India is set to update its guideline on monkeypox as the number of cases creep up, but experts, both within and outside the government, said that exact risk factors that puts some people at higher risk of the severe disease are yet to be defined.
The latest confirmed patient of the disease in India is a woman in Delhi with no history of international travel. This takes the total case tally of the viral disease in the country to nine which included five people who had returned from abroad recently and four others without overseas travel history.
In the current global monkeypox outbreak, 10 deaths have been confirmed so far, of which one was in India, reported on July 30 in Kerala.
Government sources said that a meeting has been convened by the emergency medical response division of the Union health ministry on Thursday to deliberate on the need of updating the guidelines earlier, in line with rising cases in the country and its transmission in the community.
“In the meeting, among other things, the focus will also be on specifying clinical management of the disease in order to avoid complications and severity in confirmed patients,” said a senior government official.
An official in the ministry’s health research department who is also attending the meeting conceded that at present, there is not enough understanding about the exact transmission mechanism or risks for developing severe disease though these factors remain major concerns.
What makes some people more prone to complications, death?
While monkeypox is usually a self-limiting disease with the majority getting cured in two to four weeks with symptomatic treatment, Rajeev Jayadevan, a clinician and researcher from Kerala, said that not enough is known at this time about each one of the deaths that are linked with monkeypox in 2022.
A 41-year-old man who died in Brazil due to the disease, for example, has been confirmed by Brazil’s health ministry to have also suffered from lymphoma (a type of cancer involving blood cells) and a “weakened immune system”, the nature of which has not been specified.
The two deaths from Spain were reportedly not associated with immune compromise or underlying chronic disease, despite early rumours of cancer in one patient, said Jayadevan.
Back home, the death from Kerala occurred in a 22-year-old who recently returned from the United Arab Emirates.
“His detailed investigation report is not available yet,” said Dr Jayadevan. “Based on the symptoms reported, it is possible he developed encephalitis, but that’s speculative.”
Poonam Khetarpal Singh, regional director, World Health Organisation, South East Asia, underlined that factors that may lead to the death due to monkeypox include respiratory complications such as pneumonia, abnormal liver function and other organs failure, skin infection, dehydration due to skin lesions and inability to drink because of mouth sores and lymph nodes causing obstruction.
A higher number of lesions can also have an impact on the severity of the disease, she said.
Singh, however, stressed that more data is needed to better characterise cause of death and risk factors.
“WHO is working with experts from its clinical network to collect and assess this data and strong infection prevention and control measures both at home and in health facilities as well optimised supportive care in facilities are needed to avoid complications,” she said.
Immunocompromised more vulnerable?
Ankita Baidya, a consultant, infectious diseases, with HCMCT Manipal Hospitals in Delhi, highlighted that as per the US Centers for Disease Control, patients who are already immunocompromised or on some medication that decreases immunity like anti-cancer agents or steroids may be more vulnerable to complications.
Other than this group, patients with existing skin diseases like eczema and dermatitis, children younger than eight years, pregnant or breastfeeding women or patients in whom the initial monkeypox infection has resulted in to severe symptoms of gastroenteritis such as diarrhoea, and those with altered sensorium also need close medical supervision.
Though the mortality rate from the disease is low, she said, complications, though rare, may happen in special populations which include patients in whom clinical outcome may not be good or there may be a complicated course of recovery.
Kirti Sabnis, infectious disease specialist with Fortis Hospitals in Mumbai, too emphasised that as the risk of transmission is high in immune-compromised people and kids, they should take the necessary precautions to prevent themselves from contracting the virus.
“These people in the high-risk category should avoid contact with people with a recent travel history with symptoms and known disease cases,” she said.
‘Low death rate’
An official attached with the National Centre for Disease Control under the health ministry said that even though the government was taking all possible measures to prevent a large outbreak of the disease in India, the situation as of now was under control.
“We must realise that very few people globally are dying due to the disease and with proper public health measures, a widespread transmission can be prevented,” he said.
Dr Jayadevan, too, pointed out that the death rate from monkeypox this year is very low at about 0.04 percent.
“Also noteworthy is that 98 percent cases are men, among whom 36-41 percent of officially published case series in 2022 were HIV positive,” he said, but stressed that there is little data from these cases to recommend specific preventive measures for death, in addition to what’s already known about prevention and treatment of the disease.