Monkeypox: WHO lights warning sign

Since May 6, the world has been dealing with a global outbreak of the disease, which began in Europe

While the monkeypox outbreak is spreading rapidly around the world through new modes of transmission, about which science still knows very little, the World Health Organization (WHO) declared the disease a public emergency of global concern on July 23. “Although I am declaring a public health emergency of international interest, at the moment this is a concentrated outbreak among men who have sex with men, especially those with multiple sexual partners,” General Director Tedros Adhanom said at a press conference in Geneva, adding that stigma and discrimination can be as dangerous as any virus. Britains Wellcome Trust chief of epidemics and epidemiology Josie Golding said the world faces a double challenge: an endemic disease in Africa that has been neglected for decades and a new outbreak that affects marginalized communities.“ Governments should take this more seriously and work together internationally to control this outbreak,” he added.

But after all, what have the researchers found out so far about the transmission? A team from the Spallanzani Institute in Rome, a hospital and research center for infectious diseases, first revealed evidence of the virus in semen in four patients in Italy, in the article entitled “Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact”. Early results suggest that sperm may be a vehicle for infection. In Spain, researchers have also discovered high viral loads in semen, urine, saliva and other samples. The research “Frequent detection of monkeypox virus DNA in saliva, semen, and other clinical samples from 12 patients” examined 147 clinical samples from different regions, collected in 12 infected patients, at different times of infection.

Although the WHO does not consider this virus to be a Sexually Transmitted Infection (STI), clinics that treat this type of infection in the United States, which are already struggling to contain an explosive increase in syphilis and gonorrhea, for example, are now at the forefront in the fight to control the rapidly growing outbreak of monkey pox. David Harvey, executive director of the National Coalition of STD Directors (NCSD) explains that monkeypox is not technically an STI, although, based on ongoing research, it can be classified as such. “We are referring to the disease as a ‘sexually-associated infection’ because it is transmitted through very close contact, including sex, and seems to spread during sexual activity,” he adds. Because the disease causes blisters or pimples in the genitals, many patients seek care for what appears to be herpes, syphilis, or other STIs. “STI clinics are severely underfunded in the United States, but have become the frontline hotspots in this outbreak. “They know how to identify common infections and how to address these issues in a non-stigmatizing way. Unfortunately, many patients are turning to health professionals who do not have the same level of experience or cultural competence as clinicians who focus on STIs, and some are having horrible experiences when seeking tests or treatments, he points out.

Harvey notes that the United States government has been asked for immediate funding of $100 million, including $30 million for STI clinics, to help systems respond to monkeypox. “America already has an epidemic of more common STIs, such as syphilis, gonorrhea, and chlamydia, and these epidemics are being left unattended while the nation also deals with this latest outbreak. We urgently need the government to act to stop this outbreak and help us control the existing epidemics. Our public health system cannot withstand the pressure of another epidemic without more resources,” he concludes. Infectious disease experts and public health advocates in the United States say the response to monkeypox reflects the worst parts of the early days of the Covid-19 pandemic, with severely limited testing and slow vaccine rollouts leading to a virus that spreads undetected.

In Brazil, the situation seems worse. Infectologist Dr. Marcelo Daher, responsible for the municipal STD/AIDS and viral hepatitis program in Anapolis (GO), recognizes that there may be underreporting of cases, given the delay in carrying out laboratory tests that are in high demand. “The average time for the result of diagnostic tests here in Anapolis is ten days (the patient is unlikely to be isolated for all this time). On the private network, we have the result in 24 hours, he emphasizes. For him, it is necessary to reduce bureaucracy in the collection of exams and do them quickly, as well as speed up the results. Regarding vaccines, the infectologist is categorical in stating that the problem is to have them, but it is urgent for Brazil to negotiate the purchase, at least so that the country enters the waiting list. “For example, Portugal and Spain are already vaccinating, especially men who have sex with other men. In addition, the government should negotiate medicines (tecovirimat, brincidofovir, cidofovir), which we do not have available today, he argues. Finally, Dr. Daher advises that patients should not be afraid to seek medical attention, because the sooner the diagnosis is made, the better.

The Ministry of Health said in a statement that the control of monkey pox is a priority for the board, which carries out constant monitoring and analyzes the epidemiological situation daily to guide surveillance and response to the disease in Brazil. Also according to the Ministry of Health, diagnostic tests are available for the entire population that fits the definition of suspected cases, and are currently performed in four reference laboratories in the country. Minister Marcelo Queiroga reported that the federal government is already negotiating the purchase of the immunizer through the Pan American Health Organization (PAHO). However, in a report published on Folha de São Paulo, infectologist David Uip, Secretary of Science, Research and Development in Health of the Government of the State of São Paulo, recalled that there is a fierce dispute worldwide for the vaccine and that it should not reach Brazil in the short term. He also mentioned that actions against stigma and prejudice that may surround the disease, since the highest prevalence has been higher among men who have sex with men, are important.

Monkeypox can contaminate people of any gender or sexuality, although recent cases cause damage to genitals, in the perianal and vaginal regions, it is understood that sexual contact is a route of transmission, but it is not the only one. If the disease transmission chains are not broken, eventually the disease will spread to other segments of the population. The outbreak started among men who have sex with men, but its not restricted to them. Although the highest incidence is in this group, some women are already infected (https://globalnews.ca/news/8990360/1st-female-monkeypox-case-ontario/ and

https://medicalxpress.com/news/2022-06-france-monkeypox-woman-infected.html). In addition, the United States Centers for Disease Control (CDC) has declared two children infected – one in California and one non-U.S. resident, but who was tested in the Washington DC area. The first cases in this group were reported as the epidemic took a new direction. Also according to local health authorities, children under the age of eight are at higher risk for severe monkeypox.

Scientists push for non-discriminatory nomenclature

In an article published on the Virological portal on June 10 entitled “Urgent need for a non-discriminatory and non-stigmatizing nomenclature for monkeypox virus”, a group of 30 scientists from 11 countries requested a change of nomenclature to refer to monkeypox. According to them, in addition to the terminology used for the disease, there are also problems regarding some references to the African continent and its countries, considered incorrect, discriminatory and stigmatizing. For the group, when taking into account that since May a new version of the virus circulates around the world, the name should only be hMPXV (h for human). They observed that the circulating strain in the 32 countries outside Africa is probably different from the virus found in animals. Another suggested defense is the name of the virus variants, which are associated with West clade, and Central Africa in the Congo region (Congo clade). The proposal is to adopt “Strain 1” in place of Congo clade and “Strain 2 and 3” in place of West clade. Discussions about a change in the name of the disease gained the support of the WHO. The goal is not only to change the name of the virus that causes the disease, but also its variants and even the disease itself. Tedros Adhanom confirmed that the virus will be renamed. According to him, the WHO has been working with partners and experts around the world to change the name of the virus and that the announcement will be made as soon as possible. Dr. Daher also expresses his full support for the change of nomenclature. It is important to move, in Goiânia, for example, some residents killed monkeys for fear of the disease, he regrets.

Monkeys are not responsible for disease transmissions

Despite the name of the infection, monkeys do not transmit the disease. A statement issued in June by the Brazilian Society of Primatology and other entities reinforced that transmission is not associated with primates. The document points out that monkeys (non-human primates) are not “villains”, but victims like us (humans), and should not suffer any retaliation, such as assaults, deaths, scaring, or any kind of mistreatment. “The fear of contagion by transmission of this and other diseases, such as yellow fever, by proximity to monkeys is not justified. Many microorganisms affect the health of human and non-human primates, and often primates get sick beforehand and this alerts us in advance about the presence of a disease that can have an impact on peoples health. That is, the monkeys serve as sentinel animals on the risk of being exposed to diseases, the statement emphasizes.

Pathogen was named Monkeypoxvirus

Belonging to the genus Orthopoxvirus, which also comprises the pathogens responsible for human and bovine smallpox, MPXV was discovered in 1958, when researchers investigated an infectious outbreak in monkeys from Africa that were being studied in Denmark. The previously unknown pathogen was named Monkeypoxvirus because it was found in samples of these primates. Subsequently, scientists found that monkeys did not participate in the dynamics of infection as reservoir animals of the virus and that they were also affected by the pathogen as well as other mammals. Even today, it is not known exactly which are the reservoir species of MPXV, nor how its circulation is maintained in nature. According to the MSD Manual for health care Professionals, small rodents from tropical forests in Africa are suspected to be the reservoirs. According to the WHO, the majority of animals susceptible to this type of smallpox are rodents, such as rats and prairie dogs. Monkeys, as well as humans and other animals, can be infected by these rodents and develop the disease. The first human case was identified in a child in the Democratic Republic of Congo (DRC) in 1970.

Transmission

The transmission is mainly due to intimate contact and exchange of secretion between people: hugs, kisses, sexual contact, sharing of personal objects (towels and bedding) and personal hygiene (makeup and razors), cutlery, etc. In addition, the virus can also spread through the respiratory secretions of infected people, less common. Therefore, the use of a mask remains important. Personal hygiene is a strong ally to prevent monkeypox, as well as for most infectious diseases. Transmission speed and forms of contagion  alert the scientific community. and nothing prevents the virus from becoming stronger and more contagious, as the study published in Nature Medicine entitled “Phylogenomic characterization and signs of microevolution in the 2022 multi-country outbreak of monkeypox virus” warns.

Bavarian Nordic Pharmaceuticals Third Generation Vaccine

IMVANEX ® (MVA-BN or Modified Vaccinia Ankara-Bavarian Nordic) is a non-replicating smallpox vaccine developed in collaboration with the United States government to ensure the provision of a smallpox vaccine to the entire population, including immunocompromised individuals who are not recommended to be vaccinated with traditional replicating smallpox vaccines. The vaccine was approved by the European Commission in 2013 for immunization against smallpox in adults aged 18 years or older and subsequently obtained regulatory approvals in Canada (marketed as IMVAMUNE ®) and the United States (marketed as JYNNEOS ®), where approvals were extended to include the indication of monkey smallpox as the only vaccine that has obtained it to date.

Smallpox outbreak in 2022: global trends

Check out the document “2022 Monkeypox Outbreak: Global Trends”, which provides a general overview of the epidemiological situation of smallpox, as reported to the WHO on July 22, 2022. The report focuses on laboratory confirmed cases.