Monkeypox: How India can tackle the outbreak
Educate health care workers and the public about disease symptoms; support individuals to get tested and work against prejudice; strengthen contact-tracing and sharing of data; and craft a clear strategy for developing drugs and vaccines
We have been here before. A virus originally from animals, now seen in humans. Infections spreading rapidly from one country to another, numbers rising, and descriptions of unpleasant and dangerous symptoms abound. The World Health Organization (WHO), deliberating on whether to call it a public health emergency of international concern, and finally doing so, while vaccines and drugs are unavailable or in short supply, with little clarity on whom to vaccinate or treat.
Perhaps the most important, and the most misunderstood aspect of the circulating monkeypox (MPX) is that this is distinct from Sars-CoV2, including in the type of virus, whom it infects, the disease it causes, and possibly the immune response. This is a disease caused by a DNA virus that has been in West and Central Africa for over 50 years, with continuing case reporting in more recent times. In 2022, there has been a sharp increase of detection and reporting across multiple countries outside Africa, mostly in the western world. In general, DNA viruses do not evolve quickly, but the monkeypox virus circulating now appears to have acquired a number of mutations, which have been proposed by some researchers to be responsible for the potential sustained circulation in humans for the past five years. Not all researchers agree, and the rapid increase in just the past few months has led to questions about why now, the pattern of infections and how best to control the spread.
WHO director-general TA Ghebreyesus has declared monkeypox a public health emergency of international concern. This is a time where the world needs to work together to establish mechanisms to share data, anticipate and prepare for detection and diagnosis of cases, and implement measures for control and medical management.
With about 17,000 cases reported outside Africa and five deaths, all in Africa, we know that this is a self-limiting disease in healthy people, which can be managed at home with symptomatic treatment. While self-limiting, the lesions, particularly ulcers, the fever and the pain, can be challenging for the two to three weeks needed for recovery. Children and people with underlying conditions, particularly those that are immunocompromised, can have more severe disease and could die — although the case fatality rate with the currently circulating strain is estimated at 3-6% in Africa. There have been, so far, no deaths outside Africa.
In the current global outbreak, the bulk of cases have been reported in men who have sex with men, although there are a small number of cases in women, children and household contacts. While monkeypox is not a sexually transmitted disease in the traditional sense, most, but not all, transmission is believed to have taken place through skin-to-skin contact during sexual encounters.
We have incomplete knowledge about how this outbreak has evolved, and what the future holds. But based on public health principles, we can and must decide on what should be done today, and adapt our strategies as new information emerges. The first and most important principle is that, as with any infectious disease, we have a shared responsibility — the government and its policies, the health care providers and the community, particularly the groups that are at highest risk.
Health care workers and the public should be educated about the symptoms and about unusual presentations. While a fever, respiratory symptoms and a rash that progresses to vesicles, pustules and umbilicated late lesions are common, ulcers, joint pains and fatigue with few skin lesions may also be seen so clinical diagnosis must be strengthened along with testing.
The government must support potentially affected individuals to get tested. This will require expanding the availability of testing, at both public and private facilities. Testing at a restricted number of “authorised” facilities will lead to many people not reporting symptoms or getting tested. At least two Indian companies have already made PCR tests, and these should be made widely available in public and private laboratories. The government should focus on ensuring the quality of testing, including sequencing, and on collating and sharing data to inform and estimate the impact of isolation and other control measures.
Once an infection is identified, the person must be encouraged to isolate, preferably at home, and only if very ill or if the domestic environment is not conducive to isolation, then at a public or private health care facility. If India follows the rest of the world in the communities that are most affected, then men who have sex with men must be educated about the disease and encouraged to test and isolate, as needed. This is less likely to happen if there is labelling and stigmatisation. Isolation to prevent further transmission is essential, and whether at home or in a facility, infected individuals should be supported and not castigated.
Along with expanding clinical and diagnostic capacity, contact-tracing must be strengthened. The acquisition of infection in a case without travel history is an indication that cases are going undetected. However, converting isolation and contact-tracing into a law and order situation as was done during the early phase of the Sars-CoV2 pandemic, will have consequences with monkeypox, driving infected people to hide.
The government and media play an important role in describing both the potential threat and the strategy for control. For men who have sex with men and others who are not in monogamous relationships, it is important to provide information on the disease and its mode of transmission, as well as advice on restricting sexual partners at this time.
Monitoring and responding to cases require data systems that track information on individuals in a single integrated database. This was a hard lesson from the separation of the Sars-CoV2 testing and vaccination information and not linking sequencing early and at scale. There is no need to repeat our mistakes.
The information from India should be shared globally, even as we design and conduct studies that inform strategies for control and build greater understanding of the virus and the infection. Linking to the world is important to establish early access to drugs and vaccines, even though the amounts that will be required will be relatively limited and can be further restricted through appropriate public health measures. The Indian Council of Medical Research (ICMR) this week invited vaccine makers, pharma companies and institutes to develop vaccines and testing kits after the National Institute of Virology isolated the virus. A strategy for research and development for drugs and vaccines, which incorporates the approach of developing interventions for virus families is a longer-term, but essential, response that must be enabled by the government to help us deal with this and future outbreaks.
Gagandeep Kang is professor, Christian Medical College, Vellore
The views expressed are personal