Monkeypox: A public health emergency in Brazil

In Brazil, there were 10,195 notifications of cases related to monkeypox, a growth of more than 219%. Of this total, 3,040 (29.8%) were classified as confirmed and 176 (1.7%) as probable. At least one confirmed case was registered in 229 municipalities in the country. Most confirmed cases are in the state of São Paulo, with 1,748. Next comes Rio de Janeiro (278), Minas Gerais (102), Distrito Federal (92), Paraná (52), Goiás (53), Bahia (25), Ceará (9), Rio Grande do Norte (8), Espírito Santo (7), Pernambuco (13), Tocantins (1), Acre (1), Amazonas (5), Pará (1), Paraíba (1), Piauí (1), Rio Grande do Sul (29), Mato Grosso (2), Mato Grosso do Sul (8), and Santa Catarina (22).^1,3,4

In this context, the low testing capacity impairs the identification of cases and, consequently, the control of the spread of the virus. Today, the country has only four places for testing suspected monkeypox samples. All are in the Southeast. The Adolfo Lutz Institute (in São Paulo), the Oswaldo Cruz Institute and Federal University of Rio de Janeiro - UFRJ (both in Rio de Janeiro), and the Ezequiel Dias Foundation (in Belo Horizonte) are part of the diagnostic reference network. Reference labs are in a backlog of demand because they are dealing with two public health issues at the same time: COVID and monkeypox.² If there is no recognition by the Ministry of Health for other laboratories to carry out the analysis, there may be a damming of the data. In this situation, there is an alert for the risk of lack of reagents used for testing, as Brazil has been facing difficulties for months in importing medical supplies.³ Although monkeypox has a lower transmission capacity than COVID, its control depends on the increase and capillarity of testing in the country. To increase the level of alert and surveillance, the Ministry of Health activated the Emergency Operation Centre, with the objective of preparing a Contingency Plan for the disease for the Unified Health System (Sistema Único de Saúde - SUS).^1,3 At the time of writing this manuscript, Brazil is the third country with the most smallpox cases in the world. What no one expected is the so-called sustained – or community – transmission of the monkeypox virus from one person to another, increasing the number of cases.⁴

It is paramount that the Brazilian authorities also become aware of the public health emergency, the recommendations and the appropriate measures.^1,4 The greatest risk of complications in children occurs because they do not yet have a fully formed immune system.⁵ What is observed in Brazil is the little attention given to neglected diseases, the increase in the mobility of people with the end of restrictions related to COVID, the lack of immunity of the population against the viruses of this family, a pattern of transmission and a mixture of all.^1,4 An important fact to mention is that monkeypox unfolds at a time when most restrictions related to the COVID-19 pandemic have been completely abandoned by countries. With each year since the eradication of smallpox from monkeys, the population with little or no immunity against this group of viruses has only increased.⁶

The scenario in Brazil is worrying. If the population is not properly oriented and professionals are not trained for the correct recognition and early isolation of cases, the situation can worsen.⁷ Experts suggest that Brazil declare a Public Health Emergency of National Interest (Emergência de Saúde Pública de Interesse Nacional - ESPIN), a health legislation that facilitates the hiring of people, the establishment of a diagnostic network, and the purchase of vaccines and medicines. While other countries have already started vaccination and have repositioned antivirals for more severe cases, Brazil still has none.1, 2, 3, 4^,7 In a recent publication in The Lancet Regional Health- Americas, Rodriguez-Morales et al., (2022)⁸ warned that, despite the absence of specific therapeutic alternatives for monkeypox, drugs with proven experimental efficacy and potential clinical impacts, such as cidofovir (especially its lipid conjugate brincidofovir) and tecovirimat, are not widely available in Latin America.

The warnings so far given by the Brazilian public authorities are not enough to put the population on alert. A campaign with information on how people can defend themselves against the monkeypox virus is missing. But how to know who is the carrier of the disease? It is a question that disturbs the tranquillity of the Brazilian population.⁹

Contributors

PSG, LS, MFN, JEBA, JGJ, APSM and MLRN: conceptualisation; data curation; formal analysis; funding acquisition.

BFO, LMA, PCPA, PSF and MLRN: Investigation; methodology; project administration; resources.

PSG, LS, JEBA and MLRN: writing-review & edition.

Declaration of interests

PSG, the corresponding author of this manuscript, certify that the contributors' and conflicts of interest statements included in this paper are correct and have been approved by all co-authors.