India only chases the emergence, pandemic preparedness is critical, Dr Gagandeep Kang

A: Building pandemic preparedness and epidemic preparedness is absolutely critical. What tends to happen with us is when we have an emergency we devote a lot of time, effort, and resources to that emergency.

There’s Zika. Let’s chase that. There’s Sars-CoV-2. Let’s do that. H1N1. Do that. There’s Monkeypox. Let’s focus on that. This mechanism of “Let’s start, stop, start again for something else, stop again” won’t work.

There needs to be a stable surveillance system in place. This system has to constantly improve not just the ability to collect samples but also the range of pathogens that they detect. So, the baseline must be something that we keep over time, even as we make sure that the breadth and the reach of what we are doing continue to expand.

That requires resources, and it doesn’t require the “Let’s start, stop, start again for something else, stop’ kind of mechanisms that we have had.

Q: What is leading to the increase in viral-disease outbreaks?

A: One can argue that an increase in virus outbreaks in humans could be due to two reasons. One, we have upset our environment so much that we are acquiring viral infections from species with whom we would normally not come in contact. The second may be the bias of increased detection because we have increased awareness. Therefore we are identifying something that may have flown under the radar previously.

Monkeypox cases in Africa/Creative Commons

For instance, Monkeypox in particular. What is a hot topic of discussion is, “Why are we now seeing so much Monkeypox now?”

It has been a disease in central and west Africa for the last 50 years. There have been cases… a very small number of cases.

Is this a virus that has been circulating in humans for a while and we are able to better identify it only now? Did it adapt in animals and then make the jump to humans? Does that mean the new variant has the ability to spread from human to human much better than before? These require more investigation. And they will be required for any other infection.

A combination of epidemiology that actually tracks patients and their contacts to look at the spread of a disease as well as genomic epidemiology, where we can track the strains along with the illness they produced, is much needed.

On Monkeypox

Q: Four cases of monkeypox have been reported so far in India. A person in Delhi had no international travel history, indicating human-to-human transmission within the country. Should we be worried? 

A: Anytime you have a new disease coming into a population, it is a matter of concern. But this is a disease that is only in about 17,000 people worldwide outside of Africa. And it is a disease that can be controlled with public health measures — early detection and isolation of individuals.

If we are aware and we have the facilities to get the diagnosis quickly, then we don’t have to worry too much. It is painful for people who are infected: They do get quite sick but, it is a self-limiting disease. Recovery happens in two-three weeks.

Q: Is the transmission of this virus happening differently in different populations?

A: In Africa, it is frequently transmitted from animals to humans. It can be transmitted through prolonged contact with an infected animal or by eating an infected animal’s meat.

In terms of human-to-human transmission, the primary mode of transmission is skin-to-skin contact.

Another way that people can get infected is through the respiratory route, but that requires fairly prolonged face-to-face interactions for long-ish periods of time before you acquire the infection.

Q: Does the Monkeypox virus mutate like the Sars-Cov-2?

A: In general, DNA viruses don’t mutate as much as RNA viruses. It’s actually interesting that in Monkeypox viruses that were sequenced between 2017-18, 47 mutations were identified. Of these, 42 are very similar sort of mutations in a family of human proteins.

There are theories that this is a virus that has been circulating undetected for at least five years, but a few others have looked at it and said that it is not the case.

Q: Immediate steps to manage Monkeypox?

How a monkeypox blister looks like/Creative Commons

A: There is a need to increase our capacity to be able to diagnose cases — not just laboratory cases but also clinical cases. People should know how to recognise these cases.

When you say fever with rash, it can occur in many viral infections.

So, fever that is followed by rashes that become blisters then become like pustules, and then develop depression on top are characteristic of a pox infection in general.

We have not seen a pox infection for a long time, so they [people] should know to recognise it.

Q: Can Monkeypox be managed at home?

A: Most Monkeypox cases can be managed by isolating at home.

They will not necessarily require hospitalisation if they can isolate appropriately at home.

Q: Are the 3 Ts we learnt from Covid-19 important here as well?

A: Testing and tracing are very very important here. To be able to make a diagnosis and then identify contacts that the infected persons might have had is important.

One needs to follow up on the contacts for the period of incubation, and if any person is found to be infected, their contacts should also be isolated or quarantined.

Q: Should everyone be vaccinated for Monkeypox?

Representational picture of monkeypox vaccine/Creative Commons

A. No no no no. Everybody should not take the vaccine.

There are some groups that are at a particularly high risk of acquiring the infection: For example, right now nine out of 10 cases at least that we are seeing are in men who have sex with men.

If we can protect that population, then we will actually stop the spread of the disease in its tracks.

This is not a Sexually Transmitted Disease. This is largely a disease that is transmitted by skin-to-skin contact.

But vaccinating people who might potentially acquire this infection helps to protect them and the community.

We need to be aware that there shouldn’t be any stigmatization, but there should be a recognition of epidemiological principles on whom to vaccinate.

Covid’s role in this outbreak

Q: Can a newer variant of concern of Sars-CoV-2 emerge with an interaction of the two viruses?

A: No. Monkeypox is a DNA virus and Sars-CoV-2 is an RNA virus. Those two are not going to create a hybrid virus!

Q: Can Covid-19 make the Monkeypox outbreak worse?

A: No. But the other virus that can lead to greater severity of infection, particularly for Monkeypox, is HIV.

If you are an HIV patient with a compromised immune system, and the infection is not well-controlled by medication, you might have a very severe case of Monkeypox and die. But the number of such people is very low.

On the Covid-19 situation

Q: How are southern states faring on the Covid-19 front? 

A: Look around you. What’s happening in the hospital, that’s really the most important thing.

Given that the bulk of our population is both vaccinated and infected, I think by and large that they can overcome all adversities in the absence of a new variant.

We are in a pretty good place. That doesn’t mean people cannot fall sick. Some people can be quite miserable for a few days and experience long-lasting effects.

It is not something to be taken lightly, but it’s not something where we should expect the kind of situation that we had in April and May last year.

We had hospitals being full, high mortality, etc. That is not going to happen now.