Are we now at risk of monkeypox too?

I wonder how many of you will remember living through a time when smallpox was a dreaded disease?

  • Regardless of when you were born, you might know that just over 42 years ago, the World Health Organization (WHO) had declared smallpox eradicated.
    • A testament to science, surveillance, and a concerted global effort to eradicate a disease that had killed at least 300 million people in the 20th century.

As to why we continue talking about smallpox when we have already eradicated this horrendous disease, there are a few reasons:

  • the main being, there were two frozen vials of this virus that were stored for future research – one at the CDC in Atlanta, GA, and the other one in Moscow, Russia (in the former Soviet Union).

And as to why would we want to hang onto a virus we had eradicated, the answer is

  1. fears of bioterrorism, and
  2. research: to find better vaccines, better tests, and antiviral drugs to shorten the duration of the illness or reduce likelihood of death in the event of a bioterrorist attack with the smallpox virus.

Even after smallpox was eradicated, the U.S. continued manufacturing vaccines and storing it in the nation’s strategic national stockpile (SNS) as part of the national medical response infrastructure.

  • This means if we ever saw a smallpox emergency in our lifetime, there’s enough vaccine for all of us in the U.S. to have the option of getting vaccinated.

And getting vaccinated means three things:

  1. you directly factor into building herd immunity – at any given point in time, there is always a sub-population of individuals who cannot get vaccinated, either because they are very young, very old, or immunocompromised for any reason – these individuals can be protected against a contagious illness, if the majority of immunocompetent individuals are immune against that illness;
  2. you, yourself, have a reduced chance of getting the disease or of getting infected
    • (exact percentages depend on the disease and the vaccine);
  3. you reduce your chance of getting infected by 75 – 100% if you get vaccinated as soon as possible, and preferably within 72 hours of exposure to someone with smallpox
    • (a huge advantage in the midst of an ongoing outbreak, epidemic, or pandemic).

Were there any benefits to the research that was done on the frozen vials?   

1. September 24, 2019:

  • FDA announced approval of a joint smallpox and monkeypox vaccine (Jynneos) for use in adults 18 years and older and at high risk of smallpox or monkeypox,
    • which would either be individuals working with these viruses or caring for people who initially get sick with these viruses.
    • We live in an age where increasingly, more and more people are able to manage chronic conditions such as auto-immune diseases, certain cancers, or even infections with viruses such as HIV.
    • However, these individuals have a precariously balanced immune system that may not be able to handle the burden of a vaccination.
      • The higher the herd immunity, the better the protection we can provide for even unvaccinated individuals. 

Jynneos is part of the SNS. Although both monkeypox and smallpox viruses belong to the same family and genus (which means there are similarities), monkeypox is typically much milder and less contagious.

2. June 4, 2021:

  • FDA approved Tembexa (brincidofovir) as an antiviral treatment for smallpox.
    • If brincidofovir sounds familiar to you, it’s because it was used as an experimental drug during the 2014 Ebola virus epidemic in West Africa.
    • However, it’s effectiveness against Ebola virus disease was not conclusively proven because the epidemic itself had neared its end, and there weren’t enough patients who needed treatment with this drug.
    • Moreover, in 2019, the vaccine Ervebo was approved for use by the European Medicines Agency, followed by the U.S. FDA approval in the same year.
      • The vaccine was deemed to be 100% effective when no new Ebola cases were diagnosed 10 days or more after Ervebo was deployed in Phase III testing in Guinea.

3. May 19, 2022:

  • FDA approved TPOXX (tecovirimat) as an intravenous antiviral treatment for smallpox (oral formulation was approved in 2018).
    • TPOXX may be useful against monkeypox as well.

Monkeypox is a zoonotic disease, and since its first identification in the Democratic Republic of the Congo in 1970, monkeypox in humans has also been identified in Central and West Africa.

  • The first cases of monkeypox outside of Africa was seen in the U.S. in 2003, when 47 cases (both confirmed and probable) were reported from six states.
    • In this instance, infection was transmitted from pet prairie dogs who had been kept near small mammals imported from Ghana.
  • To date, the following countries have reported monkeypox outside of the endemic zone in Africa:
    • Australia, Belgium, Canada, France, Germany, Italy, Portugal, Spain, Sweden, United Kingdom, and the U.S.
  • Studies are ongoing to determine the sources of infection and routes of transmission.  

If we exclude the population from the continent of Africa, where monkeypox is endemic in a few countries, there are over 6.5 billion people on our planet.

  • Out of these 6.5 billion, we have seen 92 confirmed and 28 probable cases of monkey, with most cases showing mild symptoms.
  • These numbers will likely rise in the next few weeks to months, before coming back down.

Is monkeypox the next big scare? Although my opinion is No, I am a firm believer in my 2020 phrase (subsequently picked up by Howard Stern):

  • Prepare for the worst and hope for the best.

However, if cases were to increase over the next few weeks to months, we have to remember ways the virus can get transmitted:

  1. prolonged face-to-face contact with an infected individual
    • What’s helpful to know is that a person is contagious once monkeypox lesions appear on the tongue and in the mouth, and stays contagious until all the pox lesions have dried and fallen off (could be 2 to 4 weeks)
    • we are all familiar with facemasks, which should lower some, if not all, of the risk of inhaling this virus
  2. all mammals are considered potential carriers (such as non-human primates, rodents, and squirrels) and especially if they have been imported from countries in Africa
  3. monkeypox virus from these animals can be transmitted to humans through bites and scratches
    • If you do get bitten/scratched, wash the area well with soap and water, and call your healthcare provider immediately
      • Time from exposure to symptoms has a range of 5 to 21 days (usually 7 – 14 days)
  4. monkeypox virus can also be transmitted via contaminated surfaces – which brings us back to the refrain heard aplenty in the last two years – disinfect surfaces that show high traffic and experience high touch, followed by good hand hygiene and one last reminder for all of you to
  5. not touch your face (includes your eyes, nose, and mouth) until you have cleaned your hands well –
    • monkeypox virus can enter the body through broken skin, inhalation, or contact with contaminated surface, followed by touching eyes, nose, or mouth.
    • In addition, this virus can be introduced into the human body via animal bites or scratches, and during preparation of bushmeat for food (not a problem in the U.S.).

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