MPOX: cases continue and require attention, alert specialists

After a vaccine shortage in the international markets, the SBIs recommendation is to prioritize doses for people with HIV/AIDS, who are with TCD4 lymphocite counts under 350

During the 57th Congress of the Brazilian Society of Tropical Medicine (MEDTROP), held in Belem (PA) from November 13 to 16, one of the themes on the spolight was Monkeypox, which since late November is now referred to as MPOx, according to recommendation by the World Health Organization (WHO). However, the question of when Brazil will begin the vaccination campaign, which overtook the debate, remais without answer by the Ministry of Health. Despite the board having announced, in September, the purchase of 50 thousand doses of the vaccine against the disease, Brazil only received the first shipment with 9.8 thousand doses. Expectations are that the remaining doses will arrive by the end of this year. Meanwhile, the USA and Brazil lead the world ranking of deaths (20 and 14, respectively, of the 65 recorded deaths), followed by Nigeria, Ghana and Mexico (4 each). As of December 09th, Brazil had recorded 10.231 cases, while the rest of the world recorded 82.594 cases of the diseases, according to OurWorldinData.org, a platform that compliles the data.

A survey conducted by the Brazilian Society of Infectology (SBI) points out that the majority of the deaths by MPOX were people living with HIV/AIDS. Given this scenario and the shortage of vaccines in the international market, the recommendation of the entity is to prioritize the doses for those living in this condition. SBI vice-president, Dr. Alexandre Naime, emphasizes the need for Brazil not only to purchase, but also to apply the vaccine in more vulnerable groups, especially in people with HIV/AIDS whose TCD4 lymphocyte counts below 350. It is essential that we have this immunizer, especially for this public, since almost all the cases of death in the country were people with HIV (13 out of 14) and immunosuppressed. It is also important to extend the vaccination to the immunosuppressed, who are possibly part of the vulnerable population, adds the professor and researcher at the Universidade Estadual Paulista (UNESP).

Asked about the possibility to immunize other groups, Dr. Naime stresses that this has been debated, since the transmission remains high in Brazil, while in other countries it has  Everything will depend on the future epidemiological future; for now, there it is impossible to predict or to make any assertive statement. If cases remain levelled as they are or begin to drop, it will be not necessary. But if there is a large increase in the number of cases, vaccine may be extended,, he alerts. Asked if the situation is still especially concerning and if cases still require attention, the SBIs vice-president says all emerging or re-emerging diseases require special attention, especially in the epidemiological issue, whether to trace suspected cases or to confirm them. For him, the disease obviously should be viewed with great attention by the entire scientific and medical community, as well as health managers.

Finally, Dr. Naime acknowledges that the virus may circulate below the radar of the public health detection systems, since the clinical manifestation of MPOX is very similar to other sexually transmitted infections (STIs), like herpes and syphilis, for example. Also according to him, if professinals who provide care are not properly trained and have a high suspicion index, cases may go unnoticed and treated erroneously, without the correct diagnosis. For this reason, the SBI and Tropical Medicine, have insisted in medical and continued health education to increase diagnostic suspicion,, concludes the infectious disease specialist.

Risk of disease not being contained in Brazil if pandemic response mistakes are repeated

A paper published in the scientific journal The Lancet Regional Health Americas entitled Monkeypox in Brazil between stigma, politics, and structural shortcomings: Have we not been here before? calls attention for that, if the MPOX outbreak is not properly contained in Brazil, similar mistakes made in the response to Covid-19 may be repeated. The paper points out five risks that should be prevented: stigma associated with the infection, health care system deficiencies, dependence on foreign vaccines and treatments and the governance crisis which takes place in the fight against the disease.

Dr. Mário Scheffer, professor at the USP Medical School, first author of the paper, explains that the main goal of the paper was to alert to the Monkeypox situation in Brazil. Although the data indicate that the outbreak has slowed down, as occurred in other countries (in relation to the peak of viral circulation in August and September), currently we have more than 9,500 confirmed cases and a total of 11 deaths, which puts us as the country with more deaths from the disease in the world,  he adds while saying that as observed in the history of other epidemics and transmissible diseases in Brazil, for example, HIV, tuberculosis, syphilis, and more recently Covid-19, if measures are not taken aiming a more effective control, there is a chance of MPOX spreading in the huge Brazilian territory and among more vulnerable groups that tend to be more affected.

Also according to Dr. Scheffer, the MPOX situation is especially concerning due to Brazils recenet awful response dealing with Covid-19 and that cannot happen again. We are also concerned that the Health Ministry has announced budget cutbacks, and resources will not be enough even to cover treatment and prevention of HIV, tuberculosis, hepatitis and leprosy. This way, we present five interconnected critical factors, which should be considered in a new MPOX combat plan, he explains.

The professor stresses that MPOX calls attention for two themes that should compose public health campaigns and measures. First, to avoid the stigma of an infection that disporportionally affects the most vulnerable populations; second, the role of fake news, misleading or innacurate information that hamper prevention. Not only when it comes to MPOX, measures to combat epidemics today need to consider a specific plan to combat misinformation, he argues. Also according to Dr. Scheffer, the paper also evidences Brazils dependence on foreign vaccines and compounds, as happened during the Covid-19 pandemic.  Therefore, according to him, the Butantans initiative is very important, as it is in negotiation with the USA National Institute of Health (NIH), aiming to produce the MPOX vaccine in Brazil, in face of the increase of cases and deaths in the country.

Finally, we stress that the services of the Unified Health System (SUS) in Brazil have a history of successful responses in fighting HIV and other outbreaks and epidemics, such as dengue, Zika, yellow fever, and Chikungunya. If the Ministry of Health, which renounced the national coordination during Covid-19, returns to lead the articulation with states and municipalities, the MPOX will be more adequately controlled in the country, concludes the FMUSP professor.

WHO decides for a new name: MPOX

After calling for a public consultation and listening to several advisory bodies, with experts representing authorities from 45 different countries, the World Health Organization (WHO) released a new nomenclature for the disease, now called MPOX. The decision was made after several deliberations with global experts. The Organization said that both names can be used for a period of one year, until people get used to the new nomenclature. Also according to the WHO, the term MPOX can be used in all languages. The new name assignment is formalized by the International Classification of Diseases (ICD). With this, the new nomenclature will be included in ICD-10 online, the current version of the document that is the global standard for health data, clinical documentation, and statistical aggregation, in the following days. The switching process will be completed at the release of the ICD-11 edition in 2023, when the term Monkeypox will be replaced.

Understand the case

Since June, scientists had been pushing for a non-discriminatory nomenclature in order to avoid stigma and prejudice against infected individuals and violence against animals. The article published by the Brazilian Society of Tropical Medicine (SBMT) revealed that an article published on the Virological website on June 10, entitled Urgent need for a non-discriminatory and non-stigmatizing nomenclature for monkeypox virus, signed by a group of 30 scientists from 11 countries, called for a change in the nomenclature to refer to monkeypox. According to them, besides the terminology used for the disease, there were also problems regarding some references to the African continent and its countries, which were considered incorrect, discriminatory, and stigmatizing. For the group, taking into consideration that since May a new version of the virus was circulating around the world, the denomination should be just hMPXV (h for human). They noted that the strain circulating in the 32 countries outside Africa was probably different from the virus found in animals. Another defense suggested at the time concerned the naming of the virus variants, associated with West Africa (West clade) and Central Africa in the Congo region (Congo clade). The proposal was to adopt Strain 1 instead of Congo clade and Strains 2 and 3 instead of West clade.