Monkeypox 2024: a new pandemic?

Monkeypox, which is now called Mpox, is not a new disease. It was first discovered in 1958 in monkeys kept for laboratory research, and later in humans in 1970. Until 2022, cases of monkeypox were identified yearly, but in very limited numbers and just in a few countries in Africa. Some cases were also diagnosed outside Africa, but always with a travel link to the continent. In 2022, the monkeypox situation exploded with cases in more than a hundred countries, mostly in Europe and the Americas. Pakistan also identified nine of these cases in 2023 and registered one death. That was a new situation where a disease that was localised for fifty years suddenly exploded in a hundred countries. Luckily, 2022 monkeypox cases were from Clade 2 (group 2) of the monkeypox virus, which is a mild form, but through evolution it became more transmissible.

In September 2023, a new variant was identified. This change was in Clade 1, which is endemic in the Democratic Republic of the Congo. The new variant is now called Clade 1b, and with this change, it has become deadlier and more transmissible. In 2024, Africa registered 15,000 cases and 550 deaths. More than 20 countries have reported Mpox cases in 2024, including three cases in Pakistan. The rapid spread of a deadlier version of Mpox necessitated the WHO to declare a Public Health Emergency of International Concern (PHEIC) so that countries and international organisations could quickly mobilise resources to effectively control the epidemic.

Though most patients will recover from Mpox in 2 to 4 weeks, there are some vulnerable groups too. Young children, pregnant women and immunocompromised patients are at a higher risk. As most of the Clade 1b patients are coming from the DRC, the initial data is suggesting 70% of patients and 90% of deaths are under 15 years of age. The disease cycle starts with fever, rash (which is similar to chickenpox), and swollen lymph nodes, especially in the armpits. Vulnerable groups could protect themselves by avoiding interaction with those who may be sick. Do not use common towels, and keep the bedding and utensils separate from any suspected patient.

The most common question we come across is: will it be a repeat of the Covid-19 situation? There are some major differences. Monkeypox is an old disease, and the health sector has a lot of experience dealing with it, while Covid-19 was a new disease and our bodies, and our health care staff, did not know how to deal with it. As monkeypox comes from a family of smallpox diseases, the vaccines against smallpox are effective against monkeypox too. However, at least one vaccine is not recommended for people under 18, while 70% of initial cases of Clade 1b are under 15 years of age. But still, we know how to develop vaccines for it. Covid-19, initially and later more effectively with new variants, was being transmitted by our breaths and the surrounding air. Also, around 50% of Covid-19 cases never showed any symptoms, so they were spreading the disease without knowing. In contrast, monkeypox is still predominately spread by droplets and very close face-to-face contact or by touching the patients' affected areas. So controlling the spread is much easier; however, we also know that a certain number of monkeypox patients become infectious one to four days before their own symptoms start.

So yes, Mpox will spread to more countries in the coming months but may not be at the level of Covid-19 spread in the initial months. But as the virus has evolved in September 2023 to become more infectious and deadlier, there is no guarantee that it will not do the same in the future. If that happens, we will need to revise our projections.

There is a simple way out. Set up 'Health Intelligence Systems' which should go beyond last century-modeled disease surveillance systems. Viruses are not waiting in a queue to start new pandemics, and we may face multiple threats at any given time. Our current public health measures are based on the world a hundred years ago, and they are not working in today's fast-paced world. Time of change is NOW!