Warning signs of monkeypox outbreak gone unheeded, experts say

CDC concerned about possibility of undetected spread of monkeypox in UK
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Monkeypox seems to have exploded out of nowhere over the past two weeks, spreading across Europe, the Americas and other regions. But the warning signs seem to have gone unheeded.

An unusual and long-lasting outbreak in Nigeria should have signaled that it was only a matter of time before this orthopoxvirus made its way to the center stage of infectious diseases, experts say.

After decades without cases, Nigeria experienced a major outbreak of monkeypox starting in 2017 which continues to this day. Prior to this year, this outbreak had spread beyond Nigeria’s borders eight times, with those infected traveling to the United States, United Kingdom, Israel and Singapore.


Chikwe Ihekweazu, the former director general of the Nigeria Center for Disease Control, said his country had asked for help in trying to decipher what was going on with monkeypox. But the requests were not very successful.

As such, some critical questions about monkeypox – including the true lethality of the West African clade of the virus, the one currently circulating, as well as the number of people, on average, each infected person transmits – remain unclear.


“There hasn’t been much interest in supporting this work so far – unfortunately,” said Ihekweazu, who was recently appointed to head the Organization’s new Pandemic and Epidemic Intelligence Center. World Health Organization, based in Berlin. “He never really got the interest he needed to answer some of these questions.”

Nigeria has detected 558 suspected cases – 241 of them confirmed – since the start of the current outbreak in 2017.

Nigeria CDC

“When we saw this suddenly emerge in Nigeria in 2017 literally out of the blue, we were all very surprised,” he told STAT. “In a way, it’s similar to the surprise in the world right now, because it’s a similar scenario. Suddenly, out of nowhere, we had a lot of cases in the southern part of Nigeria, in the Niger-Delta.

Further investigation revealed cases across the country, Ihekweazu said. “So interesting that a virus that we hadn’t seen for about 40 years at the time in Nigeria suddenly appeared and appeared in multiple places at the same time.”

The Nigerian CDC has been trying – so far unsuccessfully – to figure out how people were infected with the virus. Some small mammals are thought to be the host species for the virus, but efforts to find the virus in nature have so far failed.

The rest of the world seems to be catching up with Nigeria fast. More than 300 suspected cases have been detected since the UK reported in mid-May that it had diagnosed cases of monkeypox in people who had not traveled to any of the South African countries. ‘west or central where the virus is endemic. Of the cases outside Africa, 219 have been confirmed, the European Center for Disease Prevention and Control said wednesday.

Ihekweazu said before the Covid-19 pandemic he tried to raise awareness of the problem monkeypox could pose. In 2019, the London think tank Chatham House called a meeting to discuss the risks, said David Heymann, professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine, who chaired the meeting. Among them was the possibility of sexual transmission of monkeypox as some people who contracted the virus developed lesions on their genitals or in their genital area.

The current epidemic appears to have taken off when the virus began to spread among men who have sex with men.

The virus is not transmitted through sex per se; there is no evidence, for example, that it passes through semen or vaginal secretions. But skin-to-skin contact experienced during sex can result in transmission, if either partner has monkeypox lesions.

Anne Rimoin, an infectious disease epidemiologist at the University of California, Los Angeles, who has studied monkeypox since 2002, agreed with Ihekweazu that people who study poxviruses know the spread of monkeypox is a possibility. The eradication of smallpox in 1980 and the discontinuation of use of the smallpox vaccine – which offers some protection against monkeypox – created an ecological vacuum that experts feared another poxvirus would fill.

“There’s been a million bench exercises and stuff, watching the spread of monkeypox, smallpox, other poxviruses. It’s not a completely unforeseen situation here,” Rimoin said. “We knew from the start that as population immunity waned and individual immunity potentially waned for those who were vaccinated, we would potentially see cases of monkeypox or other poxviruses spread.”

As of 2018, there have been sporadic cases where infected travelers to Nigeria brought the virus to countries where monkeypox is not found. Ihekweazu said each export puts recipient countries on high alert to try to prevent national spread, with cases being treated in high-containment facilities while infectious. But help to stop the virus from spreading at its source has not followed.

“So basically you pull out the military whenever there’s a single exported case. But there is no point in working with the country where the cases are coming from to try to understand it a little more,” he said.

He suggested that in the aftermath of the Covid pandemic, the world could be more open to understanding the need to nip infectious diseases in the bud. “This was all pre-Covid. So…hopefully people’s general sense of these things has changed a bit so that we pay a little more attention to them.

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