Is Monkeypox a new global threat?

It was in December 2019 when China reported the first cases of the SARS-CoV-2 virus - the deadly pathogen that subsequently took over the globe and enforced global shutdowns. Over the next two years, many theories have surfaced, some plausible, others downright hilarious, others worrying. Many demanded accountability and recognition for the doctors who first reported their findings.

One thing is certain - China knew about the virus much earlier than it let on; our Editor at The Kable had been tracking the news out of China as early as November 2019. Well before the whistleblowing doctor from Wuhan flipped the lid on the biggest story of this century and forced China to acknowledge the problem.

Undoubtedly, Beijing's leadership eventually brought the pandemic under control brought back life to "normal," unlike Europe and the US. As a result, the country is now the world's shining economic outlier. Wearing masks wasn't a political debate, and bureaucrats took virus testing seriously. The central bank resisted the temptation to take shortcuts to boost the economy. But (yes, there is always a but) there was significant neglect from the same management in the initial days. Today, we're analysing parallels between the early lapses in global handling of the Covid-19 outbreak with monkeypox.

The Wuhan Files
According to CNN and the documents leaked by a whistleblower within the Chinese healthcare system, an influenza epidemic 20 times that of the normal level was first seen in the Hubei province around the time of the first recorded coronavirus cases. The cities of Yichang and Xianning were hit more than Wuhan, the city most commonly associated with the start of the virus. While the documents don't suggest the two outbreaks were linked, information about the magnitude of this influenza spike had not been made public.

In the initial days, China struggled to test at scale, taking up to three weeks to produce a test result in some cases. They initially used SARS testing kits from the previous outbreak of a SARS virus — which ended up yielding a multitude of false negatives. An alternate method devised, using nucleic acid tests was still only 30-50 per cent effective at diagnosing confirmed cases. During the initial months, the average time to process and confirm a case was 23.3 days. In early February, China officially declared 3,000 new COVID-19 cases per day in Hubei. However, internal documents suggest confirmed, suspected, and clinically diagnosed cases at least 3x more. China officially included clinically diagnosed cases in the confirmed category in mid-February. Still, even in March the country was reporting a different set of figures to the world than what its internal documents showed.

During the same time, AP reported that China was sacking officials, including the ruling party chief in Hubei, the party secretary in Wuhan and early provincial health commission leaders. This came after widespread criticism from within China for their botched handling of the epidemic. The report highlights bureaucratic inefficiencies compounding China's ability to handle the outbreak in its early days. While the World Health Organisation began its investigation into the origins of the novel coronavirus, China appeared to be focusing blame on other nations for the outbreak. Few Chinese scientists claimed India as a possible origin of the virus. Other officials suggested the US Army had brought the virus to China during the 2019 war games in Wuhan.

There is no evidence of deliberate attempts to obfuscate data; instead, China faced the same struggles many other countries did when first presented with the threat of the unknown virus.

WHO vs COVID-19
Along with China, several initial lapses came from the WHO. According to its own report, WHO should have declared a global emergency much earlier than it did. Millions of people around the world have now died of Covid. The Independent Panel for Pandemic Preparedness and Response's report said that the month following the WHO's declaration was "lost" as countries failed to take appropriate measures to halt the spread of the virus. The panel said WHO was hindered by its regulations that travel restrictions should be a last resort. As a result, Europe and the US wasted the entire month of February and took action only when their hospitals began to fill up.

The report said that when countries should have been preparing their healthcare systems for an influx of Covid patients, much of the world descended into a "winner takes all" scramble for protective equipment and medicines.

The WHO also erred in delaying the declaration that Covid was air-borne, meaning the world lost countless months where everybody was walking around maskless.

The Big Players
In May 2021, the US administration announced that it would support the waiving intellectual property protections for COVID-19 vaccines under the World Trade Organization's Agreement on Trade-Related Intellectual Property Rights (TRIPS), a deal that took the WTO nearly two years to broker. Predictably, the move drew fiery condemnation from drug companies. Many disinterested observers criticised the support for a TRIPS waiver as empty symbolism, arguing that vaccine patents are not the major obstacle hindering the currently flagging drive to make vaccines available worldwide.

Other immediate constraints were the massive drive of technology transfer, capacity expansion, and supply line coordination to bring vaccine supply in line with global demand.

On the other side, countries that sought the waiver shied away from it too, because the deal fell well short of what the ask was.

Is the COVID-19 pandemic over?
The WHO Chief, Dr Tedros Adhanom, said, "the virus is running freely, and countries are not effectively managing the disease burden based on their capacity, in terms of hospitalisation for acute cases. In addition, the expanding number of people with post-COVID conditions is often referred to as long-COVID."  He highlighted a disconnect in COVID-19 risk perception between scientific communities, political leaders and the general public, describing it as "a dual challenge of communicating risk and building community trust in health tools and public health social measures like masking, distancing and ventilation".

Despite this, India and other powerful nations have already started treating COVID as a thing of the past. The efforts to employ masking, improved ventilation and testing and treatment protocols have halted.

Monkey Pox - Is it another global threat?
The first case of monkeypox in this current outbreak, linked to travel in Nigeria, was recorded in the UK on May 7. Infections have since been found across Europe, Australia, the United States, the Middle East and Asia. The monkeypox virus is already endemic in Western and Central African countries. That said, recent cases in countries where monkeypox is a rare occurrence have not been traced back to Africa.

Scientists are predictably confused by this unusual spread of monkeypox and concerned about the new cases. Although monkeypox is not known to be a sexually transmitted virus, the WHO virologist Oyewale Tomori said viruses that had not initially been known to be sexually transmitted (such as Ebola) were later proven to be sexually transmittable. And this could end up being true of the monkeypox virus. In the 1980s, Australia portrayed the Grim Reaper as a stereotypically gay man in an attempt to personify the fear around the then HIV epidemic. Now, after 40 years, one might think that we as a society have grown enough not to spread stigma in public health messaging.

Unfortunately, not so much. The monkeypox outbreak happened to witness a similar misrepresentation from all directions.  With the virus endemic to African countries, Western media gave no second thought before painting their reports with shades of racism and bias. Further, the earlier cases showed a disproportionate concentration amongst gay or bisexual men, which became a central talking point about the spread, terming it a "gay disease."  The World Health Organisation wrote on their website that "anyone who has close contact with someone infectious is at risk" of contracting the virus, with children, pregnant women and immunocompromised people at particular risk.

Just one month after the WHO determined the outbreak's severity at an emergency level, on July 23, the agency declared monkeypox a global public health emergency, even if it took three meetings and an overriding vote from the WHO chief.

According to Reuters, African scientists criticised the WHO in June as its committee considered whether to declare monkeypox a public health emergency for the first time. Because as of June 1, more than 1,400 monkeypox cases were reported by the WHO in Africa alone, where at least 72 people had died. And no one has kept track of the total number of cases Africa has reported since the first infection was detected in 1970.

As long as monkeypox was limited to Africa, the world couldn't care less. There was no concerted effort to develop drugs and vaccines. There was no urgency on research or prevention.

Now though, within two months, the disease has quickly spread to more than 16,000 cases in at least 75 countries. The US CDC reported that monkeypox cases are occurring outside of Africa in countries that don't usually have monkeypox, including the United States, which also declared it a public health emergency.

And as with Covid, now that monkeypox is spreading in Europe and North America, countries there have started ordering and hoarding vaccines again. Not a single African nation has received even a single vaccine or antiviral drug. Brazil, which has the largest number of cases in South America, has received 50 - yes FIFTY - doses of an antiviral which is not yet approved by Brazilian regulators.

If Covid had originated in Africa, we would most likely have cut off trade with the entire continent very early and vaccines would not have been developed at the speed with which we actually did make them.

Why the change?
Based on the evidence, Monkeypox began mutating a few years ago to become sexually transmissible. Till then, it was not very contagious, and person-to-person transmission was rare and easily checked. A Nigerian physician, Dr Dimie Ogoina, who observed this change, has been trying to warn the global community about this since 2017. But, as usual, the world didn't listen. He says the current global outbreak can be traced back to an 11-year-old boy he treated in 2017.

About the virus
According to a report by the US Department of Homeland Security, the virus can remain stable for days (and weeks) in water and refrigerated food, which is far longer than what is indicated in WHO's clinical response guidelines. Monkeypox can be infectious before people have a rash and weeks after they heal. It can survive in scabs for years. It can also survive in hot, cold and dry environments and on food. It is not an STD, but it can be transmitted during sex because of skin-to-skin contact. It has the potential to be transmitted in respiratory droplets, but that is a very remote possibility. The virus doesn't stay suspended in the air for long. However, respiratory protection protocols have to be maintained.

Symptoms
Common symptoms include

  • rash
  • fever
  • chills
  • body aches
  • fatigue
  • headache
  • respiratory symptoms, such as a sore throat, cough, and nasal congestion
  • swollen lymph nodes

The rash may appear on the

  • face
  • genitals
  • mouth
  • hands
  • feet
  • chest
  • anus

The rash often begins with flat lesions that become raised (similar to blisters or pimples) and then gets filled with fluid and pus. While the rash is present, the skin may become highly sensitive and painful. The blisters usually scab or become crusty before falling off, potentially leaving scars on the skin.

Have we learnt nothing?
While we can't predict what the future holds for us, the only thing we as a collective can do is make sure not to give any place to stigma in medicine. You don't even have to be an ethicist to point out the misinformation propagated with the monkeypox spread and the need for it to be debunked, not reinforced as is.  Media and public health officials must diligently focus on how they talk about an evolving infection. Communication demands care to avoid stigmatising communities, which we are essentially trying to reach out to and remember that the viruses don't recognise global borders or social networks.  Here, the work should focus on building testing capacities, analysing patterns in modes of transmission, looking out for mutations, expanding the healthcare apparatus for effective public health messaging, and vaccination developments. But most importantly, creating an environment where people feel safe to come forward, report symptoms, and get tested.

Those who don't learn from history are doomed to repeat it. Again. And again.

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