infections doctor Jake Dunning
‘We have to accept uncertainties’: infections doctor Jake Dunning © Anna Gordon for the FT

Earlier this year, Dr Jake Dunning, who has studied infectious diseases all his working life, was catching up with a colleague about monkeypox in the Central African Republic. Then, a phone call caught him by surprise: a cluster of cases had been identified in the UK.

“We had often talked about transmission during sex, but I had never considered we would have an outbreak in the UK, let alone internationally, affecting people with a shared characteristic — men who have sex with men, where most transmission occurs during sex,” he recalls. “I never heard anyone else propose it as a likely scenario, either.”

As the outbreak developed, many patients were admitted to his communicable diseases unit at London’s Royal Free Hospital, says Dunning, who is also a senior researcher at Oxford university. “We all realised we had to prepare.”

Cases of monkeypox, a disease that had only been seen in sub-Saharan Africa, surged in May. But, five months later, Room 0, where the first patient was admitted, is no longer used for monkeypox patients. Global case numbers have tumbled from 7,477 in the week to August 14 to 2,167 as of October 17, according to the World Health Organization. The main theory for the fall is behavioural change among men who have sex with men, helped by a vaccination campaign.

Fears that the disease might move into other, more vulnerable population categories, such as children or the elderly, have not materialised. But, while the experience of caring for the sickest patients gave Dunning and his team some clues on how to manage a disease not frequently seen in the global north, big questions remain as to the future trajectory of monkeypox.

It is possible cases could rise again if there is another change in behaviour in the communities affected. That could lead to a low but stubborn level of disease that becomes near impossible to eradicate, leaving the virus endemic where it had not been before 2022.

In Britain, in August, the LGBT+ groups of the five main political parties criticised the UK Health Security Agency’s approach to vaccine buying, saying it risked making the disease endemic. But, in October, the government rejected advice from the agency to buy extra vaccine doses on value-for-money grounds.

Poorer countries, in some of which monkeypox has been endemic for decades, also remain severely underserved in terms of diagnostics, therapeutics and vaccines.

Nobody has died of monkeypox in the UK and there have been 29 deaths worldwide compared with 73,000 cases. However, clinicians say the illness can be extremely painful and require hospital treatment. Dunning and his colleagues have seen some “very complicated disease”, affecting the eyes and throat in some cases. Some patients have needed heavy painkillers.

Speaking in August, Dunning said hospitalised cases were tapering off, though he was not fully sure why. “It may be because treatment of monkeypox outpatients has improved,” he said. “It could be that people are having less high-risk sex.”

Scientists are still looking for a definitive origin of the 2022 outbreak. “Clearly, we know there are zoonotic [animal-to-human] reservoirs in some countries in Africa,” says Dunning. “I’ve always been concerned about monkeypox because I was concerned the sub-Saharan burden [of the disease] was greater than we thought.”

Jessica Joyce, a sister and ward manager, says staffing was the ‘biggest’ challenge © Anna Gordon for the Financial Times

But he never thought he could see the outbreak happening in men who have sex with men. “It’s found a niche, an opportunity — it spreads through close contact,” he says. “It’s the fact that it’s a closed sexual network, because gay and bisexual men who have sex with men have sex with other gay and bisexual men who have sex with men.”

One challenge in hospital has been treating patients before full evidence on monkeypox drugs became available, notes Dunning.

Jessica Joyce, a sister and ward manager, says the team was able to respond quickly, and that staffing has been the “biggest” challenge. “Patients have been incredibly tolerant,” she says. “It’s hard being in isolation and being told you can’t go home yet.” She says the team tries to re­assure them.

Antonia Scobie, consultant doctor, says one difficulty has been navigating stigma and helping patients to disclose their diagnosis easily © Anna Gordon for the Financial Times

Antonia Scobie, a consultant in infectious diseases, says one difficulty has been navigating stigma and helping patients to disclose their diagnosis easily. In the early stages of the epidemic, patients being transferred to another ward would be wrapped in sheets to prevent skin shedding into the environment. “One patient told me it brought to mind how HIV patients, in the past, may have felt stigmatised by their illness,” she says.

The ward had a total of 35 inpatients in the current outbreak, most of whom were admitted for medical purposes, rather than because they were unable to safely isolate at home.

Dunning says the most important lesson is to involve affected communities in the response. “Get representative bodies on board,” he says. “You make mistakes, you correct them.” But he cautions: “We are not at zero new cases in the UK. It’s at a low level currently and there could be a long, low tail on the epidemic curve . . . We have to accept uncertainties. With all these things we do get surprises.”

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