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mexico

This electron microscope image depicts monkeypox virus particles collected from
a human skin sample from the 2003 outbreak. On the left are mature, oval-shaped
virus particles; on the right are crescent and spherical immature viruses.
CDC/Cynthia S. Goldsmith/Science Source
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 * Science




MONKEYPOX CASES ARE RISING—HERE’S WHAT WE KNOW SO FAR

An outbreak of monkeypox, which is related to smallpox, has public health
officials concerned. But the virus can be contained with vaccines that are
already stockpiled and available in some countries.


ByPriyanka Runwal
Published May 26, 2022
• 12 min read
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When experts in the United Kingdom confirmed the first case of monkeypox on May
7 this year, epidemiologist Andrea McCollum and her colleagues at the United
States Centers for Disease Control and Prevention kept a close watch.

Human monkeypox infections are rare, especially outside of Central and Western
Africa where the virus is endemic in animals and circulates primarily in heavily
forested areas. Since 2018, only eight cases had been confirmed in non-endemic
countries including Israel, Singapore, the U.K., and the U.S.—and all were
associated with travel, just like the May 7 patient, who had taken a trip to
Nigeria.

But as cases with no known travel links to Africa popped up in several
countries, alarm bells went off, McCollum says. “We've never really seen this
type of observation from monkeypox before,” she says, “so this is particularly
concerning.”

Between May 13 and 24, at least 16 countries in Europe and North America, as
well as Australia and Israel, reported more than 250 confirmed and suspected
monkeypox cases. The West African strain of the virus seems to be causing these
infections. It triggers flu-like symptoms followed by a rash on the face which
can spread to other parts of the body. This rash transforms from red spots to
pus-filled blisters that eventually scab and fall off. Most often, these
symptoms go away on their own within a few weeks, but they are fatal in about
three percent of the cases. Its counterpart, the Congo Basin monkeypox strain,
causes a more severe disease and kills nearly 10 percent of those infected. The
smallpox virus, which was eradicated in 1979 and is a close relative of
monkeypox, was much deadlier, killing 30 percent of those infected.

“It [monkeypox] is very different from COVID,” said Maria Van Kerkhove, an
infectious disease epidemiologist at the World Health Organization, at an online
public Q&A on May 23. “Transmission is really happening from close physical
contact, skin-to-skin contact.” Monkeypox, unlike COVID-19 which circulates via
tiny air-borne droplets, doesn’t spread as easily.



“This is a containable situation,” Van Kerkhove said. There are potential
antivirals for those infected and vaccines for people most at risk: those who
come in close contact with infected individuals. “This [vaccination] is not
something that everybody needs,” she said.

Fortunately, so far, no one has died in this ongoing multi-country monkeypox
outbreak, but where it began and what’s causing its spread remains unknown.

At the moment, there are many open questions, McCollum says.

Here’s what we know so far.


CASES TO DATE

Since the identification of the May 7 patient, monkeypox case numbers in
non-endemic countries have increased.

Public health officials are now contact tracing and searching for connections
between the cases to find clues. This might also help them locate undiagnosed
cases that could potentially be asymptomatic or have mild symptoms.

A large proportion of the currently confirmed cases have been reported from
Europe, particularly the U.K., Spain, and Portugal. Most of these infections
were among men, many who self-identified as men who had sex with men. In a May
23 interview with The Associated Press, a key advisor to the WHO said that the
leading theory to explain the ongoing outbreak was sexual activity among men at
two recent raves in Spain and Belgium.


HOW IS THE DISEASE TRANSMITTED? 

Although monkeypox can spread through sexual contact, it’s not a sexually
transmitted infection, said Andy Seale, an advisor to WHO’s HIV, hepatitis, and
sexually transmitted infections program, at an online public Q&A on May 23. That
typically requires the infectious virus to be carried via semen or vaginal
fluids, and currently there is no evidence to suggest that.

The disease is not confined to men who have sex with men. “Anybody can contract
monkeypox through close contact,” Seale said.



The disease spreads via an infected person’s bodily fluids—spit or pus—that can
harbor the virus. Bedsheets or clothes contaminated with such virus-laden fluid
can also be a potential source of infection.

Given the widespread nature of the current outbreak, epidemiologists and
virologists are trying to understand if there’s enhanced person-to-person
transmission of this virus. Some experts are studying the genetic sequences of
the virus obtained from infected patients to see if there are any mutations that
could make the currently circulating virus potentially more transmissible than
any previous versions. They’re also checking whether the monekypox virus is
present in semen or vaginal fluids, and if it is infectious, to confirm this
isn’t a sexually transmitted disease.


ARE THERE VACCINES AND TREATMENTS FOR MONKEYPOX?

Not all monkeypox patients are hospitalized; many get better on their own
without treatment while isolating at home for three weeks. Some countries,
including the U.K., advise those who had close contact with the infected
individual to quarantine for 21 days. In the U.S., President Biden said that
such quarantining is not needed as vaccines are available for those exposed to
the virus.

In 2019, the U.S. Food and Drug Administration approved Bavarian Nordic's
monkeypox vaccine called Jynneos, which can prevent the disease or make it less
severe. Another vaccine called ACAM2000 that’s approved for smallpox could also
be used. The U.S. and the U.K., for instance, are offering the Jynneos vaccine
to healthcare workers who treat or may have been exposed to infected patients.
The CDC suggests getting the two-dose vaccine within four days of exposure.

However, no medications have been approved to treat monkeypox. An oral antiviral
drug called Tecovirimat was approved by the FDA in 2018 for smallpox treatment,
but there is no data to show it is effective in humans for either of these
infections. For severe monkeypox illness, two other therapeutics, an antiviral
cidofovir and a monoclonal antibody called vaccinia immune globulin may be used.




HOW DOES MONKEYPOX DIFFER FROM SARS-COV-2?

Unlike SARS-CoV-2, the RNA virus that causes COVID-19, monkeypox virus is a DNA
virus. Its genome is encoded with about 200,000 genetic units whereas the
SARS-CoV-2 genome is much smaller: roughly 30,000 units. Such DNA viruses tend
not to mutate, said Rosamund Lewis, head of WHO’s Smallpox Secretariat, at an
online public Q&A on May 23, and tend to be fairly stable and less likely to
generate variants.

The two viruses also transmit somewhat differently. SARS-CoV-2 spreads quickly
through the air in tiny droplets when infected people speak, sneeze, or cough.
Monkeypox doesn’t spread as easily by air and often requires close physical
contact with an infected person or their contaminated clothes or bedding.


SHORT HISTORY OF MONKEYPOX

The virus was first discovered in 1958 in Denmark when researchers noticed
pox-like skin eruptions on cynomolgus monkeys that came from Singapore and were
housed in an animal research facility—hence the name monkeypox. In the next
decade, more outbreaks were reported in the U.S. in captive monkeys imported
from Asia, where monkeypox hadn’t been identified. These primates were
considered accidental hosts of the virus.

The first human monkeypox infection was documented in 1970 in the Congo’s
Équateur Province in a nine-month-old baby who was initially thought to have
smallpox—a disease that was close to eradication and resembled monkeypox. By
1985, the World Health Organization had recorded 310 monkeypox cases in rural
West and Central Africa, with the majority in Congo.

This prompted a search for the primary source of the monkeypox virus. A 1985
survey of 383 wild animals including monkeys, rodents, and bats in northern
Congo revealed monkeypox-specific antibodies in the blood samples of two
Thomas’s rope squirrel—a diurnal rodent, which is likely hunted and consumed for
meat. One of the squirrels had skin eruptions and researchers successfully
isolated a monkeypox virus identical to the ones seen in humans from the
animal’s tissues.



In March 2012, another team of researchers isolated the virus from a monkey
species called sooty mangabey in Côte d'Ivoire’s Taï National Park and in 2020
from western chimpanzees. Recently, another study that’s yet to be peer-reviewed
has found evidence of the virus in shrews and some rodents living in the Congo
Basin.

While rodents are suspected to be the primary reservoirs of monkeypox, there’s
no direct evidence which shows that these animals, hunted for meat or kept as
pets, spread the virus to humans, says Joachim Mariën, a disease ecologist at
Belgium’s University of Antwerp. 

Still, the infamous 2003 monkeypox outbreak in the U.S.—the first outside
Africa—provides a glimpse of how animal-to-human transmission of this virus
occurs. At least 37 people from six states: Illinois, Indiana, Kansas, Missouri,
Ohio, and Wisconsin became ill after handling or petting infected prairie dogs.
Turns out, these rodents very likely caught the monkeypox virus while being
housed alongside dormice and Gambian giant pouched rats that an Illinois animal
distributor imported from Ghana.


WHY ARE MONKEYPOX CASES RISING?

In parts of Central and West Africa, where the virus is endemic, human monkeypox
cases have been rising since the 1970s. A 2022 study estimated a minimum 10-fold
increase in global confirmed, probable, and possible case numbers in the last
five decades. That increase is most dramatic in Congo, which recorded more than
28,000 cases between 2000 and 2019, and in Nigeria, where the disease reemerged
in 2017 after 40 years.

One big reason for escalating monkeypox cases is the elimination of smallpox. In
1980, the World Health Organization declared smallpox eradicated and vaccination
against the virus ended. But researchers have shown that this discontinued
smallpox vaccine, which can have side effects, provided 85 percent protection
against monkeypox. A 2010 study from Central Congo found that vaccinated people
had a nearly fivefold lower risk of getting monkeypox than unvaccinated ones. 



Escalating deforestation can also expose more people to the virus. Clearing of
forests to make way for plantations and agriculture is likely to bring humans
closer to infected wild animals, increasing opportunities for the virus to jump
species, as is suggested for Ebola.

Also, a 2014 study documented one version of the Congo Basin monkeypox virus
strain with a deleted gene that may be associated with an adaptation for
human-to-human transmission.

“We knew that monkeypox was a disease we needed to keep a close eye on because
of its epidemic potential,” says Laurens Liesenborghs, an infectious disease
specialist studying the virus at the Institute of Tropical Medicine in Belgium.
“However, what’s happening now is something quite peculiar.”


IS THIS MONKEYPOX OUTBREAK CAUSED BY A MORE TRANSMISSIBLE VIRUS?

Another lingering question is whether the virus evolved to spread more easily
among humans. For pox viruses, which are DNA viruses, that typically means
either losing or gaining genes that make it more transmissible, says Gustavo
Palacios, a virologist at the Icahn School of Medicine at Mount Sinai in New
York.

Based on the genome sequences of the virus taken from three recently infected
monkeypox patients from Portugal, Belgium, and the U.S., there is no evidence
for such gene deletion or addition, he says. In fact, the Portugal genome draft
sequence presents a close match with that of the virus exported from Nigeria to
Israel, Singapore, and the U.K. in 2018 and 2019. The draft gene sequence from
Belgium is very similar to that obtained from the Portuguese patient, which
makes sense, says Philippe Selhorst, a virologist at the Institute of Tropical
Medicine in Belgium, given that the Belgian man had recently traveled to
Portugal.

But to identify subtle changes in the monkeypox genetic makeup, researchers need
to sequence viral DNA from more patients and compare regions across the genome
that may be different to sequences from previous outbreaks. The question is
whether those variations, if found, amount to how the virus infects humans.



Selhorst’s worry, however, is that even if the virus hasn’t changed yet, it
might have more opportunities to mutate, the longer this ongoing outbreak
continues.

Even though monkeypox is not as contagious as COVID-19, Selhorst says “it’s just
never good when a virus that’s been in an animal reservoir is now circulating
more and more in people.”

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