A sudden surge of monkeypox cases sparked concern and confusion in recent weeks as experts grapple to explain why the virus is spreading in the community outside Africa for the first time.
Public health workers are isolating people infected with the virus and locating their close contacts, isolating them for 21 days and offering smallpox vaccines. Most people over 50 are vaccinated, and they're effective against monkeypox due to the similarity of the two viruses. This is a strategy previously successful at containing monkeypox, which causes a rash, usually starting on the face before spreading to other parts of the body, according to the NHS.
Dr Hugh Adler, 34, was part of a team at Royal Liverpool Hospital who treated a case of monkeypox in 2018. Liverpool has one of five specialist units in the country with the isolation facilities and clinical expertise to handle what the government calls 'high consequence infectious diseases' (HCID), including monkeypox, ebola, SARS, avian flu, and pneumonic plague. The junior doctor said: "Being a specialist centre, it's something we prepare for, and we felt very well prepared for it. We were trained in terms of PPE and we had pretty well-rehearsed drills. It's always a learning curve, but we felt we were ready for it."
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Based on that patient and research, carried out as part of a team, into other cases in the UK between 2018 and 2021, he said "we didn't see severe illness, we didn't see death, and that's really important". But what they realised was it can be deeper than "a superficial skin disease". The "big surprise" was being able to detect monkeypox virus in blood samples and throat swabs, not just the skin rash, and that tests came back positive months after patients were infectious. Clinicians also "saw some unusual features of the disease", with one patient having an abscess requiring intervention.
The recent outbreak of cases in the UK - with 106 cases confirmed in the UK and more than 200 across Europe - is "definitely a suprise", but it isn't new like covid, so public health experts and specialist healthcare workers have a strategy to deal with it.
Hugh, who also works at the Liverpool School of Tropical Medicine, said: "The number of cases we're seeing shows there has been onward transmission that's happened before the early cases were picked up. That's something that can happen with any infection. It hasn't happened before, and up until now the HCID network approach has been very effective at containing the infection. But we do think that as long as we're able to do the case finding and diagnose the cases that we should be able to interrupt chains of transmission."
What the research team found from looking at people infected with monkeypox between 2018 and 2021, was that medicines like brincidofovir "showed great promise in preclinical studies for monkeypox", according to Hugh. Although such drugs aren't licensed for monkeypox, they are available on 'compassionate use', meaning they can be used to treat seriously ill patients for whom other treatments haven't worked.
But for most people, monkeypox is mild and goes away by itself in two to four weeks, according to the NHS. It's a more serious concern for young children, pregnant people, and people with compromised immune systems, which is why Hugh hopes treatments and vaccines will be made available to people in West and Central Africa where monkeypox is more common but there's less access to adequate healthcare.
Previously, monkeypox has entered the UK in people who've recently travelled from these areas, where bushmeat is an important source of protein in rural regions, increasing the risk of catching it from infected host animals. The two cases in 2018 had both recently returned from Nigeria, and as far as we know right now, that's really all that sets this outbreak apart from previous cases. Rather than being travel-related cases with infection contained to households and healthcare settings, this time there is spread within the community. But, although we don't know for certain why so many cases have been confirmed, the virus itself does not appear to have changed.
Professor Julian Chantrey is a vet at Liverpool University's institute of infection, veterinary and ecological science who's researched monkeypox in animal populations. He said: "These viruses are almost the other end of the scale to covid in that they are very stable and they don't mutate much at all. They slowly change over time, but it's really slow."
The virus Hugh treated in 2018 appears to be the same as the virus circulating in the UK now, and it's one whose name is misleading. Like chickenpox isn't found in chickens, and cowpox doesn't infect cows, monkeypox mostly doesn't come from monkeys - it was just first identified in lab monkeys. Rodents are the usual carrier of the monkeypox virus, and when there was an outbreak in the USA in 2003, it was sparked by the importation of infected giant Gambian rats. These then infected prairie dogs, which passed the virus to humans.
Such chains of transmission have sparked fears that pets could be quarantined or culled to prevent the monkeypox virus becoming endemic in the UK. But Julian thinks "it would be a real long shot for that to happen" because it would need to go through an intermediary like a cat. He said: "I think the chances of it becoming established in the UK are slim. There is a good vaccine. [Monkeypox] is nasty, it's unpleasant, but like chickenpox, it'll give you a fever and make you feel miserable and itch like hell, but it's not going to kill you."
Hugh said: "It has a potential to really be stigmatising because it's got this exotic name - it definitely should have a better name - and it's been linked in the media to gay and bisexual men, and men who have sex with men, who have historically been persecuted and marginalised. Monkeypox is not a big public health threat to the UK or Europe monkeypox. It can be a mild disease, we can tackle it, and the important thing is for people who might have the infection to seek help and be given help, and that the public health response can do its thing. We'll be able to tackle it that way."
The UK Health Security Agency (UKHSA) has purchased more than 20,000 doses of a smallpox vaccine to aid the efforts to contain the outbreaks. It said the risk to the UK population is low, but people should be aware of any new rashes or lesions that can appear like spots, ulcers or blisters anywhere on the body.
Dr Susan Hopkins, the UKHSA's chief medical adviser, said: "We are continuing to promptly identify further monkeypox cases in England through our extensive surveillance and contact tracing networks, our vigilant NHS services, and thanks to people coming forward with symptoms. We are asking people to look out for new spots, ulcers or blisters on any part of their body. If anyone suspects they might have these, particularly if they have recently had a new sexual partner, they should limit their contact with others and contact their local sexual health service as soon as possible, though please phone ahead before attending in person."
