Almost 20 days after the international health alert that uncovered the existence of the first major outbreak of monkeypox in non-endemic countries, which has already exceeded 800 confirmed cases, the news that invites optimism is mixed with other worrying in the findings of the first published studies on the origin of infections in Europe.
On the positive side, it is observed that almost all cases are mild and that the growth of diagnoses, although sustained, is far from being exponential. Very few infections are occurring outside of the practices that have caused most cases, such as group sex sessions or multiple relationships with strangers that facilitate the close contacts necessary for the virus to continue circulating. This fits with previous knowledge of the pathogen, that it is barely transmitted in most daily activities, and that being DNA, it is much more stable than RNA, prone, like the coronavirus, to mutations that increase its transmissibility. All this, together with the existence of effective vaccines and treatments, allows experts to look to a horizon, albeit a complex one, free from the great uncertainties experienced by the world at the beginning of the recent covid pandemic.
On the other side of the scale, however, important issues remain to be resolved. The monkeypox virus is known, but it has never been transmitted outside the endemic areas of Africa, as it is doing now. We must understand the reasons that have led to it and develop new strategies to contain the outbreak. One of those considered key, contact tracing to identify new cases and end the chains of contagion, is being very difficult “in contexts such as group sex”, collects a study published in the journal eurosurveillance on the first 86 cases diagnosed in the UK.
“Several cases declined to share the personal data of their sexual contacts or reported having had multiple relationships with strangers. This makes public health actions and the calculation of secondary infection rates difficult”, the authors explain.
The United Kingdom is one of the countries most affected by the current outbreak, with 225 confirmed cases. It is followed by Spain, which this Friday has reported 30 new infections (up to 186) and Portugal, with 143. The three account for nearly three-quarters of the cases in Europe, although diagnoses are also growing in Germany (65), the Netherlands ( 40), France (33) and Belgium (14), according to data available in the early afternoon of this Friday. Outside of Europe, the most affected country is Canada (58), followed by the United States (22).
eurosurveillance has also published two other studies focused on the first 27 cases in Portugal and the four from Italy, three of whom were infected at a massive party in Maspalomas (Gran Canaria). “Contact tracing has been difficult, since a majority of positive cases have had relationships with multiple sexual partners or these are unknown,” says the Portuguese report.
The dates of the cases studied reveal that the virus began to circulate in Europe, at least, in the first half of April. “Most of the cases are not part of the identified contagion chains, they have not traveled abroad or have had contact with symptomatic people, which suggests the prior existence of an undetected spread of the virus,” states this latest work.
This is one of the reasons that have led the authorities of the affected countries to recommend reducing the practices in which most infections have occurred. In Spain, the latest report on the outbreak from the Ministry of Health urges “minimize risk behaviors associated with the transmission of this virus.”
Adrian Aguinagalde, director of the Public Health Observatory of Cantabria, is committed to the “self-declaration of contacts” as a way of circumventing tracing difficulties. “If someone thinks that he may have been exposed to the virus, it is important that, without having to give many details, he can agree to be vaccinated and receive all the information he needs,” she explains.
“In the current context, this route may be more effective than trying to obtain all contacts through the infected person. This allows, with the collaboration of the contact, to know other information, such as whether he was vaccinated against smallpox or has other infections, which will be important to define the post-exposure strategy, which can use the vaccine or antivirals, to prevent the development of serious pictures”, adds Aguinagalde.
Spain, unlike countries like France and the United Kingdom, still does not have the traditional smallpox vaccines from the Bavarian Nordic company, which have proven to be effective against monkey pox. Although this is a limitation that will likely be resolved in the coming days. Minister Carolina Darias announced this Thursday that Health will “imminently” receive the first 200 doses, a purchase made from a third country that she did not disclose and that is not included in the centralized acquisition of thousands of doses that will be made through the European Comission. In the absence of specifying the definitive strategy, vaccination will be aimed at the closest contacts, those with the highest risk of developing serious conditions and perhaps also health personnel.
The UK study, however, also shows reluctance about this measure. “Only 69% of exposed health workers (169 of 245) and 14% (15 of 107) of contacts had accepted the possibility of being vaccinated on May 24,” the document states.
All this leads the authors of the report to note the difficulties of putting an end to the current outbreak in the short term. Although the objective is the elimination [de la circulación del virus]For public health measures to be successful, a concerted international effort will be necessary to identify cases and contacts, involve all groups in their search and also to develop prevention measures.
Outside of the practices considered risky, studies confirm that the infections that have occurred have been very rare, almost always among people who lived under the same roof, so the risk of contracting the virus in daily life is very low. Of the 116 contacts, including health workers, who had the first case detected in the United Kingdom – a person from Nigeria unrelated to the other cases – and of the 98 of a family group of three cases, “none have developed the disease ”.
In the current situation, Adrián Aguinagalde prefers not to make predictions about the duration of the outbreak: “We cannot foresee what has not happened. This is new because we do not have a disease with these characteristics, nor has it manifested itself like this before. The hypothesis that the outbreak lasts over time in the current context is plausible, but it is also plausible that it self-limits until it disappears. When two incubation periods have elapsed since the alert [a finales de junio o principios de julio]we will probably know more, although there may be other factors that influence ”.
A joint communication from the European Center for Disease Control and Prevention (ECDC) and the World Health Organization (WHO), published this Thursday, warns that with the arrival of summer, the celebration of numerous “festivals and events (including Gay Pride) in which large concentrations of people will take place, which offer an environment in which that the transmission of the virus can be accelerated.” The two organizations call to take advantage of these celebrations “as an opportunity to develop prevention actions with specific population groups and transmit the appropriate public health messages.”
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