Monkeypox

As of the 23rd of May, the UK Health Security Agency has detected 70 cases of monkeypox in England, and Public Health Scotland has identified one case in Scotland. What does this mean for pwMS?

We are getting an increasing number of queries from our patients about Monkeypox.

Yes, the current monkeypox epidemic is worrying. As of the 23rd of May, the UK Health Security Agency (UKHSA) has detected 70 cases of monkeypox in England, and Public Health Scotland has identified one case in Scotland. No cases have been identified in Wales and Northern Ireland. This takes the total cases identified in the UK to 71. Spain has reported over 100 cases, and several other countries have now identified cases, including Portugal, the USA, Canada, Australia, Pakistan and Argentina. As with all emerging epidemics, the identified cases are likely to be the tip of the iceberg. 

Source: The Economist

Monkeypox is usually confined to Africa. The symptoms are similar to those of smallpox: fever, tiredness/fatigue and pustules that spread across the body. The disease rarely kills healthy adults when treated early. It is more severe in children, pregnant women and immunocompromised people. The latter will include people with MS on immunosuppressive DMTs, particularly the DMTs that affect T-cell function, such as the S1P modulators and IRTs during the depletion phase of the treatment cycle.

In recent monkeypox outbreaks, case fatality rates are reported to be between  3-6%.  A Congolese strain is much more likely to kill those infected than the west-African variant, which is the strain now spreading in the UK and Europe. There are no reported deaths from monkeypox outside of Africa during the current epidemic.

Monkeypox is transmitted through skin-to-skin contact, bodily fluids or contaminated material, such as clothing and bedding. The infections in Europe are linked to large gatherings, including a gay-pride parade in Spain and a fetish festival in Belgium. As transmission is linked to public gatherings with close contact between attendees, particularly at parties and festivals,  personal hygiene is important, i.e. hand-washing. For healthcare workers, personal protective equipment will be paramount. WHO has stated that infected people and their contacts should isolate for 21 days, and UKHSA and other public health agencies have started contact tracing to minimise the spread. The latter will be augmented by ring vaccination to try and prevent further spread. 

Monkeypox

The UKHSA has purchased supplies of a safe smallpox vaccine (Imvanex, Bavarian Nordic), which is being offered to close contacts of someone diagnosed with monkeypox to reduce the risk of symptomatic infection and severe illness. If the number of cases increases, the vaccine programme will need to be expanded. Will it include immunosuppressed people, such as people with multiple sclerosis (pwMS), on immunosuppressive DMTs? I suspect not, as the Imvanex vaccine is a live modified form of the vaccinia virus called ‘vaccinia Ankara’, which is also related to the smallpox virus. In general, live vaccines are contraindicated in people on immunosuppressive therapies, with the exception of those who have reconstituted their immune systems after being treated with an immune reconstitution therapy (alemtuzumab, cladribine, mitoxantrone or HSCT). 

Please note that monkeypox is related to smallpox, which is why the smallpox vaccine is partially effective against monkeypox, i.e. about 85% effective. Although smallpox has been eradicated and national vaccine programmes were stopped in the early 70s, there are several stockpiles of vaccines in the world. The latter is because smallpox remains a bioterrorism threat. However, I suspect many of these stockpiles to be quite old and may not be that effective. Therefore, I would not be surprised if we see another vaccine race to develop new component vaccines to target the poxviruses. 

Please note monkeypox is not as rapidly transmissible as SARS-CoV-2. Poxviruses do not mutate as quickly as influenza or coronaviruses. Therefore it is unlikely to become more infectious and dangerous suddenly. We also know how to deal with it, and therefore I suspect the current epidemic will be short-lived. 

If you suspect that you might have a rash or lesions on any part of your body, particularly if you have recently had a new sexual partner, please limit contact with others and contact NHS 111 or your local sexual health service. 

UKHSA health protection teams are contacting people considered high-risk contacts of confirmed cases and advising those who have been risk-assessed and remain well, to isolate themselves at home for up to 21 days.

So the advice for pwMS with MS on immunosuppression is to remain vigilant, maintain your personal hygiene and avoid unnecessary contact with people in large gatherings. I suspect we will get more information from the UKHSA and the WHO as necessary.

I hope this information is helpful. If you have any queries, please don’t hesitate to ask.

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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry or Barts Health NHS Trust. The advice is intended as general advice and should not be interpreted as personal clinical advice. If you have problems, please tell your own healthcare professional who will be able to help you.