“A death from monkeypox is not ruled out, although it is unlikely”

“A death from monkeypox is not ruled out, although it is unlikely”

The development of the world's greatest outbreak of monkeypox outside of Africa has surprised the common people. Although isolated cases have been documented in different parts of the world in recent years, this is the first time that an endemic disease in Africa has affected such a large number of people in more than a dozen nations with no clear source. The good news is that monkeypox has nothing to do with Covid-19 in terms of epidemiology.

Agustin Benito (Madrid, 1959), head of the National Center for Tropical Medicine since 2004 and president of the Spanish Society of Tropical Medicine and International Health, is one of the foremost experts on this sort of "strange" pathology that is increasingly affecting our country. In 2014, this scientist by training had to deal with the Ebola outbreak. Globalization and the climate crisis, he adds, are the ideal breeding grounds for zoonotic disease organisms to spread more and more frequently among humans. Stopping the spread of an interconnected world like this appears to be one of the greatest challenges of our time.

-Monkeypox is not a new disease, then why is it causing the largest outbreak in European history right now?

-Monkeypox is a zoonotic illness that is spreading across Europe and North America but is endemic in regions of Africa. Cases had already been identified in Central and West Africa in 1989 and the 1990s. In the last five years, there have been multiple outbreaks with cases reported worldwide. In 2003, more than 70 cases of monkeypox were reported in the United States. Monkeypox cases were also reported in Nigerians traveling to Israel in September 2018. September 2018, December 2019, May 2021, and May 2022 in the United Kingdom. In Singapore in May of this year. Also in July and November 2021 in the United States.

What's surprising about this outbreak is that no obvious link to an endemic country has yet been established. Studies are being conducted to better understand the epidemiology, origins of infection, and transmission patterns in instances spread widely across Europe, the United States, Canada, and Australia.

-How far may this epidemic spread?

—According to protocol, an alert was issued at the national level, sent to the Alerts Committee, and important stakeholders were alerted in order to organize a response. The duration of the outbreak will be determined by the infectivity of the agent, the mode of transmission (in this case, direct contact through saliva or respiratory excretions or contact with the exudate of the lesion or the scab material), and the size of the susceptible population, as with any infectious-contagious disease (here, those vaccinated against smallpox have a degree of protection, except for the loss of immunity over time).

If you have vesicular exanthema (rashes) anywhere on your body and any of the classic symptoms, such as fever, severe headache, arthralgia, back pain, myalgia, or lymphadenopathy, and you have been linked to a confirmed or suspected case in the 21 days prior to the onset of symptoms, you should be considered infected. In order for infection to occur, close and direct contact is required, human-to-human transmission is limited, and outbreaks are often small and brief.

Because a considerable portion of the population still maintains some degree of cross-immunity against smallpox, most instances are mild. Furthermore, the virus studied so far belongs to the West African clade, which has a lethality of 1% and lacks the same degree of the potential transmitter as the Central African clade. As with a wide range of infectious diseases, some death cannot be ruled out, but it is unlikely to occur as a result of the above.

-Can we infer that the epidemiological surveillance systems have failed again, given the number of cases that are surfacing in various parts of the world?

-On the contrary, because the mechanisms are working, instances are being recognized at a high rate, which has fueled the Covid-19 pandemic. If there is anything we have learned or should learn for the future, I believe it is that we must be watchful against emerging and re-emerging infections, particularly those of zoonotic origin.

-What accounts for the large majority of cases in guys who have had relationships with other men? So, what's your theory?

-The fact that a large number of confirmed cases have occurred in males who have sex with other men does not imply that monkeypox is a sexually transmitted illness or that it only affects men. Sexual behavior that involves personal contact, whether between people of the same or opposite sex, can enhance the odds of transmission.

It would be prudent to use extreme caution so that the protocols in place do not stigmatize. Because sex between men is not a transmission mechanism, it should not be regarded as a risk factor but rather a health determinant. Let's hope we don't make the same mistakes as before. Behaviors such as unprotected intercourse, regardless of gender or sexuality, are risk factors

-Only a few months ago, a paper in the journal PLOS cautioned about the changing epidemiology of monkeypox and how it could pose a hazard.

-Clearly, the current Covid-19 pandemic, as well as the avian flu and other illnesses that have created outbreaks, are all zoonoses that are highly prone to generating epidemics, and this is even more true now with climate change and the return to travel. There are several examples in the literature, and in today's globalized world, actions involving sick animals or persons are on the rise. As a result, monkeypox is a new disease that has the potential to spread outside of its endemic range, such as in Central and West Africa.

-Since Covid's introduction to the world in 2020, we've witnessed the emergence of diseases that have never been seen before in the West. Monkeypox was the most recent, although there have also been outbreaks of Nile fever, cholera, and other diseases... What's going on?

-What is taking place is nothing but globalization. As a result, humans are coming into more touch with rural areas and wild animals. When we consider ecosystem changes, climatic change, and global change, we might conclude that infectious agents have no boundaries.

-Are we ready for the possibility of a new epidemic erupting?

-We should be, especially now that we know about the current pandemic. That of SARS-CoV-2 would correlate to that x illness, which was one of the WHO's ten global challenges. This pandemic has demonstrated that it is the global community's responsibility to prepare the entire world for these new challenges. The message from the lessons learned should be that science and research and development will be one of the cornerstones that will enable us to be prepared for subsequent epidemics. The other pillar must be collective action in the face of the threats we confront, as well as solidarity and cooperation.

Many species are being displaced as a result of climate change, according to a study published in Nature just a few weeks ago. This is leading to the appearance of novel infections, epizootics, and pandemics. Is the Earth on the verge of exploding?

A global approach to health is required. It will be important to create "one health" or "one health" policies and collaborations, in which we will have to focus on new alarms or hazards through interdisciplinary collaboration between animal, human, and environmental health specialists.

-What other tropical diseases should we be concerned about in Spain?

-In a world where a human, animal, or pathogen can travel from one area on the earth to another in less than 24 hours due to globalization, any developing disease, tropical or not, with rapid and effective transmission mechanisms and high mortality can pose a threat. Some tropical infections transmitted by vector arthropods may cause outbreaks as a result of their settlement as a result of climate change, but zoonotic viral diseases from tropical areas should worry us, and while we are becoming better prepared to identify them in time, R&D&I in emerging and re-emerging diseases must be greatly strengthened.

-You had to cope with the Ebola situation in Spain in 2014, and you've already stated that the National Health System's collapse could lead to additional unforeseen events. Is there anything that's changed since then?

-I believe it is self-evident that stronger health systems have handled the pandemic better. Case surveillance, administration, prevention, and control have all been critical in dealing with new issues. The high immunization rates attained in our country serve as an example. The stronger our healthcare systems are, the more prepared we will be to deal with unforeseen situations. If we have been following this pandemic, the example is plain. We must continue to enhance health systems in order to be better prepared and take use of the lessons learned from this pandemic, including, as I previously stated, greater scientific development, evidence-based data, and improved knowledge dissemination and transmission.