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Addressing questions, concerns, and misinformation about monkeypox

The recent monkeypox outbreak raises questions about the virus’ nature—and its potential to start another pandemic.

On the heels of the current COVID-19 pandemic, another virus threatens to disrupt lives and healthcare systems worldwide: monkeypox. Once considered a rare disease, monkeypox—as of the time of writing—has infected more than 31,000 people across 89 countries, many of which are ill-equipped to contain it.

With the world still grappling with COVID-19, the ascent of monkeypox transmission into a public health emergency of international concern (PHEIC), as declared by the World Health Organization (WHO), raises questions about the virus’ nature—and its potential to start another pandemic.

Starting points

Characterized by flu-like symptoms and pockmarks, monkeypox is a viral infection initially discovered in monkeys in the 1950s. Nearly 20 years later, the virus began infecting human hosts, particularly in West African countries such as the Democratic Republic of the Congo, Nigeria, and Sierra Leone. Since then, it began spreading among people through skin-to-skin contact and respiratory fluids.

Infectious disease specialist Dr. Mark Pasayan articulates that the recent worldwide reemergence of monkeypox could be related to the elimination of smallpox in the 1980s. With both viruses belonging to the Poxviridae family, those who received the smallpox vaccination in the 1950s and 1960s also got indirect protection against monkeypox. However, when distribution of the vaccine was discontinued, immunity against the viruses weakened, causing monkeypox’s return.

Clinical manifestations

Like any viral infection, monkeypox is preceded by an incubation period—the time between acquiring the virus and becoming symptomatic—of one to three weeks. Following this, infected people experience flu-like symptoms such as fever, body pain, and swollen lymph nodes, which last about two to four days.

Subsequently, skin rashes begin to appear, typically distributed on the face and extremities such as hands and feet. Initially, these rashes appear as flat pockmarks and develop into pimple-like lesions that further progress into vesicles—fluid-filled sacs on the skin. Eventually, this fluid turns into pus and the vesicles become pustules before drying out and ultimately turning into scabs. Despite this being the general progression of monkeypox symptoms, “it actually depends on how good your immune system is,” Pasayan adds. He emphasizes that if one’s immune system is “very good”, they can “easily control the virus” and that it is expected that there will be less skin lesions.

Though the symptoms may not seem life-threatening, monkeypox has a relatively high mortality rate of three to six percent. Nonetheless, Pasayan highlights that the usual cause of death is paired with other factors such as complications from the viral infection such as sepsis, poor access to healthcare, and a weak immune status or overall physical health.

Care and containment

Being a viral infection, monkeypox is self-limiting—it typically does not require antibiotic or antiviral treatment. However, Pasayan advises that patients increase their fluid intake and are given medication to treat other symptoms such as paracetamol for the fever and acetaminophen for the body pains.

But because of the recent outbreak, Pasayan says that the United States has released an antiviral medication that may be used as treatment for monkeypox called TPOXX. “However, I don’t think it’s approved already by our Food and Drug Administration for use nor is it even available [in the Philippines],” he notes.

To avoid further spread of the virus, Pasayan urges people to “make sure that if you are in a social gathering or in close contact with other people that are not sick or, better yet, avoid social gatherings because you will never know who you will be in close contact with in that event.” He also recommends that people wear masks to prevent transmission through respiratory fluids.

Comparisons to COVID-19

The turmoil brought about by the COVID-19 pandemic has caused many to worry about the implications of this rising monkeypox outbreak, especially now that it is a PHEIC. Even though the future of monkeypox is uncertain, the differences between monkeypox and SARS-CoV-2 suggest a path unlike COVID-19.

Pasayan imparts that monkeypox is a DNA virus while SARS-CoV-2 is an RNA virus. The former is more stable and is thus less likely to undergo several mutations as we have seen with the various strains of SARS-CoV-2. The infectious disease specialist also points out the differences in the affected body parts, “COVID-19 involves most commonly or if not entirely the lungs—the respiratory tract—while monkeypox is more cutaneous, or [involves] skin.”

Despite these differences, the two viruses share characteristics regarding their transmission and treatment. For example, both viruses can be transmitted through respiratory droplets. However, only SARS-CoV-2 has conclusive evidence of being airborne.

Furthermore, the two viruses are fortunately preventable through vaccination—a point that may bring hope for a more favorable future for monkeypox, especially since vaccines treating similar viruses have already been successfully created in the past.

Not a ‘gay disease’

Due to monkeypox’s entrance into the spotlight over the past few weeks, combined with messy public health messaging, misinformation and disinformation about the virus’ nature continues to circulate the internet. A particularly incorrect and damaging piece of misinformation about the virus being shared online is that it is a sexually transmitted disease (STD). This mistaken line of thinking is often maliciously used to label monkeypox as a “gay disease” due to a large proportion of those infected with it being gay men

Pasayan puts this notion to rest, “It’s not really sexually transmitted per se; you don’t get monkeypox because you transmit the virus through vaginal or seminal fluid.” He clarifies that while monkeypox is not sexually transmitted, the act of sex itself involves skin-to-skin contact, kissing, and contact with bed linens—all of which are routes of transmission for the virus.

In light of this, Pasayan says that the Research Institute for Tropical Medicine, where he works, has conducted several lay fora on the issue as not to stigmatize people in the LGBTQ+ community. “Whether you are gay or not, whether you are heterosexual, homosexual, as long as there is close contact [you can get monkeypox]—and having sex involves close contact,” he affirms.

The P word

With the global reach of monkeypox continuing to grow, an important question looms: could monkeypox grow into a new pandemic? “Any infectious disease…is an infectious disease with pandemic potential. We never thought [the] COVID-19 outbreak would turn into a pandemic until several cases were reported until almost all countries around the world reported cases,” Pasayan warns.

The infectious disease specialist confides that the only answer we have for now is “maybe,” but maintains that people can apply what the world has learned from the COVID-19 pandemic. In this regard, he stresses the importance of active surveillance, active case reporting, and isolation of infected persons. These, he says, are the key to curbing the current monkeypox outbreak. “If we put our guards high up again and prevent new cases in our country and even our community, then we can prevent monkeypox from becoming a pandemic,” he states.

By Jasper Ryan Buan

By Anceline Rhys Imson

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