The monkeypox outbreak and an era of emerging viruses

Clip You’re listening to a Frequency Podcast Network production in association with CityNews.

Jordan Unlike COVID-19, monkeypox is not a new virus. We’ve known about it for decades. We have treatments. We have a vaccine. We have everything, and yet we are still struggling to contain this.

Clip The global monkeypox outbreak represents a public health emergency of international concern.

Jordan Here’s the thing. There’s something different about this monkeypox outbreak. And while we know it is different, we don’t know exactly how just yet. And in the meantime, cases are rising. The good news is that so far there have been no fatalities. The bad news is that on top of its symptoms and its spread, this outbreak poses a difficult public health challenge. Because when a virus is attacking a particular community, a community that already faces discrimination, how do you walk the line between making the facts plain and obvious and available to everyone who needs them to protect themselves without increasing the stigma of that community in the general public? It’s not easy. Not much about viruses and public health is these days, which is why we’ll also talk to our guests about what it means to be an expert in emerging viruses when the viruses keep emerging. I’m Jordan Heath-Rawlings. This is The Big Story. Dr. Jason Kindrachuk is an assistant professor in medical microbiology and infectious diseases at the University of Manitoba. He is also Canada Research Chair in yes, emerging viruses. Hello, Dr. Kindrachuk.

Dr. Jason Kindrachuk Good morning.

Jordan Thank you so much for joining us today. And I want to begin with the basics here because I’m not sure how solidly the emergence of monkeypox has been covered sort of on a general level. So let’s just begin with what is monkeypox? Where did it come from?

Dr. Jason Kindrachuk So with monkeypox was first identified in the late 50s, but originally in animals. And we have to appreciate this is at a time when we have very little virus, which is the cause of aging of smallpox, also still you know endemic throughout most of the world. So we didn’t actually see any human cases of monkeypox until 1970. It’s a virus that belongs to the same family of viruses, the Poxviridae family and the Orthodoxvirus genus. So it belongs to the same family as smallpox, very old virus, cowpox virus and vaccinia virus. So they all share some similarities. They’re large DNA viruses, they have about 200 genes which made them abnormally large. But they’ve been in our, I think eyesight for the better part of 50 years now. And certainly, we’ve heard about the endemic disease that’s caused in various areas of Africa, but certainly, we’re learning about it very quickly on a global platform right now.

Jordan In terms of that global platform, what are the typical symptoms of monkeypox? And you know I guess I’m not asking for the worst-case scenario, but I think we’re always thinking about it. What can it do to somebody who’s got a bad case of it?

Dr. Jason Kindrachuk This is a great question. Right. So we have to kind of separate what we’re seeing now in regards to the global outbreak versus what we’ve seen in endemic areas. And in endemic areas, there are two different clades. There’s clade one and clade two. Clade one is the Congo Basin clade. Clade two is the West African clade. Those two causes different severities of disease. Clade one, the one that we find mostly in the DRC that has about a 10% case fatality rate, can cause a very large disseminated pustular rash, which we’ve seen lots of pictures of. The clade from West Africa can also cause of your disease still presents similarly. You get lesions on the face that move down to the arms and the hands, legs and feet and then a little bit on the trunk and certainly has caused some fatalities, though at a much lower rate than what we’ve seen in Central Africa. The current outbreak is very different and distinct. Right. So what we’re now seeing is really this overrepresentation of cases with lesions within the groin. We’re not seeing this much larger disseminated rash across the entirety of the skin surface in individuals that are infected. And we also have not heard about fatalities that have been linked directly to this particular clade or clade three, which were moving towards calling this. So it is fairly distinct. It’s also transmitted largely through sexual contact, at least from what we’ve seen so far with cases. And again, we have to appreciate we’ve had 50 years to learn about monkeypox, but there is still this caveat which is, listen, in many cases we’ve seen the presentation of cases that had fully disseminated rash, but we don’t necessarily know where there are other cases that may have been much more limited in severity that maybe didn’t present health care settings or worries about stigma or being ostracized that with genital rashes people maybe didn’t present and it was largely self-limiting. So these are questions we’re still trying to address.

Jordan We’re definitely going to talk about the politics of how this is transmitted and stigma in a minute. But first, because I’m interested now that you’ve introduced this. So what you’re saying is this is a new sort of monkeypox and again, forgive me for asking dumb questions here, but does this mean the disease has mutated? We’re definitely familiar now with different strains of different viruses, like, do we have any idea what’s actually happened to this disease?

Dr. Jason Kindrachuk Yeah, so we do. Right. And again, part of this is we have to appreciate over the last ten to 20 years we’ve had this massive increase in our technological ability to be able to look at viral genomes and understand changes at the genomic level, things that we didn’t necessarily have before.

Jordan Right.

Dr. Jason Kindrachuk Certainly right now, what we’re seeing with the phylogenetic analysis, where you actually look at the different virus isolates that have been found and align them based on their sequences, what we’re seeing is that this particular isolate that is moving across the globe seems to be somewhat different than either clade one or clade two. So there has been a proposal to actually name this as clade Three. It seems to be behaving differently. The question I think still remains of is it truly distinct. And that’s something that frankly, first of all, we need to get more clinical data, but we also need things like animal data or data from cell culture studies to be able to tell us on an even playing field, are these different clades or are these different isolates behaving differently? And if so, how are they behaving differently?

Jordan The last time we discussed monkeypox on this program, it was a few months ago, and it was kind of as an addendum when we were speaking with Dr. David Fisman about the latest COVID measures and it was just an outbreak. And we had a few cases in Canada. Now, the who has labelled this a global health emergency. And I feel like I should remember from two years ago what that means. But maybe can you explain both? What does it mean as a level of concern, but also what does it mean practically like what happens once that’s declared?

Dr. Jason Kindrachuk Yeah, listen, I kind of carved my eye teeth in the field working in West Africa during the Ebola epidemic. When I hear public health emergency, I have a very specific take which is, oh, this is something that is a big deal that we need to be appreciative of. It could expand, it could impact not only global health but also global economies. So with a public health emergency, what we have to appreciate is right now we’re at a point where basically WHO has declared this emergency that hopefully now enables basically increased collaboration amongst world leaders. This certainly should have all leaders of member states working together to try and reduce overall transmission. This should also bring about basically temporary recommendations in regards to how to deal with this public health emergency. And those should essentially be followed by member nations. The biggest thing I think that we need to consider coming out of COVID is that in regards to things like travel restrictions, those need to move through a formal process, or should move through a formal process through the WHO to at least be considered as to the reasons why those are potentially being implemented. So for us, from a practical perspective, what a public health emergency should tell us is, listen, what we are seeing is not normal. This is certainly something that is different than what has previously been seen. It doesn’t tell us about what our level of concern should be outside of saying we need to get this contained and there needs to be a global effort in getting this contained.

Jordan Specifically, what is Canada dealing with right now? I know we have cases. I know numbers have risen. What’s our situation?

Dr. Jason Kindrachuk It’s a good question. Right, so listen, we’re still seeing cases that are predominantly overrepresented within Quebec and Ontario. We’re seeing a movement of cases into other regions. I think there’s now a dozen cases in Alberta. There were two recently announced in Saskatchewan. I think BC is, I think, somewhere in the neighbourhood of 40. The last one that I looked, Manitoba, we still don’t have any cases that have been reported. But I think what we can kind of deduce at this point is based on the trajectory we’ve seen in other countries, cases will continue to increase and of course, we’re seeing over-representation within very specific communities on a global level. So that should enable all the provinces to work together to try to get messaging out to those communities and appreciate that this is not going to just simply start to plateau and fall off on its own. We now need to try to implement different recommendations and messaging systems to try and get this contained.

Jordan And this is where we get into the tricky part, given stigma, given politics, and given practical public health messaging. So let’s talk about it. Who is predominantly catching monkeypox?

Dr. Jason Kindrachuk Yeah, so far this public health emergency and outbreak has really been overrepresented within the men who have sex with men community, which is very different from what we’ve seen with prior outbreaks of monkeypox. And when you look at the cases initially, the cases that were coming in from the UK, Spain and Portugal a couple of months ago were suggestive of this, but I think there was this sense of saying, okay, well, is this going to continue to be the case or are we seeing overrepresentation because of a very distinct transmission pattern within a particular group or associated with a particular event? And that hasn’t happened out, it has continued to transmit within that community. The tricky part here is that we have to appreciate, when you look back on 50 years of monkeypox data from West and Central Africa, even from the US in 2003, this is not a virus that is exclusive to the MSM community. This certainly is a virus that can move out to others right now, but it’s found a foothold and in the area for consistent transmission. So we have to be able to try and get messaging out to the community to say, look, we have a problem. Here are the things we need to do and the messaging we need to take, and how you can get access to testing. But we also still have to consider that the rest of the public does still have the potential of also being impacted if we start to see movement out into other communities as well.

Jordan That sounds like a very tricky line to walk with your messaging.

Dr. Jason Kindrachuk It is. Right. And part of this is, unfortunately, when you start to look at, obviously the over-representation within the MSM community, and then we think back to, I was born in 77 so grew up during the 80s, obviously very much remember what happened with HIV and obviously how stigmatized that disease was and continues to be. We don’t want that same position where now monkeypox is viewed as being only an MSM disease. It’s not. Listen, people are at risk. We know certainly kids that are under the age of 18 have a higher potential for severe disease. We know the people that are immunocompromised. We also have a higher risk for severe disease. And by the way, we have ongoing endemic disease in West and Central Africa that impacts all communities. So we have to find a way of being able to say, here’s the situation, but here is also all the data that tells us that this situation could impact and potentially will impact everybody.

Jordan What kind of stigma does it represent that the WHO is only now declaring something, a global health emergency that parts of Africa have been dealing with for so long? Is that natural? Is there something going on there?

Dr. Jason Kindrachuk No, this is such a great question. Right, and it gets back to this idea of how we’ve been turning a blind eye for too long, and then once we start to see an impact on the global north and in high-income countries, that’s when we’re willing to pull the alarm. I think listen that what they should do is hopefully again raise the spotlight onto the fact that we have diseases that not only are newly emerging, but that have been circulating for many, many years, but we have really cast a blind eye because they weren’t impacting us directly. And I think to me, what this should impart is, yes, there has been a stigma towards West and Central East Africa and frankly the majority of the continent for an unbelievably long period of time in regards to infectious diseases. So we have to appreciate, if we want to reduce the global burden of these diseases, we want to reduce the economic impact of these diseases. Again, our best defence is investing in preparedness and response in all areas of the world. So I completely agreed with solidarity with our African colleagues who have called us out and saying, why are we only doing this now? My hope is that in having those voices amplified that this will change. And I hope that it does bring about change by certainly our young researchers and young leaders that are acutely aware of the situation.

Jordan What does the fact that so far the predominant number of victims have been men who have sex with men done to the efforts to fight and contain this outbreak? Because I imagine there are definitely negatives to that in terms of messaging and in terms of stigma. There also must be positives in that. Like, at least you have a place to start from, practically.

Dr. Jason Kindrachuk Well, I think it’s kind of an addendum to the latter point. One of the things that we have is we have strong community advocacy groups within the MSM community that have been impacted by HIV, that have been impacted by stigma, that are taking this on their back and going into their communities and talking openly about it. We certainly have those types of advocacy events happening here in Winnipeg that are very much grassroots types of events. We need that. We absolutely need that from a community level. You know when we start to think more broadly in terms of how this is going to play out and how we look at this, it is this big part of saying, okay, we have the advocacy, we have the messaging. Now we have this continued full concern with access for testing as well as access for vaccines and therapeutics. That is something that we continue to need to have to figure out is how do we get people access to testing? How do we ensure that there is an adequacy of testing? And by the way, how do we also ensure that vaccines or therapeutics are making their way into those overrepresented groups that are being impacted by the disease now?

Jordan Because you led me right into it, we have vaccines. What kinds of treatments do we have? How available is the vaccine? Who can get it right now? Who should get it?

Dr. Jason Kindrachuk Yes, this is a good question. Listen I am but a humble virologist and I think the second smartest doctor Kindrachuk in my own household. So I always lean back to our public health folks and our clinical infectious disease folks to give us guidance. When I look at this, though, one of the things that I appreciate is, listen, we know that there’s an overheadation of cases in the MSM treat. So certainly I think it makes sense to try and get vaccine access to those groups. We know that’s where the disease continues to spread right now, certainly, in Canada, we know areas within the country where we are seeing more cases than others. So we certainly can divert vaccines to those areas. But we also have to consider health care workers. We know that with COVID that healthcare workers had a big impact. We need to ensure that healthcare workers also are getting access to vaccination as well as people that are going to be providing close contact with these groups. The problem is that for the new vaccine for Virginia dose, we don’t have a massive supply of this vaccine either. And that puts us in a bit of a predicament. The prior vaccine, ACAM2000, which is the vaccine that I bought for a few rounds when I was still at NIH. That vaccine is contraindicated for specific groups, in particular those that are immunocompromised, those that have underlying skin issues like atomic dermatitis or eczema. So Virginia dose is a little bit different. You can actually apply that vaccine to those groups that previously had contradictions. We just don’t have doses. And that gets into the issue of saying, okay, well, we need to figure out how to combat this from a containment standpoint, from a vaccination standpoint, and by the way, we still have a vaccine equity issue in West and Central Africa which does not preclude our need or shouldn’t preclude our need to also get vaccines to those areas where we have ongoing transmission.

Jordan So you mentioned that in Canada you expect to see cases continue to climb. What happens next year? What will you be looking for with regards to monkeypox as we move towards the fall?

Dr. Jason Kindrachuk Well, I think the big part is watching, certainly what’s happening in international areas where they had prior transmission chains, but before Canada had recognized theirs. Certainly looking at places like UK, Portugal, Spain, where we’ve seen a high presentation of cases, are we seeing any sort of indications of a plateau? Or if we are seeing those, what types of containment procedures that they use that have helped? Are we adopting those here? I think for us it’s going to be a question of how many cases do we see move across the country out of the regions that are predominant right now. And then I think the other question is, do we start to see movement out of the MSM community and start moving into other communities that may have a higher impact? You know certainly, kids are always but also those communities where we have people that are immunocompromised. So I think those are going to be the big indicators over even the next few weeks.

Jordan Doctor Kindrachuk, thank you so much for this. Before you go, I want to ask you about your job as a research chair in emerging diseases. There are a lot of diseases emerging right now.

Dr. Jason Kindrachuk Yeah, tell me about it. The last few years have aged me about ten years. Listen, my background is ebola influenza viruses, coronaviruses and poxviruses. So the last couple of years has been rough just from my standpoint. For us, a big part of this is we have an obligation to the public to be respondent to new viruses as they emerge. And that doesn’t just mean in Canada, that means across the globe. So we have to be able to shift years very quickly, much as we’ve had to do with COVID and shifting over to monkeypox. We still have COVID work, we still do ebola work, but now we have to go full throttle to monkeypox. I’m one person, thankfully, I’m supported by a lot of other amazing researchers across Canada that are in a similar predicament. We all work together and we work collaboratively. We work nationally with folks, we work with people within vulnerable communities and within the global south. It’s my dream job, but it’s also a nightmare at many points because you don’t get away from it either.

Jordan Right.

Dr. Jason Kindrachuk So I love what I do, but I wish that I wasn’t having to do all this on a daily basis.

Jordan And finally, in the True Big Story podcast tradition of asking a doctor who’s talking to us about one disease about a new one. Should I be worried about the Marburg virus? What’s going on?

Dr. Jason Kindrachuk Yeah, listen, the Marburg virus again, listen, this is ebola’s potentially tougher brother Marburg we’ve been worried about for a long time. It first emerged in 1967. It’s caused sporadic outbreaks, has a high case fatality rate. You know I think again, it’s this idea of what’s our level of worry. Our level of worry should be, are we doing anything in regards as to investment in surveillance and infrastructure in areas that we know Marlborough is circulating in? To me, that’s the biggest thing is you have surveillance and you have early warning systems in place that can reduce your overall impact of this disease. So I’m worried in the sense that are we missing a boat on being able to get these systems implemented? We know that the incidence of emerging viruses, outbreaks is increasing. We need to appreciate we live in their world, it’s not them living in our world. So we need to do what we can to try and at least bring about a stalemate in this trench warfare that we’re in.

Jordan As I always say to doctors who talk to us about diseases, this was a pleasure. I hope we don’t talk again, but I feel like we will.

Dr. Jason Kindrachuk I appreciate that as well, Jordan. I also feel the same way.

Jordan Thank you very much. Take care.

Dr. Jason Kindrachuk Thank you.

Jordan Dr. Jason Kindrachuk living the life of an emerging virus expert in 2022. That was The Big Story. For more from us, head to thebigstorypodcast.ca. Find us on Twitter at @TheBigStoryFPN. Email us anytime. You can find us at [click here!]. And you can even call us and leave us a good old-fashioned voicemail. The phone number is 416-935-5935. You can get this podcast wherever you like to get them. You can download it, you can subscribe, you can like, you can follow, you can do whatever they let you do, especially review. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow. Back to top of page