A journey on the trail of Mpox, the so-called monkeypox, declared a global health emergency by the WHO. Published by the portal of the scientific magazine ‘Science’, signed by Jon Cohen and Abdullahi Tsanni.
The beginning
Port Harcourt University Hospital, southern Nigeria, May 1, 2017: A 35-year-old man with lesions all over his body and a deep ulcer in his private parts comes to the attention of dermatologist Bolaji Otike-Odibi. Tests and her experience lead her to rule out chickenpox, syphilis and other infectious diseases. “It was something we had never seen before,” Otike-Odibi recalls. The specialist collects the man’s sexual history, which includes having had multiple partners and a condom that broke during intercourse a few days before the sores appeared. During his 45 days in hospital, a second man comes with similar lesions, and a similar sexual history, who is also HIV positive. “We were worried it was an epidemic,” says Otike-Odibi. Months pass, the doctors see two more patients, same profile. “I took photos, collected their stories,” says Otike-Odibi.
How the virus circulated in silence
A reconstruction of how the virus circulated silently in Nigeria from 2017, for years. A crucial step to understand how we got to today, the second declaration of a global health emergency (PHEIC) in two years by the World Health Organization for this pathogen. Otike-Odibi realized that his mystery patients must have had the same disease in September of that year, when others with similar symptoms began to flock to a teaching hospital in Yenagoa, the capital of Bayelsa State, a 3-hour drive west of Port Harcourt. Many were young men with genital lesions and many also had HIV. Eventually, tests revealed that they had monkeypox, a viral disease documented in Nigeria only three times until then. Five years later, monkeypox exploded into a global epidemic, mainly in men who have sex with men (MSM). This is the time of the first declaration of Pheic by the WHO, which renamed the disease ‘Mpox’ to avoid stigma. Pheic was revoked in May 2023 after cases collapsed, but so far almost 100,000 people have been infected in 116 countries.
The diffusion
Returning to the Nigerian case, it turns out that the virus had been spreading under the radar there for at least 2 years before Otike-Obidi saw the 4 men with the lesions. Many questions remain. Why did the Nigerian outbreak fail to raise international alarm? Why did sexual transmission, undocumented before 2017, go unnoticed? And could this outbreak have been stopped before it went global? The authors feel it is urgent to answer these questions and learn lessons from what has happened so far, given that a separate Mpox outbreak has broken out in the Democratic Republic of Congo (DRC) this year, where the new, more lethal variant being talked about these days (clade 1b) passed through a mining town, circulating among men visiting prostitutes, then spread to Goma, a city of almost 2 million, and related cases have emerged in the past month in neighboring countries Uganda, Burundi, Rwanda and Kenya, none of which had ever seen Mpox before. Then, on August 15, Sweden, in Europe, reported a case: a person who had traveled to Africa.
The origins
The virus has come a long way. The origins of it all go back decades and decades. Mpox was initially improperly named monkeypox after being discovered in Asian monkeys by a Danish laboratory in 1958. But the natural hosts of the virus, a relative of smallpox, are mainly small rodents that live in forests in Africa, such as Gambian marsupial rats, squirrels, and dormice. Epidemics begin when people come into contact with these animals, the two authors retrace. The first human case was detected in 1970 in the DRC: a 9-month-old child. “Evidence indicates that this rare and sporadic disease is not highly transmissible and does not appear to be a public health problem,” concludes a 1978 WHO report.
In 1980, meanwhile, the UN agency declared smallpox (caused by the Variola virus) eradicated and a global commission announced that vaccination against this virus could also be concluded. Could the vaccine in question have somehow acted as a shield against the rise of Mpox? For the experts, perhaps yes. Between 1981 and 1986, an intensive surveillance program led by the WHO led to the identification of 338 people infected with Mpox in the DRC, the variant identified is ‘Congo Basin’, renamed clade 1 in 2022 to avoid stigmatizing the region. Estimated mortality rate of 10%, compared to 1% for clade 2. However, Mpox epidemics have always petered out, even a surge recorded in 1996 that lasted more than 1 year.
In 2003, however, epidemiologist Anne Rimoin of the University of California at Los Angeles, who began collaborating with a team led by microbiologist Jean-Jacques Muyembe, hypothesized that there were probably many more Mpox infections in the DRC and that no one was seeing them. Rimoin was right: the incidence in the DRC continued to rise dramatically. More than 90 percent of those affected had never received a smallpox vaccine.
When the picture changes
The picture really changed in 2017, however, with the epidemic that emerged in the state of Bayelsa in Nigeria, the authors of the report reconstruct. The first suspected case was an 11-year-old boy, who seemed to have a serious form of chickenpox. But after him, other patients ended up at the attention of doctors in hospital, showing that a serious outbreak was underway. As the epidemic intensified, fear and stigma also grew, as evidenced by the stories of some patients. Infectious disease specialist Dimie Ogoina, looking at the situation in that key year, was perplexed: until then he had read that Mpox outbreaks were dying out, but here it didn’t seem like that. Is the virus moving from person to person? And how? Two-thirds of the Mpox cases confirmed in the laboratory involved adults, with men affected twice as often as women. However, at that time the Nigerian Center for Disease Control Ncdc concluded that there was still no evidence of “sustained” human-to-human transmission.
Ogoina begins to suspect the sexual route, but does not receive encouragement to investigate further, rather criticism. This possible mode of transmission is therefore only mentioned in a work published in ‘Plos One’ in 2019. Then the Nigerian epidemic seems to fade. In the meantime, other warning signs emerge, until May 2022 when cases of Mpox begin to appear in Portugal, Spain, the United Kingdom, almost all in MSM. The spotlight turns on. Studies continue, evolutionary biologists Áine O’Toole and Andrew Rambaut of the University of Edinburgh publish an analysis, concluding that there has been sustained transmission from human to human “at least since 2017”. Some experts today argue that the world should have paid more attention to Ogoina’s findings in 2017. Now, however, the nature of the epidemic is clear, its dynamics are clearer. While the new variant of clade I knocks on the world’s doors, there is less fog.
Africa CDC Director-General Jean Kaseya, who separately declared a continent-wide public health emergency to strengthen countries’ “collective will” to create a joint action plan, said more support was needed during the first PHEIC. When that emergency was declared over, “Africa’s cases continued to rise and we are now facing the consequences of not having adequate care,” he said. “If we don’t address MPOX the way we need to, we could be surprised” by the virus, he warned.
#Monkeypox #Heres #Virus #Silence
