Another Monkey on Your Back – Monkeypox

Dr. Jacob Eapen-

Dr.Jacob Eapen

Dr. Jacob Eapen, a Medical Director at the Alameda Health System(AHS) and a member of the Board of Directors at the Washington Hospital in Fremont, California. He is also the Regional Vice President of the Federation of Kerela Association in North America(FOKANA). 

The world has become tired of pandemics and epidemics. It seems like endemic is a word that is here to stay. The latest surge in monkeypox, a member of the Orthopox family of viruses has created another source of anxiety around the globe.  Monkeypox is one of many DNA viruses which are known to be better at repairing mutations than RNA viruses. This means the monkeypox virus is less likely to suddenly mutate. Monkeypox, which was endemic to central and western Africa, was relatively ignored by the rest of the world as it was considered a disease of the African region. The name is derived from the discovery of the virus in a Danish laboratory monkey in 1958. The first human case was identified in a child in Central Congo Republic in 1970.

This virus is transmitted by close contact with body fluids, large respiratory droplets and contaminated materials such as bedding. The incubation period is usually 6 to 13 days but can range from 5 to 21 days. Eating inadequately cooked meat and other animal products of infected animals is a possible risk factor. Close proximity to rodents, like giant rats and squirrels, can also be a source.

The first case of monkeypox in a non-endemic area was reported in May 2022 and since then more than 400 confirmed or suspected cases has emerged in at least 20 non- African nations, including Canada, Portugal, Spain and the United Kingdom. Scientists are on alert because the monkeypox virus has emerged in separate populations across multiple countries and there is no obvious link between many of the clusters.

Since the outbreaks have begun scientists have collected samples from patients with monkeypox and done genomic studies. The findings are that each of the sequencing from countries like Belgium, France, Germany, Portugal and the United States resemble strains from West Africa. This strain has a lower mortality rate, less than 1%, compared to the much more lethal strain from Central Africa which has a death rate of about 10%.  There are 2 clades of monkeypox virus: the West African clade and the Central African clade. The Genome sequence from a confirmed case in Portugal showed a close match to exported cases of monkeypox from Nigeria to United Kingdom, Israel and Singapore in 2018 and 2019.

The signs and symptoms are:

  • Headache
  • Acute onset of fever
  • Swollen lymph glands
  • Body aches
  • Backpain
  • Profound weakness

Within three to four days a generalized papular rash develops with mostly centrifugal distribution (mostly on the face and outer extremities). This distribution is similar to smallpox, unlike in chickenpox where the rash has a centripetal distribution (more towards the central part of the body).

Diagnosis is performed by PCR testing. The monkeypox genome is much larger compared to other viruses. It is about six times larger than the genome of SARS-COV-2 virus, hence the monkeypox virus genome is about six times harder to analyze compared to SARS virus.

Since the current outbreak began, some nations have been procuring smallpox vaccines which are thought to be highly effective against monkeypox. Smallpox vaccine is about 85% effective in monkeypox. In 2019, a monkeypox vaccine, Jynneos, was approved for adults in the USA. Even if public health officials can stop the transmission of monkeypox, virologists are concerned that the virus could spill back into animals. If new reservoirs in animals develop that would increase the probability of continuous transmission.

Prevention is by vaccination. There are three types of vaccines available. One vaccine is licensed for monkeypox and smallpox and is a two dose vaccine given four weeks apart. The other two are one-time vaccinations. At least for now the plan is to do ring vaccination- that is, to vaccinate all with close direct contact with a known case.

There are lots of questions to be answered by the scientific community. Though not common, can the virus mutate into a more lethal form? Are we seeing a surge now because the virus has already changed itself? Has the Covid pandemic affected the immunity of the population which might be causing this surge? We might have the last laugh, but I am reminded of a quote from Louis Pasteur who had remarked “Gentlemen, it is the microbes who have the last word.” All of us will have to work together and be innovative so that we have the last word.