With over 20,000 confirmed cases of monkeypox, what do we know about the outbreak?

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With over 20,000 confirmed cases of monkeypox, what do we know about the outbreak?

Also called monkeypox (simian orthopoxvirus), this disease was first detected in the 1950s, when two outbreaks occurred in colonies of monkeys used for research purposes. The first human case was reported in 1970 in the Democratic Republic of Congo (DRC).

A week after the World Health Organization (WHO) declared the current monkeypox outbreak a global health emergency, the number of cases has topped 20,000. Here are seven questions to understand the state of the situation.

No. Dr. Darrel Tan, infectious disease specialist at St. Michael's Hospital in Toronto, and Dr. Sapha Barkati, assistant professor in the Faculty of Medicine and Health Sciences at McGill University, are of the opinion that the number of cases is probably grossly underestimated.

If, at the beginning of March, we discovered a handful of cases each day, we have recorded more than 500 on average per day since mid-July.

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According to the United States Centers for Disease Control and Prevention (CDC), of more than 20,000 confirmed cases, 98% are in countries that historically had no cases on their territory. The epidemic is now present in 78 countries. Only seven of these countries had observed cases of monkeypox in the past.

The United States, Spain and Germany are the countries with the most confirmed cases . Canada, with 803 cases (as of July 29), is among the top 10.

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On Friday, Brazil and Spain each reported their first death from monkeypox; these are the first deaths outside of Africa, where the virus is considered endemic.

Drs Tan and Barkati add that not enough testing is done and contacts are often unknown, making tracing difficult to achieve.

We are already seeing that the time between test and result is too long, adds Dr. Tan.

And as with COVID-19, some infected people may be asymptomatic yet contagious, blurring the picture.

Others have very mild symptoms that may be confused with other types of lesions. In some people, the lesions look like acne or a mosquito bite.

In fact, according to a study published last week in the New England Journal of Medicine, co-authored by Dr. Barkati, 39% of over 500 cases analyzed in 16 countries had less than 5 lesions and 25% had between 5 and 10.

Dr. Barkati adds that in some cases the diagnosis may not be correct. To date, monkeypox is a disease that physicians in Europe and North America have rarely seen, Dr. Barkati recalls, although physicians are increasingly aware of the symptoms to look out for.

All this contributes to the increase in cases, because these people will continue to transmit the virus to others, without knowing it, says Dr. Tan.

The WHO reports that 99% of all infections outside of Africa were in men and of these, 98% were in men who have sex with men.

Dr. Barkati's study also found that 98% of those infected were gay or bisexual, 75% were white, and 41% had already been diagnosed with HIV. In approximately 30% of cases, sexually transmitted infections were reported.

The most common symptoms before lesions appeared were fever (62%), lethargy (41%), muscle aches (31%) and headaches (27%); and lymphadenopathy (palpable enlargement of lymph nodes) (56%).

However, the study noted that while the current epidemic disproportionately affects men who have sex with men, monkeypox can affect anyone and spread to many places. ;other populations is to be expected.

In fact, Dr. Barkati points out that cases have been confirmed in other demographic groups. In particular, there have been infections in children in the United States and Brazil. Spain reports around 70 women out of the approximately 4,000 cases. In Texas, a pregnant woman was infected.

” You have to be careful; it is not a disease specific to the LGBTQ+ community. This is why the outbreak must be contained; we don't want it to overflow and affect even more bands.

— Dr. Sapha Barkati, McGill University

Dr. Tan says the answer is unclear, but there are some assumptions. According to him, it is probably a combination of circumstances.

Seeing what is happening, the logical conclusion is that there is an element of chance that led to someone from the LGBTQ+ community becoming infected at the start of this outbreak. And then, this person was part of a network that has connections around the world.

According to Dr. Barkati, an infected person likely brought the virus into a situation with lots of close contacts. These people then returned to their country and it settled elsewhere. In fact, 28% of those infected had traveled in the month before their diagnosis, his study shows.

For example, experts suspect that the spread of the virus in Europe and in North America could have been triggered during two raves in Belgium and Spain.

According to Dr. Tan, the fact that the majority of cases are in the LGBTQ+ community cannot be ignored, but extreme care must be taken not to stigmatize this group.

Dr. Darrel Tan, infectious disease specialist at St. Michael's Hospital in Toronto

Wednesday , the WHO director advised men at risk to reduce the number of sexual partners for the time being.

However, several experts, such as Dr. Tan, fear that this kind of message from the authorities may cause many people to consider this virus as a homosexual disease that poses no risk to them.

The same mistakes as with the HIV pandemic should not be repeated, says Dr. Tan. Gay men, in particular, have endured stigma from the start of the HIV/AIDS pandemic, when the disease was widely considered a "gay disease".

For her part, Dr. Barkati fears that people will be reluctant to seek care for fear of stigma, which will inevitably lead to more transmission.

Scientists believe that the main route of transmission is skin-to-skin contact with a person who has symptoms. The virus can also spread through mucous membranes, saliva, and respiratory droplets during prolonged face-to-face contact, such as kissing and hugging.

It is also possible to become infected by touching objects that an infected person has touched, such as towels or sheets.

Is it possible that it is transmitted by aerosols ? Yes, but it is not an important mode of transmission. If so, we would have seen clues by now, says Dr. Tan.

Dr. Barkati adds that it is not certain whether the virus is sexually transmitted. In fact, since the first human case in 1970, monkeypox has never been recognized as a sexually transmitted disease.

In her study, she notes , genetic material of the virus has been found in the semen and other bodily fluids of infected people. However, she points out that it is not yet known whether the virus in these bodily fluids is active and whether it can replicate. One should not jump to conclusions.

The British Medical Journal pointed out last week that some observations indicate a new clinical course of the disease and that some symptoms have changed.

Scientists are trying to understand why human-to-human transmission seems be done so easily right now. Is the virus more transmissible? Has he adapted to us? […] And just because a symptom was not reported in the past doesn't mean it didn't exist…

Dr. Barkati reminds us that this virus has been neglected for a long time by the international community and that there is still a lot that we do not know.

Imvamune contains a weakened strain of vaccinia virus, which elicits the immune response needed to fight smallpox and monkeypox.

The Imvamune vaccine, from the Danish company Bavarian Nordic, was approved by Health Canada in 2013 for immunization against smallpox. In 2020, Canadian authorities expanded this approval to include immunization against monkeypox.

As of July 23, 2022, the Government of Canada has distributed over 70,000 doses . Just over 1,300 doses were administered in Montreal alone.

The limited amount of vaccines and drugs to treat this disease is one of the reasons why experts want to limit the spread of the virus.

According to the CEO of Bavarian Nordic, there are, currently, approximately one million doses available in the United States, as well as one million doses worldwide.

There aren't enough. It will be very difficult to intervene if transmission continues, fears Dr. Tan.

The United States has already distributed some 340,000 doses to states, and the country has ordered an additional 5.5 million doses of vaccine for the coming year. The number of doses administered is not known, but vaccination clinics in San Francisco, New York and Washington have had to temporarily close, due to a lack of doses.

That's why some health authorities, including those in Ontario and the UK, are offering only one dose to preserve limited supplies.

Studies have shown that the immune response after one dose remains elevated for at least 2 years.

In the face of rising cases and the limited supply of vaccines, Dr. Barkati is d& #x27;not to panic. However, she believes that by declaring a global emergency, the WHO has issued a warning to states that the situation must be taken seriously and that mitigation measures must be intensified.

In particular, she wants intensified surveillance, testing, contact tracing, vaccination of people at risk and isolation of infected people.

Dr Tan hopes that this statement will push more elected officials to provide more funding, not only to organizations that work to educate and assist the public, but also to help infected people isolate themselves. Remember that a person infected with monkeypox must self-isolate for at least 21 days.

We have seen during the COVID-19 pandemic the importance of providing time off disease if we want to limit the spread of the virus in the community. In my experience, people who are infected with COVID-19 or monkeypox want to isolate themselves to protect their families, their loved ones. But often they can't because they don't have the type of job that allows them to telecommute or that doesn't offer them compensation if they have to be absent for several days.

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