Background
Monkeypox is back in the news following the WHO’s declaration of the outbreak in Africa being a Public Health Emergency of International Concern. Coming so close to the end of the restrictions suffered following the COVID pandemic, many people will be asking whether Monkeypox – now called Mpox – will be the cause of another worldwide outbreak. The TRIP Group reached out to Dr Simon Worrell from Chiron International to get his expert advice on this latest outbreak.
Until recently, the current Mpox epidemic has been chiefly restricted to Congo but has now spread to the surrounding countries of Rwanda, Burundi, Uganda, and Kenya. More than 15,000 people have been estimated to have been infected, resulting in over 500 fatalities, many in the young. As there has been a solitary case now reported in Sweden, is there a cause for concern for Europe, as well as further afield?
Mpox – the Basics
Mpox is a virus in the same family as smallpox. This is relevant as it is likely that since the eradication of smallpox, and the cessation of smallpox vaccination, there has been a potential for a similar virus to take up the space that smallpox left. Nature abhors a vacuum. As we now have no immunological defence against the family of viruses, the field is clear for the Mpox virus. For those of us who are old enough to have received a smallpox vaccine, we should have some protection against Mpox if only to lessen its effects – but most will be completely unprotected.
First discovered in laboratory monkeys in 1958 (hence the name), Mpox has been found to infect many species of animals, living wild in Central and Western Africa. If such infected animals are handled or prepared for food inadequately, humans can catch the disease. From then onwards, people can pass the infection to other people chiefly by particularly close contact. Although much is unknown of the present epidemic, it is likely that COVID, for example, is passed much easier to others than Mpox.
Clinical Progress
As is seen with many viruses, there is an initial set of symptoms that is common to many infections as the virus affects the body, and the immune system responds. Fever, headache, muscle aches, sore throat, and a dry cough often occur. In Mpox infection, this is usually followed by enlarged glands around the neck and the throat. Mpox then produces a pustular rash which may last for 2-4 weeks.
The important complications that may subsequently occur are secondary bacterial infection and inflammation of the brain. Both are potentially life-threatening and are likely to have been the causes of the recent deaths seen in Africa, where receiving adequate treatment for these complications can often be challenging. Even in the sophistication of the US health market, deaths have occurred during the Mpox outbreak of 2003, chiefly in those who were also immunocompromised with HIV.
Are there treatments for Mpox?
Yes. Several antiviral agents are available for the treatment of such viral illnesses although their utility with the present outbreak is not certain. There are also vaccinations to both smallpox and Mpox.
2022 – 2023 Outbreak
The last significant outbreak of Mpox was seen only a couple of years ago. Worldwide this affected around 74,000 people and occurred in over 200 countries. The epidemic occurred principally in the male gay community that responded with a widespread vaccination effort, dramatically reducing the cases of Mpox infection. Importantly, the infection affecting one section of society did not progress to affect other communities. This highlighted both the responsible efforts of the gay community, the effective healthcare response, and also the dynamics of the virus, which is more difficult to transmit than others.
Given this – why are we concerned about the present Mpox Outbreak?
Mpox exists in two different clades: one from Central Africa (clade 1) and the other from Western Africa (clade 2). Clades are variations in the virus that have occurred during the evolution of the virus over time. Perhaps it’s good to think of them like second cousins: clades will still have a strong family resemblance, but with often important differences.
The 2022/23 outbreak was caused by the clade 2 virus; the present outbreak in Congo and further afield by Clade 1. Importantly, the evidence to date is that Clade 1 infections are more virulent – what this means precisely for its transmission and the effects that mpox has on the patient, are yet to be fully understood but it is feared that they may be more severe. Added to this, is that there is a completely new variant of Clade 1, termed Clade 1b, and it is this variant that has spread to the Congo’s neighbouring countries and to Sweden. It has been associated with chiefly adults acquiring the virus through sexual contact. Little else is known during this early stage of the outbreak.
Commentary
We know that during established epidemics, a virus usually becomes more infectious but produces mildersymptoms. It has to be this way, as successive mutations must infect more people in order to become the dominant mutation. It’s no good if a virus produces more severe symptoms than the established virus mutation, as patients will be laid up in bed and unable to pass it on to others who haven’t had the virus yet. We predicted this was going to be the case with COVID, and this is exactly what happened: COVID become easier to catch and cause fewer symptoms – despite the Press stories to the contrary.
However, we are in a different situation with the Mpox epidemic, as we are right at its start. There is no incumbent strain; we have no immunological memory of similar viruses since smallpox vaccination stopped more than 50 years ago. If Clade 1b takes hold of a population that is unprotected, the outcome is uncertain to say the least. There are several unknowns; the new variant’s ability to transmit and cause disease, the protection that the old monkeypox vaccine affords and the efficacy of anti-viral treatments. I strongly suspect that vaccination will be effective but at this stage it is just supposition. The WHO were certainly correct in calling the current situation a Public Health Emergency of International Concern.
For companies, it is likely that the epidemic will be of increasing consequence. Having a medical authority ‘on-tap’ to discuss and plan staff deployment, precautions, testing and vaccination, will be important. As we already have a vaccine and possible treatments, for Mpox we are in a stronger position than we were with COVID. Added to this, is the likelihood that Mpox requires much closer contact with others to pass it on. But we have to be vigilant with the complexities of the epidemic as it evolves if we are to have learned anything from recent history.
Dr Simon Worrell is the Founder and Chief Medical Officer of Chiron International. Simon has two decades of experience in the delivery of international medical assistance and emergency care, bringing significant specialist expertise in immunology and communicable diseases. In addition to providing direction to medical assistance teams, Simon focuses on wider international health challenges faced by global companies. He was central to the innovative Covid testing regimes in the UK and US airports, as well as the employee testing programs for many multinationals. His career has involved senior positions in several global assistance companies.
Chiron International is a global medical services company with deep experience. They offer services ranging from part-time medical director programs and medical consultancy, to occupational health and VIP services.
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