Should we be worried about monkey pox? This virus endemic to West and Central Africa has been spreading for several weeks all over the world, and especially in Europe. The Old Continent has become “the epicenter of the largest and most widespread epidemic outside endemic areas”, warns the European branch of the World Health Organization (WHO), Tuesday, May 31. Its experts are worried and confess to not knowing if they “will be able to completely contain its spread”.
According to the international body, the priority objective is now to contain this epidemic by stopping human-to-human transmission. All the lessons of the Covid-19 pandemic “can and must better inform our future actions”, emphasizes WHO Europe. But with only 600 cases listed worldwide, including 17 in France, the seriousness of the situation could appear overestimated. The media, which are particularly active on the subject, inform the population, but don’t they also worry them? In summary, are we doing too much with monkeypox? Certainly not, retorts Antoine Flahault, director of the Institute of Global Health and professor at the Faculty of Medicine of Geneva, according to whom it is necessary on the contrary to take the problem head-on as long as the situation is benign in order to protect oneself. of a possible aggravation of the situation.
L’Express: Would we be so worried about monkeypox if we had not experienced the Covid-19 pandemic?
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Antoine Flahault: Difficult to decide on the “what if” since there was indeed a Covid-19 pandemic. Therefore, should we blame ourselves for retaining the lessons learned from a pandemic or rather welcome it? As for worry, it seems to me that there are two subjects. The first concerns the general public, even the media. They probably don’t need to worry or worry about every new disease that emerges. But for health specialists, researchers, epidemiologists and authorities it is another matter. On the contrary, they must be extremely vigilant in order to try to break the chains of transmission.
However, with only 600 cases identified worldwide, the phenomenon does not seem very worrying.
Indeed, there are only 600 cases. But it should first be noted that it was probably possible to identify them so quickly thanks to our experience with Covid: we detect quickly and already quickly follow the spread of the virus, even if we probably did not identify all the outbreaks [NDLR : l’OMS Europe a d’ailleurs annoncé que des foyers existaient en Europe depuis mi-avril, alors que le premier cas officiellement identifié – au Royaume-Uni – remonte au 7 mai].
Then, we are at a stage where the alert is paid for at a very low cost. When you only have 32, 64, 128 or 256 cases, it is easy to isolate them for 21 days in hospitals and to dismantle the chains of transmission by isolating the contact cases. This is much less easy when there are thousands of cases, which could happen due to the exponential progression of the disease [NDLR : de trois cas en France la semaine dernière, il y en a désormais 17].
If we were used to the emergence of small benign viruses that do not bother us, we could legitimately say to ourselves “don’t overdo it”. But have you experienced, in your life, the emergence of a virus that has not bothered you? Isn’t it always better to nip epidemics in the bud? Wouldn’t you have liked to avoid chickenpox, for example, measles, mumps, or meningitis? I’m not sure that some pathogens should be considered negligible.
You are in favor of “test, isolate, trace”, a strategy that has never worked against the Covid in France. Why would it work for monkeypox?
They are two very different diseases. If the incubation time is short, as with Covid-19 (five days for the historical strain, even less with Omicron), the “test, isolate, trace” strategy is very difficult to implement. When there are thousands, or even hundreds of thousands of cases, it is then logistically impossible, for lack of personnel. Even the Chinese, who are the most competent and the most drastic in this matter, have great difficulty in applying it, because the “zero Covid” strategy is very costly logistically and socially.
Regarding monkeypox, there are only 17 cases in France. Isolating them in hospital for three weeks is entirely possible and will not overload our healthcare system. We can still hope to find all the chains of transmission and quarantine at-risk contacts in order to break the epidemic. We can have this ambition in France today. It’s not necessarily easy, but it is possible. Especially since there is, a priori, no asymptomatic case with smallpox, even if this remains to be confirmed. So all infected people should show symptoms, which helps in identification. Without forgetting that the long incubation period – 21 days – gives the possibility of finding people before they infect others.
Are we sure that sick people are not contagious during the incubation period? Preliminary reports indicate that the disease is transmitted through contact with the skin lesions, the famous pustules, but also through saliva, coughing and sneezing. Patients could be contaminating even before having these eruptions, when they only have fever and headaches. Are infected people contagious? before or during the onset of symptoms?
Certainties are changing, as we have learned with the Covid-19. What we know at the moment is that this tropical disease is poorly transmissible to humans. And if it is not very transmissible, this suggests that contagiousness is rather at the time of the rash, when the vesicles filled with virus from the infected person come into contact with the skin of a healthy person. We have no indication that this disease is highly transmissible without the blisters. Even with smallpox, where pustules could appear in the mouth and thus “aerosolize” the virus [NDLR : le rendre transmissible par l’air]these cases were rare, and it was not the usual mode of transmission.
Monkeypox seems less contagious than Covid or chickenpox. Do we know its reproduction rate (R0)?
It is possible to calculate an R0 from the doubling time of the number of cases and the period of infectiousness. So we can try to get it with monkeypox. The problem is that we do not know today if the rather exponential increase that we observe is caused by an R0 greater than 1 or if the number of cases suddenly increases because the disease has been very publicized and many people are went to see their doctor to get tested. We will get those answers in a few weeks.
The first data, fragmented, seem to indicate a low severity and low lethality of the disease – no deaths outside of African countries have been recorded -, what do you think?
With 600 cases worldwide, we are not able to say whether monkeypox is ten times more or ten times less serious than chickenpox. Twenty out of 700,000 people die from chickenpox, so you would need 700,000 cases of monkeypox to compare. Although the latter is probably not as serious as smallpox, we are not sure that this disease is harmless. Waiting for 700,000 cases to obtain this certainty is a risky bet. I think that we must support those who carry out health policies aimed at avoiding an epidemic. In fact, I sincerely hope that we do and that we do too much. Doing too much is not a reproach, on the contrary, it is an honor.
Other studies point out that the lethality of this disease could vary between 1% and 10%.
Monkeypox emerged in the 1950s and was first observed in the Democratic Republic of Congo and Nigeria in the 1970s. Studies indeed suggest that mortality could range from 1% to 10% in these areas. But these are certainly poor estimates for two reasons. First, the studies focus on epidemics that took place in low-income countries with low access to care, and therefore potentially overestimated mortality in certain places. Then, these countries had low access to screening tests, so a bad denominator [NDLR : la létalité s’obtient en connaissant le nombre de cas et le nombre de décès liés à la maladie]leading to potentially underestimated mortality.
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We are today at the beginning of a phenomenon that is still poorly understood and for which the data show no worrying signs of seriousness. But I repeat, the numbers are too low to make estimates of the severity. It must be recognized that, unfortunately, these estimates are impossible to make for the moment.
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Interview by Victor Garcia
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