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With over 20,000 confirmed cases of monkeypox, what do we know about the outbreak?

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1. Do we really know the exact number of cases?

No. Dr. Darrel Tan, infectious disease specialist at St. Michael’s Hospital in Toronto, and Dr. Sapha Barkati, assistant professor in the Faculty of Medicine and Health Sciences at McGill University, believe that the number of cases is probably greatly underestimated.

If, at the beginning of March, we discovered a handful of cases each day, there have been more than 500 on average per day since mid-July.

According to the US Centers for Disease Control and Prevention (New window) (CDC), out of more than 20,000 confirmed cases, 98% are in countries that historically had no cases on their territory. The epidemic is now present in 78 countries. Only seven of these countries had observed cases of monkeypox in the past.

The United States, Spain and Germany are the countries with the most confirmed cases. Canada, with 803 cases (as of July 29), is among the top 10.

On Friday, Brazil and Spain each reported their first death from monkeypox; these are the first deaths outside Africa, where the virus is considered endemic.

Drs Tan and Barkati add that not enough testing is done and contacts are often unknown, making tracing difficult.

We already see that the delay between the test and the result is too longadds Dr. Tan.

And as in the case of COVID-19, some infected people may be asymptomatic while being contagious, which blurs the picture.

Others have very mild symptoms that can be mistaken for other types of lesions. In some people, the lesions look like acne or a mosquito bite.

In fact, according to a study published last week in the New England Journal of Medicine (New window)of which Dr. Barkati is one of the authors, 39% of the more than 500 cases analyzed in 16 countries had less than 5 lesions and 25% had between 5 and 10.

Dr. Barkati adds that in some cases the diagnosis may not be correct. To this day, monkeypox is a disease doctors in Europe and North America rarely sawreminds Dr. Barkati, even if doctors are more and more aware of the symptoms to watch out for.

All this contributes to the increase in cases, because these people will continue to transmit the virus to others, without knowing it.says Dr. Tan.

2. What is the profile of infected people?

The WHO reports that 99% of all infections outside of Africa were in men, and of these, 98% were in men who have sex with men.

Dr. Barkati’s study further revealed that 98% of those infected were gay or bisexual, 75% were white, and 41% had already been diagnosed with HIV. In about 30% of cases, sexually transmitted infections have been reported.

The most common symptoms before the onset of lesions were fever (62%), lethargy (41%), muscle aches (31%) and headache (27%); and lymphadenopathy (palpable enlargement of lymph nodes) (56%).

However, the study noted that while the current epidemic disproportionately affects men who have sex with men, monkeypox can affect anyone and the spread to other populations is predictable.

Moreover, Dr. Barkati recalls that cases have been confirmed in other demographic groups. In particular, there are infections in children in the United States (New window) and in Brazil. Spain reports (New window) about 70 women out of the approximately 4000 cases. In Texas, a pregnant woman was infected (New window).

You have to be careful; it is not a disease specific to the LGBTQ+ community. This is why the outbreak must be contained; we don’t want it to overflow and affect even more bands. »

A quote from Dr. Sapha Barkati, McGill University

3. Do we know why the LGBTQ+ community seems more affected?

Dr. Tan says the answer is unclear, but there are some assumptions. According to him, it is probably a combination of circumstances.

Seeing what is happening, the logical conclusion is that there is an element of chance that led to someone from the LGBTQ+ community becoming infected at the start of this outbreak. And then, this person was part of a network that has connections around the world.

According to Dr. Barkati, an infected person likely brought the virus into a situation with lots of close contacts. These people then returned to their country and it settled elsewhere. Moreover, 28% of infected people had traveled in the month preceding their diagnosis, shows his study.

For example, experts suspect that the spread of the virus in Europe and North America could have been triggered during two raves in Belgium and Spain.

According to Dr. Tan, one cannot ignore the fact that the majority of cases are in the LGBTQ+ community, but one must be extremely careful not to stigmatize this group.

Portrait of doctor outdoors.

Dr. Darrel Tan, infectious disease specialist at St. Michael’s Hospital in Toronto

Photo: CBC/Lauren Pelley

On Wednesday, the director of theWHO advised men at risk to reduce the number of sexual partners for the moment.

However, several experts, such as Dr. Tan, fear that this kind of message from the authorities will lead many people to consider this virus as a homosexual disease which poses no risk to them.

The same mistakes as with the HIV pandemic should not be repeated, according to Dr. Tan. Gay men, in particular, have endured stigma from the start of the HIV/AIDS pandemic, when the disease was widely considered a “gay disease.”

For her part, Dr. Barkati fears that people will be reluctant to consult, for fear of stigmatization, which will inevitably lead to more transmission.

4. What is the mode of transmission?

Scientists believe the main route of transmission is skin-to-skin contact with someone who has symptoms. The virus can also be spread through mucous membranes, saliva, and respiratory droplets during prolonged face-to-face contact, such as kissing and hugging.

It is also possible to become infected by touching objects that an infected person has touched, such as towels or sheets.

Is it possible that it is transmitted by aerosols? Yes, but it is not an important mode of transmission. If so, we would have already seen cluessays Dr. Tan.

Dr. Barkati adds that it is not certain whether the virus is sexually transmitted. In fact, since the first human case in 1970, monkeypox has never been recognized as a sexually transmitted disease.

In her study, she notes, genetic material of the virus was discovered in the semen and other bodily fluids of infected people. However, she points out that it is not yet known if the virus in these bodily fluids is active and if it can replicate. One should not jump to hasty conclusions.

5. Could the virus have mutated?

the British Medical Journal (New window) pointed out last week that some observations indicate a new clinical course of the disease and that some symptoms have changed.

Scientists are trying to figure out why human-to-human transmission seems to be happening so easily right now. Is the virus more transmissible? Has he adapted to us? […] And just because a symptom wasn’t reported in the past doesn’t mean it didn’t exist…

Dr Barkati recalls that this virus has long been neglected by the international community and that it there are still a lot of things we don’t know.

6. Do we have enough vaccines?

One dose of monkeypox vaccine.

Imvamune contains a weakened strain of vaccinia virus, which elicits the immune response needed to fight off smallpox and monkeypox.

Photo: The Canadian Press/Graham Hughes

The Imvamune vaccine, from the Danish company Bavarian Nordic, was approved by Health Canada in 2013 for immunization against smallpox. In 2020, Canadian authorities expanded this approval to include immunization against monkeypox.

As of July 23, 2022, the Government of Canada has distributed over 70,000 doses. Just over 1,300 doses were administered in Montreal alone.

The limited supply of vaccines and drugs to treat this disease is one of the reasons why experts want to limit the spread of the virus.

According to CEO from Bavarian Nordic, there are currently approximately one million doses available (New window) in the United States, as well as one million doses worldwide.

There’s not enough. It will be very difficult to intervene if the transmission continuesDr. Tan fears.

The United States has already distributed some 340,000 doses to states (New window) and the country has ordered 5.5 million additional vaccine doses for the coming year. The number of doses administered is not known, but vaccination clinics in San Francisco, New York and Washington have had to temporarily close due to a lack of doses.

This is why some health authorities, including those in Ontario and the United Kingdom, offer only one dose in order to preserve limited supplies.

Studies have shown that the immune response after one dose remains elevated for at least 2 years.

7. Why was a public health emergency of international concern declared?

Faced with the increase in cases and the limited quantity of vaccines, Dr. Barkati is of the opinion that we should not panic. However, she believes that by declaring a global emergency, theWHO issued a warning to States that the situation must be taken seriously and that mitigation measures must be intensified.

In particular, she wants to intensify surveillance, screening, contact tracing, vaccination of people at risk and isolation of infected people.

Dr. Tan hopes this statement will inspire more elected officials to provide more funding, not only to organizations that work to educate and assist the public, but also to help those infected isolate themselves. Remember that a person infected with monkeypox must self-isolate for at least 21 days.

We have seen during the COVID-19 pandemic the importance of providing sick leave if we want to limit the spread of the virus in the community. In my experience, people who are infected with COVID-19 or monkeypox want to isolate themselves to protect their families, loved ones. But often they can’t because they don’t have the kind of job that allows them to telecommute or that doesn’t offer them compensation if they have to be away for several days.

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