Explained: Second case of monkeypox confirmed in Kerala, is there a risk of an outbreak in India?

The first case of the disease was reported on July 14 — a 35-year-old person who returned from UAE. A high-level multi-disciplinary central team was sent to Kerala to collaborate with state authorities in implementing public health measures.

An alert has been sounded in all 14 districts, and help desks have been set up at all four airports in the state.

How widespread is the outbreak globally?

Since early May, monkeypox has been spreading rapidly around the world, mainly among gay and bisexual men, who often present with rashes in the genital and anal area that doctors may confuse with herpes or syphilis.

The WHO has said that a multi-country outbreak is currently underway, including in places where the disease has not been typically found before — in Europe, the Americas, Africa, the Western Pacific, and countries of the Eastern Mediterranean. Even in those parts of Africa where cases have been previously reported — Nigeria, Democratic Republic of the Congo, Central African Republic — the incidence of infection in 2022 has been higher than usual.

Out of 11,500 confirmed cases globally so far, 1,469 are in the United States and 1,856 are in the UK, Reuters reported on Monday. The largest number of cases were in Spain — nearly 2,500.

In a separate report, Reuters said that the European Commission has secured about 54,000 additional doses — after an initial supply deal for 110,000 doses — of a monkeypox vaccine developed by the Denmark headquartered biotech firm Bavarian Nordic.

“I am concerned by the increasing number of monkeypox cases in the EU,” the report quoted the EU health commissioner, Stella Kyriakides, as saying. Kyriakides said there were now over 7,000 cases of the infection in the EU, a nearly 50% increase from last week, according to the Reuters report.

So is there now a danger of a worldwide public health crisis from monkeypox?

No. Monkeypox is a largely self-limiting disease — which means it will resolve itself on its own, and will leave no long-term harmful effects on a patient’s health. Most children and adults with healthy immune systems will not, even if they are infected, come down with severe illness.

The smallpox vaccine, with which older Indians have been immunised over the past decades, works against monkeypox, and provides long-lasting immunity. Smallpox was eradicated in India in 1977.

“The bottom line is that even those that were vaccinated many decades before maintain a very, very high level of antibodies,” The New York Times quoted Dr Luigi Ferrucci, scientific director of the National Institute on Aging, as saying. “Even if they were vaccinated 50 years ago, that protection should still be there.”

But that said, certain groups are more vulnerable to the infection, which can present some difficult phases, especially if it infects the lungs and eyes.

“The high risk group comprises children, pregnant women and immune-compromised patients, including those who have diabetes. They can have more severe consequences compared to others,” Dr Pragya Yadav, the top scientist at the ICMR-National Institute of Virology (NIV), Pune, and group leader of the maximum containment laboratory at the lab, told The Indian Express in a recent interview.

How does monkeypox spread?

Human-to-human transmission is known to occur primarily through large respiratory droplets. As such, transmission generally requires prolonged close contact with an infected individual.

The Union Health Ministry says monkeypox can also be transmitted through direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linen.

However, monkeypox is primarily a zoonosis, that is, a disease that is transmitted from infected animals to humans. Animal-to-human transmission is the primary way in which the disease has spread in Africa, but the conditions for such transmission would be rare in India.

The Health Ministry says animal-to-human transmission can happen through the bite or scratch of infected animals like small mammals including rodents — rats, squirrels, etc. — and non-human primates like monkeys and apes, or through bush meat preparation.

And what are the clinical features of monkeypox?

The monkeypox virus is an orthopoxvirus, which is a genus of viruses that also includes the variola virus, which causes smallpox, and vaccinia virus, which was used in the smallpox vaccine. Monkeypox causes symptoms similar to smallpox, although they are less severe.

Symptoms last between two and four weeks. During the first, prodrome phase (0-5 days), patients can experience one of five symptoms: fever; headache, muscle aches; exhaustion; chills and/ or sweats; and sore throat and cough, according to the Health Ministry.

Next, the Ministry says, patients experience rashes: this usually begins within 1-3 days of the onset of fever, and lasts for around 2-4 weeks. “Lesions are often described as painful until the healing phase when they become itchy,” the Ministry says.

According to the Ministry, skin rashes are more apparent on the limbs and face than on the trunk. “Notably the genitalia can be involved and can be a diagnostic dilemma in STD population,” the Ministry says.

The case fatality ratio of monkeypox has historically ranged from 0 to 11% in the general population and has been higher among young children. “In recent times, the case fatality ratio has been around 3-6%,” the Health Ministry says.

What is the treatment for monkeypox?

There is no proven treatment for monkeypox yet. The WHO recommends supportive treatment depending on the symptoms. Those infected are advised to isolate immediately.

According to the Ministry of Health guidelines on supportive management of monkeypox, skin rashes should be cleaned with simple antiseptic, and covered with light dressing in case of extensive lesions. Oral ulcers should be managed with warm saline gargles.

Doctors say monkeypox is a very well-understood condition that can be managed efficiently with available clinical remedies. “We urge individuals to not panic and most importantly, not confuse monkeypox with another common viral infection,” said Dr Hemlata Arora, Senior Consultant, Internal Medicine and Infectious Diseases, Nanavati Hospital.

No specific vaccine for monkeypox is widely available at the moment.

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