Doctor explains | How worried should we be about mpox, a global health emergency?

In the world of illnesses, monkeypox or mpox is a cousin of smallpox. Mpox is, however, new compared to its more infamous sibling. Nobody knew about it before the late 1950s. But it has been a public health concern in parts of Africa for decades. The first human case was reported from Congo in 1970, and the country has had outbreaks ever since.  

The World Health Organization (WHO) recently declared mpox a global health emergency for the second time in two years. The last time it sounded that alert was in July 2022, when a form of the disease was reported from several countries.The WHO ended the emergency alert 10 months later as the outbreak was brought under control through an extensive awareness campaign among the affected populations.

The current outbreak has come on the back of a new and more virulent strain of the virus. We spoke to Dr Raj Kamal Choudhary, who has had over a decade-long experience with the World Health Organization (WHO) working in India, and currently is Professor of the Medicine Department at theJawaharlal Nehru Medical College in Bihar’s Bhagalpur, to understand the gravity of the mpox situation and what people and government can do to contain its spread.

It is the second time that WHO has declared mpox a global health emergency. It’s largely limited to Africa. How worried should people in India and other countries be?

We should be careful as just after Covid-19, India had mpox infection in 2022 but we were able to clean it with Amphotericin injection easily available in india. Some patients who did not take it seriously lost their lives or parts of the body before surgery.

Since January 2023, the DRC [Congo] has reported the largest number of yearly suspected clade I mpox cases on record. While clade I monkeypox virus (MPXV) is endemic, or naturally occurring, in the DRC, the current outbreak is more widespread than any previous DRC outbreaks and has resulted in clade I mpox transmission to some neighbouring countries.  

The Republic of the Congo declared a clade I mpox outbreak in April 2024, and there have been confirmed cases in the Central African Republic. In late July 2024, Burundi, Rwanda, and Uganda reported confirmed cases of mpox. Mpox is not known to be endemic in these countries.  

But since mpox has been reported earlier from India and the current outbreak has reached Pakistan, which has a poorer health infrastructure and recording mechanism than India’s, it poses a significant health risk to people in the country.  

How does Mpox transmit and how can we prevent its spread?

Despite being a serious illness, the best part of mpox compared to Covid-19 infection is that the Covid-19 is a respiratory infection and spreads through breathing, coughing and sneezing, while mpox has limited way of infecting such as contact with infectious skin or lesions on the mouth or genital, sexual contacts including kissing, direct contact with infected animals, contaminated materials including clothing, bedding and towels.

To stop the transmission we should consider banning or at least screening arrivals from affected African countries to India, especially if it starts rapidly increasing in Asian regions and even otherwise though it is largely limited to African region in the current outbreak.

Another alternative can be a plan to vaccinate the target population for mpox vaccination and those planning to travel to affected countries, with two doses of JYNNEOS vaccine. Eligible patients who received one dose of the JYNNEOS vaccine more than 28 days ago should receive the second dose as soon as possible.

The common symptoms of mpox overlap with other infections such as smallpox. How can we know it’s mpox and not other skin conditions?

Monkeypox (mpox) and smallpox are both viral diseases caused by different viruses that can cause similar symptoms, such as fever, headache, muscle aches, backache, chills, and rash. However, there are some differences between the two that can help differentiate them.

Lymph node swelling is a key differentiator. Mpox causes lymph node swelling, also known as lymphadenopathy, while smallpox does not. The swelling can affect a few areas or multiple locations, such as the neck and armpit.

Mpox has a much lower fatality rate than smallpox, with a case fatality rate of 1-10% depending on the clade. Smallpox is fatal in 30-50% of cases.

Is any particular population group more at risk for mpox? Who needs extra protection?

Outbreaks of clade I MPXV associated with sexual contact among men who have sex with men and female sex workers and their contacts have been reported in some provinces.  

At some places, patients acquired the infection through contact with infected dead or live wild animals, household transmission, or patient care (transmitted in the absence of appropriate personal protective equipment); a high proportion of cases have been reported in children younger than 15 years of age.

This pattern of the spread of infection makes sex workers and children more vulnerable. But a clearer pattern is yet to emerge with the new strand.

An anti-mpox vaccine underwent clinical trials in Congo. Are there any preventive or curative drugs for this infection?

Like I said, Amphotericin injection is easily available in India and the last time mpox was doing rounds in the country, this medicine came handy in controlling its spread. As of now, JYNNEOS (Imvamune or Imvanex) vaccine can help reduce the severity of the disease and also contain its spread. Incidentally, the same vaccine is used to prevent smallpox among adults.  

About the vaccine tested in Congo, it is currently out of reach for most people, especially due to its high cost. Teh MVA-BN vaccine, as we know, is an mpox vaccine that the US’s Food and Drug Administration and the EU’s European Medicines Agency have approved. But its large-scale production is still a question that health agencies have to decide.

Tecovirimat (TPOXX) is another drug for mpox. It’s available in both an oral and intravenous formulation. Although the antiviral was only approved for the treatment of smallpox, its FDA approval was based on studies in nonhuman primates infected with monkeypox virus (mpxv). Its efficacy needs to be ascertained beyond doubt on humans.

With the experience of tackling Covid-19 pandemic, what kind of international cooperation is needed to effectively stop mpox in early stages?

We have the experience of handling Covid-19 as the last epidemic and we can handle mpox smoothly if the government has enough vials of Amphotericin B injection for patients of mpox.  

One more thing, since the new variants have emerged of monkeypox, the infection has become highly infectious and virulent as we repeatedly saw in the case of Covid-19. It’s this reason why mpox is now spreading to other countries.  

Better international coordination is required than we saw during Covid-19 to prevent the current outbreak from becoming an internal disease burden. We have to screen travellers, something we were late in enforcing during the Covid-19 pandemic and paid a huge price as the spread became virulent.

Is India prepared to tackle an outbreak of mpox on a large scale?

Fresh from the Covid-19 experience, we can say India is prepared to tackle mpox outbreak. By doing active surveillance for the disease, patients having fever, malaise and eruptions on any part of the body we should rule out patients for mpox. And Indian hospitals have this capability.  

India has the experience of working with the WHO, whose ring immunisation strategy has been quite helpful in controlling outbreaks. Ring immunisation basically is screening of population and immunising vulnerable people within a radius of five kilometres around an outbreak case.  

In this mpox case, if and when new infection is reported, the ring immunisation strategy can be adopted to vaccinate people. The only obstacle I see is the availability of vaccine doses. That should be in enough quantity in advance. Otherwise, I am confident that India’s healthcare is prepared to deal with an mpox outbreak.