Monkeypox: “No reason to panic”

The monkeypox virus continues to spread around the world. The World Health Organization announced this week that there are now more than 2,000 cases of the disease in at least 42 countries worldwide. In an interview with RFI, Celso Cunha, professor at the Institute of Hygiene and Tropical Medicine at the Universidade Nova de Lisboa, explained to us what is known so far about the disease.

RFI: The World Health Organization (WHO) said this week that the number of cases exceeded 2,000 in 42 countries outside the African continent, where the disease is endemic. I start by asking you why the virus is only now spreading around the world, since it has been circulating in Africa for several years.

Celso Cunha: I do not think that the WHO has a concrete and rigorous answer on this question because we do not yet know the context in which the first case arose and, therefore, it is difficult for us to speculate why the virus left Africa and whether it is spread to other areas where it is not endemic. Right now, what we’re seeing is that there are outbreaks, in different countries, that probably have different origins.

In Portugal, we have a concentration in the community of men who have sex with other men and this also happens in most of the cases that have been written, outside Africa, and this can lead to believe that the initial case has arisen within community and is being spread due to some risk behaviors that are being carried out, at the moment, therefore, that is, people who, at this moment, are infected and who, being themselves also not very alert to the initial symptoms, are helping to spread the virus. I think it is a transitory issue at this point and that we will soon return to a certain normality regarding this matter.

RFI: The WHO will discuss, later this month, whether or not to classify monkeypox as “a public health emergency of international dimension”. If this happens, what changes from then on?

CC: In terms of illness, nothing changes. What changes is in terms of measures that can be taken or that can be advised to be taken by governments and local authorities. At this point, I think it’s still early. There are about 2,000 cases worldwide. In Portugal, about 300 and in France there are also dozens of cases. At this time, being a disease that has a relatively benign clinical course, compared to normal smallpox, in which mortality rates are relatively low, there is, at this point in time, no danger of it becoming a major pandemic, as Covid was. -19. This danger still doesn’t exist, at this moment, because, in relation to Covid-19, when the virus started, we didn’t have vaccines or any effective treatment. Here, from the start, we already have vaccines, we already have some drugs that are effective to treat this disease. It’s not an emergency, we call it that, as there was in Covid-19. There’s no reason to panic at this point.

RFI: Is there a risk of this virus mutating or is this factor still unclear?

CC: This virus is a virus in which its genetic material is in a different molecule than, for example, SARS-COV2, which causes Covid-19. Covid-19, as we know, is a molecule called RNA. In this case, this virus is in a molecule that is DNA, similar to what we have inside our cells.

When this molecule, DNA, multiplies, mutations also occur, but these mutations are too small to correct. The mutation rate of DNA viruses is much lower than that of RNA viruses, such as SARS-COV2, HIV or even the flu virus, for example. In this case, although, for example, the genetic material of this virus, the molecule where the genes are located, is 6 times larger than that of SARS-Cov2, which causes Covid-19, it is not expected that there are very relevant mutations, which arise during this outbreak in the near future. It is not expected that there will be a big difference in the genetic material and that variants or strains may arise, that are more infectious or that cause a more severe disease, with a higher mortality rate. This is not expected with this virus.

RFI: The way the virus spreads suggests that the disease happens through very close contact. What are the most common forms of transmission?

CC: Transmission occurs through close contact between a person who is infected and a person who is not infected. This close contact has to be a prolonged contact, in principle, and transmission is made through respiratory droplets or through contact with contaminated fluids, that is, containing viral particles from infected people.

For example, if we touch one of those small pimples, which have viruses inside, so that liquid that appears in people who are sick, then they can transmit the disease. This disease is transmitted by the transmission of bodily fluids from infected people, namely, through respiratory droplets. But another difference from Covid-19 is that here, for a person to be infected by someone infected, a longer, much longer, close contact is necessary.

We are not aware of the risk of going, for example, on the bus, and having an infected person next to us and catching the disease. It is very unlikely that this will happen. It’s not an impossibility, but it’s a pretty high improbability. Contact takes place, above all, between people who live together, who occupy the same spaces for a long time.

RFI: What are the main symptoms? How can the disease be identified?

CC: In the first three days, the symptoms are relatively non-specific, that is, they can be confused with another viral illness, even with a flu because the symptoms are fever, muscle aches or headaches and sometimes a small rash that can appear as a a little later now, but the initial signs are relatively nonspecific.

What differentiates this disease, for example, from normal smallpox, which we were used to and which has been eradicated, is that the lymph nodes here tend to appear quite swollen. This is what differentiates, above all, this monkey pox from classical smallpox. Apart from that, I would say that the first symptoms are non-specific and then small rashes begin to appear, which evolve and begin as small, relatively flat spots, and then small bubbles appear that become a transparent liquid and , at a later stage, with a more dark yellow liquid. Then they burst and become a crust. Then when they fall, people are considered healed. This entire process, from infection to healing, can take approximately 2 to 4 weeks.

RFI: So far, only mild forms of the disease have been recorded. Is there a risk of death associated with this virus?

CC: There is always a risk of death, but it is very low. The risk of death in monkeypox is substantially lower than in classic smallpox. In classic smallpox, we could have mortality rates, well above 30% and here we are talking about 10 times less, approximately. These fatal cases unfortunately only occur, mainly, in countries with weak health systems because in countries where health systems are richer, more robust and where there are better conditions for treatment, the death rate of monkeypox has approached that of if enough from 0 almost.

RFI: Cases recorded on several continents affect more men than women. Why do men have a less resistant immune system to this virus?

CC: I don’t agree with that, that is, I agree that they affect more men, they are mainly men, but that is due, according to what we know, nowadays, because the virus has started to spread within a community of men who had sex with other men and is not exactly about differences between the immune system of men and women, but with behaviors and their transmission, through behaviors.

RFI: The Director-General of the WHO, Tedros Adhanom Ghebreyesus, regretted a few days ago the fact that due attention was only given to the virus when it began to affect rich and developed countries, since the virus has been circulating in Africa for several years old. What is his point of view on the matter?

CC: The virus has been circulating in Africa for several years, it is true. It was first identified in 1970, the first human case. We know that in Central Africa it is endemic, and that there are periodic outbreaks, but these have been very limited.

Despite the fact that sometimes a few dozen or even hundreds of cases have appeared, the disease has been concentrating in that region. This also has to do with the fact that in these countries there are also reservoirs of animals because this is a zoonotic virus, that is, the virus can be in the reservoir of animals and these animals can transmit it to humans as well.

These reservoirs do not exist in western countries in the wild and, therefore, the risk of contamination, through contact with animals, did not exist, at least in the West and in Africa it did exist, hence there is an endemicity in these regions.

What happens here is that we went from a virus that was limited to a region and with a mortality rate that was around 10/15%, but this is more related to the weakness of health systems, not because the severity of the disease is greater. of what is now. Now, what is happening differently is that the virus is spreading all over the world and, as a result, more attention is being paid.

RFI: Finally, speaking now in the specific case of Paris and other European cities, the number of cases has been increasing substantially. Is it worrying, at a time when Covid-19 contagions are also increasing?

CC: It is worrying because it could be a burden on health systems, although most cases of monkeypox that we have recorded do not require any hospitalization and can be treated as an outpatient, by isolating people at home and restricting contacts.

Despite everything, it is not foreseeable that this disease will have a significant weight in health systems. It may have an economic burden due to abstaining from work because people will miss work and stay at home for 2 to 4 weeks. If the virus spreads a lot, there may be some economic weight, but for health systems I don’t think there will be as serious a pressure as happened with Covid-19 because it will not force hospitalizations in such large numbers. For health systems, in principle, it won’t be a big problem.