Doubling of Monkeypox Cases Outside of Endemic Countries Raises New Alarm Bells at WHO  
Monkeypox lesions

In just a matter of three days, the number of monkeypox cases reported to WHO outside of central and west Africa has doubled – with reports Wednesday of some 550 cases in more than 30 countries outside of the countries where the disease is endemic, WHO Director General, Dr Tedros Adhanom Ghebreyesus told a press briefing on Wednesday. 

That, as compared to reports of 257 cases outside of Africa, as of Sunday, 30 May. 

The ‘sudden appearance’ of monkeypox in so many non-endemic countries is prompting new concerns that it could spread to more “vulnerable populations” in countries where it has suddenly emerged, including pregnant women and children, added WHO’s Maria Van Kerkhove, Health Emergencies technical lead. 

WHO Briefing, 1 June 2022

“Investigations are ongoing, but the sudden appearance of monkeypox in many countries at the same time suggests there may have been undetected transmission for some time,” said WHO Director-General Tedros Adhanom Ghebreyesus during a press briefing Wednesday.  

“WHO’s priority now is to first provide accurate information to those groups most at risk, and second to prevent further spread among at-risk groups, to advance our understanding of monkeypox.” 

WHO is organizing two R&D meetings of experts on Thursday and Friday of this week, to further discuss monkeypox and understand the current surge in cases. 

Ecological pressures prompting rapid disease emergence 

Gambian pouched rat – rodents are a common animal reservoir for monkeypox

Monkeypox has long circulated in 12 countries of central and western Africa, with a rising incidence over time. Disease prevalence is highest in the Democratic Republic of Congo, which has reported several thousand cases a year, and where the monkeypox clade, or variant, in circulation is more deadly. 

The disease has been reported to have mortality rates of up to 10% in the DRC. Noone has yet reported to have died from the outbreak that has occurred abroad recently  – which has been traced to the milder West African clade.  

Cases of monkeypox in endemic countries between 15 December 2021 to 1 May 2022

Increased circulation of the disease in Africa in recent years has been linked to deforestation – which put wild animals in closer contact with humans, as well as increased agro-food storage, and consequent infestation of food containers by infected rats. 

Additionally, human travelers as well as the trade in exotic animals has been linked to the appearance of some cases overseas in the past.  But the appearance of so many cases abroad is a new phenomenon, where community transmission is now occurring, including among networks of men who have sex with men, WHO said. 

The changes in ecosystems, trade and travel have been exacerbated by a decline in human immunity to the disease, due to the discontinuation of smallpox vaccination in the 1970s, which was protective against monkeypox as well.   

Ecological pressures need to be addressed 

Michael Ryan, WHO Executive Director, Health Emergencies

Beyond the immediate health system measures needed to track and trace the spiral of increasing human cases occurring daily,  more attention needs to be given to the underlying drivers, and ‘ecological pressure’ that has caused disease outbreaks to expand in size and scope,WHO’s Executive Director of Health Emergencies Mike Ryan told the briefing. 

“Animals are changing their behavior, humans are changing their behavior. What we’re dealing with is a lot of ecological fragility,” said Ryan. 

“We’re dealing with the animal-human interface being quite unstable, and the number of times that these diseases cross into humans is increasing, [as well as] that ability to amplify the disease and move it within our communities.” 

But he did not elaborate on how WHO might address such drivers – beyond saying that they could be a topic of discussion at this week’s R&D meeting convened by the global health agency. 

Inequity of investment in monkeypox in Europe versus Africa already apparent

The current outbreak also highlights once more, the boomerang effect of inequitable investments in health systems and disease control in Africa, where monkeypox has been circulating for decades in countries that lack the tools to track and tackle such infections, Ryan said.  

“There are thousands and thousands of cases of monkeypox every year in Africa, and there are deaths every year….. And now, we have a concern about this disease spreading in Europe, but I certainly haven’t heard that same level of concern over the last five or ten years.” 

“Are we in a position to collectively respond? Are we in a position to share resources in order to stop transmission of these diseases within human communities?,” Ryan asked. 

Already, countries such as the United Kingdom have vaccinated more than 1,000 people at risk of contracting the virus, and the European Union is in discussions to buy smallpox vaccines from Bavarian Nordic, the only maker of the vaccine licensed in Europe, according to media reports. 

Smallpox vaccines are estimated to be about 85% effective against monkeypox, which is in the same orthopox family of viruses – but there have been no such vaccination campaigns in monkeypox hotspots such as DRC for decades. 

“It’s a bit uncomfortable that we have a different attitude to the kinds of resources we deploy depending on where cases are,” said Dr Jimmy Whittworth, of the London School of Hygiene and Tropical Medicine, speaking to the Associated Press

“It exposes a moral failing when those interventions aren’t available for the millions of people in Africa who need them.”

Stigma against disease may prevent care, increase transmission 

Tedros Adhanom Ghebreyesus, WHO Director-General

Meanwhile, WHO’s Tedros urged people to fight against stigma associated with the transmission of monkeypox in networks of men who have sex with men (MSM) – and underlined that the disease can be transmitted in a range of ways.

Those include through contact with: infected saliva and mouth lesions, bedding as well as transmission of pregnant women to their unborn children through the placenta, according to a WHO seminar on the issue Tuesday.   

Tedros said that MSM advocacy groups “are working hard to inform [members of their community] about the risks of monkeypox and prevent transmission. But all of us must work hard to fight stigma, which is not just wrong. It could also prevent infected individuals from seeking care, making it harder to stop transmission.”   

“Anyone can be infected with monkeypox if they have close physical contact with someone else who was infected,” he said. 

The virus was first identified in 1958 in a colony of captive African research monkeys. The first human case was identified in the DRC in 1970, during the period of smallpox elimination campaigns.  

Even before the current outbreak, there have been limited waves of cases reported in non-endemic countries through channels such as the export of exotic animals, such as infected mice, squirrels, and rats, from Ghana to the United States in 2003, as well as by infected travelers. 

Misinformation campaign to target monkeypox 

Maria van Kerkhove, WHO Technical Lead on COVID-19

WHO is also mounting a campaign on disinformation about the disease, said Gabby Stern, WHO Communications Director. 

WHO is currently working with both social media companies and tech companies, urging them to filter out the misinformation and push out accurate information through their channels and platforms, said 

She said that misinformation and disinformation was a ‘major priority’ for both WHO and the United Nations. 

“Misinformation kills, just as these viruses kill, misinformation kills as well,” added Dr Maria van Kerkhove, WHO technical Lead on COVID-19.  

“This remains a constant challenge, not only COVID-19 across the entire spectrum of interventions and the response that we have. It’s the attacks on science that undermine the effectiveness of our countermeasures.” 

Image Credits: Tessa Davis/Twitter , Laëtitia Dudous, WHO, Disease Outbreak News, 21 May 2022 .

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