How Prepared for a Monkeypox Outbreak Are We?

Monkeypox isn’t a new disease in the same way Covid-19 was. That means we’re in a much better position.

Sam Fazeli

25 May 2022, 04:29 PM IST

How Prepared for a Monkeypox Outbreak Are We?

(Bloomberg Opinion) -- The World Health Organization has revealed that there are now 131 confirmed cases of monkeypox, and a further 106 suspected cases, in 19 countries. Experts describe the event as “random” but “containable” and was likely sparked initially by sexual activity at recent raves in Spain and Belgium. Nevertheless, with the world still reeling from the effects of the Covid pandemic, the rise of a different disease is putting many people on edge.

Bloomberg Opinion’s Bobby Ghosh hosted a live Twitter Space discussion with Bloomberg Intelligence senior pharmaceutical analyst Sam Fazeli to get the lowdown on the disease and find out whether we should be worried.

Bobby Ghosh: Let me start by asking the most basic question possible: What is monkeypox?

Sam Fazeli: There are, seemingly, an endless number of viruses that circulate in nature. This happens to be one of them. It’s an orthopoxvirus, like smallpox. Monkeypox is less problematic than smallpox was in terms of the mortality rate. The virus which is currently circulating seems to be the strain that is endemic in West Africa.

We’ve known about two strains for a few decades. Both are endemic in different parts of Africa — Central Africa and West Africa, respectively — and there have been occasional cases reported outside of the African continent, usually from someone traveling from an affected area. But this outbreak seems quite unusual in that cases are being reported in so many different parts of the world all at the same time. What’s happening?

There was actually an outbreak of 71 cases in the US in 2003, not because of a person traveling but because of imported rodents from Ghana. Those rodents then infected pet prairie dogs, who then infected people. There was a possibility of some local transmission back then, but it certainly was passed on from animals to humans. That’s a problem we’re dealing with in many of these viral outbreaks, from bird flu to Covid.

In terms of today’s unusual outbreak, we have to be aware that it’s too early to be able to be sure whether the virus has genuinely been separately seeded in different countries or whether at least most of the cases came from a super spreader event. The best way to know how related the cases are is to sequence them. The first genome was published by Portuguese scientists and they found that the virus seems to be quite close to the virus which was found in several countries in 2018 and 2019. That already tells you that it hasn’t necessarily changed a lot. Although all of this is up for revision, it suggests that hopefully we’ll find that the majority of these cases are actually related.

In passing, it’s worth just unpacking that, although it is called monkeypox, it doesn’t really come from monkeys. We only began to pay attention to it when monkeys began to get it. Does it originate with simians now? What do we know about how the disease is transmitted?

Orthopox viruses, especially monkeypox, are viewed as generalists. That means this virus can and does infect a variety of species. Rodents are the most common vehicles for infection, then it jumped to monkeys and now humans. The transmission can happen relatively easily, not necessarily through a specific route. In this case, the view is that it’s spread through contact with contaminated fluids from an infected person and it needs to be relatively close contact.

The likelihood is that the majority of transmission will be when you’re either in very close proximity to somebody who’s got the virus, so you’re picking up their exhaled droplets, or you’re in physical contact with them. It could also be passed on via fomites — touching a surface that someone infected has touched.

There have been some reports suggesting that it happens mostly through intimate contact, including really close proximity or having sex with a person.

I think we have to be very careful not to misinterpret the conversation and the information that’s coming out. Just because the majority of cases have been found in men who have sex with men doesn’t mean anything with regards to sexual transmission. We are only looking at the way this particular spread happened. It could have easily been any other kind of intimate contact, heterosexual or whatever.

What are the symptoms of monkeypox?

It starts with a headache and fever, the usual things that you deal with when you get a viral infection. These symptoms are basically your defense system kicking in. A lot of viruses don’t like higher temperatures, which is why the body raises its temperature. We get a headache and muscle aches because of all the chemicals — such as cytokines — which get released to fight the infection. Then, within a week or two, some people get a rash which develops into pustules.

If you’re covered in these pustules, then you’d have the risk of bacterial infection and, in some cases, sepsis. That’s where the lethality can come from.

There have been zero deaths so far in this particular cluster. The 1-3% mortality rate or the 10-13% mortality rate for the Central African strain has been mentioned a lot, but you have to remember that, just like Covid, it depends on how patients are looked after. If a patient is at home with no oxygen available, no ICU, no medical professionals looking after them, their risk of death is higher. That may be the situation in rural Africa where these numbers have been calculated, but in countries with good healthcare and drugs, I’m sure the fatality rate will remain below 1% — 0%, hopefully!

The symptoms remind me of my childhood when I got chickenpox. I was bedridden for several days and I remember it being very uncomfortable. Then it went away. Do we have a sense of whether monkeypox is more painful, or more threatening than chickenpox?

It’s a much more uncomfortable infection if you get the full-blown pustules on your skin. But it varies, I’ve heard of a case where somebody was infected who had previously been vaccinated against smallpox. They had just one or two lesions, which is nothing. That’s what you assume and hope is going to be the case with most people who have been vaccinated already. The question is around folks who aren’t vaccinated. How bad do they get it?

Because I grew up in India in the 1970s and 80s, I was vaccinated for smallpox as a child. Then smallpox was eradicated and in many countries, vaccines were no longer given. Does that make us more vulnerable to monkeypox?

Yes, I think it does, which is what’s likely going on here. There was the suggestion that maybe the Covid lockdowns increased our susceptibility to disease. You might say that for flu and the coronavirus, both of which are respiratory viruses. But really in this case, I think it’s just a coincidence. We have an endemic virus in Central and West Africa which has then been given an opportunity to spread among a population of people who have never seen an infection or a vaccine that gives them protection against the virus.

It’s good news that the vaccine already exists, unlike with Covid. We have vaccines that work both prophylactically as well as after one has got the disease. So they can be preventative as well as a cure.

Correct, a few days after a diagnosis of infection, the vaccine seems to still do the job. The interesting thing is that both vaccines are manufacturable today. Stocks may not be as high as one would like in situations like this, but many countries had already been stockpiling it, not in fear of monkeypox, but in fear of a bio-terrorism attack by smallpox.

Because the disease is less transmissible than Covid, you don’t need everybody to get vaccinated. You can use it to treat people who get diagnosed and vaccinate the people around them. This method is called ring vaccination, and it’s proven successful in controlling smallpox before.

There was a great deal of discussion about whether poor countries would be able to afford Covid vaccines. Is that an issue for monkeypox vaccines?

The Covid vaccine from Pfizer was between $15 and $20 a shot. For most of us who live in England, Sweden or the United States, that’s not expensive given the protection it gives you. I expect that for controlling and better managing the global spread of this virus, the equivalence of COVAX will buy vaccines for countries who can’t afford it. At the same time, the cost is determined clearly by the volume. If we only need one million doses, as opposed to a 400 million doses, then companies will probably have to charge a little bit higher because margins will be lower at those sorts of volumes. But I’m not expecting this to be a very expensive vaccine.

That’s reassuring. How have leaders responded to monkeypox? President Biden felt compelled to answer a question about it during his trip abroad in South Korea. Have we learned things from our fight with Covid at a policy level that are particularly useful in dealing with monkeypox?

The good thing is, as we’ve said already, that this is not a disease which we’ve never dealt with before, even if it may not be necessarily the living memory of many people. It’s only 50 years ago or so that we stopped the smallpox vaccination programs. Bavarian Nordic, one of the manufacturers of a smallpox vaccine, apparently already had meetings with health authorities from several countries just in the past few days, which were arranged six months ago. That shows countries were already thinking about this — whether it was more smallpox than monkeypox that they were thinking of doesn’t really matter.

Is there any reason to think monkeypox is seasonal?

At the time of year when people are more outdoors than indoors, you’d expect most infections, especially respiratory ones, to decline. But this is transmitted by contact. So I don’t think we can classify it as seasonal.

What about variants — which have been a real issue with Covid? Has the monkeypox virus shown any sign of developing new variants that are resistant to the existing treatments?

It’s way too early to know. Nigeria gathers great epidemiology data, but with the number of monkeypox cases, it’s not anywhere near the scale of SARS-CoV-2. With SARS-CoV-2 also being an RNA virus, it probably has a higher opportunity to mutate.

The early data that we do have from the Portuguese scientists suggests the virus’s genome is similar to what it was in 2018 and 2019, and that’s quite reassuring. But, when viruses multiply at high levels, you can’t escape the fact that mutations will occur. So we’ll have to monitor it.

What do we do to protect ourselves from monkeypox?

We’ve had this with Covid. There are choices that we can all make in our lives relative to our own circumstances, such as opting to wear a mask. If you’re worried or feel threatened, you can take precautions. But I think the expectation by most scientists is that this will self-limit eventually, especially when the awareness is so heightened, because it doesn't transmit that easily.

Now that it’s been a couple of weeks since the story broke and there have been cases reported in various countries, are we already seeing more research being devoted to this outbreak?

I know that the genomics folks are working 24-7 on sequencing the genomes of the virus to better understand the epidemiology. That’s the best way when you only have 200 cases of knowing how these incidents are potentially related to each other. We already have at least two drugs that could treat the virus and two vaccines, at least. So I don’t think we need to do enormous amounts of research. What we do need to do here is to have the right healthcare public health policy in place to manage it and decide where do we go next? Do we go back and vaccinate everybody that wasn’t vaccinated, or do we just manage it using ring vaccination?