox is common the rashes in mild monkeypox may be mistaken for chickenpox rash. These could make transmission easier and cause more outbreaks.

However, the infection's characteristics could deter widespread infection and help prevent or contain the outbreaks. The monkeypox virus is not known to be transmitted during incubation period, which is beneficial in contact tracing and quarantine implementation. Another positive aspect is the absence of asymptomatic cases. The typical lesions of monkeypox are quite different from the rashes that occur in the exanthems of the currently prevalent diseases; hence, they are easily identifiable so that isolation can be initiated on time. Due to the COVID-19 pandemic, the infection control measures are almost impeccable in majority of the healthcare settings, and knowledge of the population about it is also very good. This would also help in the prevention of monkeypox as the measures are the same for respiratory droplet transmission. Even though accessibility may not be universal now, vaccination can be improved by equipping laboratories worldwide for vaccine production. The mortality rate seems to be low at present with the West African clade, which means that the outbreaks would not be as devastating as would have been with the CB clade.

Is India prepared? The Ministry of Health and Family Welfare, Government of India website, has a document, “Guidelines for management of monkeypox disease” . There is no other information, document, or guidelines in other apex government portals. Considering that it has spread to several European and American countries, it is only a matter of time before we start seeing cases in India. We need to brace ourselves for monkeypox infection in the country. Rather than firefight after it arrives, it is better to take preemptive steps to battle the disease before it reaches the country. Irrespective of what potential it has to cause large outbreaks and deaths, the outcome will be better if the country is well prepared for it in advance. Formulating guidelines for prevention and control, including framing case definitions, equipping laboratories for diagnosis, and strengthening vaccine production capacity, would all be essential strategies to cope with the inevitable. Risk communication and accurate information for the public should also be part of the strategy. Liaison between the center and the states and international collaboration should also be pursued to make the best out of the available logistics, capacity, and human resources. A separate budget should be earmarked for the same so that there is no scrambling for funds in the hour of need. Hoping that the country is not taken by surprise and that monkeypox (or whatever name the WHO gives it) does not cause significant damage to population health.



 
  References Top

1.
Bunge EM, Hoet B, Chen L, Lienert F, Weidenthaler H, Baer LR, et al. The changing epidemiology of human monkeypox – A potential threat? A systematic review. PLoS Negl Trop Dis 2022;16:e0010141.  Back to cited text no. 1
    
2.
Adler H, Gould S, Hine P, Snell LB, Wong W, Houlihan CF, et al. Clinical features and management of human monkeypox: A retrospective observational study in the UK. Lancet Infect Dis 2022;22:S1473-6.  Back to cited text no. 2
    
3.
Reynolds MG, Davidson WB, Curns AT, Conover CS, Huhn G, Davis JP, et al. Spectrum of infection and risk factors for human monkeypox, United States, 2003. Emerg Infect Dis 2007;13:1332-9.  Back to cited text no. 3
    
4.
WHO to convene emergency committee on monkeypox spread - STAT. 2022. Available from: https://www.statnews.com/2022/06/14/who-to-convene-emergency-committee-on-monkeypox-spread/. [Last accessed on 2022 Jun 24].  Back to cited text no. 4
    
5.
Wilson ME, Hughes JM, McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis 2014;58:260-7.  Back to cited text no. 5
    
6.
Organization WH. Multi-country monkeypox outbreak: situation update. 2022. Available from: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON393. [Last accessed on 2022 Jun 24].  Back to cited text no. 6
    
7.
Breman JG, Kalisa-Ruti, Steniowski MV, Zanotto E, Gromyko AI, Arita I. Human monkeypox, 1970-79. Bull World Health Organ 1980;58:165-82.  Back to cited text no. 7
    




 

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