Is clade 1 a pandemic? Yes, in my opinion. It is a novel virus that has acquired the ability to spread human to human sustainably. It has spread to multiple countries within Africa and has spread to at least one other continent - Europe. It is likely that there are other cases throughout the world that have not yet been detected. Does the fact that MPOX clade 1 is not a respiratory virus mean that it can't cause a pandemic? No, this is nonsense. HIV is not a respiratory virus, is only spread by very close contact and yet has caused a pandemic that has killed over 40 million people. Smallpox was spread the same way that MPOX clade 1 is being spread and killed over 300 million people worldwide. The only reason smallpox is not continuing to kill people is because an effective vaccine was developed and deployed.
The most effective way to prevent the spread of MPOX at this point is travel restrictions. These are difficult to impose in the Democratic Republic of the Congo (DRC), where MPOX clade 1 originated, due to chaotic conditions there. Neighboring countries would do well to limit travel from the DRC to their countries, but may lack the resources to do so. Shutting down international airports would greatly slow the spread of MPOX clade 1. There is no legitimate public health reason to keep them open and an excellent one to shut them down. However, I recognize that this is unlikely to happen due to the political power of the airline and travel industries.
Children and pregnant women are most at risk from monkeypox clade 1, the latter because this virus causes miscarriages and stillbirths at high levels. Unfortunately, there is currently no vaccine that is approved for children. Hence, vaccines are unlikely to be available for this group. There are two vaccines, originally developed as protection against smallpox, which are available - JYNNEOS and ACAM2000. JYNNEOS has been shown to be about 80% effective in protecting against MPOX clade 2. It is not clear that it is effective against clade 1. Supply of JYNNEOS is very limited. Supplies of ACAM2000 are more plentiful, but this vaccine has serious side effects. Also, it is not clear how effective it would be against MPOX clade 1. A patient who had been immunized with ACAM2000 was not protected against MPOX clade 2.
Given the shortage of the preferred vaccine, JYNNEOS, prioritization of deployment of available supplies is imperative. Since it cannot be given to children at this time, the highest priority for vaccination should be health care workers, especially OB/GYNs, pediatricians and others in contact with pregnant women and children including daycare workers and elementary school teachers. Pregnant women, women of child bearing age and parents with small children should also receive priority. The goal should be to create a ring of protection around the people most likely to be at risk of death and serious disease. Sexual transmission of monkeypox, both clades 1 and 2, can be prevented by not having sex with infected people. Limited vaccine should not be used so that some individuals can have promiscuous sex. This behavior should not be prioritized over protecting pregnant women and children.
Tecrovirimat (TPOXX) was originally developed as a treatment for smallpox. For clade 2 MPOX, it appeared to decrease the length of time patients suffered with skin lesions. Unfortunately, a recent study suggests that is not effective against clade 1 MPOX. However, it does appear that advanced medical care, which is mostly supportive, decreases the probability of death from infection with MPOX clade 1. This makes it essential that hospitals be kept open by vaccinating health care workers and rigorous attention to infection control.
We are likely to see the same economic arguments against any type of "lock down" that occurred with COVID. I was surprised at how willing many were to accept the deaths of older people in order to continue to patronize bars. I wonder if we will see the same callous disregard for the lives of small children and the unborn. This will be crunch time for values.
References
Sustained human outbreak of a new MPXV clade I lineage in eastern Democratic Republic of the Congo . Vakaniaki, et al. Nature Medicine. June 13, 2024.
https://pubmed.ncbi.nlm.nih.gov/38871006/
High Rates of Miscarriage and Stillbirth among Pregnant Women with Clade I Mpox (Monkeypox) Are Confirmed during 2023–2024 DR Congo Outbreak in South Kivu Province. Schwartz. Viruses. June 26, 2024.
https://www.mdpi.com/1999-4915/16/7/1123
Monkeypox in Patient Immunized with ACAM2000 Smallpox Vaccine During 2022 Outbreak. Turner et al. Emerg Infect Dis. 2022 Nov; 28(11): 2336–2338.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9622228/
Monkeypox pandemic containment: does the ACAM2000 vaccine play a role in the current outbreaks? Katamesh et al. Expert Review of Vaccines. 2023
https://www.tandfonline.com/doi/full/10.1080/14760584.2023.2198600#d1e227
The antiviral tecovirimat is safe but did not improve clade I mpox resolution in Democratic Republic of the Congo. August 15, 2024. NIH.
https://www.nih.gov/news-events/news-releases/antiviral-tecovirimat-safe-did-not-improve-clade-i-mpox-resolution-democratic-republic-congo
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