https://orcid.org/0000-0002-6263-0812
Human monkeypox (MPX) is a zoonotic disease that was endemic to remote regions of central and western Africa (e.g. the Democratic Republic of Congo (DRC) and Nigeria). It is caused by a double-strand DNA virus, which is an Orthopoxvirus of the Poxviridae family, that causes a similar disease to the other Orthopoxviruses, in particular smallpox, although less severe. Two clades of this virus exist, the West African and Central African ones, both causing a similar clinical syndrome but with different degrees of severity, with the Central African variant being associated with up to three times higher mortality.1
Since May 2022, thousands of cases of MPX were identified in multiple non-endemic countries, mainly in a community of men who have sex with men (MSM), although not all of them are, causing the largest outbreak of MPX ever reported outside of Africa.1 The sudden increase in the number of cases with changes in its transmission modes lead the World Health Organization (WHO) Director-General to declare the disease a public health emergency of international concern (PHEIC) on 23 July 2022.2 As of 1 September 2022, a total of 51 163 laboratory confirmed cases and 302 probable cases, including 17 deaths, have been reported to WHO.3
Mass gatherings (MGs) whether religious or sport related are impacted by PHEIC. We have seen the impact of prior PHEIC like influenza A H1N1 in 2009 and the more recent coronavirus disease 2019 (COVID-19). It took two and half years for the world to get over COVID-19 pandemic restrictions with the largest MG event taking place in Makkah this year with 1 million attendees. Sports events such as the Olympics were postponed for a year due to COVID-19. Now Federation Internationale de Football Association (FIFA) world cup 2022 is at the doorsteps of Qatar, which is one of the six Gulf Cooperation Council (GCC) states. Sports events are an appropriate place for the transmission of infectious diseases due to close contact and the high density of people occupying limited space.4 The FIFA world cup 2022 is an important mega-sporting event that will be held in Qatar by the end of 2022. Qatar expects to receive 1.7 million travellers or visitors during this event.4 Up to 1 September 2022, Qatar has reported three MPX confirmed cases.3 Although neighbouring GCC states like Saudi Arabia (n = 8) and United Arab Emirates (n = 16) have reported multiple cases among visitors and returning travellers from Europe.3 No cases of MPX were reported among pilgrims performing the Hajj in July this year.
However, the FIFA world cup 2022 may be a more likely venue for the potential spread of MPX since sports events attract younger people who are there to have fun with significant social gatherings indoors in a closed environment with excessive alcohol intake and frequent sexually transmitted infections (STI) being reported in previous events.5,6 Although it is established now that MPX virus spread through close contact with contaminated materials (i.e. fomites), respiratory droplets, infected skin lesions and bodily fluids.1 Recent data on MPX modes of transmission are alarming where it was shown that infection-competent MPX appears to be present in aerosols, suspended skin particles and dust, highlighting noncontact contamination in closed environments occupied by infected patients.7
With COVID-19, the concerted efforts of the global public health community were successful in producing multiple effective and safe vaccines within 12 months. The mass vaccination campaign was pivotal in the control of COVID-19 spread and a significant reduction in morbidity and mortality of the disease. For this year’s Hajj, it was a compulsory requirement to have two doses of the COVID-19 vaccine to be able to perform the Hajj.
Ring vaccination to close contacts of monkeypox-confirmed cases.
For MPX virus, due to the cross-protection (85%) between monkeypox and smallpox, two US Food and Drug Administration (FDA)-approved smallpox vaccines (ACAM2000 and JYNNEOS™) are available in limited quantities and can be used against MPX. ACAM2000 is a live-replicating vaccina virus, whereas JYNNEOS™ is a live non-replicating virus. JYNNEOS™ is preferred over ACAM2000 due to fewer side effects (i.e. No ‘take’ lesion), preventing the transmission risk to others.8
Because of the limited supply of the MPX virus vaccine, it will be impossible to apply the vaccine mandate to all FIFA cup attendees this year. An alternative strategy called ring vaccination is being proposed.9 Ring vaccination, which is vaccination of close contacts to MPX confirmed cases (Figure 1), is an appropriate approach in the context and setting of FIFA world cup 2022 due to its effectiveness in small populations and isolated communities, possible implantation in case of limited availability of vaccines and medical personnel, ability to lower the risk of MPX virus spread and finally cost-effectiveness, which means a low number of vaccines can complete the ring.9 More importantly, due to the MPX slow transmission and long incubation period,10 ring vaccination is appropriate for early containment of potential MPX spread. It can break the MPX transmission chain and prevent the MPX progression at the same time.9 Primary contacts are those in close contact with the MPX confirmed cases, whereas secondary contacts are in close contact with the primary contact, not the MPX confirmed cases. Once identified, confirmed cases and primary close contacts should be vaccinated.9 However, some obstacles should be addressed to get the maximum efficacy of ring vaccination. Since this approach depends mainly on contact tracing and multiple tests,9 Qatar, FIFA and WHO should use this event to raise public awareness regarding attenuating or even preventing stigmatization against MSM because MPX can be transmitted sexually through them.10 As a result, visitors should not feel reluctant to seek diagnosis or care for fear of being judged or discriminated. Qatar also should ensure its readiness regarding providing the needed logistics such as screening facilities, vaccines and personal protective equipment. It should also provide PrEP to clinical laboratory personnel, research laboratory workers and healthcare workers, engaged with MPX-infected cases. Furthermore, the FIFA world cup represents a good opportunity to enhance the trust in vaccination and prevent vaccine hesitancy not only for the visitors but also for several populations around the world since available vaccines can lead to serious side effects in rare settings.10
The centres for disease control and prevention (CDC) endorses PrEP to get full protection against MPX. In addition, in case of exposure to confirmed cases, CDC suggests vaccination during 4 days after exposure to prevent MPX incidence. However, vaccination can reduce the MPX progression but may not prevent its incidence if the period becomes 4–14 days after exposure. In this regard, travellers, or visitors to the FIFA world cup 2022 from all over the world also have duties. They should be certain about getting PrEP either in their countries before travelling or in Qatar. Also, people without PrEP should seek vaccination as soon as possible after close contact with infected cases. They should also commit to preventive measures such as avoiding close contact with confirmed cases or vaccinees with ACAM2000 during the 28-day vaccination period.
Finally, cooperation between WHO, FIFA and Qatari authorities should be established and prioritized regarding reporting confirmed cases and following appropriate measures.
Since May 2022, cases of monkeypox have been reported to WHO in an alarmingly increasing fashion with 98.2% (26 608/27 093) of cases are among males who have sex with men (defined as homosexual or bisexual males) networks with median age of 36 years. Of all settings in which cases were likely exposed, the most common was in party setting with sexual contacts. FIFA world cup and the Olympic and the Paralympic games attract young athlete participants, and spectators from around the globe. Previous major sport events were independently associated with a significant increase in alcohol-related emergency room visits and STIs. High vigilance and preparedness for prevention of MPX during the FIFA in Qatar is critical and the availability of enough therapeutics and vaccine supply is paramount.
Funding
No sources of funding were used to assist in the preparation of this article.
Authors’ contributions
RAF was involved in acquisition of information, drafted the article and final approval of the version to be submitted. RAF and ZAM took the responsibility of the conception and design of the study, revising it critically for important intellectual content and final approval of the version to be submitted. RAF, MYE and ZAM were involved in interpretation of data, and revising it critically for important intellectual content. All the authors gave final approval of the version to be submitted.
Conflict of interest
The authors have declared no conflicts of interest.
Patient consent for publication
Not applicable.
Ethics approval
This study does not involve human participants.
