Global Emergency: Monkeypox Outbreak
We need to increase national vigilance against the possibility of cases occurring in Indonesia, both from within the country and the possibility of transmission between countries.
The World Health Organization (WHO) on 23 July declared the monkeypox outbreak as a global-health emergency.
The statement that monkeypox is a public-health emergency of international concern (PHEIC) is a kind of alarm for the world to make maximum efforts so that the situation is under control and does not escalate into a pandemic.
Monkeypox has been known for a long time. The first case occurred in Denmark in 1958 when two such cases of smallpox appeared in a colony of monkeys kept for research. The monkeypox virus itself is a member of the Orthopoxvirus genus, the same genus as the variola virus that causes smallpox and the vaccinia virus used in the smallpox vaccine.
Smallpox was eradicated from the earth in 1980. Since it was discovered, there have always been cases of monkeypox from time to time, although only in certain countries. However, around May 2022, there was a new phenomenon, namely the discovery of this disease in countries where there had been no cases before, or at least there had been no case reports for a long time. Since the beginning of May 2022, more than 15,000 cases of monkeypox have been reported in more than 60 countries.
Also read:
> Unexplained Severe Acute Hepatitis
> The Impact of COVID-19 Virus Mutations
Symptoms of this disease usually begin with a fever for several days and swollen lymph nodes, followed by red patches on the skin that can leave scars in the form of scar tissue. So far, most cases have recovered without having to be hospitalized.
As of 7 July 2022, three people have died from monkeypox, all in Africa. In comparison, when Covid-19 was declared a PHEIC on 30 January 2020, there were 83 cases in 18 countries and at that time there were no deaths.
The international agency Center for Infectious Diseases and Research Policy (CIDRAP) on 24 June 2022 published an article entitled "Virus Causing Monkeypox Outbreak has Mutated to Spread More Easily". It was revealed, based on a scientific article in the journal Nature Medicine, that the virus that causes monkeypox in non-endemic countries today is different from its origin in several African countries. The current virus has mutated and is also more easily transmitted.
The article was based on data sequenced from 3,000 cases in Europe and America. The researchers found differences in the 50 sites of single nucleotide polymorphisms (SNPs), and several mutations were found. The researcher also mentions the role of the super-spreader as one of the causes of easy transmission in the community.
Meanwhile, the scientific journal Lancet Microbe (24/6/2022) reported the results of research modeling the spread of cases if the state did not handle public health properly. It is estimated that if there are three cases, there will be 18 cases of transmission. If there are 30 cases, it will be 118 cases, and so on. If the management is carried out properly through the process of identification, contact tracing, surveillance isolation and ring vaccination, the number of secondary cases will drop by 81 percent.
Public-health emergency
The term PHEIC is listed in the International Health Regulation (IHR) which was passed in 2005 and has become the world's guide to this day. When I became director general of the Directorate of Disease Control at the Health Ministry, I introduced the Indonesian term from PHEIC, namely “public-health emergency that is troubling the world [KKMMD]”, which contains four aspects.
First, it must be formally declared by WHO. Second, it is an extraordinary event. Third, it poses a public-health risk due to transmission between countries. Fourth, it requires international coordination to manage.
There are three areas of this definition of PHEIC, namely: first, it is a serious, sudden, unusual or unexpected illness/condition. Second, it has public-health implications in other countries. Third, it requires immediate action for international treatment.
In accordance with existing regulations, in determining the PHEIC, the WHO director-general forms an emergency committee (EC). I used to be a member of a committee like this during a discussion about MERS CoV. At that time, we decided that MERS CoV was not a PHEIC. From experience, so far, usually EC members agree to declare an event as PHEIC or not, then the WHO director general validates it.
For the monkeypox case, the EC members have met twice and have yet to come to an agreement. However, due to the complexity of the problem, the WHO director general still declared it a PHEIC.
Also read:
> Preventing the Resurgence of Covid-19 Cases
It should be noted that what is being declared as a PHEIC is not only new diseases, because monkeypox is not a new disease, unlike Covid-19, which is a completely new disease. PHEIC status is declared for monkeypox outbreaks that occur in several countries (multi-country outbreak of monkeypox) because the disease exists in several countries, complete with specifications.
The same thing happened in the case of the Zika virus, which is also not a new disease. In Zika, the PHEIC status is declared for a cluster state of microcephaly and other neurologic disorders and their possible association with the Zika virus.
Declaration of a disease/condition as a PHEIC does not necessarily mean that it will become a pandemic. The PHEIC declaration was followed by a declaration of a pandemic in the cases of Covid-19 and influenza A(H1N1). Covid-19 was declared a PHEIC on 30 January 2020, and was followed by a pandemic declaration on 11 March 2022. Influenza A(H1N1) was declared a PHEIC on 25 April 2009 and declared a pandemic on 11 June 2009.
On the other hand, there were several PHEIC declarations, which later did not become a pandemic, for example Zika, Polio and Ebola. The diagnosis of a PHEIC is a kind of alarm for the world to make maximum efforts so that the situation is kept under control and does not grow into a pandemic. In the case of monkeypox, WHO stated that one of the reasons it was declared a PHEIC was because they saw a window of opportunity for the situation to be well controlled if there were adequate joint efforts.
WHO Recommendations
To that end, WHO has made quite detailed recommendations for four groups of countries. First, for countries that have no history of monkeypox cases in humans, or have not detected monkeypox cases in the last 21 days. If it is true that Indonesia has no cases yet, it will fall into this category.
For this group, there are 10 recommended actions that need to be taken, ranging from multi-sectoral coordination, epidemiological surveillance, detection capabilities and appropriate-risk communication. Public understanding needs to be improved, including about the signs and symptoms of disease as well as efforts to prevent and protect them. Also, from now on, preparations need to be made immediately so that if there is a case later, all health systems are ready to deal with it.
Good preparation will result in appropriate control if monkeypox enters Indonesia later.
The second group is countries that import monkeypox cases and/or show human-to-human transmission, including in key populations and communities at high risk. For this group, there are six main recommendations and their various descriptions, including how to treat patients in the clinic, the drugs used, prevention of transmission in the community and recommendations related to international travel.
The third group is countries where there is suspected or actual transmission of monkeypox from animals (zoonotic). Here, the coordination of One Health (health for all) covering human, animal and environmental health must be improved. The fourth group is countries that have the ability to make medicine and vaccine for monkeypox. They were asked to increase production capacity.
In conclusion, we need to increase national vigilance against the possibility of cases occurring in Indonesia, both from within the country and the possibility of transmission between countries. Good preparation will result in appropriate control if monkeypox enters Indonesia later. Currently, there are cases of monkeypox in Singapore, Malaysia and Thailand.
Tjandra Yoga Aditama
Tjandra Yoga Aditama, Director of Postgraduate Studies at YARSI University/Professor of FKUI, Former Director of WHO Southeast Asia, Former Director General of P2P and Head of Balitbangkes
This article was translated by Kurniawan Siswo.
