Warning signs before the monkeypox outbreak went unheeded


CDC concerned about possible undetected spread of monkeypox in UK

MOnkeypox seems to have exploded out of nowhere in the last two weeks, spreading across Europe, America and other regions. But warning signs seem to have gone unheeded.

An unusual and long-lasting outbreak in Nigeria should have served as an indication that it was only a matter of time before this orthopoxvirus burst into the heart of infectious diseases, experts say.

After decades without cases, Nigeria experienced a major monkeypox outbreak starting in 2017, which continues to this day. Prior to this year, this outbreak spread beyond Nigeria’s borders eight times, with infected people traveling to the United States, United Kingdom, Israel and Singapore.


Chikwe Ihekweazu, the former director-general of the Nigeria Center for Disease Control, said his country was seeking help to try to decipher what was going on with monkeypox. But the requests didn’t get much traction.

As a result, some critical questions about monkeypox — including the true deaths of the West African virus group now circulating, as well as how many people, on average, each infected person is transmitted to — remain unclear.


“Until now, there hasn’t been much interest in supporting this work – unfortunately,” said Ihekweazu, who was recently appointed to head the World Health Organization’s new Berlin Center for Pandemic and Epidemic Information. “It never really generated the interest it needed to answer some of those questions.”

Nigeria has detected 558 suspected cases since the current outbreak began in 2017 – 241 of them confirmed.

Nigerian CDC

“When we saw this literally appear out of the blue in Nigeria in 2017, we were all very surprised,” he told STAT. “In a way it’s similar to the surprise around the world right now because it’s a similar scenario. All of a sudden, out of nowhere, we had a lot of cases in the Niger Delta in southern Nigeria.”

Further investigation found cases across the country, Ihekweazu said. “So very interesting that a virus that we hadn’t seen in Nigeria for about 40 years at the time is suddenly emerging and popping up in multiple places at once.”

Nigeria’s CDC has been trying – so far without success – to figure out how people contracted the virus. Some small mammals are thought to be the virus’ host species, but efforts to find the virus in the wild have so far failed.

The rest of the world seems to be catching up to Nigeria fast. Over 300 suspected cases have been detected since the UK reported in mid-May it had diagnosed cases of monkeypox in people who have not traveled to any of the countries in west or central Africa where the virus is endemic. Of the cases outside of Africa, 219 have been confirmed, the European Center for Disease Prevention and Control said on Wednesday.

Ihekweazu said he was trying to raise awareness of the problem monkeypox could pose before the Covid-19 pandemic. In 2019, London-based think tank Chatham House convened a meeting to discuss the risks, said David Heymann, a professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine, who chaired the meeting. Among them was the possibility of sexual transmission of monkeypox, as some people who contracted the virus developed lesions on their genitals or in their genital region.

The current outbreak seems to have started when the virus started spreading among men who have sex with men.

The virus is not transmitted through sex per se; For example, there is no evidence that it is passed through semen or vaginal fluid. But skin-to-skin contact during sex can lead to transmission if one of the partners has monkeypox lesions.

Anne Rimoin, an infectious disease epidemiologist at the University of California, Los Angeles, who has studied monkeypox since 2002, agreed with Ihekwea that people who study smallpox viruses know that monkeypox can spread. The 1980 eradication of smallpox and the cessation of use of the smallpox vaccine — which provides some protection against monkeypox — created an ecological void that experts feared another smallpox virus could fill.

“There was a million desk exercises and other things that dealt with the spread of monkeypox, smallpox and other smallpox viruses. This is not a totally unexpected situation here,” said Rimoin. “We knew all along that as population immunity waned, and possibly individual immunity of those who were vaccinated, we would potentially see cases of monkeypox or other smallpox viruses spreading.”

As of 2018, there have been sporadic cases of travelers infected in Nigeria bringing the virus to countries that do not have monkeypox. Ihekweazu said each export put recipient countries on high alert to try to prevent domestic spread, with cases being treated in high-security facilities while contagious. However, no help followed to stop the spread of the virus at its source.

“So basically you withdraw the army if even a single case is exported. But there’s no interest in working with the country where the cases are coming from to try and understand it a little bit better,” he said.

He suggested that the post-Covid world could be more open to understanding the need to nip infectious diseases in the bud. “That was all before Covid. So…hopefully people’s general perception of these things has changed a bit so that we pay a little more attention.”

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