A Call for Action: The Triple Threat of Polio, Monkeypox, and SARS-CoV-2

Kevin Kavanagh, MD

Last week’s news regarding infectious disease was nothing short of depressing. There are fears of a significant polio outbreak, monkeypox has sustained exponential growth, and SARS-CoV-2 has a new emerging variant, BA.4.6.

Polio

Polio has reemerged after being absent almost a decade, with a Rockland County, New York, resident contracting the infection. For every case of paralytic polio, there are hundreds of other infections. According to the CDC, approximately 72% of individuals infected with the polio virus are asymptomatic. These individuals can shed the virus for days or weeks after infection, spreading it asymptomatically, so with 1 case, community spread in New York is likely.
 
About 25% of those infected with polio will have flu-like symptoms. About 1 in 200 develop paralysis (half of 1%). Between 2% to 10% of individuals with paralysis will die (1 in 2,000 to 1 in 10,000). The Associated Press reports that 7 different wastewater samples from Rockland and Orange Countries were positive for the virus, raising prospect of community spread.

Rapid and aggressive public health interventions are immediately needed. There is concern that the public resistance we have seen in attempts to stop SARS-CoV-2 will spill over to other pathogens, such as polio, and stopping polio will not be easy. Polio has an R naught of 5 to 7, meaning that between 80 to 86% of the population would need to be vaccinated before viral spread would stop. With the levels of vaccine hesitancy in rural New York counties, this goal will be difficult to achieve. Rockland County has a polio vaccination rate of 60.3%, and adjacent Orange County has a vaccination rate of only 58.7%.

Credit to Global.health team. github.com/globaldothealth/monkeypox

Monkeypox

Monkeypox infections in the United States continue to undergo exponential growth. The CDC reported on August 5, 2022, that cases occur 99% of the time in men, 94% of whom reported recent male-to-male sexual or close intimate contact. The US has more than 7,500 cases, more than any other country in the world. Worldwide, there is a total of 28,220 cases in 88 countries.
 
Vaccines are in short supply, and changing the method of administration allowing for more doses to be administered per vial is under consideration.

Further, the monkeypox virus is related to smallpox, and there are more lethal variants in Africa. The bottom line is that if we continue to spread the virus, it may enter the rodent population becoming endemic, or even worse, mutate and become more lethal.

Credit to Our World in Data. OurWorldInData.org/coronavirus

SARS-CoV-2

New hospitalizations during the BA.5 variant wave appears to have peaked. Currently, BA.5 comprises 85.5% of isolates. However, a new variant, BA.4.6, has emerged and is defined by the CDC as a “variant of concern”. This variant appears to be outcompeting BA.5. It is not known if this variant has more of an immune escape potential than BA.5. Currently, BA.4.6 comprises 4.1% of isolates.
 
SARS-CoV-2 is at an unacceptably high level with almost 500 deaths per day. This level of disease and its associated long-term disability is not sustainable. It is estimated that 2.1% of the population in the United Kingdom has long COVID-19. The UK’s workforce shrank by 440,000. This decrease was attributed to the effects of long COVID-19. In the United States, it is estimated that 2.4% of the workforce is no longer working due to long COVID-19. New SARS-CoV-2 variants are emerging at almost an alarming rate, making it more difficult for therapeutics, including vaccines, to keep pace.

Return to Middle Ages?

The US is at substantial risk of having a reemergence of polio, the largest outbreak of monkeypox in the world and is enduring repeated surges of SARS-CoV-2 variants. Rapid and aggressive public health interventions are needed. If the resistance we have seen in attempting to stop SARS-CoV-2 becomes commonplace with other pathogens, we will be no better off dealing with disease than in the Middle Ages.
 
Ironically, if SARS-CoV-2’s public health interventions were widely adopted by the public, the large and expanding outbreak of monkeypox may not have taken place. Intimate contact with multiple strangers is not acceptable. It is apparent we cannot simply vaccinate our way back to normal. We must also encourage the public to adopt public health strategies, including the wearing of N95 masks, avoiding close contact with strangers, and improved indoor ventilation. Now, more than ever, infection preventionists are needed to do the work that needs done to turn this tide around.