COMBATING THE RE-EMERGENCE OF MONKEYPOX IN NIGERIA.

Department of Biological Sciences, College of Science and Technology, Covenant

University Diji-geske R. I., Olasehinde G. I.

ABSTRACT

The re-emergence of Monkeypox infection in Nigeria after a thirty nine year hiatus, having
occurred in the 1970’s, is a major threat to public health. In recent times, there have been one
hundred and sixteen suspected cases and thirty eight confirmed cases in Nigeria. Thus
signalling a distress call for continued and increased public health measures such as
monitoring and surveillance (Breman, 2002), government commitment, the synergy of public
and private health sectors as well as inter and intra-professional bodies. Human monkeypox
is a rare zoonotic viral disease characterized by exanthemata and lymphadenopathy amongst
other viral clinical manifestations (CDC, 2015). It is found in the remote areas of Western and
central sub-Saharan Africa and is an important public health issue in these areas (Rimoin et
al., 2005). It belongs to the same family (Orthopoxvirus) as the eradicated smallpox virus and
other pox viruses and presents similar but less virulent clinical features than smallpox
(Gilbourne, 2014). However it has become the most important Orthopoxvirus since the
eradication of smallpox and takes the lead from where smallpox stopped (Giulio and
Eckburg, 2004). Its host reservoirs are animals and humans, with primary infection occurring
between animals and secondary infection occurring from animals-humans or human–human
(CDC, 2015). Though it was first discovered in laboratory Macaque monkeys, its primary
host reservoir remains speculative (Tanya et al., 2006). There are no proven treatments for
the disease, however a beacon of hope hails from the smallpox vaccinia vaccine which has
demonstrated effectiveness in preventing being infected with the virus but with the
eradication of smallpox, the production of the vaccine was brought to a halt (WHO, 2016).
Faced with the possibility of monkeypox being a potential agent of bioterrorism and fearing
the development and spread of more virulent strains (Dana and Frank, 2003), it becomes
expedient to research and develop new therapeutic agents. It is also important to create a
stockpile of new vaccines against unpleasant future occurrences while also effectively dealing
with the underlying factors that influence the emergence and re-emergence of these diseases.

1.1 INTRODUCTION

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Globally, only been few recorded successes as regards eradication of infectious diseases
exist. Vaccine production and the preceding smallpox eradication globally in1979 are notably
great breakthroughs in the field of science and public health. However, this noble feat has
failed to birth other predecessors except for the eradication of rinderpest disease in the year
2011, making them the only infectious diseases to be eradicated globally till date (Clark,
2011). This forms only a minute measure of the multitude of infectious diseases ravaging
various regions of the earth, thus it is expedient that measures continue to be put in place to
contain them in order to prevent their spread and preserve the human race. According to
Anne Rimoin, monkeypox emerged under the radar after the eradication of small pox due to
the lack of surveillance (Rimoin, 2010, 2013). From her survey, the incidence of cases of
disease arising from monkey pox infection in the Democratic Republic of Congo between the
year 2005 and 2007 where this disease has been prevalent was 20 times higher than that
obtained by the WHO in 1987.

The disease which had retained a limited region of prevalence since its discovery have
recently began spreading its tentacles intercontinentally sending shockwaves as masses as
faced with the reality of combating or allowing the disease.

2.1 MONKEY POX

Monkeypox is a distinctively rare disease, first to be detected in African monkeys in the year

1958. It is of viral origin and belongs to the same family virus – Poxviridae, that cause
diseases such as Smallpox and Cowpox, and bears an identical genus – Orthopoxvirus, with
Smallpox (Gilbourne, 2014). However, it is different from Smallpox and has a far less
mortality rate than that recorded in the era smallpox. Monkeypox is the most important
orthopoxvirus infection in human beings since the eradication of smallpox in the 1970s and
there is currently no proven treatment for it (Giulio and Eckburg, 2004). Monkeypox is
carried by both animals and humans and can cause diseases in both. It is clinically important
because its clinical manifestations are similar to other pox related viral illnesses, thus making
it often times clinically indistinguishable. There are basically two strains of monkeypox in
existence – the less pathogenic West African strain and the more pathogenic Central African
strain. Severity of the disease in human is dependent on the strain responsible for the
infection.

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2.2 HISTORY, OUTBREAKS AND EPIDEMIOLOGY

The first manifestation of monkey pox disease was seen in 1970 in the DRC, even though the
virus responsible for the disease was originally discovered when a pox-like disease among
crab-eating macaque monkeys (Macaca fascicularis) was being investigated in the year 1958
in the State Serum Institute of Copenhagen, Denmark. Notwithstanding, the virus was first
recovered from captured monkeys originating from Asian regions of Malaysia, India, and the
Philippines (Tanya et al, 2006). The first incident of monkeypox infection in humans
occurred in a 9 months old infant in the Democratic Republic of Congo in the year 1970
where it eventually became endemic following major outbreaks between 1970 and 1986 in
which over 400 cases were recorded(Meyer et al, 2001), with subsequent outbreaks occurring
between 1996 and 1997(Tanya et al, 2006). Afterwards, several other cases in the DRC and
some parts of West Africa have been reported, with most of them occurring in rural and
rainforest areas.

In the year 2003 in the USA, beginning with the manifestation of symptoms in a 3 year old
girl who had been bitten by a prairie dog, some other persons who had prior contact with pet
praire dogs were diagnosed as having been infected with the disease, thus making this the
first case to be reported outside the continent of Africa (WHO, 2016). A total of 81 cases
were reported (Daniel, 2004) with subsequent outbreaks occurring over the next ten years.
Investigations tracking the occurrence of the disease in the United States imply that the virus
probably got into the USA via a consignment containing about 800 little animals from Ghana
to Texas.

Nigeria had its first recorded cases of monkeypox in 1971 and 1978 with two and one case
reports respectively. After which a thirty years hiatus ensued before another outbreak
occurred in 2017wth speculated outbreaks cutting across twenty one States which include
Bayelsa, Cross Rivers, Lagos, Nassarawa, Ekiti, Enugu, Rivers, Akwa Ibom, Delta, Imo,
Kastina, Kwara, Benue, Ondo, Edo, Kogi, Kano, Niger, Oyo, Abia and FCT, with the highest
suspected and confirmed cases occuring in Bayelsa State. A total of one hundred and sixteen
suspected cases and thirty eight confirmed cases were reported. As a measure to monitor the
events of this endemic and control the spread of the virus, a centre was established by the
Nigerian Centre for Disease Control (NCDC) and an epidemiological team of the state
Ministry of Health. The NCDC’s assigned epidemiological team remained under surveillance
and quarantine in the Niger Delta University Teaching Hospital (NDUTH) while monitoring
those who came in contact with infected persons (Ebitimitula, 2017). The case report

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confirmed that 38 of the 116 samples sent to the laboratory turned positive with the likely
source of transmission being zoonotic, followed by secondary human-to-human transmission
(NCDC, 2017). The outbreak in Nigeria was caused by the less virulent and non-deadly West
African strain, which manifests in milder disease symptoms, fewer deaths and limited human-
to-human transmission. However most of the results gotten reported negative, even though
the symptom manifested are those of monkeypox (Adewole, 2017), hence making it unknown
whether, it is a new strain or another infection to be worried about.

Subsequent reports from a survey supported by the National institute of child health and
human development showed that the incidence of monkeypox cases between 2005 and 2007
was 20 times higher than the incidence found by WHO surveys in the 1980s with greater
incidence rate in forest areas. Furthermore, it also showed that those most likely to be
infected were children younger than age 15 years, gender irrespective. According to the
World Health Organization (WHO), the ratio in reported case fatality of monkeypox is 1:10
(WHO, 2016).

Fig 1: MONKEYPOX DISTRIBUTION MAP IN AFRICA (Levine, 2007)

Animals serve as reservoirs for this infection and some such as other primates, rodents and
rabbits have been implicated as being vulnerable to the monkeypox infection. Although the
definitive natural reservoir is still unknown, studies point to rope squirrels of the African
genus, Funisciurus(Tanya et al,2006). Epidemiological study reveal endemicity of
monkeypox in the African rope Squirrels (CDC, ). According to the centre for disease
prevention and control, the virus responsible for monkeypox has only been isolated twice

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from an animal. In the first instance (1985), the virus was recovered from an apparently ill
African rodent (rope squirrel) in the Equateur Region of the Democratic Republic of Congo.
In the second (2012), the virus was recovered from a dead infant mangabey found in the Tai
National Park, Cote d’Ivoire. Additional, epidemiologic studies of monkeypox infections in
humans show that younger children and those not vaccinated against smallpox can develop
severe disease and complications, thus supporting the significance of host susceptibility and
previous immunity (Breman, 2000).

More so, monkeypox accounts for three percent secondary attack rates and fatal-case reports
due to immunization with smallpox vaccines (Rimoin et al, 2007) due to the fact that it was
discovered in the ‘70s after the complete eradication of smallpox globally. However, between
the ‘90s and the new millennium, the secondary attack rate spiked up to as high as seventy
eight percent, perhaps owing to the halt of vaccination with the smallpox vaccine following
the eradication of smallpox, which made people born after the ‘70s miss the shot, thus
reducing their immunity.

Fig 2: Monkeypox strain distribution map in Africa (Levine et al, 2007)

There is a probability that the high attack rate reported result from suppressed immunity level
in individuals and population following stoppage of routine smallpox vaccination. Another

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reason for high rates of attacks may be the existence of a viral strain different from known
viral strains. Further compounding the issue is the fact that there is inefficient case-patient
identification in the investigation due to unwillingness of all infected people in a household to
report their complete case, hence affecting surveillance (Leisha et al, 2016).

2.3 TRANSMISSION CYCLE

Transmission could occur from direct contact with the virus from the body fluid of the animal
or through bites of infected animals. It could also be from human to human through
respiration of droplets from infected humans and contact with fomites from the body fluids of
infected persons, or from viral contaminated materials. Respiratory droplets usually cannot
travel more than a few feet; therefore sustained face-to-face contact is required (CDC, 2016).
Entry points in humans are broken skin, respiratory tract and membrane mucosa of eyes, ears
and mouth. Transmission from animal-to-human may occur through bites or scratches, eating
improperly cooked infected bush meat, direct contact with body fluids or lesion material, or
indirect contact with lesion material, such as through contaminated bedding. Though
monkeypox is highly pathogenic to humans, transmission between humans is relatively poor.

Fig 3: Monkeypox versus smallpox pathway (Jehu, 2017)

2.4 Disease pathogenesis

Signs of Monkeypox infection in humans begins typically with the onset of fever, muscle
aches (myalgia), headaches, backaches and extensive weakness(asthenia), presenting
symptoms that are identical with smallpox with the exception of the development of swollen
lymph nodes (lymphadenopathy) which is usually absent in cases of smallpox. This is called

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the invasion period and it often lasts between 0 – 5 days. The incubation period for
monkeypox is usually 7−14 days but can range from 5−21 days (CDC).

Fig 4: African child showing lesions on face and palms (Nigerian Tribune, 2017)

In a second stage known as the skin eruption stage, progression of lesions occur as macules,
papules, vesicles, pustules and scabs within 10 days. It usually affects the mucous membrane
of the mouth in about seventy percent of cases, genitalia in thirty percent, conjunctivae and
cornea in twenty percent.

2.5 DIAGNOSING MONKEYPOX

In the diagnosis of monkeypox, various differential diagnoses must be considered and they
include other illnesses accompanied by rash, such as, smallpox, chickenpox, syphilis,
measles, scabies, some bacterial skin infections, and allergies resulting from medications.
However, the main distinguishing clinical feature of monkeypox from smallpox remains
the presence or development of lymphadenopathy.

Monkeypox can be diagnosed in laboratories using test methods that can identify virus
such as:

 Quantitative polymerase chain reaction (PCR) assay

 enzyme-linked immunosorbent assay (ELISA)
 antigen detection tests
 virus isolation by cell culture

Other technical methods include

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  Immunohistochemistry
 Electron microscopy

Western blot analysis for specific IgG antibody may be used in determining the virus.
Other tools that may be used include assays for plague reduction neutralization and
haemagglutination inhibition, but due to antigenic and serological cross-reactivity
displayed by monkeypox virus with other othopoxviruses, complications arise in the use
of antibody-based tests in specific diagnosis.

2.6 Treatment of monkeypox and vaccine intervention

There are no existing specific treatments or vaccinations accessible for this disease. However,
outbreaks can be controlled and broad spectrum antiviral agents can be used in very severe
cases though their efficacy remains unknown. Three antiviral agents are currently being
assessed, they include ST-246 which prevents the release of the virus from the cell. It has
been reported to be effective in controlling the infection of various Orthopox viruses, and is
partially being used as a treatment agent for Orthopox virus infection. However, it has not
been licensed to treat monkeypox infections. The second agent, Cidofovir inhibits the enzyme
responsible for viral multiplication with adverse effect manifesting as renal toxicity. It is
temporarily allowed for the treatment of other Orthopoxvirus infections. The third agent
CMX-001 is a modified version of cidofovir compound. It does not cause renal toxicity and
has been reported effective in controlling the replication phase of various Orthopox viruses. It
is a work in progress.

Vaccines used against smallpox in the past yielded 85% efficiency in preventing monkeypox
infection. But due to the global eradication of smallpox, production of the vaccine has long
been discontinued. It was however reported that those who contracted monkeypox infection
after receiving vaccines against smallpox were insignificantly affected by the disease. The
CDC recommends vaccinia immune globulin (VIG) to be used as prophylactics in severely
immunodeficient persons exposed to MPXV.

2.7 Prevention and transmission control initiative

CDC recommends that people scrutinizing monkeypox outbreaks and involved in taking care
of infected people or animals should receive smallpox vaccination in order to protect
themselves against being infected. Also, those who have had close contact with individuals or

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animals diagnosed with monkeypox infection should also be vaccinated. These people may
be vaccinated up to fourteen days after exposure. However, it does not recommend pre-
exposure vaccination for unexposed veterinarians, veterinary staff, or animal control officers,
unless such people are directly involved in field investigations. Also, only trained personnel
in suitable laboratories should handle samples taken from suspected persons or animals.
Infected persons must be isolated and the use of personal protective equipment worn when in
contact with them.

Restriction and ban on animal trade and importation into countries, regions and states
imitating the joint order issued by CDC and the United States Food and Drugs Administration
in 2003 banning importation of rodents from Africa, may be effective against the spread of
the virus (CDC). WHO recommends that captive animals should not be inoculated against
smallpox. But rather suspected and potentially infected animals should be isolated from other
animals and placed into immediate quarantine. While animals that have been in contact with
any infected animal should be quarantined and observed for 30 days, observing all safety
precautions (WHO).

Furthermore, creating awareness, taking surveillance measures and providing rapid

identification of new cases is vital in preventing outbreaks and managing the virus in the
absence of proven treatment and vaccines. Awareness should be created on the risk of
contracting the disease through improperly cooked meat and via lack of safety precaution
during animal handling and butchering. In the DRC, film-based educational activities have
been effective in raising MPX awareness, but additional health education campaigns focused
on the handling of potential animal reservoirs is needed (Katy & Peter, 2016).

Furthermore, the main reason for hunting monkeys and rodents as meat is due to the poverty
stricken state of many people living in Western and Central regions of Africa, which causes
direct and unhindered contact with the virus-carrying animals. Infection with the virus
especially in immune-compromised individual such as people with HIV/AIDS is further
enhanced by the process of deforestation and Urbanization. With respect to this, enhancing
the standard of living of the people in infection-prone areas such as providing alternative
source of food, job creation, educational campaigns and reducing deforestation activities will
do much in reducing the outbreak of the disease, and improving the general well-being of the
people.

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In addition, the World Health Organization’s WaSH initiative which projects the importance
of clean drinking water, good sanitation and hygiene especially after contact with sick people
along with protective clothing for those dealing with infected persons may help in avoiding
the risk of being infected.

3.2 MEASURES FOR ERADICATING MONKEYPOX

The outbreak of monkeypox virus in the United States clearly demonstrates the ability of new
diseases to emerge and migrate due to casual movement of species from place to place. There
is a call of urgency for research and development of therapeutic agents and new vaccines for
the treatment and prevention of poxvirus infections.

In 1981, the WHO began supporting several surveys following cases of human monkeypox
infections in Africa; conversely, owing to very few cases reported, the surveys were halted in
1986. However, due to potential bioterrorism attack with smallpox virus in 2002, surveillance
programs were designed to monitor febrile rash illnesses in humans; and these programs may
be instrumental in detecting emerging infections (Breman, 2002). Hence, the outbreak of
monkeypox virus infection should serve as a prompt to monitoring these surveillance
programs.

In 2002, military personnels and health- workers who were potentially at risk of being
infected with orthopox virus were being vaccinated with vaccine strain of Dryvax, following
bioterrorism attack with Variola Virus. Nevertheless, an extreme rate of adverse effect in
association with the smallpox vaccine has been observed, thus preventing other countries
from recommending the smallpox vaccine as a preventive therapy (Qutaishat, 2003).

Accordingly, it was concluded in the final reports of the Global Commission for the
Certification of Smallpox Eradication in 1979 that continued smallpox vaccination to prevent
human monkeypox was not justified (Daniel, 2004), but did however suggest that measures
be taken to assess the public-health implication of emerging zoonosis more accurately . In
addition to the recognised adverse effects related with smallpox vaccination in
immunocompetent patients, the emergence of AIDS in the 1980s further intensified concerns
over the use of the vaccine (Heyman, 1998). 

According to (Stittelaar et al, 2007), antiviral therapies are more effective than smallpox
vaccines and should serve as complements because post-exposure vaccination do not
essentially provide protection against lethal infections of OrthopoxVirus (OPV), neither is

10
there guaranteed protection against infection with OPV during the time-lapse between
vaccination and antibody development protection, and those available such as Cidofovir and
ST-246, have only been successfully used in treating a child with severe eczema vaccinatum
(Vora et al, 2008).

An important criterion for licensing drugs or vaccines in order to prevention or treat human
infectious diseases such as monkeypox, is the ability of these compounds to render adequate
protection in the case of a challenge with the pathogen in one or more animal models. Based
on this legislation, the United States Food and Drug Administration (FDA) recommend the
testing of drugs or vaccines directed against such human diseases in at least two animals, one
of which should be non-rodent specie (ideally nonhuman primate). This is because in vivo
studies of monkeypox virus cannot be done in humans owing to ethical reasons surrounding
the lethal conditions of the test (Marit et al, 2010). Therefore, nonhuman primates due to their
close relatedness to humans are experimentally considered test specie for vaccines and
antiviral compounds.

For eradication to be made possible, it is crucial that rural areas where endemicity of the
disease prevails are provided with easily accessible, low cost and user friendly technologies
to aid in cultivating and identifying the virus in order to implement a treatment plan before
complications arise. Tetracore Orthopox Biothreat Alert is one of such new techniques that
offer this possibility. It does not require a huge expertise and demanding temperature
conditions are not required to perform tests.

Another vital key for zoonotic infections such as monkeypox virus to be eradicated from the
globe, there must be synergy of inter, intra and trans-professional parameters in place i.e.
public health and medical specialists alone are not sufficient to dealing with the challenges of
zoonotic viral infections but a clear understanding of parameters such as environmental
science, veterinary, political behaviour, human social science behaviour, evolutionary
changes, may suffice in rendering a more straight forward solution (Cascio, 2010).

Currently, notwithstanding the improvements in laboratory science, methods of tackling

infectious diseases continue to be the same as those nearly a century ago and they include
public health awareness, isolation, sanitation and hygiene, reducing congestion, and
surveillance programs as vital tools. Mitigating the impact of this disease will require the
commitment of government, industry, and public and private partnership on a social, political,
and economic platform (Sharon and Dana, 2014).

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3.3 Challenges surrounding monkeypox in context

The smallpox Vaccinia virus vaccine has been used and proven effective in time past against
infectious cases of monkeypox due to the similarities they share phylogenetically. However,
there is a down-toll to this success because the live vaccinia virus in the vaccines could be re-
activated in immunocompromised persons, leading to further complications. Inactivated
vaccinia viruses are also used as vaccines but they are not as effective as the live virus
(Smitha, 2015).

Another challenge facing the monkeypox infection is difficulty in using Serological testing
for MPV antigens due to the closeness in antigenic variations found between the surface
antigens of orthopoxviruses. Though there are several serological methods available, some of
which include virus-neutralising test, haemagglutination-inhibition assay and detection of
specific viral antibodies, serological test are not useful for the diagnosis of acute infections
because of the varying dimension of its sensitivity and thus cannot be used reliably to test any
case of orthopoxvirus (Damon, 2003).

In the area of vaccine production, although safety studies and in vivo efficacy of vaccines
should be carried out on humans, ethically this is impossible due to the lethal consequences
involved in such experiments. Hence vaccines and antiviral compounds are tested only on
non-human primates owing to their close-relatedness to humans. The nonhuman primate
animal model used for monkeypox virus vaccine experiment to successfully induces clinical
disease is the macaque species - cynomolgus (Macaca fascicularis) and rhesus macaques
(Macaca mulatta) respectively. However, a major limitation to the use of these animals is the
lethal downside of infection caused by high infectious doses (Jordan, 2006).

However, given the possibility of monkeypox vaccine production or the authorization to

continue with the smallpox vaccinia virus vaccine, a variety of issues may contrive to prevent
the authorized vaccines among the general public from being feasible. Cost being the
principal limitation, alongside vaccine availability, and reactogenicity – as in the case of
smallpox vaccine which contains live virus, produced a large number of contra-indications
such that an estimated 30%–50% of the general public would not be eligible to be given the
vaccine in the case of an exposure or risk to an exposure (Sharon, 2014).

Furthermore, variations in epidemiological studies blur the understanding of the virulence

and transmissibility of monkeypox virus infection in humans. There also is the underlying

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 concern of unreported cases to healthcare, thereby preventing the surveillance monitoring
system from accurately estimating the number of human monkey cases. Moreover, since
there are no proven treatments for this infection and according to records it remains the most
important infection in the family of orthopoxvirus after the eradication of smallpox,
insecurity lies in its potential as an agent of bioterrorism Monkeypox is the most important
orthopoxvirus infection in human beings since the eradication of smallpox in the 1970s
(giulio and eckburg, 2004).

3.3.1 Co-infection

Monkeypox has been reported to be detected alongside chickenpox and requires adequate
care and sensitivity carrying out test due to similarities in the clinical features of both
diseases. In a co-infection with chickenpox, 75% of the rash is from monkeypox while 15%
results from chickenpox.

4.1 Factors influencing disease emergence and re-emergence

The factors responsible for zoonotic diseases in humans are often dependent on the reforms
of human behaviours, climatic and environmental change, and pathogenically related factors.
The resurgence and epidemiology of zoonoses are complex and dynamic, being influenced by
varying parameters that can roughly be categorized as human-related, pathogen-related, and
climate/environment-related; however, there is significant interplay between these factors
(Cascio et al,2011).

TABLE 5: INFECTION-DEPENDENT FACTORS (Cascio et al, 2011)

HUMAN-RELATED FACTORS CLIMATIC PATHOGEN

FACTORS RELATED
FACTORS
MODERN INDUSTRALIZAT POLITICS SCIENCE
LIFE ION
TRREND
Ecotourism Urbanization/ State reforms Novel Global Ecosystem
Megacities diagnostic warming disruption/
s Population
rearrangement

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Pet Intensive Conflicts Novel Genomic
ownership husbandry system high risk variability/
population Species
jumping/ Re-
assortment
Culinary Food-chain Loosening Biodiversity
habits e.g industry border influences/
raw meat automation control Biological
comsumptio pollution
n
Global Global trade Free-trade Virulence/
travel interaction economy Resistance
selection
stress
Human intrusion in Surveillance
ecosystem e.g. & public
deforestation health
infrastructure
breakdown
Hierarchy
issues

4.2 PREVENTING RE-EMERGENCE

Cessation of control activities plays a major role in the consequent re-emergence of

indigenous transmission of infectious diseases. However, cited as some of the reasons for
draw back on control activities are decreased funding, apathy, lack of encouragement and
awareness, and weakness in surveillance resulting in delayed detection of human infection
(Heymann, WHO).

Re-introduction of infectious diseases in present times occur both locally and across borders
and continents; thus it is expedient that measures continue to be in place to keep infectious
agents in check. For instance, between the year 2003 and 2005, Poliomyelitis in Northern
Nigeria spread and was re-introduced into some other countries in Africa and regions of the

14
world which include Asia and the Middle East (altogether 18 polio-free zones), where
intervention had been stopped and monitoring, control and surveillance neglected both by
public health professionals and Government bodies (WHO, 2008).

Similarly, after the eradication of smallpox globally, vaccination in all countries of the world
was discontinued notwithstanding the stockpile of smallpox viruses left reserved in two major
laboratories.

Fig 5: factors influencing emergence of infectious diseases (Simmerman, 2017)

According to the WHO, in other to prevent and/or control re-emergence of infectious

diseases, surveillance must be continued, there should be an international stock-pile of
vaccines readily available and control interventions hiked.

4.3 THE POSSSIBILITY OF RESISTANCE

The close similarity in clinical features of monkeypox to smallpox makes it difficult to

clinically distinguish between both infections without the use of specific diagnostic tests. The
smallpox vaccine in the past which proved effective against the infection of monkeypox is
presently not readily available following the eradication of smallpox, thus concerns are rising
that with the limited availability of smallpox vaccines in the current setting, monkeypox

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could become a more competent human pathogen, hence leading to resistance to antiviral
drugs which are presently being developed for the treatment of the disease. 

Currently, Cidofovir among other antiviral drugs is the most effective antiorthopoxvirus agent
undergoing pre-clinical study, and is at the verge of being licenced.

From the study of Donald et al, on resistant strains of monkeypox and other orthopox viruses,
cross-resistance was observed toward cyclic HPMPC (a prodrug form of cidofovir) for all the
resistant poxviruses tested. Monkeypox virus was cross resistant to HPMPA. Application of
the data from the study of Donald et al to a possible clinical situation suggests the possibility
that treatment of variola or monkeypox virus infections in humans could lead to the
emergence of CDV-R viruses that are cross resistant to other antiviral compounds (Donald, et
al).

Resistance to other microbial infections may also be instigated due to self- prescription and
medication, wrong prescription by unsuspecting / unqualified personnel, the use of drugs
inappropriately in the bid to get rid of the symptoms being experienced as well as taking
antibiotics as prophylaxis against infection, thus further breaking down the immunity of
infected persons and prolonging duration of illness.

4.4 SOCIO-ECONOMIC IMPACT OF RE-EMERGING DISEASES

All through history, human lives have been shaped by emerging infectious diseases have
shaped the course of human history and have caused innumerable death and misery. The
extent of zoonotic disease burden on human health procures an annual death record of
hundreds of thousands and tens of millions of infectious incidences. Advancements in science
and high through-put technologies round the globe notwithstanding, infectious diseases
continue to emerge at an alarmingly rapid pace, with the majority of them activated by wars,
loss of social consistency, natural disasters.

Policy creations and educational awareness against infectious diseases are vital in every
nation because no country is insusceptible to epidemics, which impacts both the economy and
society. The epidemic impact of an infection on a nation is of varying degrees depending on
the length of duration and severity. The emergence of an infectious disease in a nation is a
huge threat and poses a health risks both to human and animal population. EIDs pose a major
risk to the health and welfare of global human and animal populations. Severe disruption of
the national food chain in the case of infections in animals will eventually impact on humans

16
causing health hazards. Moreover, the amount of man-power and hours of productivity lost
greatly affects the GDP of any economy.

Most recently round the globe; novel infectious agents alongside the re-emergence of
previously epidemic infectious agent have been on the rise. An example is the re-emergence
of Ebola virus which far exceeded the previous records of the disease in West Africa (Sharon
and Dana, 2014). Outbreaks of epidemics pose heavy tolls on humans and society, as several
death occur leaving families helplessly stranded and dependent on the society for help
especially in the case of the loss of a breadwinner. People get displaced from work, cancel
financial project, and pack up personal businesses, schools get shut down and academics
delayed, tourism is affected, international trade most likely withdraw as borders become
closed. In essence every aspect of the country’s economy is affected and without timely
interventions may become crippled.

Consequently, owing to the existence of prevalent population susceptibility to these agents,

the survival of nations are placed at risk given the instance a bioterrorism event. Of which
most of the biological weapons in existence today are of zoonotic nature, and consists of high
research cost and a great deal of time required to prepare for possible attacks (Cascio et al,
2011).

4.5 HEALTH AND PSYCHOLOGICAL IMPACT

Monkeypox virus has created disproportionate fear in the hearts invaded communities as is
the case with other viral epidemics, due to the rapid and invisible mode of transmission to
which it owes its high morbidity and mortality. Outbreaks of viral diseases which are
extremely contagious fronts affected persons as victim and equally as vector (Pappas et al,
2009).

Severe and disfiguring infections such as the MPV are characteristically accompanied by
major depressive disorders characterized by depressive episodes and symptoms such as
depressed mood (Coughlin, 2014), inability to concentrate, loss of interest in most daily
activities, significant weight loss or gain, sleeping disturbances, fatigue or loss of energy,
feelings of worthlessness or excessive or inappropriate guilt, suicide attempts or recurrent
thoughts of death or suicide. In Nigeria, one victim from the recent outbreak in Bayelsa State
committed suicide despite nearing recovery (Umeha, 2017).

17
Infected individuals who are left with pitted scar may carry on with feelings of inferiority and
inadequacies due to their disfiguring looks, hence crippling their minds and becoming
mentally invalid and dependent.

Actions carried out by health operatives and surveillance groups such as isolating infected
individuals and other infringements of rights in the bid to control the spread of the disease
may also inadvertently contribute to health deterioration and diverse psychological disorders.
Effects however of the disease on overall health and psychology vary among individuals.

4.6 ECOLOGICAL CONSEQUENCES

The subject of ecological consequences of pathogen-induced changes in hosts is as delicate as

that of dramatic impact of pathogens on their hosts. The effect of pathogens on host
behaviour, reproduction, and mortality largely influences community interactions such as
competition, facilitation, predation, and invasion (Valerie). These pathogen-induced changes
in host individuals and communities can have strong impacts on ecosystem processes (e.g.,
productivity, nutrient cycling) and landscape structure and function (e.g., disturbance
regimes, land use, land-atmosphere interactions).

CONCLUSION

In a rapidly changing world that is fast advancing in scientific knowledge and technology,
infectious diseases still thrive and have remained on the rise. The long chain of incessant
outbreaks of human monkeypox in Africa and its spread to regions across the globe where it
was never previously reported indicated the red light. Its re-emergence in countries such as
Nigeria where it had been non-existent for 39 years, calls for a commitment to vigilance,
surveillance, intensity in research and development of antiviral therapies, while not
neglecting the good old sanitation and hygiene self-support therapy

It is highly significant that this orthopoxvirus remains at the vanguard of potential emerging
infectious diseases. Even though smallpox has since been eradicated from the human
population, there exists the potential for monkeypox to carry the flag. The extended person-
to-person chain of monkeypox transmissions in the Republic of Congo (2003) reveals the
potential of further adaptation of the virus to become a more successful human pathogen
(Learned et al, 2005). Moreover, since the human population is continuously changing due to
factors such as ecological disturbances and advancement of new infectious diseases such as
HIV, this may provide the platform for a more efficient spread of monkeypox disease.

18
Faced with the possibility of monkeypox being a potential agent of bioterrorism and fearing
the development and spread of more virulent strains, it becomes expedient for national and
international bodies to synergize and begin to develop and create stockpiles of vaccines and
antivirals against unpleasant future occurrences.

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