Introduction by Croakey: The World Health Organization (WHO) is holding a global consultation on monkeypox this Thursday and Friday (2 and 3 June) to identify knowledge gaps and priority research questions. See the agenda here.
The workshop comes as the Public Health Association of Australia reminded the new Labor Government and Health Ministers of Labor’s commitment to establish an Australian Centre for Disease Control with a brief to ensure, amongst other things, that Australia is better prepared to respond to infectious diseases.
Meanwhile, global health leaders have stressed the importance of ensuring appropriate public health messaging around monkeypox, reports Alison Barrett.
Alison Barrett writes
While cases of monkeypox have been increasing in Africa in recent years, it is unusual and cause for concern – but not alarm – that clusters of the infection are now being described in non-endemic countries, according to public health and infectious disease experts.
Monkeypox virus is not typically seen outside of countries in western and central Africa where it is endemic.
Since mid-May, 257 lab-confirmed cases of monkeypox have been reported to the World Health Organization (WHO), including from the United Kingdom, Portugal, Spain, Canada and the United States. Two cases have been identified in Australia.
It now appears the outbreak in Europe was underway as early as mid-April, according to Dr Hans Henri P. Kluge, WHO Regional Director for Europe.
“Rapid, amplified transmission has occurred in the context of the recent lifting of pandemic restrictions on international travel and events,” Kluge said in a statement on 31 May.
“The potential for further transmission in Europe and elsewhere over the summer is high.”
Professor Raina MacIntyre from the Kirby Institute told Croakey this week that “the degree of spread suggests there has been substantial undetected transmission”.
Global health expert Professor Michael Toole AM said it was “always of concern” when an infectious pathogen emerges outside its usual habitat, pointing to the examples of Zika and Middle East Respiratory Syndrome.
“But compared to COVID-19, the global community is better able to control it, because we know more about monkeypox after 50 years of research,” he told Croakey.
While it is too early to say if the behaviour of the monkeypox virus has changed, it is “notable” that previous cases in Africa were suspected to be predominantly spread via animal-to-human transmission, a public health expert in the UK, Professor Andrew Lee, told Croakey.
“What we are seeing around the world with cases emerging are most likely cases of human-to-human transmission,” said Lee, Professor of Public Health at the University of Sheffield.
“So, the driver here will be human behaviour patterns of social mixing and networks, where close contact enables the spread of infection.”
Most of the current cases of monkeypox have been diagnosed in men who have sex with men, which has not been described with previous cases of monkeypox, the public health experts said.
However, while there has been some speculation that monkeypox is now sexually transmitted, they cautioned against making this association, highlighting that close contact with others is a known mode of transmission.
“There is no evidence that this is a sexually transmissible disease, but the close skin contact during intimate encounters has enabled the virus to spread,” said Toole.
Public health communications campaigns are needed to address concerns about monkeypox, experts said.
“There needs to be a public communication campaign that provides evidence-based information and reduces fear and stigma. This is most important in sexual health and travel medicine clinics,” Toole told Croakey.
Toole and Lee added that it is important for public health departments and governments to collaborate and engage with sexual health clinics and community-based organisations to educate about monkeypox, with both saying that it is important to reduce fear and stigma.
“There needs to be a public communication campaign that provides evidence-based information and reduces fear and stigma. This is most important in sexual health and travel medicine clinics,” Toole said.
Lee said: “We must do our best to avoid stigmatising anyone with the disease as it will drive it underground, people will be less likely to come forward for tests or be less willing to share information about their contacts with the health authorities.”
Dr Rosamund Lewis, technical lead for monkeypox at the World Health Organization Emergencies Programme, told a webinar on Monday that public education could promote other public health measures, including avoiding close contact with and wearing a mask around people infected with the virus, cleaning hands regularly and taking care when cleaning clothes, bedding and eating utensils.
Kluge said most people who get monkeypox will have a mild and self-limiting but unpleasant and potentially painful disease that may last up to several weeks.
“We do not yet know what health impact there will be in individuals who can have severe outcomes from monkeypox, particularly young children, pregnant women and people who are immune-compromised,” he said.
He urged government, civil society and health partners to work together “to tackle this public health challenge decisively and effectively, guided at all times by science and medicine, and imbued with respect and compassion”.
Lewis told the webinar that while it is described as a respiratory disease, monkeypox is typically spread via direct and indirect contact with skin lesions, including from bedding or body fluids.
The lesions can appear in the mouth like ulcers and the virus spread through saliva or droplets, according to Lewis, who also said that the transmission of monkeypox will be one of the questions discussed at a WHO research and development consultation on 2 and 3 June.
Although the current outbreak of cases has been described predominantly in men who have sex with men and the “general risk for the general public is considered low at the present time”, Lewis said that anyone can be at risk if they come into close contact with the virus and the aim is to stop further spread.
While the West African variant (or clade) of the virus which has been genomically identified in the current cases is less severe than the Central African variant, it can be more severe in some people including immunocompromised, children and pregnant women.
Waning immunity from smallpox vaccines, which can protect against monkeypox, is another concern highlighted by the public health experts.
Lewis said it is believed that the smallpox vaccination conferred lifelong immunity. But this was not certain as it has been approximately 40 years since most people received their smallpox vaccination and the virus was eradicated.
Additionally, as large-scale smallpox vaccination programs were so long ago, there is an “increasing population that has never been vaccinated against smallpox”, MacIntyre, head of the Biosecurity Program at Kirby Institute, told Croakey.
The public health experts said that while community-wide vaccination is not required at present, vaccinating healthcare workers who are likely to be caring for patients should be a priority in addition to ensuring they have adequate personal protective equipment (PPE).
However, Toole questioned the availability of the vaccine and MacIntyre said “the main vaccine used has quite a severe side effect profile”.
Vaccines against monkeypox will be another topic of discussion at WHO’s research and development consultation.
In addition to vaccination and PPE for healthcare workers, contact tracing and isolation are important, according to the experts, and MacIntyre and Toole suggested vaccinating household and close contacts.
While WHO experts do not believe we are facing a global pandemic of monkeypox, Lewis also highlighted the importance of public education.
“We are concerned that individuals may acquire this infection through high-risk exposure if they don’t have the information they need to protect themselves and we are concerned that because the global population is not immune to orthopox viruses since the end of smallpox eradication, that the virus may attempt to exploit a niche and spread more easily between people. But we don’t have the answer to this question yet.”
With the ongoing COVID-19 pandemic, emergence of infectious disease outside of endemic countries and the possibility of new infectious diseases emerging, it is imperative governments are ready to face these ongoing challenges.
No doubt many others will be adding to the Public Health Association of Australia’s reminder for the new Government of their commitment to establish an Australian Centre for Disease Control.
Research by C. Raina MacIntyre and colleagues about smallpox and monkeypox, published by the US CDC: Influence of Population Immunosuppression and Past Vaccination on Smallpox Re-emergence
See Croakey’s archive of articles on infectious diseases