Editorial

A Plague Upon Both Your Houses

Deval (Reshma) PaRanjPe, mD, mBa, FaCs

n Shakespeare’s day, when both plague and pox were all too prevalent, to wish a plague (or a I pox!) on someone was a curse with teeth. “How quaint!”, we said of this curse as schoolchildren studying Romeo and Juliet. “How curious!” said we who had never seen a pox. Poor Mercutio, a casualty of the war between the Montagues and Capulets, utters this immortal line when he realizes he is mortally wounded so we could imagine the gravity of this curse. My medieval history class collectively dressed up in black as the Black Death for Halloween.

But plagues are no longer quaint and curious or relegated to costume parties.

Today, we have both plague in the form of ever-evolving variants of Covid, and pox in the form of monkeypox. And we have a nation bitterly divided between warring political parties which is a plague and a pox in itself. America might as well be Verona, but the days of a detente a la James Carville and Mary Matalin’s marriage seem long gone. How much medical and political carnage will we see before our nation develops unity and a strong, fast, agile, apolitical and organized public health response to new threats? Plays and novels will no doubt be written about these days we are living through.

Mercutio’s curse has teeth again.

Famed wit Dorothy Parker was wont to answer the telephone with “What fresh hell is this?”

This is not an uncommon thought for most of us while checking our smartphones for the latest news. Because variety is the spice of life, we have not one but several new plagues and poxes to face, possibilities to ponder and unmentioned implications to consider. Let us begin.

Monkeypox

Let’s start with monkeypox. Poxviruses can be spectacular in their presentation and infliction of suffering (hence Mercutio’s curse) and monkeypox lives up to the family name. The name monkeypox is somewhat of a misnomer as primates including humans are secondary hosts; the natural reservoir is thought to be squirrels and other rodents.

Monkeypox, like its closely related cousin smallpox, is an Orthopoxvirus from the family Poxviridae. Like smallpox, it presents with fever, lymphadenopathy and characteristic rash; severe cases and death can occur. The case fatality rate for the unvaccinated is much better for monkeypox but still 3-6%, while it is a stunning 30% with the variola major form of smallpox.

Smallpox vaccine offers protection against monkeypox. However since 1980 when smallpox was declared to be eradicated smallpox vaccination has ceased, leaving humanity vulnerable to both diseases.

The US has already missed the boat on containing monkeypox (as it did with COVID-19) in terms of quarantine and contact tracing. Initially reported as a disease exclusive to the gay community and spread only by close physical or sexual contact, monkeypox is now spreading widely among the population at large, often by mysterious modes of transmission. In more and more cases patients deny any sick contacts or physical contact of any kind: they have no idea how they came in contact with the virus. The lessons of COVID-19 have not been learned.

The CDC and WHO currently maintain that monkeypox is transmitted through close contact with infected individuals (via direct or droplet transmission) or contaminated materials such as bedding (fomite transmission). What implications does this have for contaminated surfaces such as hotel comforters, inadequately cleaned hotel rooms, airplane and public transportation seating, and subways? What implications does this have for

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From Page 5 the traveling public and the recovering hospitality and transportation industries?

Remember that in the early days of the pandemic the CDC and WHO were adamant that COVID-19 transmission was solely via droplet and fomite despite all the accumulating evidence of airborne transmission. Finally and quietly, these entities recognized that airborne transmission of COVID-19 was the primary route, and we all stopped washing our groceries. I suspect that we may see a similar CDC/WHO reversal regarding monkeypox. Why?

The size of the viral particles of these poxvirus cousins is comparable. Both variola and monkeypox viral particles are 0.2-0.3 microns in size. (For reference, COVID-19 viral particles are 0.1 micron in size). Smallpox can be aerosolized and weaponized, and is a major source of concern for bioterrorism experts. Monkeypox can also be aerosolized in lethal doses as shown in primate experiments and can cause death via bronchopneumonia. A review of various transmission route studies for smallpox concludes that evidence for airborne transmission of smallpox is undeniable; another cites multiple sources from the 1960s (including a WHO bulletin) which conclude that airborne transmission of smallpox is the “usual natural route of transmission in humans.”

Why then would airborne transmission of monkeypox not only be considered but widely discussed? The economic implications would be considerable, as we learned from the COVID-19 pandemic.

Consider the implications of this: all health care workers would need to be immunized against monkeypox. The airline industry could be greatly affected or at least require masks again; indeed any venue with recycled air including hospitals would need to redesign airflow systems.

Don’t throw away your N95 masks just yet.

In addition, the first case of human to dog transmission of monkeypox has just been reported in the United States; be careful what you touch and wear a mask for Fido if you won’t do it for yourself.

Polio

Everything old is new again. Lest you think poxviridae are having all the fun, our old nemesis poliovirus is coming back to play as well. We are lucky enough to live in the city where Jonas Salk developed his revolutionary polio vaccine (and refused to patent it) thereby saving countless lives around the world. Before vaccination, polio would paralyze 1 in 200 children who caught the disease, and 10% of those paralyzed children would die. Parents were terrified. We have all but forgotten the iron lung negative pressure ventilator, but there are still a few polio survivors who are still trapped in them. One of these patients is 76-year old Paul Alexander of Texas, who has been dependent on an iron lung machine since the age of 6 when polio paralyzed him below the neck.

Hopefully we will not see routine paralysis in children again from polio, but polio is rising again. Wild type polio is endemic in Afghanistan and Pakistan; imported cases have been found in Mozambique and Malawi recently.

While wild-type polio is rare, vaccinederived polio has been detected in sewage/wastewater in London, New York and Jerusalem with one case of paralysis already reported in New York State according to Reuters. Vaccine derived polio is thought to originate from the live oral polio vaccine which is given predominantly in underprivileged countries. Immunized children shed the live virus in their feces; the virus can mutate and go on to infect others via wastewater in undervaccinated communities. The COVID pandemic-induced disruption in routine immunizations is thought to have spurred the threefold increase in vaccine derived polio cases wordwide between 2020 (1081 reported cases) and the previous year.

The UK is now recommending a booster dose of inactivated polio vaccine to all children between ages 1 and 9 to reduce further spread and protect against paralysis. We may soon be in a similar situation in the US between undervaccination due to anti-vaccine movements and global travel. The method of transmission is via contact with infected fecal matter, so swimming areas, hot tubs, and water parks are potential sources for concern, as are daycares and preschools.