Here we are, past the halfway mark in 2022, still grappling with the long shadow of the Coronavirus, the war in Ukraine, economic distress, joblessness, rising inflation, and we get hit by one health crisis after another.
First, a viral zoonosis named Monkeypox. Coming on its heels, is another viral disease, tomato flu. And also the new ‘Centaurus’ strain of coronavirus, scientifically known as BA.2.75, made India its ground zero and has since been detected in more than 20 countries. Soon arrived China’s new dark star, an animal-derived Langya henipavirus, which showed up in the eastern part of the country. It appears like mankind is being challenged by viruses from the primaeval swamp from where man arose millennia ago.
On August 19, a study in Lancet sounded alarm on the spread of tomato flu in India -- 82 cases, since the virus was first reported in Kerala on May 6. With symptoms similar to Covid-19, the disease gets its name from the red blisters that appear on the body, which can become as large as a tomato.
“Just as we are dealing with the probable emergence of fourth wave of Covid-19, a new virus known as tomato flu, or tomato fever, has emerged in India in Kerala in children younger than five years. Additionally, 26 children (aged one-nine years) have been reported as having the disease in Odisha by the Regional Medical Research Centre in Bhubaneswar. To date, apart from Kerala, Tamil Nadu and Odisha, no other regions have been affected by the virus,” the Lancet report said.
Among the many viral diseases, monkeypox is the fear du jour. On July 23, Dr Tedros Adhanom Ghebreyesus, WHO’s embattled director-general, declared the escalating outbreak a Public Health Emergency of International Concern (PHEIC), like Covid in 2020. The US, too, declared it a national public health emergency after the outbreak there grew into the largest in the world.
Monkeypox, a viral zoonosis, has jumped from an animal to humans, showing symptoms similar to smallpox. Scientists say future health emergencies are likely to be zoonotic in nature. That pandemics will be a part of our life is painfully clear. The global scientific conversation centres around how, when and where a new pandemic could occur and what are measures that might prevent it.
The WHO decided to sound the alert on monkeypox in July after a global uptick in cases: 16,000 reported cases from 75 countries and territories. By August 23, over 44,000 infections had been reported from 96 locations, with 12 deaths across the world, including one from India. Notably worrying is the fact that the vast majority are from places that have not historically reported monkeypox -- the US, Spain, Germany, the UK and France.
India has nine cases of laboratory-confirmed monkeypox and one death. Five out of the nine cases reported in India, including the death, have been reported from Kerala; four are from Delhi. Epidemiologists say monkeypox is indigenous to specific regions of central and western Africa, though the outbreaks are infrequent, are quickly contained or vanish.
This time, it has travelled across the world rapidly, thanks to air travel opening up and international conferences happening. Most symptoms have been mild, including skin lesions. Asymptomatic infections, like in the SARS-Cov2 virus, go unnoticed and unreported -- a scary thought.
Dr Dimie Ogoina, Professor of Medicine and Infectious Diseases in Nigeria and President of the Nigerian Infectious Diseases Society, had sounded the monkeypox alarm in his country five years ago when an 11-year-old boy came to his clinic with an unusual lesion on his face and all over his body. The world did not take much notice. “Monkeypox was a neglected disease for over 40 years and is only gaining attention now because outbreaks are being reported in the global north,” Dr Ogoina says.
In India, the Ministry of Health and Family Welfare has issued a monkeypox guideline that runs into 23 pages. There is a Central Task Force for monkeypox. Biotechnology corporation Mylab Discovery Solutions is reportedly one of the four companies which have pitched to the Indian Council of Medical Research (ICMR) to create testing and diagnostic kits for the monkeypox virus.
Several Indian companies, including the Serum Institute of India and Biological E, have expressed their interest in developing a monkeypox vaccine. Researchers at ICMR–National Institute of Virology (ICMR-NIV) have concluded that the monkeypox virus strain A.2 from the UAE-returned patients is different from the European one -- a big concern. The good news, however, is that no secondary human-to-human transmission was observed in the close contacts of the confirmed cases from the UAE which have been analysed.
Dr Pragya Yadav, a senior scientist at the NIV, who analysed India’s first two monkeypox cases, says the “clinico-epidemiological history and laboratory analysis of two confirmed monkeypox cases in India suggest travel-associated introduction of infection in the country.” Unfortunately, there is no epidemiological data to understand how monkeypox came to the UAE.
“Monkeypox has been around for far longer and moves less easily between people than Covid-19 does. The lesson is that we should take neglected tropical diseases far more seriously. They impact large populations, but are often ignored when it comes to treatments and vaccines,” says Prof. Gautam Menon of Ashoka University, whose research interests include the modelling of infectious disease and its implications for public policy.
Dr Ogoina thinks countries like India and others in the global south must take their destiny into their own hands. “Invest in local capacities for research and development that will solve local problems with or without the support of the global north,” he says.
Even as monkeypox continues to add to the scare, the coronavirus nightmare is far from over, as new mutations appear across the world. On August 21, WHO alerted that more Covid variants with intense circulation will be seen in the coming days, even as the number of cases and deaths continue to rise. “Future variants will be more transmissible, may have further immune escape but we do not know if they will be more or less severe,” says WHO’s Maria Van Kerkhove.
On August 11, the Delhi government brought back the mask mandate in public places after the first 10 days of the month saw more than 19,000 Covid-19 cases and 40 infection-related deaths in the city alone. Other parts of India are reporting a rise in Covid infections. Sub-lineages of the Omicron variant of the Coronavirus are driving the recent spike. What do these new mutations of the Coronavirus and converging health emergencies with their attendant economic consequences mean for a country like India? What lessons have we not learnt from Covid-19?
“The worry is not about these subvariants, because we are relatively better protected owing to the immunity derived from vaccination and past infection as of now. But we don’t know when the next big variant will come. And we don’t know how severe or otherwise it can be. The big concern is whether India is prepared for a new variant,” warns Dr Rajeev Jayadevan, co-chairman of the National Indian Medical Association Covid-19 task force.
Preparedness is key.
Dr Jayadevan says, “Without testing, one will never know the true magnitude of the spread of the virus. The numbers you hear are the laboratory-confirmed cases, but many people are not going to laboratories. We need to step up our game on surveillance.”
He stresses the importance of air hygiene in preparing for future health emergencies. But there are serious challenges. Better ventilation and air hygiene would mean workspace modifications and architectural changes, which means money and effort. “Covid-19 is a cyclical disease that will continue to strike in waves,” he warns.
Dr Giridhara R Babu, a well-known epidemiologist, laments, “Unfortunately, the continual neglect of public health systems prevails in the zeal of going back to normal.”
The ‘One Health’ approach is a key piece of the conversation around pandemic preparedness.
It could be “a solution that links the monitoring of animal and human diseases. In the case of a few zoonotic diseases, animals provide an early warning to human beings. In other cases, humans manifest symptoms before the illnesses are detected in animals. Simultaneous monitoring of these health systems can serve as early warning mechanisms, which in turn will be crucial for detecting zoonotic infections in a timely manner in the future,” notes Shruti Sharma, a senior research analyst with the Technology and Society Programme at Carnegie India.
Her paper suggests that the One Health approach could be used to share pathogen genomic data that can be leveraged for the development of vaccines, diagnostics, or other therapeutics to prevent and respond to zoonotic infections.
There is a ‘but’ there. She points out, “Most countries have separate disease surveillance programmes pertaining to infections in plants, animals and humans. The siloed nature of the programmes is further exacerbated by a lack of communication and adequate data sharing among themselves, limiting the opportunities for detecting zoonotic infections at an earlier stage.”
We can’t afford to miss out the early alerts. This does not necessarily mean doomsday is close at hand, or that doomscrolling our only available recreation. It simply means we can’t take our foot off the pedal. Whether one is an individual or a country.
Who is at risk of catching monkeypox?
✥ People who live with or have close contact (including sexual) with someone who has monkeypox, or have regular contact with animals who could be infected, are most at risk. Health workers should follow infection prevention and control measures to protect themselves while caring for monkeypox patients.
✥ Newborn, young children and people with underlying immune deficiencies may be at risk of more serious symptoms and, in rare cases, death from monkeypox.
✥ People who were vaccinated against smallpox may have some protection against monkeypox. However, younger people are unlikely to have been vaccinated against smallpox because its vaccination stopped in most settings worldwide after it was eradicated in 1980. People who have been vaccinated against smallpox should continue to take precautions to protect themselves and others.
Source – WHO