SHE Pod Season 3 Episode 7: David Isaacs on Monkeypox
10:20AM Sep 5, +0000
Speakers:
Kathryn MacKay
David Isaacs
Keywords:
disease
africa
transmission
vaccines
smallpox
people
ethics
festivals
cases
australia
spread
transmitted
kathryn
monkey pox
virus
child
europe
rash
monkeys
possibly
Hello, and welcome to the SHE Research Podcast. I'm your host Kathryn McKay. And today I'm joined by Dr. David Isaacs. And today we're talking about monkeypox. But before we get into it, David, I wonder if you could introduce yourself to our listeners?
Yes. Thanks very much, Kathryn. So I'm a paediatric infectious disease specialist. I've worked for the last 30 plus years at the Children's Hospital at Westmead in infectious diseases, but right now, I'm almost retired. And I'd spend officially half a day a week as medical lead in clinical ethics. At the hospital, at Westmead.
At Westmead. Well thanks so much for joining me today.
Pleasure.
So we're gonna talk about monkeypox, which is kind of new on the scene, and somewhat recent on the scene in Australia. So, David, what is Monkeypox?
Yeah, well, ah monkeypox is a disease that was called Monkeypox, because it was first described in monkeys in lab.. laboratory monkeys in Copenhagen at the Statens Serum Institute, in 1958. At that stage, there were no known cases in humans. The first recorded case was a child actually, in the Democratic Republic of Congo, in 1970. And it's a disease that's been almost exclusively seen in Africa until the beginning of this year. So from 1970 onwards, cases were described either in West Africa, in Nigeria and the Cameroo's or in, predominantly, or in Central Africa, predominantly, the DRC, the.. in the Congo, and surrounding countries. And in Africa, it's a disease that really could be quite severe. So mortality of around 3%, in Central Africa, and about 1% in, in West Africa, and a disease that resembles smallpox in some ways. So the people will get a rash that looks a bit like smallpox, they get fevers and chills and muscle aches, headaches, lymph nodes get swollen, so and it's related to smallpox, this virus, and the West was really not interested in this disease much at all. And the disease reporting was difficult because of identifying it politically, and lack of laboratories in some of the endemic plant parts of Africa. And so the West really, you know, typical western fashion, we just said, are African disease, we don't have to worry about it. And then at the beginning of this year, it started spreading. And the spread has been really quite rapid. So for example, I was writing an editorial about this two months ago. And I said, there have been 2000 cases in... described outside Africa, mainly in men who have sex with men, almost exclusively. And there have been eight cases in Australia at that time, two months ago. Since then, the number of cases in the world outside Africa has increased to over 35,000. And the number of cases in Australia is over 100 now. So quite a steady increase. And the World Health Organisation has described this as a public health emergency of international concern, which is not quite a pandemic, but it's sort of a... they didn't want to call it a pandemic, so soon after our last pandemic, but it's, you know, a pandemic means a disease that's spreading around the world. That's one definition of pandemic and it is a pandemic, really, it's just a question of how severe it is. In Europe, and Australia and elsewhere, there have been almost no people who've died from it. So it seems to have different epidem- And it's almost exclusively in men who have sex with men, whereas in Africa, a bit like HIV that's been spread to a wider population than men who have sex with men. And the terminology is very difficult, isn't it, Kathryn? I mean, you're it sounds like you're othering men who have sex with men by saying the rest of the population or what have you. And so, as we talk about this, we have to be very careful about the dangers of homophobia in this and also about the language that we use, I think.
Absolutely, that actually, there's a lot of questions that I have off the back of that, a few technical ones before we get into the kind of ethical questions which you've raised. But... but when one question that I wanted to clarify off the bat is whether or not this is like an exclusively adults disease, because you said that the first human case was in a child, so have there been children affected as well?
So the disease is transmitted, certainly in Africa, children have been affected, not in Australia yet. And so I've never seen a case, I've just seen photos of it. And mostly in Europe, where most of the disease has been in the United Kingdom, interestingly, probably because of people travelling to and from Africa. So legacy of Britain's colonial past, if you like. But... so by and large, in Africa, there have been cases in children and not so much elsewhere, the disease is spread by, so you've got the virus in these pox that you have, these blisters, and the blister fluid is infectious and possibly respiratory secretions. So the most of the transmission is by close physical contact. It's possibly to be trapped... possible to be transmitted by towels, and so on. So people talk about, you know, being careful not to share towels with someone who you know has got it. The question is, do you know they've got it? It is possible to have monkey pox without the rash. Although, by and large, it's almost exclusively that people who are infected do have a rash. But to avoid transmission, if you know someone's got it, we talk about socially isolating or physically isolating from them. And they're not sharing secretions in any way if you possibly can. So it's a close bodily contact seems to be the major way of transmitting. And of course, if you're sleeping with a child, and you've got it as happens in some communities, then the child can catch it. So yes, children could get it. And they can get very severely unwell. And there have been deaths in children in Africa, certainly from it.
And what happens besides death, what kind of illness kind of comes from it?
I look at like a severe. I mean, apart from the rash, it's like a severe influenza, which is a bit like severe COVID, if you like, and it's worse, you get muscle aches, and so on. And these chills, you feel very unwell, but you're going to recover. And there aren't the Quealy you don't get nasty side effects later on from it.
Okay.
But it's under studied, a lot of it is. And so the reports now are just coming in from Europe. There's just been one in New England Journal of 500 cases in Europe. No, nobody died from that. And we'll, we'll go on and talk about the ethics of it. But I mean, a couple of interesting things that I'll just tell you as anecdotes. So I knew virtually nothing about monkey pox, having just read about it in New England Journal of Medicine and it said, Oh, well, it's mainly an adult... You know, once before I read about an article that only affected gay men, and I thought, well, this won't affect children as much, and that was in 1981. And that disease were sort of course HIV infection. And, and it does in fact affect children, of course, you know, get infected through blood supply, and so on. And so there are parallels. And what then happened was that I got a phone call. I was walking in the bush one morning, as I do, and I got a phone call from a friend of mine in England in a panic, saying that his pregnant daughter had been doing a life support course, and had just been told afterwards that the person that was training her had been diagnosed with monkey pox, and it can cause a nasty infection in pregnant women and cause them to miscarry. Doesn't cause a sort of congenital disease like German measles does, but it can cause them to miscarry. And so they were in a panic about her, so I had to find out about it fast. And luckily, I knew a very good public health physician in in London who's a friend and and he rapidly went in to bat for them and was able to reassure him... her that the risk was much... was really very low and that she didn't need anything special doing. I mean, there are things you can do. You can give antiviral drugs, there's an antiviral drug called Tecovirimat that has been used, not very much. You can actually give smallpox immunisation as a post exposure prophylaxis. But she didn't qualify for that. So we were able to reassure her about that. So I thought, right, I write regular editorials for the Journal of Paediatrics and Child Health. I'm the editor of that journal. And I thought, Oh, this is interesting. I'll write one about monkey pox. So I wrote it about monkey pox. And I sent it to this public health physician friend in the UK to, you know, I always send it off to other people to review. And he came back at me with some... the fiercest criticism of my, what I've written that I've ever had. And I thought, 'Whoa', you know, and he was right about all of them. It was fascinating. And so one of the things that I had mentioned was about gay men going to festivals in Europe. And apparently, there's a sort of a festival season. And people go from one festival to another in different cities in Europe, around this time of year. And I'd mentioned that, and he absolutely hammered into me about that and said, of the cases in England, only a quarter of them have been associated with festivals. This was gay shaming, if I wasn't ga... he didn't call it that, but basically was saying, here's the risk of homophobia and so on. Now, that's actually quite interesting, because I happen to be talking to someone very high up in public health in New South Wales recently about this. And she was saying, Well, that's all very well, but if it is transmitted in festivals, through, through contact there, perhaps gay men need to know about that, at least to modify their behaviour, not saying don't go to the festivals, but just be careful and so on, and take the appropriate precautions. And so that there is a public health message that may inform men who have sex with men about risky behaviour in the circumstances and the risks in Europe. So there's a sort of, you have to weigh up the benefits of how you communicate if you like, but I wasn't doing that really. I'm not talking to gay men in writing to in a paediatric journal. So he was ripping into me about it. And I quickly took it out of the article. He also has sort of said one or two things about this very little transmission in Australia. And I use some adjective like, 'commendably' or something like that. He said, Oh, so Australians are commendable that the Europeans aren't, is that right? And (laughs) thae 'commendably' quickly went out as well. And it just shows you about language and the way we talk about it. So...
There's so many interesting things there.
Yeah, exactly.
And I think one one thing that I wanted to kind of, I guess, pick up on and ask you about, it's kind of like, it's, so I've seen the reports as well, saying that it... monkeypox seems to be most common right now in men who have sex with men. And then like you were saying it's kind of like this balance between stigmatising the group, and also alerting the group to the fact that something is going on. So it's kind of like that public health initiative to try to inform against worrying that you're causing greater stigma.
Yeah.
But at the same time, it doesn't seem like I mean, so it seems to be the case now, that that's the group that is most affected, but there doesn't seem to be anything. Like there's no reason for that in the virus itself, from what I've understood.
No no no, absolutely. And so, I mean, most human viral infections start in animals, and then may transmit to humans. And the way... mode of transmission more depend on the nature of the virus. So HIV is thought to have been transmitted from monkeys, by people butchering monkeys, cutting the monkey and themselves and it gets into their bloodstream, okay. And it's the bloodstream spread predominantly in HIV infection. And the fact that it started in gay men is interesting in itself. And that's one mode of transmission through sexual contact with HIV. But initiated probably possibly in the gay population in men who have sex with men, but in Africa, it very quickly became a heterosexual disease. And in the... and in countries outside Africa, it was predominantly a gay disease to begin with, but once If you had blood transfusions from men who have sex with men, and that was much more likely when blood was sold as a commodity in the US, for example, than it was in places where it wasn't sold as a commodity, then then it would spread to females and then mother to child transmission occurred. So mother to child transmission is very common in Africa originally. Now prevented by interventions to reduce the amount of virus there. But in the West, mother to child transmission was relatively uncommon, and remains relatively uncommon. But anyway, to go back to your point, there is no reason that this should not spread from men, to women, to children, and even to babies. And yes, and that's part of the reason for sort of trying to prevent transmission. And the vaccine where... we've not got good smallpox vaccines, they've all you know, they were used to wipe out smallpox. And that was originally wiped out in 1978, smallpox, and then smallpox vaccination worldwide was able to be stopped saving billions of dollars. But the vaccines are still there, and people are now actually using them to try to limit disease spread, of course, they're using them in countries that couldn't afford them not in Africa, surprise, surprise, and so on. So there's a global inequity about vaccine supply, as there has been with COVID-19 vaccines.
Yeah. Wow. Really, really interesting. Like so many different sets of issues. I mean, in terms of the ethics of it, there's the public health aspect, balancing harm against protection. There's the vaccine and justice side of it. There's also what you said at the beginning, which is that this is a neglected disease, the fact that we just haven't been paying attention even though it's been around since 1958, you said.
Yeah. And that's exactly thank you for summarising that so nicely Kathryn, because that's exactly why I sort of elected to talk to you today about a disease that I've never seen. But that's intrigued me because of the ethical aspects of it, as well as the viralogical aspects of it. It's quite fun being an infectious disease physician from time to time.
(laughs). Yeah, absolutely. I mean, this is fascinating. I wonder if there... if you've got anything in the Australian context? You know, is there anything that you think that we should be paying particular attention to? Or, and I mean, this kind of like ethically, or you may even have pragmatic advice for listeners, but what do you think that we should be paying attention to? In Australia..
I mean I think, from a Sydney Health Ethics point of view, we should be paying attention to the ethics of this, and what it tells us about the ethics of the way we manage infectious diseases generally in the world. I mean, we all know about mobile inequity. But how do you address that? And, you know, there are some people, philanthropists like Bill and Melinda Gates, and somebody who's really done a lot to address it. Their approach has been to do it largely through vaccines, which has enormous power, compared with almost any other way that we try to address diseases. And so in the long run, hopefully, vaccines will be the answer to monkeypox or whatever pox we're going to call it later on. And watch this space in terms of where they become available. And, you know, we'll all throw our hands up in horror and say, Oh, well, it's really difficult to get them to Africa and so on. But Bill and Melinda Gates have shown that where there's a will there's a way.
Where there's a will and a lot of philanthropy dollars.
Yeah. Well, I mean, what are ways to spend your money? You know, the number of lives they've saved is into the millions now, quite extraordinary.
Well, thank you so much. I think that we're kind of at the end of our time here. It's been fascinating getting this insight.
Well, thank you for inviting me, Kathryn. I've enjoyed talking to you. It's a pleasure.
And thank you so much for listening to this episode of the SHE Research Podcast. You can find David's paper, linked in this episode's notes along with a transcript of our discussion. SHE Pod is produced by SHE Network and edited by Madeline Goldberger. You can find our other episodes on Spotify, Radio Public, Anchor or wherever you get your podcasts of quality. Thanks again for listening. Bye.