Monkeypox in Pakistan: challenges and recommendations

According to the World Health Organization (WHO), a country should spend a minimum of 5% of its budget on health care. Pakistan, being a low middle-income country, spent only 1.2% of its GDP on health in 2021. This neglect by the government might bring the nation’s health system to its knees if it is faced with an epidemiological emergency of monkeypox1. Pakistan is one of the 2 countries in the world that have not yet eradicated polio. For years, Pakistan has dealt with a range of infectious disease outbreaks such as hepatitis and typhoid, and the repercussions of the COVID-19 outbreak still have not been completely addressed. The introduction of another infectious disease will severely deplete the limited resources and supplies that Pakistan currently possesses, which may steer away valuable medical supplies and attention that other diseases, such as tuberculosis, desperately require1. Another major challenge is the responsiveness of the health care system. Years of underfunding and neglect of the monetary needs of the health care sector have resulted in weak responsiveness to outbreaks, as depicted by the presence of limited surveillance systems for current rampant diseases. It can be keenly inferred that if monkeypox were to become a health hazard in Pakistan, timely responsiveness cannot be expected, which would lead to increased incidence and prevalence of monkeypox, potentially leading to more lethal consequences due to lack of adequate and timely treatment1. In Pakistan, like any other major communicable disease, there is limited or no awareness of symptoms, transmission, and prevention of monkeypox. This could lead to delays in diagnosis and treatment. Furthermore, misunderstandings about the disease could fuel stigma and discrimination2. According to WHO guidelines, a confirmed diagnosis of monkeypox is based on polymerase chain reaction. Although the most eminent laboratories are equipped with polymerase chain reaction machines, they lack the testing kits required. Diagnosing monkeypox on symptoms alone is not a reliable approach as its symptoms are very much similar to chicken pox, measles, rubella, dengue, and other infectious diseases which can lead it to be misdiagnosed. To prevent the spread of disease, it is important that the Government of Pakistan urgently procures the required testing kits, primers, and reagents to combat a possible viral epidemic2. Currently, there is no specific vaccine available for monkeypox. Since monkeypox and smallpox belong to the same viral genus, it has been stipulated that the smallpox vaccine can be effective against monkeypox2. According to a recent study, properly administered prior vaccination against smallpox has around 85% efficacy in preventing monkeypox. However, these approved vaccines are not widely available in Pakistan, and there are concerns about its safety in individuals with weakened immune systems3. Monkeypox is a zoonotic disease. The close proximity between humans and animals and the lack of hygiene and poor sanitation practices, particularly in rural areas could exacerbate the spread of infection. Fortunately, Pakistan’s health minister has notified all provincial and national health authorities to be on alert for any suspected cases and screening has also been launched at every border for people incoming from abroad, especially regions of Africa4. According to recent reports, 4 overall cases have been reported in Pakistan up to May 4, 20235. Cessation of the smallpox vaccine has reduced the immunity to monkeypox. In lieu of a limited global supply of monkeypox vaccines and the hesitancy of Pakistanis, a ring vaccination approach can be implemented, which consists of vaccinating only those in close contact with the infected people2. In addition, monkeypox can be prevented more effectively by increasing awareness among the locals and health care workers, particularly in recognizing the signs and symptoms of the disease, rather than just targeting symptomatic management with the need of hospitals especially being well equipped with isolation units6. Furthermore, strict surveillance measures and prompt contact tracing must be established to promptly record any new cases or properly manage a viral outbreak2. Ethical approval None. Sources of funding None. Author contribution All authors equally contributed. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Abdullah Malikzai. Consent for publication All authors agreed to the publication of this manuscript.