July 03, 2022

Will Monkeypox See a Replay of AIDS and Covid-19?

Prabir Purkayastha

WITH more than 4,000 cases (as on June 30, 2022), the recent outbreak of monkeypox in Europe and North America has become international news. World Health Organisation (WHO) has reacted by monitoring the progress of monkeypox globally and issuing guidelines regarding testing, and taking immediate measures. But WHO has not yet declared monkeypox a public health emergency.

As long as monkeypox was confined to Africa, where similar outbreaks have been happening in Central and West Africa for years, it raised little concern. But with monkeypox now reaching the rich countries, it has become an immediate media event with headlines and TV coverage.

Before we get into our response to monkeypox, what is monkeypox, and why has it appeared now?

Monkeypox is a misnomer; it is not endemic in monkeys but the rodent populations of Central and West Africa. It was wrongly named, as the initial case was an infected monkey biting a child and transmitting the disease. The virus is in a family of Orthopoxvirus, including smallpox and cowpox.

From 1970 onwards, sporadic monkeypox outbreaks have occurred in Central and West Africa, but with a tepid response from the rest of the world. In the last ten years, the Democratic Republic of Congo has seen thousands of suspected cases and hundreds of suspected deaths. A significant outbreak occurred in Nigeria in 2017, with over 700 confirmed and suspected cases of monkeypox. While the West African variant that is spreading in Europe and North America has a mortality of about 1 per cent, the mortality of the Central African variant is around 10 per cent or ten times higher.

Genomic studies now show that monkeypox has been circulating for quite some time in Africa. One major reason why it has increased now and not earlier is the discontinuation of the smallpox vaccination once it was eradicated. The smallpox vaccine also protected people against monkeypox. As the younger people are no longer vaccinated, the fraction of people who have no immunity against monkeypox has increased with time and the threat of catching monkeypox. The only ones who still have immunity are the people in the age group of 45 and above today.

In 2017, Adesola Yinka-Ogunleye, an epidemiologist in Nigeria and others had warned that the virus was spreading in unfamiliar ways. Before the 2017 Nigerian outbreak, the virus seemed to have been confined to rural areas, where hunters would come into contact with animals. Post-2017, it appeared in urban settings. The infected people sometimes had genital lesions, suggesting that the virus might also spread through sexual contact.

 Once the virus spread from sparsely populated regions to more densely populated urban settings, the current rapid spread was an event waiting to happen. Monkeypox is no longer a zoonotic infection, meaning from rodents to humans, and petering out after some cases. It is now human-to-human transmission that is taking place in many countries, with large numbers infected in the UK, Germany, Spain, and Portugal.

Genomic studies show that the virus probably circulated in East and North Africa from 2018 onwards. Even in Europe, there has probably been community circulation for some time. The initial cases would have been mistaken for a skin condition or allergies and not recognised as monkeypox until there was heightened public awareness. Currently, the speed of the transmission may appear more rapid, but that may be more due to monkeypox being recognised more quickly.

It will take a few more weeks before we work out its transmission rates. There are some advantages in combating this virus over the SARS-CoV-2 or the Covid-19 virus. It appears to spread more by contact, and it is easier to isolate those infected. Even when patients shed dry skins, which are airborne and carry the virus, it can still be contained much more easily than the spread of viruses like SARS-CoV-2 or the flu virus. We also have the small pox vaccines, which can be deployed quickly to contain the virus among health workers and those who have come into contact with those infected. Given early, it can even protect people from developing the disease.

In the recent cases of monkeypox, the infection seems to have spread among men who have sex with men. As the experts have explained, this is not a sexually transmitted disease and spreads through contact, and respiratory droplets. It has spread among a certain section because they tend to be closed groups, and sex obviously provides close contact. The problem for health officials is how to warn high-risk groups without stigmatising them, as happened in the AIDS case. During the initial period of the spread of AIDS, it was regarded as a disease of the gay population. This led to the public health systems ignoring the problem and its much wider spread subsequently.

The current outbreak is the result of not addressing monkeypox in Africa when it was still sporadic and could have been easily contained. If monkeypox is easy to detect and contain, why is it that we have let the disease work unhindered in Africa when outbreaks of monkeypox have been taking place there since the 70s? Why does the global health system wake up only when the rich countries are affected?

Anthony Fauci, the well-known US infectious disease expert said that the West believed antibiotics and vaccines had won them the victory against the threat of infectious diseases. This is what the molecular biologist Peter Hotez wrote in his book Forgotten People, Forgotten Diseases, diseases that were forgotten by the rich countries. The rich countries believe that infectious diseases are only a problem of the poor countries and what they need to do is to restrict the entry of people from poor countries. So it was of little concern to the rich that infectious diseases endemic in poor countries are killing millions every year.

The West might have forgotten such diseases, but not the people at risk from tuberculosis, malaria, dengue, yellow fever, and other diseases that threaten more than 60 per cent of the world’s population. This belief in ‘victory’ over infectious diseases led to the collective amnesia in the West about a host of diseases that still plague the world. Their other mistake was to believe that microbes do not evolve and our defences against them will hold for a long time. But disease has a way of striking back. The AIDS epidemic provided the first obvious breach. The Covid-19 pandemic proved that we are always only one mutation away from a new infectious disease emerging.

The West’s belief that they could keep such diseases outside their borders is what led to their unpreparedness for the Covid-19 pandemic. This has been repeated again for monkeypox.

Unless patients are already immune-compromised or have what we now call co-morbidities, monkeypox is not life-threatening. There is also an antiviral drug Tecovirimat that has been authorised for use against smallpox and is also effective against monkeypox. It is a small molecule drug, so easy to manufacture as well as scale up production if required, provided high-cost intellectual property rights do not cause an AIDS-like disaster again. Similarly, many countries have a stock of smallpox vaccines that can be rapidly deployed to vaccinate people who have come in contact with a possible case of monkeypox. The old-fashioned epidemic control measures, test, isolate, and vaccinate all those who have come in contact with a patient, should control the epidemic.

So why such were measures not taken for Africa? Not taking such measures earlier has led to a much larger spread of the disease. African health experts also point out that though countries have pledged 31 million doses of smallpox vaccine to WHO in case of emergencies, no vaccine has been made available to Africa for addressing monkeypox. This needs to be addressed urgently, as also ramping up testing and use of antivirals at prices that people can afford. If we do not, we are going to see a repeat of the Covid-19 vaccine apartheid to a replay of the high-cost patented antiviral drugs that caused AIDS disaster in Africa.