Monkeypox spread unusual, says WHO’s Dr Soumya Swaminathan

In an exclusive interview, the WHO chief scientist said it is clear that in the context of COVID-19 immune responses are waning over time and there should not be any slack in testing and genetic sequencing.

Monkeypox spread unusual, says WHO’s Dr Soumya Swaminathan
Dr Soumya Swaminathan, chief scientist at WHO says that countries have reduced testing and genetic sequencing.

Even as the concerns around COVID still linger, the emergence of Monkeypox and the Marburg virus signal that infectious diseases have made a comeback. This adds an important element to healthcare in a country that had begun to see non-communicable diseases (NCDs) like diabetes, cancer, stroke, and cardiac ailments as the predominant health concern and the reason behind the bulk of the deaths due to illness. 

What do we need to be worried about and focus on for Monkeypox, which is now a new concern since it spreads through human-to-human contact, skin-to-skin contact, and sharing of clothing or linen, there are good reasons to stay alert and take an expert view on the safeguards and surveillance, especially in areas that are densely populated. 

In fact, the first question most experts ask whenever Monkeypox is reported now is: What has been the mode of transmission? Dr Soumya Swaminathan, the chief scientist at the World Health Organisation (WHO), who has been having similar concerns, sees monkeypox spreading in a highly unusual manner around the world. This is significant as experts have been already saying that what has been happening is new from an epidemiological perspective with concerns around the routes of transmission, as there is local transmission taking place in newly-affected regions or countries with no links to the countries that had previously reported cases (such as from Africa). 

On COVID, she cautions that “it is clear that our immune responses wane over a period of time (especially the neutralising antibodies in blood). Hence, it is possible to see repeated waves or surges of infection every 4 to 6 months.” Of concern, she says, is also a “fact that countries have reduced testing and genetic sequencing.”

Excerpts from an exclusive interview with Dr Swaminathan The Monkeypox and Marburg virus are both pointing to a comeback of infectious diseases. How concerned are you and what can this mean for a country like India? How does one build surveillance at the primary care level, as perhaps there is a reason why cases get first spotted in Kerala, for example? 

Dr Soumya Swaminathan: In recent weeks, many countries are reporting unusual disease outbreaks – the most concerning one being monkeypox, which is spreading in a highly unusual manner around the world. There have been reports of Marburg virus cases in Ghana as well as detection of polio in wastewater in London and New York. This could partly be due to enhanced surveillance capacity and greater awareness as well as rapid reporting of these events by countries. However, the larger picture of loss of forests, climate change, increasing human-animal contact, international travel, and densely populated cities are all risk factors for the emergence of new and unusual spread of known infectious diseases.

All countries need to evaluate their preparedness at the national, state, and district levels and strengthen systems where needed. A careful and critical analysis of what went well and not so well during COVID can provide pointers to where efforts need to be prioritized. Investments into data systems, passive and active surveillance capacity and human resources are critical. Rather than siloed data collection for diseases, the integrated disease surveillance platform should be strengthened and real-time data analytics used. Investments into research and development for countermeasures (drugs, diagnostics, vaccines) in public-private partnership mode must be enhanced. Finally, at the global level, an international pandemic preparedness and response treaty or agreement will allow a globally coordinated response to epidemics and pandemics, including the equitable sharing of scarce supplies.

FE: How concerned are you about the way Covid is manifesting now, the rise in the transmission rate both in India and in other geographies? 

SS: From what we know about this virus, we can expect SARS-Cov2 to continue to mutate and evolve – to be successful, each new variant will either have to be more transmissible, more immune evasive, or both. It is also clear that our immune responses wane over a period of time (especially the neutralising antibodies in blood). Hence, it is possible to see repeated waves or surges of infection every 4 to 6 months, as we are seeing with BA.4 and BA.5 in the USA and many parts of the world.

Of concern is the fact that countries have reduced testing and genetic sequencing. Despite that, over 6.3 million weekly cases and over 12,000 deaths have been reported to WHO over the past several weeks, indicating that viral transmission is still active globally. It is clear that the pandemic toll is still very high and that we will have to stay on alert for the foreseeable future. The reassuring thing is that existing vaccines continue to provide protection against severe disease and death and that after a third dose, this protection appears to last. Therefore, with high vaccination coverage (including boosters especially in high-risk groups), the health impact of future surges can be minimised.

FE: How many Omicron variants are doing the rounds currently and what do we know about each of them? Which one should India be most concerned about?

SS: The dominant Omicron variants today (from submissions to GISAID) are BA.4 and BA.5 globally. We know that BA.5 is good at evading immunity even among people who had BA.1 infections earlier this year. While hospitalisations have increased in some countries, overall, clinical severity is similar to previous Omicron variants.

FE: Among them, what is your reading of the trend on transmission? The R-value has apparently moved up from 3/4 to about 7 or so. Is this correct?

SS: The R-value of currently circulating Omicron variants is higher than previous ones. R is also affected by the preventive measures that people take and in many countries, masking and other precautions have been abandoned.

FE: How effective are the current vaccines against them? Since none of the vaccines were designed for Omicron and its sub-lineages, what is the view on the level of protection now?

SS: The effectiveness data that’s available shows that while protection against severe disease is maintained after the third dose of vaccine (homologous or heterologous), protection against infection declines within 12 to 16 weeks. This means that vaccinated individuals can develop COVID infections, but the majority of cases will not be severe. Vaccine effectiveness studies have been conducted mostly in high-income countries with the 3 or 4 most commonly used vaccines, There is an urgent need for data from countries like India to understand the duration of protection in individuals with 2 or 3 doses of vaccines among different age groups and in individuals with underlying illnesses. This type of information is needed to develop policies for the future on the need for additional doses, if at all, and to identify the risk groups and timing of such doses.

FE: Will there be a need for a fourth dose now? If so, of which vaccine? Any thoughts on an updated booster?

SS: The need for additional doses will be driven by the data being generated now. Some companies are making vaccines that incorporate the Omicron variant – we still need clinical effectiveness data to determine if boosters using these variant-adapted vaccines will have any advantage over existing ones. Ultimately, a vaccine that targets conserved proteins of the coronavirus and elicits broadly protective immunity (a so-called pancoronavirus vaccine) will be the solution.

FE: What is your key message to governments, healthcare providers, and to the proverbial man on the street?

SS: Stay alert, adjust public health measures based on local epidemiology, continue surveillance, sequencing and look out for new variants, strengthen health systems, especially the workforce, ensure high vaccination coverage, and communicate often with the public about measures that are needed.

Also, invest in research and development for vaccines, antivirals and diagnostics – also for future infectious disease outbreaks and implement a One Health program in the country.

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