This is yet another post of a few quick notes from the last couple of weeks.

The headline message remains: The risk is low so don’t be concerned, but do be vigilant.

1. Cases are appearing with no known contacts with confirmed cases, suggesting transmission is being missed due to undetected circulation of the virus. [1]
2. Many cases appear non-typical with the rash appearing before other symptoms. [1]
3. DNA sequencing suggests monkeypox may have been circulating in people for years. [2]
4. The pattern seen means that there has been sustained human to human transmission since at least 2017 and spreading quite widely in people in Africa. In some African countries person-to-person spread is likely to have gone unnoticed for years. [2]
5. Genome sequencing shows that the monkeypox viruses responsible for these cases are closely related to ones detected in a small number of cases in Israel, Nigeria, Singapore and the UK between 2017 and 2019. [2]
6. The 47 DNA-letter changes in the latest viruses compared with earlier ones is an unexpectedly high number of mutations. [2]
7. We shouldn’t assume that monkeypox won’t evolve to be better at spreading in people if given a chance. [2]
8. There is no reason to panic as this is something we can get under control. But we have to take it seriously. [2]
9. Genetic testing identified two strains of monkeypox in the US. Most US cases involved the strain linked to the recent outbreak first identified in European countries. However the presence of a second variant suggests the virus may have been spreading unnoticed for some time. Data from many more patients will be needed to estimate how long the virus has been circulating in the US. [3]
10. In England it is now a legal requirement for doctors to notify their local council or health protection team about any suspected monkeypox cases – as they have to for measles, scarlet fever and tuberculosis. [4]
11. The UK Health Security Agency (UKHSA) has detected to 524 cases as of 14 June. [5]
12. More than 1800 cases of monkeypox have now been confirmed in dozens of countries outside Africa in the latest outbreak. [6]
13. The World Health Organization has said it will rename monkeypox to avoid discrimination and stigmatisation as the virus continues to spread. The working name is “hMPXV” for “human monkeypox virus”. [6]

References

[1] https://www.bbc.co.uk/news/health-61696974
[2] https://www.newscientist.com/article/2323019-monkeypox-dna-hints-virus-has-been-spreading-in-people-for-years/ [£££]
[3] https://www.the-scientist.com/news-opinion/monkeypox-likely-spread-undetected-in-us-before-recent-reports-70102
[4] https://www.bbc.co.uk/news/health-61723964
[5] https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-updates
[6] https://www.theguardian.com/world/2022/jun/15/who-to-rename-monkeypox-virus-to-avoid-discrimination

I’m not going to provide another round-up of news on monkeypox; I’ll do that when there is some useful news.

However there are two important articles in the last couple of days which I want to draw attention to.

How to tell if your rash is monkeypox? See this from the BBC: Got a new rash? Monkeypox or something else?

Secondly many experts are saying that monkeypox is actually not what we should be worrying about; there are far more dangerous diseases waiting to pounce. See: Monkeypox isn’t the disease we should be worried about.

Here’s some more background on Monkeypox, following my item from Friday.

Let’s be very clear, right up front … We are not witnessing another Covid, and we’re not days away from lockdowns to contain the spread of monkeypox. However, this is an unusual and unprecedented monkeypox outbreak which has taken scientists who specialise in the disease by surprise – and that’s always a concern. [4]

Spread & Behaviour

1. Monkeypox is so rare that that most doctors will never see a case in their lifetimes. [2]
2. Monkeypox is not known to spread easily between people, although cases emerging in several countries at once, and signs of transmission in the community is striking. [1,2]
3. However the UKHSA saying the risk to the population “remains low”. [1]
4. The US Centers for Disease Control (CDC) states: “Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required.” [1]
5. The virus doesn’t usually spread easily between people as it requires prolonged close contact. [3]
6. Its R value is generally less than 1, so outbreaks naturally peter out. [3]
7. Monkeypox can also spread through close contact or by contact with clothing, towels or bedding used by an infected person. [1,3]
8. It isn’t regarded as a sexually transmitted infection, but it can be passed on during sex via skin-to-skin contact. (This should not be surprising!) [1]
9. It’s not clear why gay and bisexual men are disproportionately affected. Are sexual behaviours making it easier to spread, or is this just coincidence? After all this is, in general, a community that is more aware of sexual health and getting checked out. [4]
10. So the latest cases raise many questions and the scientists don’t really have the sense yet of what’s driving this, especially as there’s no travel link that’s identified that links the cases. [2]
11. So the scientists are very much in response mode: trying to identify cases and trace potential contacts. And because many of the cases don’t join up scientists are aware they’re seeing only the tip of the iceberg. [2,4]

Symptoms

1. The incubation period between infection and symptoms is long, ranging from five to 21 days. [3]
2. The first symptoms of monkeypox include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion. [1]
3. A rash can also develop, typically on the face first and then on other parts of the body, mainly hands, feet and genitals. The rash can initially look like chickenpox, before forming scabs. [1]
4. Swollen lymph nodes are a defining feature found in monkeypox but not so common in chickenpox. Currently there are very few kids with monkeypox but the UK is seeing a big surge in chickenpox. So sick kids are more likely to have chickenpox, but be vigilant. [5]
5. The pictures of large blisters and scabs in the media are an unusual presentation and thought to be more common with the more serious Congo strain of the virus. Most presentation is with small pustules and lesions which are no more than 5mm in size. (Pictures in the references.) [5]

Different Strains

1. There are two main types of monkeypox: the Congo strain and the West African strain. Only the West African strain has been identified in the UK. [1]
2. The death rate from the Congo strain is thought to be 1 in 10, whereas it is only 1 in 100 for the West Africa strain.
   These are likely to be upper estimates as it is unknown how many (mild) cases go unreported. [1]
3. It is unknown at this time if the current outbreak is due to a new strain of monkeypox. The sequencing work now being carried out should tell us. [1]
4. Very early genetic analysis suggests the current cases are very closely related to forms of the virus seen in 2018 and 2019. It is too early to be sure, but for now there is no evidence this is a new mutant variant at play. [4]

Treatments

1. The antiviral drug tecovirimat is approved in Europe for treating monkeypox, smallpox and cowpox; and approved in the US for smallpox. [1]
2. The Jynneos vaccine is approved in the US and Europe for preventing monkeypox and smallpox in people aged over 18.
3. In addition, those who are old enough to have been vaccinated against smallpox as babies should have some protection. Routine smallpox vaccination ended in the UK in 1971 and in the US in 1972. [1]

Pandemic?

1. Monkeypox isn’t COVID. They’re very different diseases caused by different viruses with markedly different properties. COVID was completely unfamiliar when it first appeared, but monkeypox is a known quantity, and experts on the virus actually exist. [3]
2. While researchers aren’t completely ruling out a pandemic, they don’t think it is at all likely. [1]
3. Experts stress that monkeypox is very different from coronavirus. Monkeypox is a DNA virus so it does not mutate as rapidly as Covid or flu. [4]
4. They’re also saying it’s important not to put this on the same level as a novel coronavirus. [1]
5. Nevertheless monkeypox is a test of the lessons that the world has (or hasn’t) learned from COVID. [3]
6. The US, at least, is in a better position with monkeypox than with Covid. They had not planned for a coronavirus pandemic, but they have spent decades thinking about how to handle smallpox bioterrorism. [3]
7. The UKHSA are saying the risk to the UK population amid the ongoing outbreak “remains low”. [1]

Finally … Be vigilant. If you’re at all concerned phone 111 (in UK) or your doctor. But if you think you might have monkeypox DON’T just turn up at a doctor’s surgery (or sexual health clinic, or hospital); phone ahead so they know you’re coming and can prepare appropriate PPE and protective measures. [5]

References

[1] https://www.newscientist.com/article/2321212-could-monkeypox-become-a-pandemic-heres-everything-you-need-to-know/
[2] https://www.washingtonpost.com/health/2022/05/18/monkeypox-faq/
[3] https://www.bbc.co.uk/news/health-61524508
[5] Meaghan Kall of UKHSA on Twitter; https://twitter.com/kallmemeg/status/1528044499288657920

OK guys, so here’s another (not quite new) zoonotic disease for us to get our heads round and which piques my forensic nature: Monkeypox.

As of writing there are now 20 cases reported in the UK [1], with over 100 across mainland Europe [5] – where there seems to be a hotspot in Spain – and cases in the US, Canada and Australia. It is being suggested [2] that a number of cases will be being missed due to a similarity with chickenpox.

Monkeypox is a viral disease which is thought to be carried mostly by rodents and is prevalent in remote central and western areas Africa. Cases outside Africa are almost always associated with travel to that continent. That makes the current outbreak in the UK and beyond especially interesting. Although the first reported UK case in early May was in someone recently returned from west Africa, many of the more recent cases apparently do not have an obvious connection to African travel. Perhaps even more interesting is that a significant number of the UK cases are in men who have sex with men (MSM).

The virus is not transmitted in the same way as Covid or flu, but through close bodily contact with an infected person; it can enter the body through broken skin, the airways, eyes, nose or mouth [3]. However it has not previously been described as a sexually transmitted infection – although sex tends to involve close bodily contact! Spread is also possible from infected animals (eg. monkeys, rodents) or from virus-contaminated objects (eg. bedding and clothing).

Unfortunately the initial symptoms are very much like most viral illnesses: fever, headaches, swollen glands, back pain, aching muscles and a general listlessness. Only later does the rash develop; it often begins on the face, and then spreads to other parts of the body, most commonly the palms of the hands and soles of the feet. The rash, which can be extremely itchy, goes through several stages before forming a scab, which later falls off. Although there is no treatment for monkeypox, and no specific vaccine, most cases resolve within 2-3 weeks.

As the name implies, monkeypox is an Orthopoxvirus very closely related to smallpox (also cowpox). The smallpox vaccine is reportedly highly effective protection [3], so anyone who has been vaccinated against smallpox should have some protecton. Have you been vaccinated against smallpox? Smallpox vaccination was compulsory in the UK between 1853 and 1971 [4] so many people over 50 will have been vaccinated, although apparently compliance was falling before the vaccination requirement was removed.

Should we be worried? Current advice is NO. The risk to the public at large is thought to be very low especially as the virus does not spread easily. But then we originally thought that about Covid-19. So no, don’t panic or be alarmed; but do remain alert and if in any doubt about symptoms talk to your GP.

References
[1] https://www.bbc.co.uk/news/health-61506562
[2] https://www.thisislocallondon.co.uk/news/national/uk-today/20154025.monkeypox-cases-uk-double-20/
[3] https://www.bbc.co.uk/news/health-45665821
[4] https://www.ncbi.nlm.nih.gov/books/NBK545998/
[5] https://www.independent.co.uk/news/health/monkeypox-virus-infection-case-symptoms-live-uk-b2083515.html