Monkeypox is here, and it’s diffusion. The few dozen cases in a few countries that we were talking about last month there are now more than a thousand cases worldwide, including 35 reported in the United States. But the United States almost certainly has more cases than the statistics suggest, and there’s reason to suspect we’re already botching the outbreak response in ways that will feel uncomfortably familiar.
We don’t test enough
During the early months of the COVID pandemic, when we were lucky enough to contain the virus if only we could trace all cases and their contacts, testing was woefully inadequate. Many people infected with the virus have never been tested, and people who wanted a test could not always get one. The way we knew early on that the virus was spreading unnoticed was that there were cases in the United States that were unrelated to each other. The genetics of different groups in an outbreak may show that the virus must have spread undetected for some time.
That’s what’s starting to happen here :There are small clusters of monkeypox cases that are genetically different enough from each other that we know there must be far more than the 35 reported cases in the United States. So many cases must go unnoticed.
One reason for the undertest is that people with monkeypox may not realize they have it. Normally, monkeypox lesions are widespread throughout the body. In the current epidemic, it sometimes happens that a person only has lesions in one part of the body, or even that he has only one lesion. When this happens you don’t think, “Oh my god, it must be monkey pox”, you think, “huh, I wonder what this place is. And maybe you’ll see a doctor, or maybe you won’t.
Doctors also don’t necessarily look for monkeypox and might not recognize it at first. It’s not a common disease in the United States (or many other areas where it spreads) and the symptoms of this outbreak don’t always follow textbook sequence. Normally, you would expect a fever first, then a rash; but some of the known cases had the rash before the fever. Some people have lesions only in the anal or genital area, which may sound confusingly similar to STIs like herpes or syphilis. (Molecular microbiologist Joseph Osmundson collected an information sheet that includes photos of anal and genital monkeypox lesions here.)
So the first obstacle to testing is that there are not enough tests going on. Screening for monkeypox involves collecting secretions or crusts from lesions and sending them to one of a few specific laboratories. Former FDA Commissioner Scott Gottlieb tweeted that the current bottleneck is the lack of sampling.
But if awareness improves, we may soon encounter a bigger problem: laboratories test capacity. There is currently a network of 74 labs that can test for orthopoxviruses, and they can process around 7,000 tests per week. Monkeypox is the only orthopoxvirus of concern at the moment, as smallpox has been eradicated and other viruses in the family, such as cowpox, are rare. If a sample is positive for orthopoxvirus, the CDC will perform additional testing to confirm that it is indeed monkeypox.
People with monkeypox (or an orthopoxvirus suspected of being monkeypox) are supposed to self-isolate for 21 days, and in the meantime, health authorities will contact-trace and offer vaccines to the affected person and their close contacts. There are also antivirals that can be helpful. But the vaccine brings another problem.
We have a vaccine, but we don’t know if it works well
The good news about the vaccine is that we already have one. More than one, in fact: Svaccination against malvola dates back to hundreds of years, with several modern vaccines still available. (Smallpox was declared eradicated from the world in 1980, the only human virus to have that honor.) People can sometimes have life-threatening reactions to some of the older smallpox vaccines, so those – those using a live virus – don’t are not taken into account. for monkeypox.
In the United States, there is a licensed vaccine for use against monkeypox. It is known as MVA (for Modified Vaccinia Ankara) and its brand name here is Jynneos. It does not replicate in humans, but it still triggers an immune response against smallpox. According to a 1988 study, vaccination is 85% effective against transmission of monkeypox, but this was a small study and we don’t know if this is the efficiency we can expect of the current vaccine and the current strain of monkeypox.
We also don’t know if we’ll have enough. The US National Strategic Stock says they have 36,000 doses and ordered 36,000 more. The company that makes the vaccine also has a lot of recent orders from other countries, for obvious reasons, and they plan to ship small batches to the different countries so that everyone can start vaccinating quickly.
That’s not enough vaccine to start vaccinating everyone, so the current strategy is “ring vaccination,” in which the vaccine is offered to people who were close contacts of someone known to have monkeypox. (The monkeypox vaccine can also be given to the person with monkeypox, as it can reduce the severity of the disease if caught early enough.) But contact tracing isn’t perfect and, in many recent cases, people had no names or contact details. for all their loved ones. Another possible strategy would be to offer the vaccine to all members of high-risk groups, which currently include men who have sex with men. So far, this strategy has only been tested in Canada.
People already misunderstand how it’s transmitted
Many of the recent cases involve men who have sex with men. This has led some people to assume that it is transmitted sexually, like HIV or other STIs; I’ve seen posts on social media before from people misunderstanding this and saying you can only get monkeypox by having sex with someone who has it.
Knowing that a virus is sexually transmitted is helpful in knowing if sexual transmission is the primary way the virus spreads, as with HIV. But we do know that monkeypox can be spread through close contact of any kind, including contact with an infected person’s lesions or their respiratory droplets (like a cough or sneeze) and possibly even with aerosols.
And on that note: TThe CDC briefly issued a recommendation that travelers wear masks to avoid catching monkeypox, then withdrew this recommendation saying it “caused confusion”. Can monkeypox be airborne? Maybe! But if you’re worried about catching a virus while traveling, you should still wear a mask. We already know that masks (especially tight-fitting N95-style masks) are effective in protecting us from COVID, and COVID cases are on the rise again, not that they’ve ever gone away. So, yes, wear a mask. But also be on the lookout for monkeypox symptoms and don’t be afraid to seek testing or vaccination if you think you have monkeypox or have been exposed.