Q&A: What you should know about monkeypox, COVID BA.5 variant
As COVID-19 transmission trends back upward with the emergence of the BA.5 omicron variant, concerns are also growing about the ongoing spread of monkeypox with U.S. cases on the rise.
Dr. Sharjeel Ahmad is a staff physician at OSF Saint Francis Medical Center and an associate professor of infectious diseases at the University of Illinois College of Medicine-Peoria. He talks with WCBU reporter Joe Deacon about coronavirus mutations and what people should know about monkeypox.
This transcript has been edited for clarity and brevity.
First off, what can you tell us about monkeypox? What are the symptoms and how dangerous of a disease is it?
Dr. Sharjeel Ahmad: So monkeypox, it’s kind of a misnomer. It was named as “monkeypox” because it was discovered in the 1950s in a colony of lab monkeys in Singapore, where they were going to use them for polio vaccine research, so they isolated the virus in them. It is actually a zoonosis, which is a disease which in humans can get accidentally infected. We are not the natural hosts for this disease. So humans and monkeys are not the natural hosts, we get incidentally infected. We probably have a reservoir in rodents.
It is a disease found – mainly we know there are two different strains of it, one in West Africa and Central Africa; the Central Africa one is probably a bit more serious. But we've known there have been outbreaks in humans known since 1970s here and there. In the U.S., they had one outbreak in 2003, when about 71 people got infected, and probably it was from handling prairie dogs who probably got infected because they were kept in the same warehouse as some African rodents. But this current outbreak in 2022 is the first major big one in the U.S. As of July 18, the worldwide case tally is around 13,340 and in the U.S. it’s 1,972.
It is, for the most part, a self-limiting disease, so obviously the problem is going to be in people who have a compromised immune system. And yeah, the pain from the lesions and stuff, and it can linger for about 2-4 weeks. So that's where the problem comes.
So again, what are the symptoms? You said lesions?
Ahmad: Yeah, so it can start with just a fever, muscle aches and pains, headaches, lymph node swelling, generalized. Then later on after a few days, you can have this rash where lesions start appearing, and they can start with like a red spot where it raises and it can become more raised – we call it a papule in our medical lingo. Then they can become filled with this clear fluid, and then they can turn into the which we call vesicles and then over the next few days, it can turn into pustules, which means that they look like these fluid filled stuff is filled out with pus. So those are the big symptoms with monkeypox.
How dangerous can it get? Can it become fatal?
Ahmad: The problem with this was that monkeypox, this is the biggest outbreak with this. They've done the DNA stuff on this and they think it is probably the West African, the Nigerian strain which has come into humans. Some suggest it looks like, yeah, this virus is kind of adapting to the human host. We've never seen this kind of transmission on such a large scale in humans. Again, it's not a disease which we’re traditionally used to seeing in humans; there used to be sporadic outbreaks in Africa. But now this is the first big one.
One of the big thing people are concerned (about) is: is it sexually transmitted? – because they've seen outbreaks in people who have had no travel history (and) the biggest group which has been affected is men who have sex with men. We don't think of itself as a true STD; we still know that it can be transmitted through close contact. But because suddenly we are seeing this cluster like over the space since mid-May, now we have so many cases (that) it's obviously a disease of concern. But for the most part, in most people it’s not fatal. It’s just the pain, the fever, the lesions, these can be very alarming and uncomfortable for the patients.
Have we seen any cases diagnosed around Central Illinois? How big of a risk does it pose in the Peoria area?
Ahmad: So right now, I checked again, we've not had any patients in Peoria right now. I think in the beginning, we had a patient who had contact with central Illinois, but it was not like he was here. So at this point, we don't have any active patients with monkeypox in Peoria.
Are there precautions that people should be taking?
Ahmad: The Peoria (City/County) Health Department, as you know, they're aware; they have a strategy right now like about if something like that happens. We should be aware about it because we've seen that (surge in cases) in New York and other parts of the country, and we've already been dealing with one pandemic already, so we got to be on our toes.
But the idea is you have to know this skin disease can present with fever, headache, muscle aches, back pain and stuff. If you have these kinds of symptoms but you've had contact with somebody, for example, who's traveled to Africa, or if you've been exposed to somebody through like the social media circle and stuff – you know, you met them through the social media and then you find out later that this person is suspected to have monkeypox or was confirmed – that's when you need to worry.
Sometimes these lesions can mimic other sexually transmitted infections. Herpes lesions can be similar, sometimes; secondary syphilis lesions can be similar. So I'm not saying anytime if you have those kinds of symptoms of other STIs you have to think about it. But if your lesions if you think or people are thinking, “Oh, this looks like a herpes rash” or something and it's not getting better with their regular treatment, that's something to keep an eye on, something to keep in the back of their mind.
What kind of treatment is required?
Ahmad: As I said, these symptoms can last two weeks or longer with this; it’s usually self-limiting. Now remember, again, this is not a very common disease, so they don’t have a lot of FDA approved treatments and stuff like that. So there are – we know this virus belongs to the same family of which there were certain pox viruses, like the smallpox virus, or the vaccinia virus, which was used to make the smallpox vaccine; it’s in the same family. So by kind of extrapolation, we think some of the medications are going to work for it.
The ones which we know probably we could use – none of these are officially approved; they're like, you know, we know they'll probably work for smallpox, and these viruses are similar enough that will probably work. So in an emergency or something, or for people who have severe illnesses who are immunocompromised, they may be candidates. So there are three big ones: there's one called tecovirimat, which is FDA approved for smallpox. You can’t just get it; it has to be gotten from the CDC. So if it is (used), you've got to be at the hospital and infectious disease physicians will be involved, and if we consider that you meet the criteria, then the CDC will be contacted for that.
There is the immunoglobulins, the antibody infusion which from the vaccinia virus, which is the vaccinia immunoglobulins; vaccinia is the virus which was used to make the smallpox vaccine. That's an infusion. Again, all of this is not like you can just get it from the pharmacy or the hospital will have it; we’ll have to get it ordered through CDC and stuff.
Cidofovir people have used; this as an oral antiviral and people have tried to use antivirals. It's again shown in like animal models that it may have some activity. And there is another drug called brincidofovir, which is FDA approved for smallpox. Again, these are all not easily available. If we find patients like that, they will be at the hospital, the health department will be involved, and the CDC is probably going to want to get those medications for these patients.
You kind of mentioned this is coming at a time where people are kind of largely worn out from dealing with COVID-19. Are people maybe being a little dismissive of monkeypox?
Ahmad: It's one of those things (where) this obviously has the potential to turn into a much bigger problem than we already have, and I think we've already dealt with one pandemic, where we think we know now in retrospect what we could have done differently to prevent this from progressing this way, I think. So, you need to be wary, but what I would say is don't be fearful, per se.
Speaking of COVID-19, what should people know about the latest mutations, specifically the BA.5 variant and how contagious (it is)? It appears to be also not reacting to vaccines very well.
Ahmad: The thing is, you know, we've been dealing with this pandemic (and) I'm not going to go over the whole history. Viruses evolve, this is their way of survival, right? So COVID has been around now, all over the world; many people have some kind of partial immunity or something. They either got the COVID before themselves, or they got the vaccination, or both. Now the virus has to survive, it has to evolve. So over time is now evolved into these variants and subvariants and stuff. It's a mechanism of survival.
The problem with BA.5 is, as we know, we had the omicron (variant) come in towards late 2021, and now it's in the same family and the virus is kind of tweaking or fine-tuning itself to be able to spread, evolve and survive. So this is basically what we are seeing. The problem with this is again, now by this time, a lot of people have already been exposed to the virus or they have been vaccinated, to it's finding a way to evolve to kind of escape the immunity.
The thing is, people have to remember it's not like, “Oh, if you're vaccinated, it's not going to work at all against the BA.5.” Remember, vaccination is still very effective against all these variants and subvariants from preventing severe disease. What the problem with the BA.5 is: yes, the vaccination is not preventing you from getting mild to moderate disease and stuff.
So the vaccination is still very effective in preventing hospitalization and death. But yes, just because you have been vaccinated and just because you've had COVID before, you can still get the BA.5 variant. You may not have a very severe disease because your immune system has seen it before or you've been vaccinated against it.
Previously, we were talking – initially, in the beginning of the pandemic, we talked about the vaccine preventing transmission and stuff. That dogma, that stuff kind of changed over time because the virus kept on evolving. So I would still say vaccines are still very effective against preventing severe disease. But yes, this virus can escape the host immune defense and still cause you to have mild to moderate disease.
As far as transmission though, should people go back to maybe some of the mitigations that they were doing with masking and being more protective?
Ahmad: I think it's going to be about common sense at this point. I think it'll be very hard now to get people back to the lockdown we have in 2020. I think it's going to be more about common sense at this point, so if you’re in areas of high transformation, I guess the local public health authorities can decide about mandates. But I think as an individual level, just use common sense.
If you yourself get COVID, please do not travel on an airplane; don't expose the people that could be somebody's grandma or grandpa on that plane or on a bus or something like that. If you're going to have a party and stuff (and) grandma and grandpa have some kind of immune system issues, again, use common sense on that. Maybe we should cancel or not invite them. If there are going to be like 100 people in a closed environment, maybe think back about masking. Try to do as much of outdoor stuff as possible if you're going to have any of those events. So I would say still use common sense; try to recognize your own risk or the risk to the loved ones and then act accordingly.
Lastly, in Ghana, two fatal cases of the highly infectious Marburg virus disease have been reported recently. How much of a threat could that potentially pose?
Ahmad: So remember, Marburg virus is similar to the Ebola virus. Again, it's a zoonosis; we can get it from bats and stuff. I don't know if you remember when the whole Ebola thing happened, it was like we were also getting calls here about, “Oh, this guy was driving through Texas” – that’s where the first case was – and “should we be worried about it?” And I was like, “well, Texas is huge.”
I would say is I think this is more of a watch-and-wait at this point. If you look at the history with Ebola and Marburg, they have been localized outbreaks before. So I think I would need more evidence to say before they say “OK, we need to get concerned and press the alarm button at this point.” The problem these days with pandemics is, again, global travel and ease makes it (more) transmissible, but I would just watch and wait. I don't think it's the time to get alarmed about the Marburg virus at this point.