Authored by: Venkat Rao
A couple of days ago, New York Department of Health confirmed the first known case of Monkeypox in a juvenile person under 18 years age. Without providing additional details on how the teenager contracted the disease, the report mentioned skin-to-skin contact as the likely path of transmission. In the past few days, other US states including Texas, California, Florida, Oregon, and Maine have reported multiple cases of children contracted with monkeypox via skin-to-skin transmission route.
Today, CDC reports of a study showing multiple surfaces testing positive for monkeypox virus genetic material in a household of two people infected with monkeypox in Utah.
What is going on here? With so much confusion and misinformation spewed in the past two years on the SARS-CoV-2 virus mode of transmission and emergence of the COVID-19 global pandemic, are we in for another round of misinformation and confusion in public health discourse on what could be another serious infectious disease outbreak?
According to the just released CDC report, Salt Lake City Health Department performed environmental surveillance of the home of two individuals with confirmed monkeypox disease to assess through sampling of household high-level contact surfaces and objects to detect presence of the virus in the samples collected during surveillance..
Environmental sampling of household surfaces of 30 specimens yielded 70% positive results of the presence of monkeypox virus material on porous surfaces (such as cloth furniture, blankets etc.) and 68% of nonporous surface samples (such as handles, switches etc.). Investigators caution that the study found monkeypox genetic material only and not viable viruses in the sample. Although, the expressed caution by the investigators addresses the environmental stability and viability of the monkeypox virus, it does not negate or rule-out the potentials for skin-to-skin, or skin-to-contaminated surfaces contacts as path of transmission of the virus.
According to the latest WHO surveillance report, more than 80 countries where monkeypox is not
endemic (monkeypox is endemic in Africa), have reported the disease outbreak with total number crossing 41,000 reported cases. Until recently, WHO and public agencies guideline have issued public notices and guidelines on monkeypox as the viral disease spreading predominantly among the homosexual men.
According to a CDC report in the first week of August, 99% of the US monkey pox cases occurred in men, 94% of whom reported recent male-to-male sexual or close intimate contact.
An earlier CDC’s communique in July 2022, cautioned that monkeypox is a communicable disease that requires close, personal contact with someone who is infected, and most reported cases in the US were among homosexual men who have sex with men. There was no reference to any other potential modes of transmission of the virus. Reports in the past few days from several US states on monkeypox infection among teenagers and young children appears entirely outside of the first round of public health communication regarding this outbreak, and yesterday’s report from CDC on the presence of monkeypox viral genome on household surfaces adds an additional layer of complexity to the viability of the virus and its mode of transmission and source of infection in the general environment.
Notably, the messaging on monkeypox is similar to what we witnessed during the early months of the COVID-19 pandemic, with a slew of apparently contradictory and confusing technical research publications and public health messaging on an emerging global COVID-19 outbreak.
CDC and NIH reported in 2020 that SARS-CoV-2 the virus causing COVID-19 may remain on plastic and stainless-steel surfaces for days. This was followed by a WHO communication in February 2020 that the then new coronavirus causing COVID disease can spread through contaminated surfaces, known as fomites. By May of 2020, WHO and other health agencies all over the world recommended community settings such as homes, buses, churches, schools, and shops clean and disinfect surfaces, especially those that come in frequent contact.
However, subsequent studies indicated that COVID-19 rarely spreads through contact of hard surface and does not constitute a route for transmission of SARS-CoV-2 virus infection.
We are almost at an identical point in time with the monkeypox outbreak, with reports of differing modes of viral transmission and likely routes of infections diverging from the primarily mostly homosexual men and requiring intimate body contact, to children and teenagers now infected with the same virus with no clear causal path for transmission, and now reports of the presence of virus on household surfaces we would normally come in contact.
Going by the general characteristics of pox viruses such as monkeypox, this category of viruses is generally transmitted through close contact with an infected person in general, and contact with materials contaminated with the virus. Close contact with lesions, body fluids, and respiratory droplets and contaminated materials such as bedding are primary sources of infection. It is critical that the public health messaging focus on the well-documented route for pox virus infection, focus less on specific demographic groups, age, gender, and related specifics which may not hold good when more data become available on the mode of transmission and paths to infection.
The painful lessons learnt from the still ongoing COVID-19 pandemic should be a teachable moment to the scientific community and government authorities on public health messaging regarding monkeypox outbreak. it is extremely critical for the public health departments to carefully assess the strategic importance of disease outbreak communication and help prepare public-at-large to assess the threat more realistically, aware of the knowledge gaps and uncertainties in the scientific data as it emerges, and remain prepared on the likely public health consequences.