The global rise in the number of monkeypox cases and the recent growth in cases in India have put governments on high alert. Within 20 days of the first case of monkeypox being reported in India, the tally has climbed to 9 cases. Of these, five patients are from Kerala with a recent history of international travel and four from Delhi with no recent travel history. Cases of monkeypox have been reported in other parts of the world too, sparking concerns at a time when the world is still fighting the COVID-19 pandemic.
According to United State CDC data, a total of 26208 cases have been reported across 87 countries since January 1, 2022. Of these, 25864 cases are from 80 countries that have not historically reported monkeypox and the remaining 344 cases are from the 7 countries that have historically reported monkeypox. United States tops the list with over 6500 cases, followed by Spain (4577 cases) Germany (2781), the UK (2759), and France (2239). On July 23, 2022, the World Health Organization (WHO) declared monkeypox a Public Health Emergency of International Concern (PHEIC). At the time, more than 16,000 cases had been reported from 75 countries. A little over a month ago, on May 31, only 600 cases were reported in 26 countries across the world.
In India, the first case of the monkeypox virus was reported on July 14 after a UAE traveller (35-year-old male) returned to Kerala. The second confirmed case of the infection was reported in Kannur district on July 18 and the third case was reported in the neighbouring district Malappuram on July 22. A 22-year-old man from Kerala, who tested positive, died on July 30, making him India’s first monkeypox-related fatality. The most recent case of monkeypox in the country was found in Delhi, of a 31-year-old Nigerian woman, who also happens to be the first woman in India to test positive.
Government issues fresh guidelines and sets up a task force
On August 3, the Union health ministry released a list of dos and don’ts to avoid contracting the disease. Among the dos, the ministry advised isolating the infected person from others so that the disease does not spread, use of hand sanitisers, washing hands with soap and water, covering mouth with masks and hands with disposable gloves when close to a patient, and using disinfectants to sanitise the environment around. Isolation rooms are being made operational for the treatment of such infections in government hospitals.
The Centre has constituted a task force to monitor the emerging monkeypox situation in the country. It has been mandated to monitor and provide guidance on the expansion of diagnostic facilities and to explore vaccination for the infection. Dr Vinod Paul from Niti Aayog, who spearheaded the policy framework to manage the Covid-19 pandemic, is one of the members of the task force. It also has Union health secretary Rajesh Bhushan and other senior health officials as members.
Authorities have reiterated that while there was no need for any undue panic, it is still important that the country and the society stay vigilant, especially if they spot anyone exhibiting any symptoms.
The Union Government also held a meeting of top health experts on August 4 on the need for revisiting existing guidelines on managing monkeypox. It was a review meeting held by the Directorate General of Health Services (DGHS), a division of the health ministry that is responsible for managing public health issues of international or national concern. The meeting was chaired by Dr L Swasticharan, director of Emergency Medical Relief and was attended by officials from the National Aids Control Organisation, National Centre for Disease Control and World Health Organisation (WHO) representatives.
According to existing ‘Guidelines on Management of Monkeypox Disease’ issued by the Union Ministry, any person having a history of travel to affected countries within the last 21 days presenting with an unexplained acute rash and symptoms like swollen lymph nodes, fever, headaches, body aches and profound weakness is to be considered to be a ‘suspected case’. Some of the guidelines for the monitoring of those who came in contact with the infected person are as below:
- If a person has a travel history from any of the prone countries or regions, then he or she should monitor contacts for one month. If a person gets infected with the disease then the person who has come in contact with the infected one should keep a track of all the people he comes in contact with for a month. He should immediately seek medical help if he observes any of the symptoms.
- Asymptomatic contacts should not donate blood, cells, tissue, organs or semen while they are under surveillance.
- Health workers who have unprotected exposures to patients with monkeypox or possibly contaminated materials do not need to be excluded from work duty if asymptomatic but should undergo active surveillance for symptoms for 21 days.
- Avoid contact with any materials, such as bedding, that have been in contact with a sick person.
- Isolate infected patients from others.
- Maintaining cleanliness by regularly washing hands after coming in contact with infected animals or humans will prevent its spread.
- Use appropriate personal protective equipment (PPE) when caring for patients.
- Family members of infected persons and healthcare workers should take extra caution.
- If a patient comes up with symptoms like fever and vesicular/pustular rash, then a combination of standard, contact, and droplet precautions should be applied in all healthcare settings.
Understanding Monkeypox and Its Origin
According to the WHO, monkeypox is a viral zoonosis (a virus transmitted to humans from animals), with symptoms similar to those seen in the past in smallpox patients, although it is clinically less severe. While COVID-19 is caused by an RNA virus, monkeypox is caused by a DNA virus. Though related to the smallpox virus, it causes mild illness in the majority with a case fatality rate of less than 4 per cent. Smallpox carries a case fatality rate of ~30%.
The eradication of smallpox in 1980 saw the subsequent cessation of smallpox vaccination.
Monkeypox started in 1958 when the disease was first found in a colony of monkeys that were kept for research. Later, the virus began to be known as monkeypox. The first human case of monkeypox was found to be known in the Democratic Republic of the Congo (DRC) in 1970. The virus is prevalent in Central and West Africa. The virus expanded its reach outside Africa in 2003 when its case was reported in the United States. The case was linked to contact with infected pet prairie dogs.
Fewer than 19000 cases were reported in humans from 1970 up until the current outbreak. Only eight cases were reported outside of Africa over the last five years, ever since a small epidemic broke out in Nigeria in 2017. Each of these eight cases had a history of travel or contact with an infected person.
How does it spread and what are the symptoms?
Monkeypox spreads through close contact with affected people, contact with clothes worn by the affected person and also through air droplets. It takes about one to two weeks for the symptoms to appear after contact. It generally starts as fever, headache, muscle pains and enlargement of lymph nodes followed by the appearance of a rash with firm lesions that soon evolve into blisters that dry out into scabs. Monkeypox may lead to a range of medical complications. It is usually a self-limited disease with symptoms lasting for two to four weeks
What it means for science and policy:
What is puzzling currently about the current outbreak of monkeypox, is the simultaneous appearance of the cases in multiple countries without a travel or contact history. A recent study published in the British Medical Journal (BMJ) found monkeypox symptoms being seen in the current outbreak varied significantly from the symptoms reported in previous outbreaks from African regions. The study, based on an analysis of symptoms seen in 197 men who tested positive for the infection in London over the past few months, also found that only a quarter (26.5%) had known contact with someone with confirmed monkeypox infection, raising the possibility of transmission from individuals who were either asymptomatic or had few symptoms. As per the study, understanding these findings will have major implications for contact tracing, public health advice, and ongoing infection control and isolation measures.
Vaccines and Treatment:
Even though there are no specific vaccines for Monkeypox, vaccines used for smallpox are being administered instead due to similarity between the two. Smallpox vaccines were initially found to be 85 per cent effective against monkeypox. Currently, two monkeypox vaccines have been recommended for use by the US CDC. These are Imvamune or Imvanex, and ACAM2000 used against smallpox and made available for use against monkeypox.
In India, the Indian Council of Medical Research (ICMR) has issued an open call for monkeypox vaccine development proposals from commercial businesses to safeguard those most at risk. Serum Institute of India (SII) has initiated discussions with partners for developing a vaccine against monkeypox.
Although many cases resolve on their own, people who are more ill from monkeypox can be treated with antiviral agents. No other drugs are approved for monkeypox; smallpox therapies may be used, although data on their effectiveness for this condition is limited.
Conclusion:
Monkeypox is a reminder that the world now is interconnected and interdependent more than ever. As our contact with wild animals is increasing through trade, deforestation and urbanization, we are at risk of contracting more zoonotic diseases. Climate change is altering ecological systems in unknown ways. We need to do what we can do at a personal level, family level, and community level. Governments should strengthen the public health system to have robust disease surveillance, alert, and containment systems and should provide resources to prevent, detect, and treat novel pathogens.
Countries must strengthen public health preparedness and response with heightened surveillance, case detection, and contact tracing. Patients need to be supported in isolation and treatment, and targeted immunisation might be needed for people at high risk of exposure. Misinformation about monkeypox should be stopped from spreading and governments should ensure correct and effective messaging. Research, development, regulatory approval, and manufacturing of drugs and vaccines should be expedited. The window of opportunity to prevent monkeypox from spreading worldwide is narrowing. Collective and timely action is the need of the hour.
References:
https://main.mohfw.gov.in/diseasealerts-0
https://health.economictimes.indiatimes.com/new-08-03&dt=2022-08-03&em=c3R1
https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html
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