The monkey pox epidemic continues in France and is still progressing rapidly. Thursday August 18, 2,889 confirmed cases of this infectious disease, also called Monkeypox, had been identified in France, according to the latest report from the Public Health France health agency. To counter the epidemic, 189 vaccination sites (centres and pharmacies on an “experimental” basis) have been opened on the territory, and more than 100,000 doses of this vaccine against smallpox have been received by France.
As of August 17, just under 50,000 of them had been administered, reports the Ministry of Health. Too slow a pace judge epidemiologists and associations. According to them, 37,000 weekly injections would be necessary to allow vaccination before the end of the summer. Director of research emeritus at the National Institute of Health and Medical Research (Inserm), epidemiologist and biostatistician Dominique Costagliola returns for L’Express to the management of this epidemic in France, the neglect of this type of emerging disease and its consequences in terms of public health.
L’Express: The number of cases of monkey pox continues to increase, nearly 3,000 cases have been recorded… How would you describe the epidemic situation in France today?
Dominique Costagliola: This figure given by Santé Publique France is indicative, but it is likely to be lower than the number of actual cases, as usually during an epidemic. There can be several explanations. On the one hand, there are asymptomatic cases of Monkeypox: a recent study published by a team from Bichat Hospital in Paris determined that there were, among people followed for taking PrEP or due to HIV infection, about 6% of Monkeypox positive people who had no symptoms. On the other hand, it is possible that the accounting is a little less good at the moment due to the holidays and the delays in reporting cases. Globally, the epidemic’s doubling time is about fifteen days. This should alert us: if the dynamic continues in this way, we risk ending up with a staggering number of cases at the end of the year.
For now, this dynamic exists mostly in the most at-risk groups, especially among men who have sex with men (MSM). Obviously, we know that this disease will not remain confined to this population. The speed of propagation of Monkeypox is essentially linked to the particularity of this population, in which there are many contacts. Today, there is uncertainty about the evolution of the doubling time: would it still be as fast in another population? We ignore it. This is one of the reasons why vaccination, and especially timely vaccination, is important. It is necessary to vaccinate very quickly at least once all these people at risk, then to pass to the second vaccination.
Do you find that the vaccination strategy is fast enough?
If you do the calculation based on the population target identified by the High Health Authority, which is 250,000 people at risk, and if we are based on a rate of 10,000 vaccinations per week, it would take 25 weeks for everyone is vaccinated for the first time. It’s too slow. This means that we would only get there at the end of the year; obviously, this is not enough. It would be necessary to be able to be three to four times faster to be able to vaccinate the entire target by the end of the summer. At present, I think that the vaccination campaign is not vigorous enough… But let’s say that the treatment could be even worse than it is now.
However, after the Covid epidemic and years of experience in the fight against AIDS, one would think that we have all the cards in hand to act quickly against Monkeypox…
Yes, and I find it surprising, for example, to go through an experimental phase in making the vaccine against smallpox available to pharmacies, with a ridiculous number of pharmacies concerned! Do we really need to know if pharmacists know how to vaccinate? They are the ones who do the vaccination against Covid in the most notable way.
At the same time, a medical prescription for this vaccine is requested. Why ? One has the impression that the greatest fear of public authorities is to do too much. After the H1N1 flu episode, they were criticized for having done too much. But it seems to me that what the Covid has shown, in relation to masks in particular, is that we have to do too much. Because if the epidemic situation becomes really serious, these stocks and this strategy are necessary.
Contact-tracing of Monkeypox cases has also been interrupted…
The contact tracing, in reality, did not work very well. It was not very easy to find the contact persons, and those infected could not all say how they had been contaminated. And it’s true that in these high-risk populations (men having sex with men and multiple partners), the dynamic is very important. We follow people who use PrEP against HIV, and we run a clinical trial for the prevention of sexually transmitted infections that is nested in this study, in which there are 500 people. As of last Friday, we were already aware of 58 cases of Monkeypox among these people. This represents nearly 10% of the people in the cohort: this proves that the virus is spreading very quickly.
Is there a real risk of this epidemic getting out of hand?
The big question is that of dynamics. Will it be the same once out of the populations most at risk? The respective share of the different modes of transmission is not well known. The cases described show that it is through proximity and contact between wounds that the virus is transmitted, and not necessarily through sexual intercourse. There is probably some aerosol transmission, but absolutely not as dominant as for Covid-19.
What do we know today about the dangerousness of this disease?
What is known about this epidemic comes from what is happening in Africa, where the most severe cases have been found to occur in children and pregnant women. For now, it is mostly men who have sex with men who are affected by Monkeypox, so we observe very few serious forms.
But if we do not take this disease seriously and if we do not take sufficiently strong and rapid measures, the virus could reach the populations most at risk of serious forms. And we will have missed the boat when we had the means to contain the epidemic. In my opinion, the only reasonable attitude in public health is to do too much. And too bad if it generates criticism.
Can we speak of a sexually transmitted disease, since traces of the virus have been found in the semen of infected people?
Is there sexual transmission rather than contact with lesions that would be genital lesions? I don’t think we currently know. That it is transmitted during the sexual act, yes it is certain. But is it really strictly speaking a sexual transmission, or a transmission simply because one is in contact with lesions? I think it’s so easy to determine.
We have the impression that we don’t really know this epidemic very well, even though it is a virus that has already been circulating for many years in Africa… How to explain it?
This is unfortunately true. And that’s the whole problem with neglected diseases. We should have funded research in Africa on this virus a long time ago to get to know it better. The problem is that we are only interested in it because of the epidemic potential that this virus now represents for us. And it was the same for the Ebola virus: we were interested in it only because we knew, in view of the mortality of this virus, that if it arrived in our country, it would be a disaster.
There are still many questions: why is this epidemic happening now? And how similar are these viruses to those circulating endemic in Africa? I don’t know how to answer it. In addition, the degree of protection conferred by one dose or two doses of this vaccine against Monkeypox is not yet well known. There are studies currently being conducted to determine this but these questions are still unresolved.
How to explain the fact that we do not communicate on the doses of vaccine?
This virus comes from the smallpox family, and for the authorities it can identify biological agents potentially usable for bioterrorism purposes. Treatments and vaccines are therefore subject to secrecy. This is why we could not officially know the number of doses of vaccine we have. It is also a problem and a challenge for research, and even for treatment.
We can understand the principle, but we know that we are not facing bioterrism for this epidemic. The context is totally different and we must act quickly. For many laboratories, this regulation is a hindrance. This means that the tests must be done in a specifically approved P3 laboratory, and not all virology laboratories, even hospital ones, have an approved P3. This is where the French regulations are a handicap. There is not necessarily this same regulation in other countries, which has also enabled certain teams to be faster in scientific publications.