Old Disease. New Outbreak: Racing the Monkeypox Outbreak

It’s a zoonotic disease: a viral infection that is primarily transmitted from animals to humans. Its catchy name isn’t due to monkeys being the primary vector for human infections, but rather because it was first identified in lab monkeys in Denmark enlisted for polio vaccine research. The first human cases weren’t identified until 1970 in the Democratic Republic of the Congo — nine months after the country eliminated smallpox.

The disease has a typical incubation period of six to 13 days, after which it can cause flu-like symptoms, such as fever, headache, chills, exhaustion, lymph node swelling, back pain and muscle aches. Within three days of the onset of these symptoms, patients could witness the spread of pox-like lesions lasting 2-3 weeks. Among the two major strains, or clades, of the virus, the Congo Basin variant has the most severe symptoms and a mortality rate of between 5% and 10%. Outbreaks of the West African clade, the one responsible for all of the current cases outside Africa, have a lower mortality rate — 3.6% — with most deaths occurring in immunocompromised individuals.

And while COVID-19 has defined many people’s understanding of outbreaks, monkeypox is vastly different and less dangerous, notes Dr. Robert Murphy, the executive director of Northwestern University’s Robert J. Havey, MD Institute for Global Health. Monkeypox traditionally spreads by direct contact with infectious lesions or infected material (such as blankets used by someone with monkeypox). It can also spread via respiratory droplets, but only through prolonged or intimate exposure.

Human encroachment on wildlife habitat in West Africa has likely contributed to the rise in zoonotic diseases, says Dr. Wafaa El-Sadr, founder and director of Columbia University’s ICAP global health center. Compounding that is the rise in human population density and a decrease in smallpox immunizations — which are estimated to be around 85% effective in preventing or reducing the severity of monkeypox cases — ever since smallpox was eradicated in the ‘80s. This may have contributed to the dramatic rise in monkeypox cases in the Congo and Nigeria.

There have also been fundamental changes in the virus itself. Whereas previously monkeypox was largely typified by transmission from animals to humans, the current outbreaks, says Murphy, seem to be the result of person-to-person transmission. And should the current outbreak cause enough human-to-animal transmission, there is the potential for the formation of a new animal reservoir in the U.S. and Europe.

This outbreak may have been longer in the making than previously thought. Originally, the current outbreak’s patient zero was thought to be a Nigerian traveler to the U.K. However, ongoing genomic analysis of cases in multiple countries has shown an exceedingly high mutation rate. So high, in fact, it suggests that there may have been undetected person-to-person monkeypox transmission in the U.S. since around 2018. However, with the monkeypox genome being nearly seven times longer than COVID-19’s, unearthing what larger effects these mutations could have remains difficult.

Months after the initial COVID-19 outbreak, notes Murphy, the world was still fumbling to implement tests for the infection. In contrast, he says, the U.S. Centers for Disease Control and Prevention (CDC) have authorized five commercial laboratories to conduct monkeypox testing within six weeks of the first case identified in the current outbreak. That expansion will enable the processing of tens of thousands of additional tests a week. Healthcare providers have also been authorized to submit specimens directly to the labs, without first consulting state officials.

Jynneos, a relatively new smallpox-monkeypox vaccine, which El-Sadr says is easier to administer and boasts fewer complications for immunocompromised patients, has become central to the ongoing fight. The U.K., U.S., Canada and several other countries have begun “ring vaccination,” a strategy of inoculating those exposed to confirmed monkeypox cases — since the shots can still lessen the severity of the disease if given within 14 days of initial exposure. The Biden administration has arranged for 300,000 additional doses to be delivered by Jynneos’ manufacturer, has another 500,000 doses on order for later this year, and just paid $119 million for an extra 13 million freeze-dried doses to be delivered in 2023 and 2024.

But many experts are concerned that the rapid spread of monkeypox is outpacing ring vaccination. Additionally, there is legitimate concern over the efficacy of vaccine options. Smallpox vaccines are, first and foremost, smallpox vaccines. The oft-touted 85% prevention estimate is largely based on older data and animal studies. Nevertheless, vaccination remains the best option for combatting this outbreak. Actual treatments are supportive, addressing the symptoms of the infection, says El-Sadr. In the U.S., there are a few antivirals approved for use in Monkeypox cases. However, their efficacy is largely unknown, and their use will likely be reserved for cases where a patient is particularly at risk for a bad outcome — such as immunocompromised patients. And while testing capacity has increased dramatically, there has been no real centralized push for mass testing.

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The gay community, specifically men who have sex with men (MSM), has had disproportionately high rates of infection during the current outbreak — putting outreach and health initiatives in a tough spot. “Viruses don’t discriminate,” says El-Sadr. By all accounts, the fact that the first few cases during this outbreak were among gay patients explains why the MSM community is particularly vulnerable. From there, it has largely circulated within networks of sexually active MSM adults. This has allowed the current monkeypox outbreak, in such cases, to essentially spread as an STI in areas where many sexual healthcare providers may not be aware of the disease, its symptoms or how to approach it.

Many healthcare officials worry that the outbreak’s association with the MSM community, the unfamiliarity many (even in a healthcare setting) may have with the disease, and the general shame around STIs could lead to a stigmatic perception of a “gay disease.” El-Sadr agrees, noting the need to be careful not to paint monkeypox as an issue only for the gay community. Echoing the 1980’s stigma towards HIV/AIDS would only suppress efforts to have people get tested and vaccinated.

Many LGBTQ advocacy orgnaizations are promoting monkeypox awareness and sexual health during Pride Month. Even the Grindr app has issued alerts about the ongoing outbreak. Nevertheless, only time will tell whether Pride Month events, especially after two pent-up years, will have served as a springboard for education and caution — or a catalyst for new cases. Monkeypox may not be COVID-19, but it will still require vaccine strategy and outreach — and test the world on the lessons it has learned from the pandemic.

How do you think outreach and education efforts should be handled to prevent attaching a stigma to monkeypox?

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