The story so far: On July 14, Kerala detected the first case of monkeypox in the country in a 35-year-old, who had flown into Thiruvananthapuram from the UAE. Four days later, the authorities confirmed a second case, this time at Kannur again in a passenger from the UAE. While both patients are in isolation and treatment, the State Health department has strengthened surveillance and control measures across all districts.
Why did cases first surface in Kerala?
As a State with four international airports, a sizeable expatriate population and being a globally favoured travel destination, the probability of any newly emerging pathogen first arriving at the shores of Kerala has always been high. The State Health authorities are, therefore, relieved that the health system managed to pick up the first two cases of monkeypox, an affirmation of the robustness and efficiency of the State’s disease surveillance mechanism.
In Thiruvananthapuram as well as Kannur, the patients themselves had approached the doctors/authorities, raising the suspicion that they might have contracted monkeypox. Doctors point to the increased public awareness, the high level of clinical suspicion maintained by the medical fraternity about the new disease and the social commitment of the people that led to the detection of the monkeypox cases.
What are the steps being taken by Kerala?
One of the first public health messages sent out by the Health department was that there was no need for the public to panic as monkeypox was not a disease which could spread through the air like COVID-19.
However, the public needed to be vigilant about maintaining all universal precautions that were put in place when COVID-19 was first reported.
As soon as the patient was isolated, close contacts were also isolated. A list of primary contacts for contact tracing was also drawn up. The contacts were put on symptom surveillance for 21 days and the respective districts were asked to monitor them closely.
Furthermore, monkeypox advisories were sent out to districts which resulted in the setting up of State and district-level monitoring cells. All districts were asked to set up isolation facilities in select hospitals and special ambulances to transport sick persons.
Next, all districts were asked to strengthen field-level surveillance of cases with fever and rashes along with one or more of these symptoms — enlarged lymph nodes, headache, bodyache and profound weakness. Help desks were set up at all airports, with trained health workers manning them.
The official confirmation of both monkeypox cases came from the National Institute of Virology (NIV), Pune. However, as part of the surveillance network, strengthening of in-house diagnostic facility was important to avoid delays in treatment. A monkeypox testing facility was thus made available at NIV’s field unit at Alapuzha.
How should monkeypox cases be treated?
The Standard Operating Procedure (SOP) prepared by the Kerala government with regard to monkeypox is a detailed document which outlines the steps that need to be followed with regard to the isolation, treatment and sample collection of suspected and probable cases of the disease which are reported to the healthcare facilities of the State.
All healthcare institutions in the State in the public and private sector are expected to strictly follow the SOP when dealing with monkeypox or cases with similar symptoms. A person having a history of travel to monkeypox-affected countries within the last 21 days and presenting an unexplained acute rash with one or more of the earlier mentioned symptoms is defined as a ‘suspected case’ under the SOP.
The SOP details how the samples are to be collected as per NIV’s directives and the precautions that health personnel have to take when a case has to be transported in an ambulance.
What does this mean for other States?
The fact that monkeypox has not been documented in other States does not mean that the virus has not reached other parts of the country. Kerala detecting the first two cases from international travellers is a signal to other States to strengthen their surveillance networks, especially surveillance among travellers, so that source cases can be identified at the earliest and prevented from establishing other contacts in the community.
States will have to focus on creating more awareness about monkeypox and its transmission dynamics among the public, the medical community and health workers so that they learn to maintain a high index of suspicion when encountering cases of fever with rashes. While airport surveillance has a huge role, monkeypox has a long incubation period and it is possible that some passengers who may have been infected, may develop symptoms only much later. These cases can be detected from the community only if adequate awareness is created.
Is Kerala worried about community transmission of monkeypox?
Public health experts point out that given the transmission dynamics of monkeypox, the secondary attack rate of the virus is less than 10%, indicating that even amongst close family contacts of confirmed cases, the chances of monkeypox spreading are remote. In fact, the Health department confirmed that two of the close contacts of the very first case of monkeypox had tested negative for the virus ( they will however remain in surveillance for 21 days).
What is now worrying the health experts are reports from the U.K. and some other European nations that many recent cases of monkeypox have been presenting with atypical symptoms — sometimes with no fever at all and the lesions few or confined to the genital region. It was reported that for many of the recent cases, health authorities had no idea how the person contracted the virus. In Belgium, asymptomatic cases were also detected.
Extreme high-risk skin-to-skin contact seems to be the way in which the virus is getting transmitted and hence the Health department will also be tapping into its HIV surveillance network to sharpen surveillance and sensitise MSM (men who have sex with men) communities about the threat of a sustained transmission of monkeypox.
