In the month of May 2022, a few men in European nations sought medical attention with monkeypox. As cases started getting noticed at a rapid rate in multiple countries who never had this disease previously, the WHO declared a PHEIC on 21 July (Public Health Emergency of International Concern). More public health emergencies have been declared since, initially in New York and California, followed on 4 August by the entire US. India has reported 9 cases at the time of writing, the global case count being 26,864.
This article discusses a few key aspects of this disease, from a public health standpoint.
The clinical features and management of monkeypox have been published by the WHO and Ministry of Health and family Welfare, India (please click on hyperlinked text to access references). The following discussion will therefore not include those topics.
The term monkeypox is a misnomer. Contrary to what the name suggests to lay people, it is not spread by monkeys. The name dates back to 1958 where the disease was first described in monkeys kept in a laboratory in Denmark. It is true that in certain pockets in Africa, people had earlier contracted the disease after hunting monkeys and rodents such as squirrels from the tropical rainforests.
In the 2017 outbreak in Nigeria however, the spread was confirmed to be human-to-human. Sexual mode of transmission was documented by doctors in Nigeria, but this invited criticism. In 2022, known transmission has exclusively been human-to-human, the overwhelming majority being gay or bisexual men with multiple sexual partners.
It was a common practice in the bygone days to name diseases after animals or places that it was first described in. Such a practice is no longer acceptable for several reasons, including prejudice and misinformation. What makes it worse is that the word “monkey” is a derogatory slang in certain countries, prone to stigmatisation. A request has already been made to designate a science-based name, but so far that has not happened.
In this context, it is worth recalling recent events where the SARS-CoV2 virus had been called inappropriate names such as “Chinese virus”, “South Africa Variant”, “India variant” and “UK variant”. This was later rectified by Greek nomenclature. A few years ago, the editor of The Lancet raised concern about a multi-drug resistant bacteria being inappropriately named the “New Delhi superbug” by UK scientists.
2. Wrong classification
Classifying diseases into predefined categories is useful for scientific publication. But it could also lead to confusion among the general public. Although the vast majority of initial cases of monkeypox were related to sexual networks among men who had multiple partners, the disease could not be officially termed an STD or sexually transmitted disease (STI being an updated term) such as gonorrhoea or syphilis.
The main reason is that the virus was also transmissible by non-sexual activity such as close physical contact such as what could occur during contact sports or massage. Thus, unlike conventional STD’s, condoms will not stop transmission of monkeypox. The term STD was also deemed inappropriate by some experts because it could lead to stigmatisation, and discourage affected individuals from availing medical care.
The more serious downside of not calling it an STD/STI, however, is that the disease continues to spread unabated through activities themed around sex, because those who are actively involved in such networks are not taking it seriously enough.
Considering the overwhelming evidence, it is more precise (and less misleading) to call it primarily an STD that can also spread through close physical contact.
If casual physical contact, aerosols or fomites (e.g. contaminated surfaces) were a significant mode of spread, far more cases would have been reported among women and children by now.
3. Wrong messaging
Due to fear of stigmatisation of LGBTQ (acronym for lesbian / gay / bisexual / transgender / queer community), public messaging worldwide so far has been overly generalized as “affecting everyone”. But by implying that “anyone could get it” for the sake of being politically correct, the flip side was that those at greatest risk did not receive the message clearly enough.
For instance, smoking is responsible for numerous cases of lung cancer. However, giving a public message themed as “anyone can get lung cancer” is unlikely to discourage people from smoking.
Regardless of stated reasons, this unwarranted generalisation is indeed a failure of communication. Papers published on the current outbreak show that over 99% of the initial patients belong to these subgroups.
4. Deaths are rare
The case fatality rate (number of deaths that occur among 100 cases of monkeypox) in 2022 is low at 0.04%, particularly for the West African clade that is in worldwide circulation at this time. Among 26,864 reported cases, the number of deaths so far has been 11. As more outcomes are reported, this rate will change.
5. Number of cases is an underestimate
Because it is a self-limiting illness in most people, it is possible that some individuals might not seek medical attention. The stigma associated with it is a deterrent, which means some people will be reluctant to come forward. Since the skin lesions are similar to other common diseases like chickenpox, cases could be missed. Limited diagnostic facilities are another problem. As a result, the number of reported cases worldwide will be an underestimate. In India, as many as 15 labs have been designated to be testing points, with ICMR-NIV Pune at the helm.
6. Excessive fear of stigmatisation led to delayed intervention
When a relatively new disease is spreading fast in a specific network, the logical thing to do is to intervene assertively in that network at the earliest.
To put this in context with a metaphor, imagine a parking lot with a hundred cars in it. If a parked BMW suddenly catches fire, it makes sense to first focus on the car that’s on fire, rather than to say “You know, a fire theoretically could occur in any car, we must not single out any brand because it might affect the reputation of that manufacturer. We must avoid stigmatisation of BMW. So, let’s treat all cars the same”. But using the available firefighting equipment to treat all cars at the same time is not advisable or feasible. Without early and focussed action on the burning car, the whole parking lot could soon go up in flames.
In a recently published study from Britain, 197 of 198 (99%) monkeypox cases in 2022 identified as gay, bisexual, or other men who have sex with men (MSM), of whom 36% were HIV positive, and 32% had other sexually transmitted diseases. Early intervention in these networks will help reduce the eventual size of this outbreak.
7. Spill-over is inevitable; a dead end is what we need
No social network exists in isolation. As the disease spreads unchecked through complex private networks of men who have sex with men (MSM) and also have multiple partners, it will eventually spill over to the general population affecting women, children and other men who have no direct connection with these groups. This might, for instance, occur through substantial physical contact or by sharing of unwashed linen used by a patient with active skin lesions.
However, as we saw with the 2003 outbreak in the US among families who bought pets infected with the monkeypox virus, it did not result in a nationwide spread. Only 71 people were infected, and no deaths occurred. This was because all those who bought the pets were tracked down, along with their contacts.
In other words, the virus reached a dead end in 2003 because the infection occurred in conventional US families who likely did not have connections with such networks.
Someone in a monogamous relationship is unlikely to spread the virus to several others as they could be feeling ill and would rather isolate themselves until recovery. A person becomes non-infectious as soon as the skin or other lesions heal. A dead end is thus an opportunity to stop virus spread. It is easily achieved when it involves a family. If each instance of infection reached such a dead end, we can halt the epidemic altogether. Besides, unlike HIV, there is no known chronic infection for monkeypox yet. Ring vaccination of high-risk contacts reduces onward transmission, thus further securing the dead ends, as we saw in the 2003 US outbreak.
Unfortunately, such a dead end does not seem possible in 2022, because thousands of people carrying the virus are continuing to pass it on to multiple others who belong to such networks. Super-spreader events including festivals, mass gatherings and parties involving gay and bisexual men occurred in Europe, amplifying worldwide transmission. A gay pride event in Canary Islands drew about 80,000 people. International travel ensured that the virus got seeded in multiple non-endemic countries, where it will hereafter remain as a new disease primarily presenting to STD clinics.
8. How to reach out to those at risk?
In India, it is possible to selectively reach out to people who are at high risk to pick up and spread this disease, which include MSM community, transgenders and commercial sex workers. At the same time, stigmatisation in the general population must be avoided. There are dedicated NGO’s who are working with these groups with guidance from AIDS Control Society at State level and National AIDS Control Organisation NACO.
9. Vaccination is not for everyone
There are two Smallpox vaccines that could also be used against monkeypox. They contain a live virus called vaccinia - a mutual cousin of the monkeypox and smallpox viruses. Immune response generated by the body against the vaccinia virus is capable of cross-protection against both the other viruses. It has been observed that monkey pox occurs less frequently, and tends to run a milder course among those who had prior smallpox vaccination.
Both these vaccines have undergone safety and immune response evaluation in humans. However, they have not been tested yet in clinical trials in actual monkey pox patients. They are considered safe overall, but safety is always a relative term. Known side effects include a 1-2% chance of non-fatal cardiac adverse effects observed among the limited number of healthy participants who took the vaccines. We do not yet know about potential adverse outcomes or vaccine effectiveness when used in large numbers of people in the real-world setting.
ACAM2000 is a relatively new model of the original DryVax vaccine used for smallpox. Rather than being grown in calf skin as in the case of DryVax, the ACAM2000 is made in cell cultures. It generates a localised skin infection (“pock”) at the site of injection. This vaccine is administered using a special bifurcated needle by scarification into the skin on the upper arm. But after vaccination, the live replicating vaccinia virus could spread from this skin lesion to other parts of the body or to other people, if the person is not careful. Hence it is not recommended for use among immunosuppressed individuals. It is pertinent here that 41% of the initial series of monkeypox patients, where HIV status was known to the WHO, were also HIV positive.
Jynneos is a relatively new vaccine, containing attenuated (weakened), non-replicating live vaccinia virus. As the virus cannot multiply in humans, there is no risk of passing on the infection to other people. It may be given to pregnant or immunosuppressed individuals. The known risk of monkeypox in pregnancy is considered to be greater than the unknown risks posed by the vaccine during pregnancy.
These vaccines are not recommended for the general population. Jynneos is recommended for those who are at high risk. Examples include healthcare workers involved with the care of monkeypox patients, or people who had recently been exposed. The long incubation period of this virus (5-21 days) offers the vaccine a chance to outrun the virus before it causes disease. If given within 4 days of exposure, the vaccine could prevent infection, and when given between 4- 14 days, severity of symptoms could be reduced. These guidelines are likely to change as real-world evidence accumulates.
In summary, the monkeypox outbreak of 2022 requires urgent public health measures to selectively sensitise the at-risk groups and networks so that we can place roadblocks or circuit-breakers to stop the unchecked spread of this virus. Until and unless it reaches a dead end in each case, it will be impossible to stop onward transmission. In any outbreak, early and effective intervention along with clear messaging take priority over debating on semantics, political correctness and terminology.