Monkeypox, another pandemic in the making?

The scientific community is baffled: it does not have all the answers to the origin of the coronavirus pandemic, nor does it know how the monkeypox virus has become another source of concern. In the end, the World Health Organisation (WHO) issued an alert after classifying monkeypox as a global health emergency.
 
So far the virus has 55 mutations with a symptomatology so complicated that it has confused doctors with the assessment of a Sexually Transmitted Disease (STD).
 
It is also unknown how the virus has jumped from its natural environment in Africa to spread to various regions. To date, it has been detected in 75 countries.
 
It all started on 29 April: the UK reported to the WHO that a British citizen had contracted monkeypox on a trip to Nigeria and first developed symptoms while on British soil. 
 
Since then there has been a progressive explosion of cases from tens to hundreds and then to thousands. By 29 July, a total of 16,000 cases of monkeypox had been reported worldwide, with five deaths (two in Spain).
 
The WHO had been working for weeks with its experts on whether or not to raise an alert until it finally did so on 23 July after assessing that there is a new international challenge. Another virus is lurking.
 
"We have an outbreak that is spreading rapidly around the world through new modes of transmission and we need to understand more about this problem which means using international criteria. I have decided that monkeypox is a global public health problem and it is important to take into account a number of recommendations," Tedros Adhanom told a press conference.

The head of the WHO, much questioned for its role in the SARS-CoV-2 pandemic from which the world has yet to emerge after more than two years of fighting the coronavirus, said the agency is closely monitoring the incidence of the virus in four groups of countries. 
 
The first group are countries that have not yet reported any monkeypox cases; the second group are countries that are experiencing human-to-human transmission and include a coordinated response to try to cut it off with special vigilance in the most vulnerable groups. 
 
Then there is the third group of countries with human-to-animal transmission (WHO recommends isolating pets of those infected with monkeypox) and then there is the fourth group of countries with the capacity to manufacture vaccines, treatments and early detection protocols.
 
"This emergency is occurring in a context with a majority of diagnoses in men who have sex with men and also have bisexual relationships," said Adhanom.
 
The head of the WHO called for no stigmatisation of the infection, nor of any group, but he did recommend greater vigilance and monitoring of groups such as homosexuals. 
 
So far, 98% of monkeypox virus infections worldwide are concentrated in men who have sex with men and in bisexual relationships.  The average age is 37 years but there are also 81 under-age children who have fallen ill. 
 
The scientific community is studying the transmission of monkeypox through semen, and several samples of seminal fluid have been found to contain the virus. This is a finding that breaks with the traditional way of transmission of this pathogen, which was first detected in 1970 in the Bokanda region of Congo.
 
"The risk of monkeypox is moderate globally and in all regions except that observed in the European region where we assess the risk as high," Adhanom said from Geneva. 
 
The WHO expert committee speaks of a rapidly spreading outbreak of which it is not known how it is spreading from country to country and whose clinical manifestations do not fully correspond to those previously identified last century and which are as follows: "It causes fever, headache, cut body, skin eruptions with oozing sores, general pain and swollen glands".
 
In addition to this clinical picture, the spreading disease is accompanied by genital, anal and oral lesions, which at first diagnosis confuse the doctor because they look like an STD, but are not. There are some cases of patients hospitalised because of pain caused by sores in the genital and oral area.  
 
Is it transmitted by having sex with an infected person? The WHO says it has no absolute conclusion on this and insists that monkeypox is not a sexually transmitted disease but there are indications that it is found in the saliva and semen of patients.

The modes of transmission of Variola virus for both smallpox (black, human or smallpox) and monkeypox are as follows: 1) directly from one person to another. Direct transmission of the virus requires fairly prolonged close contact. The virus can be transmitted through the air by droplets that escape when an infected person coughs, sneezes or talks; 2) indirectly from an infected person. In rare circumstances, the virus can spread further through the air, possibly through the ventilation system of a building, infecting people in other rooms or on other floors; 3) by contaminated objects. Smallpox can also be spread through contact with contaminated clothing and bedding, although the risk of infection by this means is less common; 4) potentially as a terrorist weapon. It is unlikely that smallpox would be spread deliberately, but vaccines are kept just in case.
 
Whether there is airborne transmission as in the case of COVID-19 is currently being analysed. For the time being, the WHO recommends a containment protocol for monkeypox and indicates that health systems are already prepared to respond to such contingencies because the coronavirus pandemic itself has taught a lesson. So, in Adhanom's words, the same path must be followed: prevention, detection, isolation, control, quarantine of those infected and close contacts, treatment and vaccination. 
 
Some countries are drawing up guidelines for their health workers: for example, Spain is the country with the highest number of monkeypox infections - more than 3,000 cases - and the Spanish Society of Epidemiology points out that its infectiousness starts from the moment the enanthema appears. "It has an incubation period of between 5 and 21 days". 
 
Border closure? The WHO has not touched the issue. With summer approaching, Europe is experiencing a festival boom. Concerts and all mass events, outdoor and indoor, are packed to capacity and most are sold out. Europe is home to 80% of the world's monkeypox cases. 
 
"Our recommendation is that neither those infected, nor their close contacts, nor anyone who has been in close proximity to them in the last 45 days since the onset of symptoms, should travel," according to the WHO.
 
The health agency has made a more personal suggestion asking people to "limit their sexual partners and interactions" to take greater precautions and help limit the spread of infection.

What is known about monkeypox
 
Information provided by the WHO indicates that it is a viral zoonosis with symptoms similar to (but less severe and deadly than) those seen in the past in patients with the so-called black pox or Variola virus also known as smallpox. 
 
"With the eradication of smallpox in 1980 and the subsequent cessation of smallpox vaccination, monkeypox has become the most important orthopoxvirus for public health. Monkeypox occurs mainly in central and western Africa, often in the vicinity of tropical rainforests, and has increasingly appeared in urban areas," the health agency explains. 
 
Interestingly, it does not come from monkeys, is not transmitted by apes to humans, but by rodents, and is a double-stranded DNA virus of the Poxviridae family. 
 
Above all, it is present in Africa: "There are two distinct genetic clades, one in the central African clade in the Congo Basin, the other in the West African clade. The Congo part causes the most severe infections with the highest transmissibility and in Cameroon there are both clades".
 
Over time it has become endemic in several African countries such as Nigeria, which is still struggling to control an outbreak since 2017 that has so far left eight people dead and nearly 600 infected, according to the Nigerian Centre for Disease Control (NCDC).
 
The WHO is concerned that the monkey virus has jumped to Europe and then to North America, Asia and Oceania and is racing against time to find the common thread of its spread.
 
This is not the first time it has left its endemic environment. The WHO cites the 2003 outbreak of monkeypox in the United States caused by the contact of prairie dogs with Gambian rats and Ghanaian dormice that had been imported into the United States. A total of 70 people were infected. 
 
Positive individuals from Nigeria made several international trips and caused infections in September 2018 in the United Kingdom, in Israel in September 2018, in 2019 in Singapore and in the United States between July and November 2021.

Cross-immunity
 
There is no vaccine against monkeypox virus. What there is is cross-immunity if inoculated with the human smallpox virus for which there is a vaccine. 
 
Hans Kluge, director of the WHO Regional Office for Europe, believes that vaccines alone are not enough to stop the outbreak, although they do provide antibodies that prevent the development of a more aggressive disease. 
 
Smallpox specialist Rosamund Lewis urges vaccination of anyone who has been exposed to interact with anyone who has tested positive.
 
How many human smallpox vaccines are available in the world so far? The WHO informed me that there are 16.4 million vaccines in stock. But the US has a significant stockpile because of its protocol for preventing a chemical or biological attack.
 
Lewis explains that while vaccination against human smallpox has been discontinued globally since the 1980s - after it was declared eradicated - this serum has proven to be very effective against monkeypox.
 
With the most worrying focus on the European continent, the EU took the decision to purchase vaccines produced by the Danish laboratory Bavarian Nordic. This is the Imvanex serum, registered in Europe and the United States as Jynneos.
 
This anti-variol vaccine uses a modified live Ankara cowpox virus. Two doses are given 28 days apart.  
 
The recommendation is to vaccinate close contacts of those infected, to isolate pets if they have them, and to quarantine the infected at home for 40 to 45 days. In any case, only go to hospital in case of inflammation, severe pain and other complications.