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June 2022

Monkeypox: some useful facts 

Cases of monkeypox are increasing in the UK – at the time of writing, 71 cases had been reported – and across the world. It has now been found in 19 countries outside of Africa, including the UAE, Spain, Portugal, the US and Australia. London Medical Laboratory says COVID-19 may have paved the way for the outbreak and that widespread PCR testing for the disease would present significant new challenges.

Chief Scientific Officer at London Medical Laboratory, Dr Quinton Fivelman PhD, writes: ‘Though typically spread by contact with an infected animal, person-to-person cases are now being recorded in the UK. The virus is likely spread by touching or sharing infected items like clothing and bedding, or by the respiratory droplets produced by sneezing or coughing.

‘So far, there seems little need for UK-wide testing in the same way we did for COVID. That’s because monkeypox, though a serious disease, is not usually life-threatening and the characteristic rash is quite distinctive. Initial estimates put the risk of fatality from the strain of monkeypox present in the UK at around 1%, though it is obviously a painful, unpleasant disease that must be taken seriously. There is a different and much more lethal monkeypox strain present in central Africa, thought to kill up to 10% of patients, but this is not believed to be in the UK or Europe currently.

‘The virus is also less likely to mutate than SARS-CoV-2. The World Health Organisation (WHO) has confirmed that mutations tend to be typically lower with this virus, which means that it is less likely to evolve new ways to spread through populations as rapidly as COVID did.  The WHO says it has no evidence that the monkeypox virus has mutated and, although it’s endemic in west and central Africa, it has tended not to change significantly.

‘However, if the virus does become of greater concern, widespread testing for it would present some challenges. Diagnostic PCR tests became well-known during the pandemic, using nose and throat samples to detect the presence of COVID. To detect the monkeypox virus, doctors also use a PCR test, taking samples of the fluid-filled blisters and scabs on the skin. The sample then goes to a lab, where testing is carried out to determine the presence of the monkeypox virus. 

‘At the moment, it is thought that such samples must be kept refrigerated, unlike COVID tests. That presents a logistical problem. Samples sent via the mail may not be useable. 

‘Of equal concern is that, as a WHO-designated Risk group 3 pathogen, these samples need to be treated carefully. The smallpox vaccine is thought likely to prove at least 80% effective against monkeypox as they are closely-related viruses. Here in the UK, we stopped regularly vaccinating against smallpox way back in 1971. Anyone under the age of 50 is unlikely to have been immunised.

‘America’s Center for Disease Control says that where possible, only vaccinated people (i.e. smallpox vaccination within the past 10 years) should perform laboratory work that involves handling specimens that may contain monkeypox virus. 

‘It says non-immunised people must use increased personal protection equipment and improved practices should be followed to further reduce the risk of exposures.

‘Obviously, this presents a problem for UK doctors, health workers and phlebotomists coming into regular contact with these PCR tests, the majority of whom will never have received a smallpox vaccination.

‘While monkeypox and COVID are entirely unrelated viruses, it is possible that COVID coincidentally paved the way for the global surge in monkeypox cases. That’s due to two factors. Firstly, COVID-19 may have left some people with weakened immune systems. New research from scientists in Cambridge indicates that some COVID patients show profound alterations in many immune cell types that persist for weeks or even months after COVID infection. This could lead to people with weakened immune systems being more susceptible to diseases such as monkeypox.

‘Secondly, there is some evidence that many of us, even those who have never caught COVID, have less resistance to viruses because we have been out less and interacted less with other people during the pandemic. We’ve all been masked-up and had less exercise and exposure to the protection offered by sunshine’s vitamin D. Certainly for children, this lack of exposure to new viruses won’t have helped build robust immune systems.

‘Another way COVID may be influencing the spread of monkeypox is through international travel. For many months, this was at a virtual standstill during the pandemic. Now it is once again largely unrestricted, families and friends from across continents are reuniting all at once. That presents a great opportunity for any opportunistic virus to spread.

‘The good news is that, unlike the COVID-19 virus, the monkeypox virus is made of double-stranded DNA, which means that it is larger and heavier and unable to travel in the air as far as the tiny, single-stranded COVID RNA virus. Once the rash forms a scab, in two to four weeks, people are no longer infectious.’

Practice Nurse 2022;52(5): online only