Monkeypox business - virus development and risk to travellers

Keeping on top of public health trends

For travel assistance companies such as World Travel Protection (WTP), preparing staff to manage new public health emergencies such as monkeypox is a priority – in particular, keeping them on top of the latest trends in infection rates, at-risk communities and regions, as well as the best responses and prevention strategies.

Dr Joel Lockwood, Regional Chief Medical Officer, Americas, for World Travel Protection (WTP), explained that ‘this vital information is in turn shared with travellers, especially those at increased risk of exposure and infection – whether they are part of an at-risk group or traveling to a destination where the prevalence of monkeypox is high’.

Fundamental to properly managing the crisis is understanding the nature of how it is developing, and what makes the circumstances surrounding it exceptional. Lockwood added: “While monkeypox is rarely fatal, health authorities are concerned about spread of the virus into countries that have not historically reported monkeypox. Until recently, it was considered a rare disease, typically reported in people in Central and Western Africa. Now … the latest figures [are] leading health authorities such the WHO and the US Department of Health & Human Services, to declare monkeypox a public health emergency.

At time of writing, the 10 most severely affected countries outside Africa include Brazil and Spain – where the first three non-African monkeypox-related deaths were reported on 29 and 30 July - as well as Canada, France, Germany, Italy, the Netherlands, Portugal, the US, and the UK.

Despite the list being dominated by countries in the Americas and Europe, cases have been reported across the Asia-Pacific region as well. Africa also remains a hotspot for the virus. Those seeking up-to-date statistics on case numbers in a specific country would do well to visit the US Centers of Disease Control and Prevention’s (CDC) Monkeypox Outbreak Map at www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html.

Recognising symptoms and avoiding infections

For Lockwood, recognising the symptoms of monkeypox is key to helping travellers avoid contracting the disease. “Symptoms generally start five to thirteen days after exposure to a person with the virus. Those who are infected develop fever and chills, fatigue, and body aches,” he said.

“A few days later, the hallmark rash tends to appear with multiple small flat, red, painful lesions. The lesions, in turn, change to form blisters, which then break and crust over. The rash can appear anywhere on the body but is most common on the face, hands, and genitalia. For most people, symptoms of MPV last two to four weeks. Those infected with MVP are considered contagious until their symptoms have improved, their rash has resolved, and all of the scabs have fallen off,” he added.

In comparison to Covid-19, monkeypox has a lower potential for transmissibility, due to its reliance on close physical contact and ‘fomite’ surfaces – objects which have come into contact with an infected person. Nevertheless, precautions can be adopted to avoid infection where possible. According to Lockwood, who quoted CDC guidance, travellers visiting locations with known monkeypox outbreaks should:

• Avoiding close contact with sick people, including those with skin or genital lesions
• Avoiding contact with live or dead wild animals, such as monkeys, apes, rats, and squirrels
• Avoiding eating or preparing meat of wild game
• Avoiding contact with materials recently used by sick people, including clothing, bedding, and eating utensils, and
• Practicing good hand hygiene by washing your hands with soap and water (ideally for at least 20 seconds) or using an alcohol-based hand sanitizer.

“Travelers should consider not only the risk of contracting MPV, but also the considerable stress and inconvenience of travel plan changes should they test positive or become a close contact. Current guidelines vary by region but require those infected with MPV to isolate for up to 28 days,” he said.

However, as a caveat, he added: “In comparison to Covid-19, current case counts for monkeypox remain relatively low. However, it is important to keep in mind that health authorities and clinicians around the world are still learning about the unprecedented spread of the virus, which until recently, had rarely spread outside of Western Africa. Travelers and those working in travel assistance industries are wise to stay vigilant to assess ongoing risk.”

Dr Charlie Easmon, CEO of London-based private healthcare provider Your Excellent Health Service (YEHS), added that: “Monkeypox for many years was mainly limited to Africa but international travel has changed that. It is now thought to spread amongst humans mainly skin to skin, and the first communities in the West to be affected quite heavily were those in which men engaged with frequent sex with men. However, now any of us is at risk. The preventative strategies are less skin contact with strangers and the use of the limited supplies of smallpox vaccine. People with monkeypox ideally should isolate and not travel. They should avoid skin contact with other people and should not share their towels and bedlinens for a period of at least one month after their infection started.”

The race for a vaccine – has already been run, 200 years ago

For most, the memory of the coronavirus pandemic looms large in their minds when news reports talk about the growing concern surrounding monkeypox. However, it will come as a comfort to many that whereas a vaccine for Covid-19 took almost a year between the disease being declared a PHEIC in January 2020, and the announcement of viable vaccine in December of the same year, there is evidence that monkeypox can be treated using existing vaccinations.

In their guidance regarding monkeypox, the CDC noted that: “Past data from Africa suggests that the Smallpox vaccine is at least 85 per cent effective in preventing monkeypox. The effectiveness of JYNNEOS (a popular smallpox vaccination) against monkeypox was concluded from a clinical study on the immunogenicity of JYNNEOS and efficacy data from animal studies.”

Easmon explained: “In my medical school library at St George’s University Hospital there used to be a framed cow skin, to commemorate Dr Edward Jenner who introduced smallpox vaccination to the world. Jenner had noticed that milk maids got a disease called ‘cowpox’ from the udders of the cows – but this protected them from the far more deadly and disfiguring smallpox. So, an attenuated version of a cowpox virus is what we used then for smallpox and what we now use again against monkeypox (the ‘vacc’ part of vaccination refers to the cows).”

This works because all three viruses – smallpox, monkeypox and cowpox – are members of the same close-knit group of diseases, which are part of the Orthopoxvirus genus of the Poxviridae family of viruses. Easmon explained: “In the case of smallpox these were overwhelming and could cover the whole body and leave horrendous, long-term scars if you survived and many did not as the death rate was very high.” By contrast, Monkeypox has a relatively lower fatality rate than smallpox (estimates vary between three to six per cent).

The CDC also said that while smallpox and monkeypox vaccines are most effective at protecting people from monkeypox when administered before exposure, ‘experts also believe that vaccination after a monkeypox exposure may help prevent the disease or make it less severe’. They recommended getting the vaccine within four days of the date of exposure in order to prevent the onset of the disease, but added that if administered within a fortnight of exposure, vaccination may still reduce the symptoms of the disease.

Jason Mercer, a Professor of Virus Cell Biology at the University of Birmingham’s School of Biosciences, speaking to the MIT Technology Review on 3 August, argued that the similarities between pox-related viruses was so strong that the end of widespread smallpox vaccinations in the late 1970s following the elimination of smallpox may have contributed to the emergence of other pox-related viruses, such as monkeypox.

“Since smallpox vaccination was stopped, the frequency and size of monkeypox outbreaks in both endemic and non-endemic countries has increased every decade. [There is] a worldwide population of individuals under 50 years old that are susceptible to infection with poxviruses,” Mercer said.

Other recommendations for treatment

Individuals who display symptoms and have travelled to areas with known outbreaks, or who have come into close contact with a known positive case, should seek out confirmatory testing from a medical professional. A positive test will alert local public health authorities to begin contact tracing, in an effort to curb the virus’s spread.

According to Lockwood, ‘most healthy people who are infected with MPV have mild symptoms that require only supportive treatment, including paracetamol or ibuprofen, and do not require hospitalization’. For more severe cases, ‘antiviral therapy’ may be employed, including for those with ‘advanced cancer, HIV’ or [undergoing] organ transplants’.

“In some jurisdictions, for high-risk groups, the vaccine may be offered after a high-risk exposure is identified or for prevention in certain populations. Currently, supply of the vaccine may be limited in some jurisdictions, such as the US, as health authorities work to meet demand. In the UK, the Department of Health and Social Care has commenced vaccination for those at risk of infection, including the LGBTQ+ community,” Lockwood added.

Conclusions

While the current wave of monkeypox remains a concern, due to rising case numbers worldwide, individuals and companies can take a range of precautions to mitigate the possibility of infection. Recognising the symptoms and being aware of where the virus is currently prevalent are key to reducing the impact of monkeypox.

Additionally, unlike other recent health crises, the surge in monkeypox cases can be combatted through the production of existing vaccinations, which offers a ray of optimistic sunshine regarding our ability to manage the spread of the disease.