Monkeypox is a zoonosis caused by a virus belonging to the genus orthopoxvirus and endemic to western and central Africa. The disease is making headlines worldwide because of a growing number of cases being reported from North America and countries in Europe and Oceania. As of June 2, 780 laboratory-confirmed cases of monkeypox had been reported to or identified by WHO from 27 member states across four WHO regions that are not endemic for monkeypox virus. Although no deaths have been reported (but deaths continue to occur in endemic countries), there is concern for the atypical emergence of monkeypox in countries where the disease had not been reported before and in individuals who have not travelled to endemic countries. Probably scarred by the ongoing COVID-19 pandemic, the media coverage of the monkeypox outbreak has incorrectly suggested that it might be the next pandemic, which is far from reality.
The first human monkeypox case was reported in 1970 and over the past five decades, several African countries have seen monkeypox outbreaks. Just this year, WHO has received reports of 1365 cases and 69 deaths due to the virus from five endemic African countries. The disease has a mortality that varies between 1% and 10%, depending on the clade, and children, pregnant women, and immunocompromised individuals are at high risk for negative outcomes. Since smallpox vaccination provides partial protection against monkeypox, its cessation over 40 years ago when smallpox was eradicated means that anyone younger than 50 years is not benefitting from that kind of protection and in fact the recent cases in non-endemic countries have been in the youngest age bracket. So far, the strategy to contain monkeypox outbreaks has relied on educating people on the disease and finding cases early to reduce the likelihood they transmit the virus. But, as described in an Article by Hugh Adler and colleagues that we published on May 24, some experience in the use of antivirals in managing monkeypox cases is emerging.
Although the investigation on the current global oubreak of monkeypox is still ongoing, it seems likely that viral transmission might have started in crowded public events in Spain and Belgium. Human-to-human transmission had already been reported in Africa, but its occurrence at a large scale in non-endemic countries caught the world by surprise. Researchers in endemic African countries have, however, expressed dismay for what appears to be an obvious double standard: whilst monkeypox was a just problem of sub-Saharan Africa, the disease had not received any attention, but as soon as cases started appearing in high-income countries, the rest of the world took note. African populations have coexisted with monkeypox virus for decades and it is time that research is done to address the needs of endemic countries. Moreover, the emergence of new zoonoses and their potential spread at the global level is something we need to be prepared for. With deforestation, migration, and conflict, the contact between human populations and wildlife is becoming more common and such proximity will favour spillover of zoonotic pathogens. What is currently missing is knowledge of what pathogens might emerge and an adequate investment in surveillance.
On June 2–3, WHO organised a consultation of experts from all over the world to define priority areas for the management of the current outbreak of monkeypox and key objectives for future research. Better diagnostic tools, better engagement with local communities, a more comprehensive One Health approach, and research on vaccines and therapeutic agents were identified as priorities.
Will the sudden attention given to monkeypox bring some benefits also for endemic countries? There is hope that this is the case. A study on the impact of smallpox vaccination on monkeypox cases among health-care workers is ongoing in DRCongo, and another study will monitor expanded access to tecovirimat, the only antiviral drug licensed for treating monkeypox, in the Central African Republic. In the meantime, the long experience in dealing with monkeypox from African doctors should be acknowledged and be an integral part of the discussion moving forward.
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