As the monkeypox cases in India now number four, doctors and health departments across the country have been put on alert. On 24 July, monkeypox was detected in a 31-year-old inhabitant of Delhi with no recent foreign travel history. This is the fourth confirmed case of the viral disease in India, the first three were reported from Kerala.
Cases of monkeypox are but on a rise in the West. The World Health Organisation (WHO) has declared the outbreak as a public health emergency of international concern (PHEIC).
What is monkeypox?
The WHO defines monkeypox as an illness caused by the monkeypox virus. "It is a viral zoonotic infection, meaning that it can spread from animals to humans. It can also spread from person to person," the UN agency says.
How does monkeypox spread biologically?
Monkeypox spreads from person to person through close contact with someone who has a monkeypox rash, including through face-to-face, skin-to-skin, mouth-to-mouth or mouth-to-skin contact, including sexual contact. Scientists are still learning how long people with monkeypox remain infectious, but generally, they are considered infectious until all of their lesions have crusted over, the scabs have fallen off and a new layer of skin has formed underneath — as it happened in the case of chickenpox.
Environments can become contaminated with the monkeypox virus, for example when an infectious person touches clothing, bedding, towels, objects, electronics and surfaces. Someone else who touches these items can then become infected. It is also possible to get infected from breathing in skin flakes or the virus from clothing, bedding or towels. This is known as fomite transmission.
Ulcers, lesions or sores in the mouth can be infectious, meaning the virus can spread through direct contact with the mouth, respiratory droplets and possibly through short-range aerosols. Possible mechanisms of transmission through the air for monkeypox are not yet well understood and studies are underway to learn more.
The virus can also spread from someone who is pregnant to the fetus, after birth through skin-to-skin contact, or from a parent with monkeypox to an infant or child during close contact.
Although some asymptomatic infections have been reported, it is not clear whether people without any symptoms can spread the disease or whether it can spread through other bodily fluids. DNA strands from the monkeypox virus have been found in semen, but it is not yet known whether infection can spread through semen, vaginal fluids, amniotic fluids, breastmilk or blood. Research is underway to find out more about whether people can spread monkeypox through the exchange of these fluids during and after symptomatic infection.
How does the disease spread from animals to human beings and vice versa?
Monkeypox can spread to people when they come into physical contact with an infected animal. Animal hosts include rodents and primates. The risk of catching monkeypox from animals can be reduced by avoiding unprotected contact with wild animals, especially those that are sick or dead (including their meat and blood). In endemic countries where animals carry monkeypox, any foods containing animal meat or parts should be cooked thoroughly before eating.
While instances of people with monkeypox infecting animals have not been documented, it is a potential risk. People who have confirmed or suspected monkeypox should avoid close contact with animals, including pets (such as cats, dogs, hamsters, gerbils etc.), livestock and wildlife. People with monkeypox should be particularly vigilant around animals that are known to be susceptible to the monkeypox virus, including rodents and non-human primates.
How big is the risk that I may get infected?
You are safe unless you live with or have close contact (including sexual contact) with someone who has monkeypox. You are at risk also if you have regular contact with animals who could be infected. If you are a health worker, you should follow infection prevention and control measures to protect yourself while caring for monkeypox patients.
Newborn infants, young children and people with underlying immune deficiencies may be at risk of more serious symptoms, and in rare cases, death from monkeypox.
People who were vaccinated against smallpox may have some protection against monkeypox. However, younger people are unlikely to have been vaccinated against smallpox because smallpox vaccination stopped in most settings worldwide after it was eradicated in 1980. People who have been vaccinated against smallpox should continue to take precautions to protect themselves and others
How many monkeypox cases have been detected worldwide?
About 14,533 confirmed cases have been reported from around 72 countries. The outbreak in Africa became a global health concern this month. "I have decided that the global monkeypox outbreak represents a public health emergency of international concern," WHO Director-General Tedros Adhanom Ghebreyesus said.
Is the word from the WHO director-general trustworthy?
Ghebreyesus is no longer considered credible after his failure to declare Covid as a global pandemic in time. When the world was reeling under the onslaught of the coronavirus in January 2020, he was seen enjoying the hospitality of President of China Xi Jinping, the regime led by whom at least six intelligence agencies suspect unleashed a biological weapon on the world or found incompetent to prevent a leak of the virus from the Wuhan Institute of Virology.
Even if the WHO says monkeypox is not yet an epidemic or pandemic, it has said it is PHEIC. What does this term mean?
A PHEIC describes an extraordinary event that is determined to constitute a public health risk to other countries through the international spread of disease and to potentially require a coordinated international response. Now, that this disease calls for a collective global response, people are comparing it with Covid and how it spread.
What are the symptoms of monkeypox?
Monkeypox can have one or more of several signs and symptoms. Some people show mild symptoms while others may develop more serious symptoms and need care in a health facility. Those at a higher risk for severe disease or complications are pregnant women, children and immunocompromised patients.
The most common symptoms of monkeypox are fever, headache, muscle aches, back pain, low energy and swollen lymph nodes, followed or accompanied by the development of a rash which can last for two to three weeks.
The rash can be found on the face, palms of the hands, soles of the feet, eyes, mouth, throat, groin, and genital and/or anal regions of the body. The number of lesions can range from one to several thousand. Lesions begin flat, then fill with liquid before they crust over, dry up and fall off, with a fresh layer of skin forming underneath.
Symptoms typically last two to three weeks and usually go away on their own or with supportive care, such as medication for pain or fever. People remain infectious until all of the lesions have crusted over, the scabs fallen off and a new layer of skin has formed underneath.
Complications from monkeypox include secondary skin infections, pneumonia, confusion, and eye problems.
Anyone who has symptoms that could be monkeypox or who has been in contact with someone who has monkeypox should call or visit a health care provider and seek their advice.
Will I die if I acquire the monkeypox disease?
Not likely in the case of normally healthy people. The symptoms of monkeypox go away on their own within a few weeks in most cases. However, in some people, an infection may lead to medical complications and even death. Newborn babies, children and people with underlying immune deficiencies may be at risk of more serious symptoms and death from monkeypox.
In the past, between 1% to 10% of people with monkeypox have died. Mortality rates in different settings may differ due to a number of factors, such as access to health care. These figures may be overestimations as surveillance for monkeypox has generally been limited in the past. In the newly affected countries where the current outbreak is taking place, there have been no deaths to date.
How do I protect myself?
Reduce your risk of catching monkeypox by limiting close contact with people who have suspected or confirmed monkeypox, or with animals who could be infected. Clean and disinfect regularly such environments that might have been contaminated with the virus from someone infectious. Keep yourself informed about monkeypox in your area and have open conversations with those you come into close contact (especially sexual contact) with about any symptoms you or they may have.
If you think you might have monkeypox, you can act to protect others by seeking medical advice and isolating yourself from others until have been evaluated and tested. If you have probable or confirmed monkeypox, you should isolate yourself from others until all of your lesions have crusted over, the scabs have fallen off and a new layer of skin has formed underneath. This will stop you from passing on the virus to others. Get advice from your health worker on whether you should isolate yourself at home or in a health facility. Until more is understood about transmission through sexual fluids, use condoms as a precaution whilst having sexual contact for 12 weeks after you have recovered.
If I have monkeypox, what should I do to protect other people from getting infected?
If you have monkeypox, your healthcare provider will advise if you should be cared for in a hospital or at home. This will depend on how serious your symptoms are, whether you have risk factors that put you at risk for more serious symptoms and whether you can minimize the risk of infecting anyone you live with.
If you are advised to isolate yourself at home, you should not go out. Protect others you live with as much as possible by:
- Isolating in a separate room
- Using a separate bathroom, or cleaning after each use
- Cleaning frequently touched surfaces with soap and water and a household disinfectant and avoiding sweeping/vacuuming (this might disturb virus particles and cause others to become infected)
- Using separate utensils, towels, bedding and electronics
- Doing your own laundry (lift bedding, clothes and towels carefully without shaking them, put materials in a plastic bag before carrying it to the washing machine and wash them with hot water > 60 degrees)
- Opening windows for good ventilation
- Encouraging everyone in the house to clean their hands regularly with soap and water or an alcohol-based hand sanitiser.
If you cannot avoid being in the same room as someone else or having close contact with another person while isolated at home, then do your best to limit their risk by:
- Avoiding touching each other
- Cleaning your hands often
- Covering your rash with clothing or bandages
- Opening windows throughout the home
- Ensuring you and anyone in the room with you wear well-fitting medical masks
- Maintaining at least 1 meter of distance.
If you cannot do your own laundry and someone else needs to do it for you, they should wear a well-fitting medical mask and disposable gloves and take the laundry precautions listed above.
Is there a vaccine to pre-empt monkeypox?
As the disease stems from the same family of smallpox virus, orthopoxvirus, vaccines used for smallpox are believed as of now to be effective against monkeypox as well. The US has registered over 2,800 cases and currently is using 2 smallpox vaccines. Another one called Jynneos was approved in 2019 for people 18 and above.
According to the WHO, “Vaccination against smallpox was demonstrated through several observational studies to be about 85% effective in preventing monkeypox. Thus, prior smallpox vaccination may result in milder illness.”
If I get infected somehow, how will I be treated?
You must follow the advice of your health care provider. If needed, medication for pain (analgesics) and fever (antipyretics) can be used to relieve some of your symptoms. Even then, stay hydrated, eat well and get enough sleep. If you have self-isolated, you should take care of your mental health by doing things you find relaxing and enjoyable, staying connected to loved ones using technology, exercising if they feel well enough and can do so while isolating and asking for support for your mental health if you need it.
You should avoid scratching your skin and take care of your rash by cleaning your hands before and after touching lesions and keeping the skin dry and uncovered (unless you are unavoidably in a room with someone else, in which case they should cover it with clothing or a bandage until they are able to isolate again). The rash can be kept clean with sterilised water or antiseptic. Saltwater rinses can be used for lesions in the mouth, and warm baths with baking soda and Epsom salts can help with lesions on the body. Lidocaine can be applied to oral and perianal lesions to relieve pain.
An antiviral that was developed to treat smallpox (tecovirimat) was approved in January 2022 by the European Medicines Agency for the treatment of monkeypox. Experience with these therapeutics in the context of an outbreak of monkeypox is limited. For this reason, their use is usually accompanied by a collection of information that will improve knowledge on how best to use them in future.
Will monkeypox spread like Covid?
Yes. A vaccine was recently approved for preventing monkeypox. Some countries are recommending vaccination for persons at risk. Many years of research have led to the development of newer and safer vaccines for an eradicated disease called smallpox, which may also be useful for monkeypox. One of these has been approved for the prevention of monkeypox. Only people who are at risk (for example someone who has been in close contact with someone who has monkeypox) should be considered for vaccination. Mass vaccination is not recommended at this time.
While the smallpox vaccine was shown to be protective against monkeypox in the past, current data on the effectiveness of newer smallpox/monkeypox vaccines in the prevention of monkeypox in clinical practice and in field settings are limited. Studying the use of vaccines for monkeypox wherever they are used will allow for a rapid generation of additional information on the effectiveness of these vaccines in different settings.
Doctors say that monkeypox will not be as transmissible as coronavirus and thus the chances of an outbreak were limited. Dr Nivedita Gupta, the head of virology at the Indian Council of Medical Research (ICMR), for example, says that monkeypox will not spread like wildfire, but vigil has been stepped up across India. "The virus will not spread like wildfire as we feared for coronavirus," said Gupta, explaining that “the virus requires large droplets to cause infections and hence is not much transmissible”.
The New York Times published a report on the virus stating that researchers who have sequenced the monkeypox virus from recent cases have noted several mutations, but it may take some time to understand the role of these changes. Still, many experts believe that monkeypox can be contained. It quoted Dr Van Kerkhove, the technical lead on Covid-19 at the WHO, "Transmission is really happening from close physical contact, skin-to-skin contact. So it’s quite different from Covid in that sense."
Researchers who have sequenced the monkeypox virus for decades have concluded that several mutations have taken place in the original virus but human knowledge about it is still limited. Experts believe that the disease can be contained as it is mostly spreading due to the incidence of close human contact, unlike Covid where variants of coronavirus spread like wildfire even because of aerosol particles in the air.
No coronavirus-like mutations or variants have been found in the monkeypox virus that can be deemed highly contagious or severely fatal. Therefore, people must take all due precautions to shield themselves against the virus even if it is not as deadly as coronavirus.