Smallpox death of monkeys warns of need to contain cases in Brazil

The record of the first smallpox death of monkeys in Brazil this Friday (29) is an indication that it is important to increase efforts to contain the high spread of the monkeypox virus in the country, say experts.

For Julio Croda, infectious disease physician and president of the Brazilian Society of Tropical Medicine, the announcement raises an important alert. “Until now, we didn’t have a serious patient. Now, we even have a death.”

The death was of a 41-year-old man who was immunosuppressed and had a history of comorbidities, including cancer. According to the Ministry of Health, the patient “was hospitalized in a public hospital in Belo Horizonte, and was later taken to the CTI [terapia intensiva]. The cause of death was septic shock, aggravated by monkeypox.” The Minas Gerais Health Department also confirms that the patient was already being followed up for “other serious clinical conditions”.

Clarissa Damaso, a virologist at UFRJ (Federal University of Rio de Janeiro) and advisor to the WHO (World Health Organization) committee for research on smallpox virus, says that immunosuppressed people are at greater risk for severe disease.

“This death is something that we anticipated could happen. We know that groups of pregnant women, children and immunosuppressed people are the ones we should pay the most attention to because there can be very serious complications from monkeypox infection.”

The death also raises concern for the degree of spread that the disease has presented in recent days. Information from the Ministry of Health this Friday points to 1,066 cases of the disease. As of July 9, there were 218 confirmed diagnoses in the country.

“We have to intensify efforts to contain this disease,” says Damaso.

Worldwide, cases are concentrated in men who have sex with men with multiple sexual partners. However, the virus can infect anyone and thus reach groups most at risk.

“We know that the transmission must expand to other groups and to household contacts. We already have confirmed cases in children”, says Croda.

The infectologist also says that the death is a warning sign for a better preparation of Brazil with regard to vaccination against monkeypox. “It is important to understand which would be the priority group of the vaccine. In terms of severity, perhaps it is immunosuppressed people”, he says.

The country does not have immunizers and the Minister of Health, Marcelo Queiroga, said this Monday (25) that vaccination should be restricted to priority groups, such as health professionals.

The small manufacturing capacity of vaccines against monkeypox is another problem pointed out by experts. “There are very few manufacturers in the world and they don’t have production on the scale that we currently need”, explains Damaso.

She also points out that there are no indications for mass vaccination. Recommendations typically point to healthcare professionals. People who have had contact with infected people can also receive the immunizing agent because it can stop the evolution of the infection even after exposure to the virus.

The Jynneos vaccine, from the Danish pharmaceutical company Bavarian Nordic, is the only licensed immunizer in the world for monkeypox. It has already been approved for disease prevention by major international agencies such as the US Food and Drug Administration (FDA) and the European Commission.

Another possibility is the use of vaccines that were developed to prevent common smallpox. One such case is ACAM2000, which is being used against monkeypox in the United States.

This Friday, the SBU (Brazilian Society of Urology) and the SBI (Brazilian Society of Infectious Diseases) released recommendations to prevent monkeypox infection. The organizations explain that symptoms common to monkeypox, such as lesions on the patients’ skin, can be mistaken for other diseases.

“The SBU and the SBI recommend that, in the event of suspicion, that the epidemiological surveillance of each region is activated for guidance on sample collection and laboratory analysis, and, whenever possible, a photographic record of the lesions is made”, say the companies in note.

Measures for prevention should also be taken, such as constant hand hygiene with 70% alcohol or soap and water, reducing the number of sexual partners and isolation in case of suspicion of infection.