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Monkeypox outbreak: Wake-up call for governments to stop the next pandemic, say experts

KUALA LUMPUR: It is time for scientists, authorities and governments around the world to act on fixing the broken relationship between humans and nature and protect people from future zoonotic outbreaks, which could potentially become pandemics.

Experts said the Covid-19 pandemic and rare monkeypox outbreak serve as a stark reminder for authorities to reevaluate potential sources of emerging pathogens at the animal-human interface and identify ways to minimise risk of zoonotic diseases.

The proverbial saying 'prevention is better than cure' remains the sensible way forward to stop a disease outbreak than having to deal with health issues or solely relying on vaccination to prevent or control a disease spread, like the monkeypox, they said.

"Zoonotic diseases like Covid-19, Ebola, avian flu, swine flu, monkey malaria, and leptospirosis are emerging and re-emerging communicable diseases all over the world," said environmental health expert Professor Dr Jamal Hisham Hashim. 

Jamal, who is also Universiti Selangor honorary professor explained that the close interactions between man, animals and environment have caused animal pathogens, especially viruses to jump from animals to humans. 

These, he said include human encroachment into forested areas through logging, mining and agriculture, wildlife poaching, and live and exotic animal markets and trading.

He, therefore, stressed the need for early response to be in place, not only in Malaysia but regionally and globally which calls for collective action.

Among others, Jamal said there should be a renewed international effort to ban illegal wildlife trafficking which is rampant in Asia.

"This should be a wake-up call for global leaders.

"Live animal markets should be banned, which is still widespread across many Asian countries. For example, the Wuhan wet market from which the first Covid-19 cases were detected sold live wild animals," he told the New Straits Times.

A July 2020 United Nations report warned that more diseases that pass from animals to humans, such as Covid-19, are likely to emerge as habitats are ravaged by wildlife exploitation, unsustainable farming practices and climate change. 

According to the National Research Council Committee on Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin, conducting zoonotic disease surveillance to detect threats to human and animal health that cross political borders and to intervene against those threats requires governance strategies and mechanisms that encourage countries to share information and collaborate on responses. 

"For disease surveillance and response systems to be effective, countries must implement international and global governance approaches within their territories, from the local to the national level, and beyond to the international community, through both formal legal rules and informal modes of collaboration," it wrote. 

Universiti Sains Malaysia virologist Dr Muhammad Amir Yunus said environmental changes, including changes in climate, landscape characteristics, and communities of zoonotic hosts and vectors could affect the distributions of zoonotic agents and their transmission to humans. 

"Animals are moving around, especially bats looking for a better habitat. In fact, the next potential pandemic is still expected to be respiratory viruses. And our country poses a potential hotspot for this," Dr Amir warned when commenting on the ongoing outbreak of monkeypox, which was confirmed in May 2022.

A study published in the scientific journal, PLOS Neglected Tropical Diseases in February 2022, months before the outbreaks which started in May, found monkeypox cases, though rare, are rising. This, it said may be related to the cessation of smallpox vaccination, which provided some cross-protection against monkeypox. 

As of June 9, more than 1,000 confirmed cases of monkeypox have now been reported to the World Health Organisation (WHO) from 29 countries that are not endemic for the disease.

Closer to home in Asia-Pacific, Australia, which on May 20 reported its first case, had confirmed six cases as of June 3.

On Monday (June 6), the Singapore Ministry of Health said that it was informed on June 4, by the New South Wales Health Ministry that a man who had transited through Singapore en route to Australia on June 2 was diagnosed with monkeypox.

WHAT IS MONKEYPOX?

Molecular virologist Dr Vinod Balasubramaniam of the Jeffrey Cheah School of Medicine and Health Sciences at Monash University Malaysia said monkeypox, a zoonotic disease caused by an orthopoxvirus, results in a smallpox-like disease in humans.  

Since monkeypox in humans was initially diagnosed in 1970 in the Democratic Republic of the Congo (DRC), it has spread to other regions of Africa (primarily West and Central), and cases outside Africa have emerged in recent years, he said. 

In those regions, he said over 1,200 cases of monkeypox have been reported since the start of the year.

"This disease got its name monkeypox because researchers first detected it in laboratory monkeys in 1958, the virus is thought instead to transmit from wild animals such as rodents to people — or from infected people. 

"In an average year, a few thousand cases occur in Africa, typically in the western and central parts of the continent. But cases outside Africa have been limited to a handful that are associated with travel to Africa or with the importation of infected animals. 

"The number of cases detected outside of Africa has already surpassed the number detected outside the continent since 1970, when the virus was first identified as causing disease in humans. This rapid spread is what has scientists on high alert," Dr Vinod said. 

Dr Vinod added that there are two forms of monkeypox, a milder west African strain and a more severe central African, or Congo strain. The current global outbreak, he said appears to involve the west African strain.

WHAT ARE THE SYMPTOMS? SHOULD WE BE WORRIED?

Monkeypox typically presents clinically with fever, rash, headaches, muscle aches, and fatigue and may lead to a range of medical complications, Dr Vinod said. 

"It is usually a self-limited disease with the symptoms lasting from two to four weeks. Severe cases can occur. 

"In recent times, the case fatality ratio has been around three to six per cent."

Monkeypox, he said is transmitted to humans through close contact (with bodily fluids, such as saliva from coughing) with an infected person or animal, or with material contaminated with the virus unlike SARS-CoV-2, the virus that causes Covid-19, which spreads through tiny airborne droplets.

"The (monkeypox) virus can enter the body through broken skin, the respiratory tract or the eyes, nose or mouth, hence a person with monkeypox is likely to infect far fewer close contacts than someone with SARS-CoV-2. 

"Besides, most people recover from monkeypox in a few weeks without treatment."

Dr Amir said there is an indicator symptom which might differentiate monkeypox from other virus illnesses (including smallpox), that is swelling of lymph nodes.

"The symptoms will be followed by the presence of widespread rashes, blisters and lesions throughout the body including the face. The lesion is typically bumped and filled with bodily fluid and then becomes puss before drying and scabbing.

"It is typically a self-limiting disease but can look nasty. Almost similar to zoster (chickenpox). However, depending on the immunity status of individuals, this disease might develop into severe form."

Media reported that hundreds of monkeypox cases found in other countries have been tied to sexual activity at two raves in Europe, involving men who have sex with men, but health officials stress that anyone can get monkeypox. 

RE-EMERGENCE OF MONKEYPOX: WHY NOW? 

Dr Vinod said there has been concern worldwide about the reasons for the resurgence in monkeypox cases, the most prevailing being waning immunity, although deforestation may be a factor or can even act in potentiation. 

Monkeypox virus, variola virus (smallpox), and vaccinia virus (smallpox vaccination) are closely related to orthopoxviruses, he said. 

At the time when smallpox was rampant, no cases of monkeypox were reported, he said, adding that this could have been either because the focus was on smallpox and the presentation of the two diseases is similar or the lack of laboratory confirmation of the etiologic agent led to an assumption of smallpox. 

"Monkeypox puts virologists on the alert because it is in the smallpox family (which is far more virulent), although it causes less serious illness. Smallpox was eradicated by vaccination in 1980, and the shot has been phased out. 

"But it also protects against monkeypox, and so the winding down of vaccination campaigns has led to a jump in monkeypox cases. 

"But one question remains. Why now?"

Dr Vinod noted that with cases of monkeypox rising in the west and central Africa, there is a possibility of spillover of these cases to other parts of the world due to travel.

Besides, with majority of the Covid-19 restrictions around the world being eased, countries are seeing higher rate of transmission in affected areas, he said. 

Dr Vinod said the waning population immunity associated with discontinuation of smallpox vaccination has established the landscape for the resurgence of monkeypox. 

This, he said is demonstrated by the recent increase in cases outside of Africa. 

POSSIBLE NEW PANDEMIC?

Jamal said there is no indication currently that the monkeypox spread will become pandemic

However, Jamal said the main concern right now is that monkeypox has appeared amongst those who have not travelled to Africa. 

"This means that there is already a local transmission of the disease in countries where it has appeared. We should not be worried but we should be vigilant of any emerging communicable disease.

"The possibility (of monkeypox cases in Malaysia) is always there as we have reopened our international borders."

Further, Jamal said since an effective vaccine is available for monkeypox, a global spread is less likely compared to Covid-19 and it is also probably not as infectious as SARS-CoV-2, unless the virus has undergone significant mutation.

Dr Amir also did not discount the possibility of monkeypox entering Malaysia since international travel is now permitted. 

Besides human-human transmission, Dr Amir said monkeypox outbreak could also be triggered by the trading of monkeys from affected regions/countries, especially from Africa.

"Due to its self-limiting nature, we know that this virus is quite stable genomically (very rare for mutation to occur), which makes it quite straightforward to manage," he said.

NEW VIRULENT STRAIN?

Asked about the possibility of a new virulent strain of monkeypox, Dr Vinod said researchers still don't have much data on this. 

"The fact that so many cases are being reported in several countries certainly suggests that this strain is more transmissible than others. 

"We still need to look at the current genomic data on the currently circulating strain to know more.

"However, in light of the current environment for pandemic threats, the public health importance of monkeypox disease should not be underestimated.

"International support for increased surveillance and detection of monkeypox cases are essential tools for understanding the continuously changing epidemiology of this resurging disease," Dr Vinod said.

PRECAUTIONARY MEASURES

Jamal said current preventive measures against Covid-19 including respiratory protection, psysical distancing and personal hygiene should be equally effective against monkeypox.

"We need to closely monitor international travellers from affected countries for signs and symptoms of monkeypox like fever and skin rash," Jamal added. 

On June 8, Health Minister Khairy Jamaluddin had said Malaysia is free from the monkeypox virus and remains alert to arrest any situation. 

WHO on Wednesday warned that there is a "real" risk of monkeypox becoming established in non-endemic countries, while also reiterating that the Covid-19 pandemic "is not over." 

RING VACCINATION, POSSIBLE DEFENCE AGAINST MONKEYPOX OUTBREAK?

Dr Vinod said historical data have shown that smallpox vaccination was approximately 85 per cent protective against monkeypox.

The ring vaccination strategy, he said vaccinates the contacts of confirmed patients, and people who are in close contact with those contacts. 

This way, everyone who has been, or could have been, exposed to a patient receives the vaccine, creating a 'ring' of protection that can limit the spread of a pathogen, he explained.

"Ring vaccination requires thorough and rapid surveillance and epidemiologic case investigation. 

"The Intensified Smallpox Eradication Program used this strategy with great success in its efforts to eradicate smallpox. 

"There are currently two vaccines available against Monkeypox. ACAM200 and Jynneos (also known as Imvamune or Imvanex) are the two currently licensed vaccines in the United States to prevent smallpox. 

"Jynneos (manufactured by Bavarian Nordic) is also licensed specifically to prevent monkeypox," Dr Vinod added.

US Department of Health and Human Services said on Monday it had instructed monkeypox vaccine manufacturer Bavarian Nordic to deliver an additional 36,000 doses this week as part of a drawdown from a US vaccine stockpile.

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