MONTREAL — The technical director for the World Health Organization’s anti-monkeypox response is a Canadian who received her medical degree from McGill University.
Raised in Thunder Bay and Ottawa, Dr. Rosamund Lewis studied medicine in Montreal, specializing in epidemiology, and practiced family medicine there for a number of years before joining the ranks of the WHO.
She was joined by the Canadian press in Geneva, Switzerland, where she is playing a leading role in the UN health agency’s response to this outbreak of a disease that 99% of the world had never heard of two months ago.
It feels like monkeypox came out of nowhere. What can you tell us about this?
It’s very, very interesting. The disease didn’t come out of nowhere. It has been known in Central and West Africa since the 1970s. Monkeypox virus was first identified in Denmark in 1958 in a colony of monkeys used for scientific research. That’s why it was called “monkeypox” because (human) smallpox was still around at the time; it was a similar disease but in monkeys.
What do we know about the spread of the disease?
It is believed to be spread by rodents, but the reservoir is unknown. In Africa, the virus has been found in Kuhl funisciura, savanna cricetomes, glirids, and similar things. People hunt in the forest and bring back this game meat which they have to prepare. This is the traditional way of exposure (to the virus). It could even be the family eating undercooked meat. And then this meat can also be offered for sale in the market, so that people who are not personally exposed to the forest can also be exposed. But another important factor is that (human) smallpox was eradicated in 1980, so people born after 1980 or in some countries in the 1960s or 1970s did not have a chance to get vaccinated against smallpox.
Had monkeypox ever been seen in the West?
There were two cases in the UK in 2021 and two in the US in 2021. And in 2003 there was an outbreak in the US, but that had nothing to do with the current situation. It was very strange. These were prairie dogs that had been imported to be sold as pets and then children would get sick from being scratched or bitten. It took about three months to figure out the nature of the outbreak and contain it.
How does the disease typically manifest itself?
Most people have a less difficult presentation than the classic presentation. It’s very annoying and irritating. It can be painful and it can be itchy. It can also leave significant scars. But how many people have not had to leave their homes to seek care? We do not know. They often show up after seven or 10 days because they want to relieve their symptoms, but that might just be the tip of the iceberg.
How did the current outbreak start?
We have again received information from the UK. She was a traveler returning from Nigeria and was found to have monkeypox. And then I said to myself, “Okay, let’s go”. The UK found an outbreak within a family and it was totally unexpected as three members of one family were affected. It was the first time monkeypox had been observed outside of Africa in someone who hadn’t traveled recently, so this was new. (The British) then found four samples in their labs that tested positive and came from men who had sex with other men. And at the same time, Portugal reported an outbreak of people with undiagnosed lesions. It was negative for herpes, negative for syphilis, so the Portuguese looked for information and pretty quickly Portugal and the UK realized they were facing the same thing. It was about men having sex with other men, attending certain events, and then returning home. The first cases were all related to travel from Central Europe. And that’s about where we’re at, except we’re seeing a lot of cases and it’s spreading in this group of people who are frequently having physical contact with more than one person, possibly in a very short space of time, hence the conditions conducive to rapid transmission and dissemination.
What is the current status of the situation?
Countries are starting to see cases that are not on contact lists, so not all chains of transmission are detected. There are around 200 cases in the UK. People start looking for help, but they don’t necessarily know how they got infected.
What weapons do we have against this disease?
The first strategy is information, the second is contact tracing and the third is of course quarantine, but maybe also vaccination, but it is not obvious because the vaccine is not available everywhere. Research is being done and it was known that (this outbreak) was likely to happen, but (the products) are new and they’ve just come out and some of the old smallpox vaccines can’t be used. I wouldn’t say the outbreak is timely because we are not fully ready with our countermeasures, but countermeasures are ready, they have been developed; They’re just not widespread yet. So it becomes a matter of equity again, knowing when countries will be able to access the products they need, when they need them.
This outbreak comes as we are barely emerging from two years of pandemic. Is there a risk that a certain “fatigue” will develop among the population, that they will say “oh no, not another virus!” and that this will harm containment efforts?
Yes completely. This outbreak evolved this way because people wanted to travel again to see other people. People are tired of being tied to their homes or isolated. The desire to find our parents and our friends is very human. Often the first lesions are found in the genital or anal area. They can, of course, be very painful, but not all progress to the hands and feet, so the condition is sometimes not visible to those you spend time with. You know, we don’t want to prevent events like Pride, but we do want to avoid other reinforcing events, like what seems to have happened in Western Europe. It looks like the virus has taken root in a population that can easily spread it. So we want to avoid new amplifying events and want people to have the information they need to protect themselves and others.
It looks like cases are increasing rapidly. What is it really?
This apparent explosion is partly due to the fact that all these cases (one diagnosis) are waiting. As I explained before, the Portuguese raised their hand because they had all these (unidentified) cases. As the information became available, the labs started testing the samples they had and started calling people, but then there were also people who started reaching out and saying, “I might have had that.” So it may be that we are two or three weeks too late with the analysis of the files. And obviously during that time, people who didn’t know what they had could continue to spread the virus. Exactly where we are in the chain of transmission is not yet clear, but there is a second wave. There’s a community transmission, a term we’ve come to know quite well over the last two years. But the transmissions are still mostly among men who have sex with other men and that’s why we say there is a way (to contain the situation). That’s why we’re actively working right now to spread information and develop technical diagnostic capabilities.
So there’s a chance to act that we can’t miss?
Yes, and it is crucial to take advantage of this before the virus reaches a broader public, family members, children, vulnerable people, for example people who are HIV positive. But don’t be alarmed. The vast majority of cases are still reported in this group, so that’s where transmission occurs, and it’s not too late to stop the outbreak in this group, although it can be difficult. That being said, there is still a lot we don’t know about this virus and we have to be honest and admit it. The virus itself may have undergone changes that make it more easily transmissible, but we’ve certainly found that behaviors make it more easily transmissible. This disease presents itself as an infectious disease that can be spread through close contact, including sexual contact. So the message to the population is: educate yourself, learn to recognize the signs and symptoms, know under what circumstances you could be infected, protect yourself and others and, if in doubt, get a diagnosis… the information is there , they are available.
The comments of Dr. Lewis have been abridged and condensed for brevity and clarity. The interview took place on June 6, 2022.