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Déjà vu: Africa, sex, virus!

It almost felt like an 80’s rerun seeing the headlines on the monkeypox cases that have arisen in Europe and North America. The articles comb

ined our general anxiety around viruses in the middle of an ongoing pandemic, with the fear of Africa and reported sexual behavior associations to result in attention grabbing headlines. We forget that this toxic combination has in the past led to misinformation and stigma with real consequences on infection control efforts.

Monkeypox is not a new disease. It was identified in the 50s with initial case reports in the 1970s. The virus is a DNA virus belonging to the same family as the smallpox, cowpox and vaccinia viruses. Waning immunity and decreased use of the smallpox vaccine may be responsible for the increased case burden. The disease resembles smallpox. Infected individuals may develop fever, headache and malaise prior to the onset of the rash. The rash may begin on the face as a few or thousands of lesions. The lesions may progress from flat to raised and into pustules spreading throughout the body including palms, soles, mucosal membranes in the mouth and genitalia. Swollen lymph nodes are common and complications can include secondary bacterial infection of lesions, pneumonia, sepsis, and encephalitis.

There are two different clades of the virus most notably the West African and the Central African clades. The West African clade tends to produce a milder disease whereas the Central African clade has immune evasion mechanisms that lead to more severe disease.

Although the virus infects humans, nonhuman primates and a variety of other species the natural host is unknown. Rodents are known carriers and likely spread infections to humans and other species. An outbreak of monkeypox virus in the United States in 2003 was linked to imported wild rodents from West Africa that were co-housed with North American prairie dogs. Contact between humans and prairie dogs was responsible for the cases.

Although many cases in the current western outbreak have been reported in men who have sex with men, it is important to note that it is not exclusively a sexually transmitted infection. Transmission can be animal to human, human to human and via contact with contaminated body fluids, with the virus entering via exposed skin, or mucous membranes and the respiratory tract. Associating the infection with sex is not only inappropriate but stigmatizes a disease where the right precautions can prevent further spread.

Since 2003 very few sporadic cases have been reported outside regions in West and Central Africa where the virus is endemic. Since December 2021, 1315 cases and over 57 deaths have been reported in Cameroon, Central African Republic, Democratic Republic of Congo (DRC) and Nigeria. Most deaths have occurred in the DRC. In the last couple of weeks (13-21 May 2022), the WHO has reported 92 confirmed, 28 suspected cases and no deaths in 12 non-endemic countries in Europe and North America. All confirmed cases in these non-endemic countries have been the West African clade. The cases have had no known travel to endemic regions.

Smallpox vaccines were highly effective at reducing infection. However, vaccines have not been distributed in most parts of the world for decades. Vaccines that are available can be used as pre-and post-exposure prophylaxis and there are antiviral and immunoglobulin therapies that are available for treatment. As with so many therapeutics and diagnostics many of these are inaccessible to parts of the world where they are most needed, particularly rural communities.

Until the reports of monkeypox in Europe no one took note of the 1238 cases and 57 deaths in the DRC. Case load and fatality rate is higher in DRC than the West African cases. This may be due to a variety of factors including population dynamics and mobility, health infrastructure as well as the biology of the virus. Studying the virology and host response would help us understand the difference between the clades and how they drive disease burden and mortality in African hosts. These insights could lead to the design of better vaccines and therapeutics. We ignore other parts of the world and infectious diseases at our own peril. This virus like so many infectious diseases remind us of how interconnected we are. If humans continue to encroach on new environments and conflicts and climate changes spark migration, new infections will continue to emerge and re-emerge.

Not only do we need to ensure that our language around new infections is precise, doesn’t drive fear, disinformation and stigma but we also need to diversify infectious disease science. We need to make sustainable global investments in science. Investments should support the scientists and bio-entrepreneurs in regions of the world where these infectious diseases are most likely to emerge. If low- and middle-income countries (LMICs) do not have strong scientific research infrastructure to develop therapeutics for their own health problems, we will continue to be unprepared for emerging biological threats. Investments must be made by LMIC governments by focusing resources on science education and enabling the industrial infrastructure that is needed to support a bioeconomy. But these governments will need help. The help needs to be in the form of balanced partnerships with high income countries. Current Global Health investments distort resources, scientific inquiry, and scientific leadership to the needs of Western partners without empowering local science and building sustainable local scientific ecosystems.

Let this and other infections not only remind us of our shared humanity but encourage us to bring the promise of biological innovation to the developing world. Access to cell phone technology led to young Africans leading significant innovations in fintech which solved problems for millions of the unbanked. Problems in biology and infectious diseases in the developed world will not all be solved by scientists from elite global institutions, but the solutions may come from the village girl who understands the social dynamics of disease in the local context, is motivated to solve the problems in her community, is provided access to technology and also happens to be a Jennifer Doudna in the making.

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