Ask An Infectious Disease Doc

First some context: Monkeypox (mpox) is a viral infection that can spread between people in close contact, and also to people from infected animals.

The illness causes a range of symptoms that can range in severity, most commonly a rash that can last for 2-4 weeks, plus the other flu-like symptoms we’ve come to know and love (fever, headache, muscle aches, back pain, low energy, swollen glands).

Usually, these symptoms go away on their own within a few weeks, but the illness can be severe or lead to complications or death in some people, especially those who have a weakened immune system

Mpox has been endemic in West and Central Africa for decades.

In 2022 the Clade II strain of the virus ( which mainly circulates in West Africa) caused a international outbreak affecting many countries that had never reported cases of mpox before.

The outbreak was eventually contained, and the spread and new cases has been kept relatively low outside of Africa since.

Fast forward to 2024: The Clade I strain (historically more severe and endemic to central Africa ) is now causing a large outbreak in the Democratic Republic of Congo and has spread to 13 countries in Africa — there’s currently over 17,000 reported cases, and hundreds of deaths.

It has also spread to non-endemic African countries and recently two cases have been reported in returning travelers from an affected African country to Sweden and Thailand respectively.

Hence the following Q&A, with the delightful Dr. Titanji.

Q: Is this a new variant, and is it more deadly?

BT: Clade I virus has reported higher mortality and causes more severe disease than Clade II virus.

Some of this increased mortality may also be reflective of limited access to adequate healthcare in resource constrained settings and may not be the case if we see imported cases outside of Africa to more developed countries.

However, it is concerning and warrants caution until we fully understand the drivers of the higher mortality being reported in the DRC outbreak.

Q: How is it transmitted?

BT: Close contact with a person who has active lesions i.e. the classic papular rash, intimate contact through sex, and also inhaled aerosols (though this is not considered to be the most significant mode of transmission).

Also close contact fomites i.e. inanimate objects contaminated with virus from an infectious person is a mode of transmission

Q: How much of the issue is cost? Do we need something like PEPFAR, at least short-term / intermittent for when things this happen?

BT: Currently the subsidized pricing point for the MVA-BN vaccine for African countries is about 80 UD per dose.

The Africa-CDC has expressed that this pricing point remains unaffordable for countries in Africa wishing to procure vaccine doses. Pledges were recently made by the US and the European Union to provide vaccine doses and I hope there is follow-through on these pledges quickly.

Q: Are there anti-virals / blockers that ameliorate the symptoms and hasten recovery?

BT: There are investigational antivirals with IND approval under the animal rule i.e. these are drugs developed to treat smallpox but which have shown effectiveness against mpox in animal studies of the disease.

Unfortunately, we do not have randomized clinical trial data confirming the effectiveness of these drugs in humans though cohort studies during the 2022 outbreaks suggested effectiveness of tecovirimat against Clade-IIb mpox. A RCT in ongoing in the US to clarify this question.

Q: I’m in Namibia. We don’t have any cases yet. We also don’t have a vaccine. I’m likely traveling to the US in a few months. Am I eligible to get the vaccine while I’m there, just by virtue of living in Africa? If so, what does it cost without any insurance?

BT: Here are the recommendations for vaccine eligibility in the US.

They are still freely available in health departments and I do not how tightly they are enforcing the eligibility criteria. My patients have not incurred any personal cost for vaccine referrals regardless of insurance status.

Q: How close is "close contact"? Is it the same 'closeness' that would lead to the spread of the common cold or flu or COVID? Or is the kind of closeness necessary for e.g. glandular fever to spread? If you were in an elevator or on a bus with someone who had it, would there be a high risk of it being spread?

BT: Good question. I know it can be vague to describe so what I tell people is more than just passing contact. Think crowded sweaty concert, intimate contact, sharing close quarters with someone with an active infection i.e. a rash that's not healed.

Q: What about shaking hands with someone with lesions on hands or wrists?

BT: It's impossible to provide an evidence based answer for every scenario imaginable. Which is why it's important to wash your hands!

That’s it, for now!

Follow Dr. Titanji on Threads to keep up with the outbreak and other infectious disease news and research updates.

If you have any further questions, drop a comment or email and we’ll do our best to find an answer for you!