There is still much to learn about the outbreak of monkeypox (renamed mpox) that is spreading across Africa and has caused the WHO to declare a health emergency of international concern, its highest level of alert. A new variant raises several unknowns about its transmission and danger that will have to be resolved over time. Taking this into account, with the caution that a health crisis advises, José Antonio López Guerrero, professor of Microbiology at the Autonomous University of Madrid, advises caution to people with risky practices (especially unprotected sex). Born in Madrid, 62 years ago, he answers the phone on the way to Esparragalejo (Badajoz), his town, where there is a park with his name.
Question: Are you worried about the mpox outbreak?
Answer: Well, it’s not good news. As Nobel Prize winner Peter Medawar said, viruses are bad news wrapped in proteins. Pox viruses are very complex, but they have good things: it’s a DNA virus, so it evolves less and mutates less than RNA viruses, such as the coronavirus. In addition, it has many parts that cannot mutate much because they would lose viability. This means, for example, that those of us who are vaccinated against smallpox, those over 50 or 60 years old, still have memory. Because of that and because of certain risky sexual practices that are more frequent in younger people, previous outbreaks have mainly affected people under that age.
Q. Until now, it was known that the virus was transmitted mainly through very intimate contact, almost always during sexual relations, but we are seeing that in Africa the most affected are children. What has changed?
A. Yes, we know that this was the way of transmission until now, but also through contact with the pustules it generates, with clothing that has been in contact with these blisters, through mucous membranes, by speaking very close, through the droplets we project when we speak. It can be passed on to children through this type of contact with parents. But, from what we know today, we are not talking about the coronavirus aerosols that float in the air and can travel meters. That is the good news.
Q. The new variant that has caused the outbreak in the Democratic Republic of Congo appears to be more lethal and dangerous.
A. As a virologist, I have my doubts. The tendency of viruses when they are in contact with a species is to find an equilibrium. It seems that clade 1B, which is the one that is currently spreading in Africa, has a fatality rate of around 3%, even higher in children. But this calculation is made by comparing the number of infected people with the number of deaths. What happens is that there are probably many more infected people and they may even be asymptomatic or not seriously ill and, therefore, are not reported. Someone who develops pustules in Africa may not go to the doctor, while in Spain they probably do. So I would take with some caution what the real fatality rate of the virus may be.
Q. What does seem to be more transmissible, right?
A. Yes, but we need more data. There are things we still don’t know, such as whether a person who is asymptomatic all the time, that is, who never develops symptoms, can be infectious. It does seem that it can be transmitted three or four days before having symptoms, but from what we know, those people who transmit the virus eventually end up developing them.
Q. Could these asymptomatic people be driving the spread of the virus?
A. It can, but then they develop symptoms. That is why we must focus more on raising awareness among people who do risky activities so that they are careful, which is in some way what controlled the outbreaks in the West. What happens is that the capacity for persuasion and dissuasion in Africa is less, because there are millions dying there from malaria, sleeping sickness… It is more difficult to transmit this change of habits. Although it is something that we achieved with Ebola. We achieved, for example, that they did not have contact with the dead.
P. Another important axis will be vaccines.
A. Of course. There are companies that have developed specific recombinant vaccines for mpox, different from the traditional one for smallpox that was being used. People also need to be made aware that the vaccines are two doses. [en España, solo la mitad de las 40.000 personas vacunadas ha recibido las dos]. Of course, you can tell someone to travel 300 kilometers to Kinshasa to go to the reference hospital in the Democratic Republic of Congo to get vaccinated twice. New antivirals are also being investigated, including some antibiotics, which seem to be effective, but that remains to be seen. The combination of antibiotics with immunotherapy with specific antibodies against the virus is being considered. That’s where the plans lie.
Q. It is inevitable that the declaration of an international emergency brings to mind Covid, but neither the virus nor the situation have anything to do with it.
A. They are completely different things. This virus has nothing to do with Covid or Ebola. The emergency does not mean that social restriction measures must be taken, it is rather to raise awareness among people to be careful in their risky practices, that if for example they have a headache, fatigue and may have rashes and so on, skin eruptions, they should be careful. But as I said, this is easier to transmit in Europe. In Africa, until people see the wolf’s ears more, they start to see dead people in the streets, it is more difficult to raise awareness. We should also raise awareness among tourists, there are African countries with a lot of sexual tourism, more than we imagine. Well, there we must raise awareness, because from what we know, the main route of transmission is intimate contact that occurs in sexual relations.
Q. The European Centre for Disease Control estimates that the risk in Europe is low. Do you agree?
A. Yes, it is still at that level of risk. The previous outbreaks that occurred in Spain, which was one of the most affected countries, have already been controlled. The fact that the WHO has declared this emergency is also a bit of a warning to governments to start getting their act together, to investigate, to carry out epidemiological surveillance, to check how and where the increases in cases occur, perhaps to monitor the genetic evolution of the virus, and to start coordinating. But it is not time to say: “My God, we are all going to die”, or to lock ourselves in our houses with masks and return to the nightmare of the Dynamic Duo. At the moment we are very far from that. We must learn from the mistakes of the past, and it is good that all the alerts are activated. But I would not sound the alarm beyond those groups in which, due to risky practices, they should be more cautious.
