Ask the Pharmacist

Q) What is monkeypox and should I be worried about it?

A) Unlike COVID-19, monkeypox has been with us for years but the recent surge of cases in countries where it has not traditionally been endemic is bringing it to world’s attention for the first time.

Monkeypox is part of the orthopoxvirus family whose most infamous member, smallpox, reeked havoc upon the world for many decades until worldwide mass vaccinations eradicated it in 1979 (hmmm, it’s probably a good thing we discovered that vaccine way back in 1798 when people weren’t as “well-read” as they appear to be now or we would still be watching our children get permanently scarred by it).

Monkeypox is also known as a viral zoonosis (i.e. the virus is transmitted from animals to humans not unlike the swine flu or the avian flu) with a number of species having been identified as being susceptible to the disease including primates (hence its name), rope squirrels, tree squirrels, dormice, Gambian pouched rats and a number of other species. Transmission can occur to humans via direct contact with the blood, body fluids or lesions of infected animals. There is concern that eating undercooked infected meat could also be a source of transmission but that has yet to be proven.

Human to human transmission can occur from close contact with respiratory secretions of an infected person, touching their tell-tale skin sores or other body fluids, or coming into contact with a recently contaminated object such as bedding. It is not anywhere close to as contagious as the coronaviruses generally are.

It is not an airborne disease and transmission via respiratory droplets usually requires prolonged face-to-face contact. It is unknown as to whether the virus can be transmitted through sex, although there are cases from a rave party in Europe that may have been transmitted via intercourse.

The virus was first identified in 1970 in the Democratic Republic of Congo in a nine-year-old boy. It primarily occurs in Central and Western Africa (which are, not coincidentally, the two main variants of the virus with the Central clade being the more severe and easily transmissible version), usually in and around their tropical rainforests but it has been increasingly found in more urban areas recently. This is all changing now which is why it has been brought to our attention more than 50 years after its discovery.

As of May 25th, there have been 16 cases identified in Quebec and various other provinces are investigating a couple of dozen possible cases throughout that are likely to be confirmed within the next few days to weeks. Worldwide, the WHO states there are currently 131 identified cases with many more likely to be confirmed in the very near future.

West & Central Africa typically are plagued by thousands of cases annually but cases outside of Africa have been rare and usually tied to travel. What makes this outbreak in the rest of the world so unusual is that the rise in incidence does not seem to have that travel linkage and the speed in which cases are being discovered seems to indicate a major shift in the behaviour of the virus and its ability to spread. This would appear to mean that the virus is “mutating” (or changing) a concept most of us are very familiar with given the constantly evolving status of COVID-19 variants.

The version that appears to be spreading is the West African one but genomic sequencing is currently being done to see whether it does indeed have any distinct mutations. There is some evidence that it is not spreading as fast as it appears to be despite the sudden surge in cases.

There are some experts who believe the virus has been outside of Africa for a number of months now, quietly spreading as the world focuses its attention on COVID, the Ukraine and the myriad of other issues we have. As such, there is speculation that the rapid rise is more a result of health experts finally starting to actually look for it rather than a very recent massive surge. That being said, the virus does appear to be more transmissible than it has traditionally been with a reproductive number likely above 1 (which roughly means that 1 infected person is likely to infect more than 1 other person and hence the virus will spread).

Traditionally with the monkeypox, a person becomes infectious to others only when they develop the rash making containment much easier. Time will tell if this remains true. Another concern is some patients may have very mild symptoms but can still infect others. So far there have not been any reported severe or fatal cases but that is unlikely to remain true given that the Congo strain may have up to a 10% mortality and the West African strain has a fatality rate of about 1%. There is speculation that given the current lack of mortality, this strain may be less virulent than the ones traditionally seen in Africa.

Monkeypox is usually a self-limited disease that typically presents with a fever, an intense headache, swollen lymph nodes, muscle aches and a general lack of energy. This is followed 1 to 3 days later by the appearance of a rash that tends to appear on the face (95% of the time) or the palms of your hands & soles of your feet (75%) rather than the trunk. The rash may also appear in the mouth, around the genitalia and eyes. The rash evolves; initially starting with a flat base and then becoming papules (slightly raised firm lesions) to vesicles (sores filled with clear fluid) to pustules (the fluid now appears yellow) to eventually crusts that dry up and fall off. Their number can vary from a few to several thousand.

The interval from infection to symptom onset is usually between 6 to 13 days but this can vary widely. Most cases go away on their own over a 2 to 4 week period but a course can become complicated by the appearance of secondary infections such as pneumonia, sepsis, encephalitis and an infection of the cornea that can lead to permanent loss of vision.

More severe cases are likely to occur in children and the immunocompromised. Our existing smallpox vaccine is about 85% effective in preventing transmission and there has been a newer vaccine approved in 2019 but neither of these are readily available currently. Canada is currently trying to procure more smallpox vaccine by 2023.

Treatment involves symptomatic care (i.e. managing the fever, maintaining fluids & nutrition) and aggressive treatment of secondary infections if they arise. There is an approved antiviral drug called tecovirimat but it too is not easy to find. For more information about this or any other health related questions, contact your pharmacist.