Why? Dr. Pragya Yadav is the top scientist in the country at ICMR-National Institute of Virology (NIV), Pune. She is the group leader of the apex lab’s maximum containment lab, where highly infectious viruses, such as the one that causes monkeypox, would be handled and tested. The Ministry of Health has ordered public health officials at ports, airports and land borders to closely monitor suspected Monkeypox cases during international travel to India. These cases would be isolated and their clinical samples would be sent to the VNI.
The WHO says its partner countries are working to better understand the extent and cause of the Monkeypox outbreak. What do we know so far about this epidemic?
Cases have been reported since May 13. So far, 18 countries have reported these cases, all of which are non-endemic for monkeypox and outside of Africa. This alerted public health authorities around the world. Different preparation approaches are used by WHO and Member States to manage patients and test specimens. The United Kingdom (UK) has also reported community transmission of Monkeypox, which has made the situation concerning. But so far, no associated deaths have been reported.
There are no established travel links to the endemic area. This is another concern that sounds the alarm. We know that Monkeypox virus belongs to the genus Orthopoxvirus of the Poxviridae family which also contains the most deadly smallpox. As these are DNA viruses, we need a PCR test. The majority of cases identified in the 18 countries belonged to the West African clade. Their genome sequencing was done from a lesion swab sample of a confirmed case in Portugal and indicated a very close match to the Monkeypox virus causing the current outbreak, which has been exported to the first time from Nigeria to the UK, Israel and Singapore in 2018 and 2019. .
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The identification of confirmed and suspected cases of Monkeypox without a direct travel link to the endemic area represents a highly unusual event. Surveillance in non-endemic areas has been limited but is now expanding. So far, no cases have been reported in the Southeast Asia region, epidemiological investigations are ongoing and a travel advisory has been issued. We continue to discuss various questions about the monkeypox virus.
Since 1970, human cases of Monkeypox have been reported in 11 African countries. Is this the first time that several cases of monkeypox have been identified in several non-endemic countries?
You’re absolutely right. Cases have been identified in 11 African countries since 1970. But the true burden of Monkeypox virus was not known until much later. For example, in 1996-97 there was an epidemic in Congo with a higher incidence and case fatality rate. Since 2017,
Nigeria has experienced a large outbreak with over 500 suspected cases and over 200 cases with a case fatality rate of around 3%.
Monkeypox has been reported outside of these defined areas in the past. In 2003, the first outbreak outside Africa was reported in the United States. It was linked to contact with infected prairie dogs. The dogs had been co-homed with infected rodents imported from Ghana. This outbreak resulted in more than 70 cases in the United States. MonkeypPox was also reported in travelers from Nigeria to Israel in September 2018. The UK reported cases in September 2018, Singapore in May 2019 and the US in July and November 2021. Different episodes of imported cases of Monkeypox have been reported from contact with an animal and community transmission has also been established. By May 2022, several cases have been identified in several non-endemic countries and the scientific community is working to understand the source of infection and transmission patterns.
What was the prevalence of Monkeypox disease in India?
This is a very relevant and important question. As we all know, smallpox was a very dangerous disease but through a mass vaccination program, we eradicated this disease in 1978. In India, there is another related disease in the same family: cowpox and buffalopox. Sporadic cases have been reported not only in cows or buffaloes, but also in humans, indicating animal-to-human transmission. However, so far no cases of Monkeypox have been reported in the country. It is therefore an exotic pathogen. This is why we need more precautionary measures in place, as this is a new disease that we have not been exposed to and have no immunity to. This is a big challenge and a matter of concern.
Monkeypox is usually a self-limiting disease with symptoms lasting two to four weeks. What are the main symptoms to watch out for?
Although this disease goes through four different phases, the phase that I would like to describe is very important for the disease itself. The first period of invasion, which lasts between 0 and 5 days, is characterized by fever, headache and swelling of the lymph nodes. Swollen lymph nodes are one of the hallmark features of monkeypox and are not seen in similar rashes causing diseases like measles and chickenpox. Patients also present with generalized weakness or lack of energy. The rashes usually appear within two days of the fever. The rash is more concentrated on the face, as is apparent in 95% of cases. In 75% of cases, it is found in the palms and soles of the feet. It affects the oral mucosa in 70% of cases. The conjunctiva, cornea of the eye and the genital area can also be affected.
The WHO says severe cases can also occur. Which group is at risk of contracting a serious illness?
Although largely a self-limiting disease, it can lead to difficult phases when it affects the lungs and eyes. The high-risk group includes children, pregnant women, and immunocompromised patients, including those with diabetes. They can have more serious consequences than others.
Experts believe that the vaccines used during the smallpox eradication program also provide protection against monkeypox. How robust is this immunity? What does the data suggest?
Since the eradication of smallpox in 1980, the use of smallpox vaccination has been discontinued for the general public. When it was eradicated, the virus was kept in two maximum containment laboratories, one in Russia and the other in the United States. In the United States, the FDA approved the smallpox vaccine Jynneos (Modified Vaccinia Ankara) for vaccination against Monkeypox in 2019. Its effectiveness was concluded from a clinical study. Previous data from Africa suggests that this vaccine is at least 85% effective in preventing monkeypox.
Experts also believe that vaccination after exposure to Monkeypox could help prevent the disease or make it less severe. The smallpox vaccine provides protection, but the waning response over time can lead to recurrence. I just want to point out that the smallpox vaccine is not available to the general public. So that’s another challenge if someone wants to go there.
What type of preparedness and monitoring is India considering?
Whenever there is a threat of a new viral disease, a travel advisory and preparedness alert is issued in all states. International travel to endemic regions and ongoing outbreak regions are believed to be the significant risk factor for importation of Monkeypox cases into India. Thus, any of these cases would be under surveillance at ports of entry. Specimens from symptomatic patients will be referred to NIV, Pune. As I mentioned before, since this is a DNA virus, we will need to do a PCR test and genome sequencing. We also have the orthopox PCR test, which can rule out other smallpox viruses, not just monkeypox. Based on confirmation and genome sequencing, authorities will be notified of positive cases, if any.