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    Monkeypox Update: June 29, 2022

    By Dr. Arthur Lavin

    Readers of Real Answers will know that a post on monkeypox was distributed not long ago, with the hopes that this newish germ would not spread and require our attention, but it has spread, and does need our attention.  To be clear, monkeypox does not pose anywhere near the danger that COVID has, but it is spreading and could be an infection we all need to be aware of and prevent.

    As with COVID, it helps to know the terms, so here is a glossary for Monkeypox:

    Monkeypox Glossary

    • Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses (genes and protein coat), and on it goes.
    • Monkeypox- monkeypox refers to a very specific disease, which happens to be caused by a virus of the same name.  Much like smallpox is caused by the smallpox virus and polio by the polio virus, monkeypox is caused by the monkeypox virus.
    • Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
    • Epidemic– a sudden burst of an illness that comes and goes over a limited time.  Influenza occurs in the US in epidemics
    • Pandemic– an epidemic that bursts across the world not just one region
    • Spreadability– how contagious is the disease, how many people will end up infected
    • Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
    • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
    • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
    • Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
    • Vaccine Terms
    • Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
    • Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19

    Why Be Concerned About Monkeypox Now?

    We will review what monkeypox is below, but in this section we will go over what has happened to the spread of monkeypox since our last post.  The bottom line is that it has not gone away, and is picking up speed and spread across the world.  The total number of cases remains quite small, but it is growing and spreading so those numbers look like they will be growing.

    As of now there are over 3000 cases of monkeypox have been reported outside of Africa, where it once was only happening.  The total number of countries reporting new cases is 50.  In the US, the total case count to date is 142, with 16 cases happening just in NYC recently and reported in nearly half of all states.  The World Health Organization met at the end of June of this year and found that monkeypox did not present a world health crisis at this time, but given its continued spread, will monitor closely.  As will we.

    The hope remains that this new infection in our nation will not spread further and new cases will cease to occur, but that hope seems to be dimming as spread picks up.

    At this moment, the risk of getting monkeypox is very, very low.  The total number of cases across the whole US is still less than 100, which makes it actually quite rare.  We will continue to monitor and report should that situation change.

    New patterns of spread

    Monkeypox used to be limited to two specific areas of Africa, not seen much in the rest of the world.  Until very recently, May of 2022.  Then the current spread outside of Africa first appeared, and it is the fact that it is already in 50 new countries that makes it a new infection worthy of watching, why wouldn’t it continue to spread?

    One new pattern seen outside of Africa is that spread is primarily, but not exclusively, happening between men having sex with men.   If this pattern persists, monkeypox may turn out to be, outside of Africa, primarily an STI, or sexually transmitted infection.  There are cases where no sexual contact has occurred, so at this time it is an infection that is known to spread by sexual contact, but not only by sexual contact.

    One series of cases where gender and age were identified in patients positive for monkeypox, a total of 468 cases found that 99% were men, average age 37.

    Review of Monkeypox

    Monkeypox, as the name implies, is related to one other viral illnesses that causes very distinctive rashes, smallpox.  So far, only smallpox and monkeypox are viruses in the same family that infect humans and now that smallpox infection was wiped out by 1978, monkeypox is the only one of its class to regularly infect humans.

    Monkeypox used to only infect people in Africa.  The virus was discovered in a lab studying monkeys in 1958, and was therefore named monkeypox.  But this virus and disease has little to do with monkeys, it just first was noticed by people in a monkey lab.  The virus actually lives mostly in rodents that live in Africa.  It likely did spread in humans and even human-to-human in the past, but since the smallpox vaccine prevents it very well, cases in humans nearly vanished while everyone got a smallpox vaccine.

    In fact, modern observations of monkeypox in humans only begin in the 1980’s, just a few years after smallpox was eradicated and use of the smallpox vaccine ceased, which was in 1978.

    From the 1980’s to now, most cases were clustered in two areas of sub-Saharan Africa.  The vast majority of cases were the result of people coming into contact with the rodents that are the natural reservoir of the monkeypox virus, and also some cases occurred by people contacting those infected, particularly caregivers.

    Until this year, 2022, cases outside of Africa were very few and far between, and none of them led to widespread infections in those nations.  All were related to either contact with an infected rodent pet from Africa, or from travel from Africa.  But none really spread, until now.

    Something new is happening since just last month, May of 2022.  For the first time we are seeing many cases spread across the world, still mainly in Europe, but around the world, with no contact with Africa at all.  Even in Africa, the number of cases was always fairly low, so the total number of cases of monkeypox going over 3000 since May has not been seen since the modern era, since smallpox vaccination was used then ended.

    Symptoms of Monkeypox

    Monkeypox, like smallpox and chickenpox has phases of fever and rash and a characteristic rash.  The rash appears as blisters that then scab.   The first symptoms are flu-like- achiness, fever, headache, muscle pains which are seen in so many infections.  But the rash is the symptom that is unique.  Those interested should google pictures of the rash.  One aspect that is fairly unusual is the appearance of the rash on the palms and soles which happens in most cases.  Sometimes the rash starts on the face, but if transmitted as an STI, the rash may be localized to the groin and genitals.  No matter where the infection starts, swollen glands are common with it too.

    Incubation period.  This is the time from the moment the virus lands on you to the first day of any symptoms.  Monkeypox has a broad range of days of incubation, it may be as little as 5 days and as long as 21 days.  In contrast, the original COVID had an incubation period of about 5 days, and its Omicron variant 2 days.

    Danger of the disease.  There are two types of monkeypox that have been brewing in Africa for awhile.  In one the chance of the disease killing you is about 5% and in the other about 30%.  It is the milder form that appears to be spreading in the world now.  In contrast to COVID, and very sadly, monkeypox causes more severe disease in young people and children, but also pregnant women and of course people with impaired immune systems.

    Most deaths from monkeypox have been seen in young children and people with active AIDS.

    Prevention and treatment

    Thankfully, monkeypox virus and smallpox virus are so similar that it appears that smallpox vaccine can prevent infection.  Data so far suggest about 85% protection rates which is very, very good.  We don’t know for sure because smallpox vaccine is not currently widely available and the number of monkeypox cases in total so far is small.  But if monkeypox should really start spreading, the world is gearing up to make smallpox vaccine available.  This would require no new development of a vaccine, only the mass manufacture of the world’s very oldest, in fact first, vaccine.

    There are also drugs that can help those with monkeypox get better faster and increase the chance of surviving it.  We are very far away from having to discuss how to use these drugs, but they exist should supplies need to be created.

    Bottom Lines

    1. Monkeypox is a very old disease, from a virus called the monkeypox virus, which is very, very closely related to the smallpox virus.
    2. Some believe the use of universal smallpox vaccine across the world and for many years snuffed out monkeypox cases, limiting them to those with very direct contact with infected animals, mainly certain types of African rodents.
    3. After smallpox was eradicated across the planet, still the only disease humanity has totally eliminated, smallpox vaccination was no longer necessary and ceased, and some few cases of monkeypox started up again in the 1980’s.
    4. Two major sites of monkeypox outbreaks, both small, percolated in central and West Africa, with very occassional clusters of isolated cases in parts of the world where African rodents got taken in as pets, or someone with monkeypox traveled from one of these areas out of these areas.  Until May of 2022.
    5. Starting just last month, for the first time in recorded history, monkeypox started spreading across the world and from person-to-person with no contact with Africa.
    6. The world, in total, is up to about 3000 cases, across 50 countries, with over 100 cases in the US spread across 23 states, and still spreading.
    7. The World Health Organization this week announced that monkeypox does nottoday pose a major threat, but declared it is worth monitoring as if the spread continues, it could.
    8. Right now, the vast majority of cases outside of Africa are being transmitted as a sexually transmitted infection, mainly from men having sex with men, but there is nothing about the virus that forces it to stay that way.
    9. We hope of course the spread wanes and the strange emergence of monkeypox ceases, in which case there will not be much to say.
    10. Should it start spreading though and spreading to people via casual, not sexual, contact, and spreading much more, and spreading to kids, then we will need to think about starting to use smallpox vaccine once again and make drugs that treat monkeypox available.  But not now.

    Monkeypox is spreading, to about 3000 people worldwide for now, let us hope it wanes, but if it spreads much more, we have vaccine and medication that can stop it, if used in time.

    Humanity has another chance to respond to a known emerging threat, we are doing the right thing watching it carefully.  Let us hope health authorities here at home and around the world do their job well this round, test and track all infections now, and get the vaccine and medications needed to those who need if and when it is needed!

    To your health,
    Dr. Arthur Lavin

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