By Mohd Naushad Khan

There are only few cases of monkeypox in India but worldwide it is considered alarming for the simple reason that the World Health Organisation has already declared it as a global emergency. In India there is some respite from the monkeypox at present but it does not mean that India can afford to be complacent at this stage. India has to remain vigilant and constantly monitor global trends and its impact.            

According to Dr Shahid Jameel, eminent virologist of India, who is associated with the University of Oxford and popularly known for his research on the hepatitis E virus, “With the reported cases in India at this time, the threat is small. But these cases (and those globally) are based not on community surveillance but were found in those who sought medical help. The actual numbers may be much higher everywhere in the world for us to be able to see over 17,000 known cases globally. For India, I would say it’s not a cause for worry at this time but can quickly become one. So we need to be vigilant and put various public health measures in place.”  

On how biologically monkeypox is different from Covid-19, he says, “The Monkeypox and Covid-19 viruses are completely different. They belong to different families of viruses. Poxviruses are the largest (size 200-400 nm) and most complex animal viruses with DNA as their genetic material (average size about 200 kilobases). Coronaviruses are simple animal viruses (size about 100 nm) with RNA as their genetic material (average size about 30 kilobases).” 

He added, “Being DNA viruses, poxviruses have stable genomes while coronaviruses being RNA viruses can change quickly – as seen with so many variants of the Covid-19 virus. The two viruses also cause completely different disease manifestations – poxviruses produce skin boils; the Covid-19 virus produces a respiratory infection. This has implications for how the two viruses are transmitted from an infected to naïve host.”

When asked whether India can afford to be complacent at this stage and how the lessons learnt from Covid-19 can help fight monkeypox, the virologist said, “No, we should not make that mistake. Though monkeypox transmits mainly through touching and among close contacts, it also spreads through body fluids and droplets (i.e. surface contamination). Such infections can spread very quickly in places with high population density. Indian cities are crowded and come in that category. The key lessons from Covid-19 are to recognise the problem early, not be complacent, put in public health measures (testing, isolation and treatment) early, communicate clearly, use the best tools available and use data to set policy. All these apply to Monkeypox as well.” 

“India’s strength is not in vaccine development but in manufacturing. We can leverage that strength to license and produce large amounts of the available third generation smallpox vaccine (which is approved for use against monkeypox as well). Research into new vaccines and bringing them to the market will take time. It will also be hard for the world to come up again with the kind of capital it did for Covid-19 vaccines, especially since most economies have been adversely affected by the ongoing pandemic,” he said on how the technological advancement made during Covid-19 can help develop vaccines for Monkeypox.

On whether emergency health preparedness is adequate or not, he said, “So far I would say yes because the reported numbers are low. But since this has the potential to spread quickly, we should have a clear and coordinated plan. The Ministry of Health and Family Welfare, Government of India issued guidelines for monkeypox management in the country on 31st May 2022 even before any case was detected. This is a very good step.”

The virologist has also made some suggestions to the government and policymakers. Going beyond the guidelines issued well ahead of time, the key elements of preparedness would be testing, tracing, isolation and treatment.

  1. Increase testing facilities beyond NIV, Pune. During Covid-19, multiple laboratories across the country developed PCR testing capability. ICMR has set up Virology units in over 50 medical colleges. Training in containment and testing can increase their capabilities and quickly expand testing. NIV can play a trainer and quality control role.
  2. Testing sewage water for monkeypox (like successfully done for Covid-19) can be implemented for cities that have the highest risk due to high population density. Cities also have a working sewage system (unlike villages). Virus in sewage is a good indicator of community transmission. This can guide public health planners and help finetune the response.
  3. Use India’s vaccine manufacturing strength to license and manufacture the Bavarian Nordic vaccine for India and other LMICs.
  4. Use India’s generic pharma industry, to license and manufacture the FDA approved drug Tecovirimat for India and other LMICs.

“The most important preparation for future is a robust and well-funded infectious disease research programme in the country. Viruses appear to be emerging at increased frequency. We can only keep ahead of them through research,” said the Indian Virologist.

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