Risk of monkeypox transmission to increase with opening of borders in Bhutan: WHO Representative

With the opening of borders and travel, globally, the risk of monkey pox transmission is likely to increase, and Bhutan is no exception, as there is every chance of importing monkeypox into the country.

Even while the world is still fighting the COVID -19 pandemic, there is now the monkeypox virus circulating in several countries, including now India. According to Hindustan Times, a 35-year-old man in Kerala, who had come from UAE, is confirmed to have monkeypox.

The Ministry of Health (MoH) has already informed all health centers in the country and allied health agencies to implement measures immediately, and surveillance of people coming from countries that have reported monkeypox.

The Bhutanese interviewed WHO Representative to Bhutan, Dr Rui Paulo de Jesus on this pressing health issue.

The Bhutanese (TB): What is Monkeypox?

Dr Rui Paulo de Jesus (Dr RP de Jesus): Monkeypox is caused by the monkeypox virus. It is part of the Orthopoxviral genus, which includes variola virus (smallpox) and cowpox virus. The reservoir is still unknown, although primates and rodents are suspected to play a part in the endemic setting. It is usually a self-limited disease (any disease whose natural history is to resolve without treatment)

The case fatality ratio has been reported to be around 3 percent in the African setting, with most deaths occurring in younger age groups. So far, only 5 deaths have been reported from the African region, the rest of the countries have not reported any death. As of 13 July 2022, globally 10,632 cases are reported.

TB: What are the symptoms?

Dr RP de Jesus: Monkeypox symptoms include fever, intense headache, swollen lymph nodes, muscle ache, and a rash that blisters and crusts. The rash tends to be concentrated on the face, palms of the hands, and soles of the feet. The mouth, genitals, and eyes may also be affected.

The symptoms can be mild or severe, and lesions can be very itchy or painful. They generally last for several weeks during which time a person can be infectious to others.

TB: Is Bhutan at risk of getting monkeypox cases?

Dr RP de Jesus: Currently, the public health risk at the global level is assessed as moderate considering this is the first time that monkeypox cases and clusters are reported concurrently in many countries in widely disparate WHO geographical areas, balanced against the fact that mortality has remained low in the current outbreak.

With the opening of borders and travel globally, the risk of transmission will increase. Bhutan is not exceptional, there is every chance of importing monkeypox. Cases reported from the countries are increasing and every few days, we see new countries reporting cases of monkeypox. So far, no countries in our region have reported any case, however, on 14 July, Kerala in India reported a case with travel history. So, it’s a matter of time (to get the virus in Bhutan) if we are not careful and don’t follow the preventive protocol advised by the relevant authority 

TB: Should Bhutan be worried about monkeypox?

Dr RP de Jesus: Yes, we should be concerned, war with COVID-19 is still ongoing and with monkeypox cases increasing globally, it will further add burden to the country which is slowly healing from the impact of the COVID-19 pandemic.

However, the Ministry of Health has good surveillance in place, and because of COVID-19, there is robust surveillance and contact tracing in place. This will help in the early detection and prevention of outbreaks in the country. Royal Center for Disease Control has the capacity to detect monkeypox and the Ministry of Health has developed a guideline for the management of monkeypox adopting the lessons learned from the COVID-19 and WHO guidelines. Health care professionals around the country and official working at Paro International Airport have been sensitized to monkeypox.

TB: What must the people of Bhutan know about monkeypox transmission?

Dr RP de Jesus: Monkeypox virus is transmitted from infected animals to humans via indirect or direct contact.

Human-to-human transmission can occur through direct contact with infectious skin or lesions, including face-to-face, skin-to-skin, and respiratory droplets (and possibly short-range aerosols requiring prolonged close contact).

In the current outbreak countries and among the reported monkeypox cases, transmission appears to be occurring primarily through close physical contact, including sexual contact (oral, vaginal, and anal).

Transmission can also occur from contaminated materials (linens, bedding, electronics, clothing, sex toys) that have infectious skin particles.

A person with monkeypox remains infectious while they have symptoms, normally between 2 and 4 weeks

TB: Who is at more risk of getting monkeypox?

Dr RP de Jesus: Newborns, children, and people with underlying immune deficiencies may be at risk of more serious symptoms and death from monkeypox.

Health workers are also at higher risk due to longer virus exposure.

There is not enough data regarding monkeypox infection during pregnancy, although limited data suggest that it may lead to adverse outcomes for the fetus.

TB:  Are there any effective vaccines or treatments against monkeypox? If yes, will WHO assist in procuring the vaccines for Bhutan?

Dr RP de Jesus: It will take some time to fully assess what is available, and how these vaccines can be used to the greatest effect. In the meantime, every effort must be made to control the human-to-human spread of monkeypox through early case-finding and diagnosis, isolation, and contact tracing. Information is a powerful tool: those most at risk need to have information on know how to protect themselves and others.

There is a vaccine for monkeypox recently, approved by some countries for which supplies are limited. Some countries may hold smallpox vaccine products that could be considered for use according to national guidance. Vaccine products may be available in limited quantities through national authorities, depending on the country

Vaccination is not recommended for the general population at this point.

TB: What is WHO’s advice to Bhutan regarding monkeypox?

Dr RP de Jesus: Strengthen Surveillance at Point of Entry, rapid assessment, and sensitizing at high-risk border areas including revamping of a COVID-19 prevention protocol. Also, sensitize health care professionals on monkeypox.

Bhutan can also adopt and learn from COVID-19 preparedness and response and carry out simulation exercises for better preparedness and response

Any individual meeting the definition for a suspected case should be offered to test. The decision to test should be based on both clinical and epidemiological factors, linked to an assessment of the likelihood of infection.   

The country should be on the alert for signals related to patients presenting monkeypox symptoms in various community and health care settings including but not limited to primary and secondary care, fever clinics, sexual health services, infectious disease units, obstetrics, and gynecology, emergency departments, and dermatology clinics.  

Information should reach those who need it most during upcoming small and large gatherings, particularly among social and sexual networks where there may be close, frequent, or prolonged physical or sexual contact, particularly if this involves more than one partner.

All efforts should be made to avoid the unnecessary stigmatization of individuals and communities potentially affected by monkeypox. 

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