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EDITORIAL
Year : 2022 | Volume
: 8
| Issue : 3 | Page : 117-119
What's new in academic international medicine? Monkeypox: The next pandemic?
Gabrielle Fonteneaux
Department of Emergency Medicine, Suny Downstate Medical Center, Kings County Hospital Center, Brooklyn, New York, USA
Correspondence Address:
Dr. Gabrielle Fonteneaux
Department of Emergency Medicine, Suny Downstate Medical Center, Kings County Hospital Center, Brooklyn, New York
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijam.ijam_86_22
Monkeypox (MPX) is the latest disease that has caught the world's attention, almost displacing COVID from news headlines. Cases of the virus have skyrocketed over the past few months in countries such as the United States (US), Spain, and the United Kingdom (UK) – countries that have not historically reported cases of MPX, at least not with regularity. At present, it is overwhelmingly affecting men who have sex with men, especially those with multiple partners.
MPX is not new on the scene, however. It is endemic in several African countries including the Democratic Republic of the Congo (DRC), Central African Republic, and Benin, among others.[1] A member of the Orthopoxvirus genus, Poxviridae family, MPX is related to the more famous smallpox and causes a painful rash of varied morphology that develops after a nonspecific prodrome. MPX is a zoonotic disease that has several animals as a reservoir, and until the current outbreak, there was not a lot of evidence for interhuman transmission. In the early 1970s, the first known human case of MPX occurred in the DRC. Since then, cases have predominantly occurred in Central and West Africa as a result of interactions with sick animals. An outbreak involving 89 persons occurred in Katako-Kombe, DRC between 1996 and 1997.[2] In the fall of 2017, Nigeria had 122 confirmed cases (276 suspected), its largest outbreak yet.[3],[4] Before the 2017 epidemic in Nigeria, there had only been a few sporadic cases since the 1970s.[4] Cameroon also had an outbreak in 2018.[4] Until recently, global outbreaks of the virus have been almost nonexistent. The first known outbreak outside the African continent was in 2003 with 47 cases of MPX in the Midwest US.[5] All the people involved had fallen ill after coming into close contact with pet prairie dogs, who were likely infected by other small mammals imported from Ghana. In addition, infected travelers who had recently visited Nigeria were thought to have been the originators of very small-scale MPX outbreaks in the UK (2018 and 2019), Israel (2018), and Singapore (2019).[6] There may have been other outbreaks, but the virus was not being routinely surveilled.
The current outbreak is due to the West African clade of the virus. This clade has a case fatality rate (CFR) of less than 1% compared to the 7% CFR of COVID-19.[7],[8] MPX requires close physical contact for transmission between people, unlike COVID-19, which is transmitted through airborne particles and droplets. Complications of infection include pneumonia, encephalitis, severe dehydration caused by vomiting and diarrhea, and retropharyngeal abscess as a complication of pharyngitis, amongst other issues.[9] It can have the long-lasting effect of scarring the skin, including the cornea, potentially causing blindness.[10] These complications are treated and managed with relative ease within the healthcare systems of high-income nations, but in areas of the world where intensive treatment or even routine outpatient or emergency care is less available, such complications could lead to significant morbidity and mortality for people of all ages. The socioeconomic impact has the potential to be great with loss of wages, cost of care, and long-term disability. In addition to our global health organizations working toward strengthening education and healthcare systems in low-income countries, funding should be dedicated to identifying and rectifying the barriers to accessible vaccination such as a lack of vaccine technology or lack of infrastructure.
In addition, some countries may be presented with some interesting public health challenges in managing both MPX and HIV. The severity of illness caused by MPX in immunocompromised hosts, like persons living with HIV, has not been fully elucidated. However, there is some evidence that patients with HIV have more morbidity versus those that are HIV negative.[11] The HIV burden is distributed more heavily in African and Asian countries.[11],[12]
There is no cure or vaccine specific to MPX. However, smallpox vaccines are sometimes offered to people who are in close contact with infected patients. Based on a small study from the late 1980s, smallpox vaccination is estimated to provide about 85% protection against MPX.[13] Currently, there are three vaccine options. The first, LC16 KMB, is approved for use in Japan, but they have been unable to ramp up production, so it has not been distributed outside their borders despite increasing global demand.[14] The second, ACAM2000, has been made available in the US under the Food and Drug Administration's (FDA) Expanded Access Investigational New Drug mechanism (sometimes called “compassionate use”).[15],[16] Finally, Imvanex (also known as Imvamune and JYNNEOS), is approved by the US FDA for emergency use and is produced by Bavarian Nordic in Denmark.[15],[16] Imvanex costs about $29 USD per dose; comparably, ACAM2000 is about $5 USD per dose.[17] More transparency regarding vaccine contracts is needed as sometimes poorer countries end up paying more than wealthier countries for the same vaccine.[18]
Data on how many doses of the vaccine each country has is limited. The US seems to be procuring the largest quantity of Imvanex currently; the US also has the highest case count worldwide, around 18,400 as of the time of this editorial.[19] The US is also testing around 1 million expired vaccine doses in their stockpile to see if they can still be utilized.[20] Brazil reportedly has been able to procure some 20,000 doses that should arrive sometime in September.[20] Low- and middle-income countries that are also dealing with outbreaks reportedly have not been able to procure any of the vaccines. Many, if not most, of the countries on the African continent have not procured any doses.[20] Cases remain low there in general, which is reassuring, but official counts may be inaccurate; and time will only tell if the number of cases will increase. Unfortunately, this lag in vaccine procurement by African nations has haunting similarities to what was seen during the COVID-19 pandemic. Rectifying this inequality should be a priority for international public health organizations.
Currently, MPX cases remain low in African and Asian nations; however, the global availability of the MPX vaccine is becoming increasingly important, especially if the prevalence of MPX continues to rise. Nations without wealth may once again be left behind as they were during the COVID-19 pandemic. COVID vaccinations continue to lag behind in low-income countries, especially on the African continent. Only about 21% of people in low-income countries have received at least one dose of the COVID vaccine.[21] High-income countries currently have a higher caseload of MPX and are able to advocate for their people by readily acquiring the vaccine, but there is not enough of it to go around. During the COVID-19 pandemic, there were efforts made to reduce the global inequity of vaccine access. The COVID-19 Vaccines Global Access (COVAX) platform was one such effort and was found to be helpful.[22] Inequity is once again rearing its head, and it seems that we may need to encourage the development of similar initiatives.
High-income nations are scrambling to vaccinate their populations, and hoarding has begun. Hopefully this time around, they are committed to disallowing vaccines to expire in the freezer. Low-income nations are yet again falling behind in the race to acquire a sufficient quantity of vaccines for their people. Vaccine access is a human rights issue. The world's humanitarian and public health agencies such as UNICEF, the single largest vaccine buyer in the world, need to be poised to intervene on this impending crisis. The human rights responsibilities of pharmaceutical companies are an ongoing debate, but these companies need to be held accountable to the public as they are one of the most important tools for advancing equitable vaccine access worldwide. MPX may not be as destructive as COVID-19, but we should not wait until it is too late to act. The world is exhausted, surely, as we have moved from one pandemic to possibly the next; however, before the impact of MPX becomes too great, let us remind ourselves of the COVID-times mantra, “no one is safe until everyone is safe.”
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The authors declare that this editorial does not require an Institutional Review Board/Ethics assessment.
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