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Monkeypox is here and it is Distribution. The few dozen cases in a few countries that We told you about last month are now up to over a thousand cases worldwide, with 35 reported in the United States. But the US almost certainly has more cases than the statistics suggest, and there’s reason to believe we’re already screwing up the epidemic response in ways that will feel uncomfortably familiar.
We don’t test enough
In the early months of the COVID pandemic, when we had the ability to contain the virus if only we could locate all cases and their contacts, testing was woefully inadequate. Many people who have had the virus have never been tested for it, and people who wanted a test couldn’t always get one. We initially knew that the virus was spreading unnoticed because there were unrelated cases in the USA. The genetics of different outbreak clusters can show that the virus must have been spreading undetected for a period of time.
That starts happening here :THere are small clusters of monkeypox cases that are so genetically diverse that we know there must be far more than the 35 reported US cases. Many cases must therefore remain undiscovered.
One reason for inadequate testing is that people who have monkeypox may not realize they have it. Usually, monkeypox lesions are widespread throughout the body. In the current outbreak, a person may have lesions in only one part of the body, or even a single lesion. When that happens, don’t you think “Oh my god, that must be monkeypox,” you think “Huh, I wonder what that job is.” And you may or may not see a doctor.
Doctors also don’t necessarily look for monkeypox and may not recognize it at first. It’s not a common disease in the US (or many other areas where it spreads), and symptoms in this outbreak don’t always follow textbook sequence. Normally one expects fever first and then the rash; but some of the known cases erupted before the fever. Some people only have the lesions in the anal or genital areas, which can look confusingly similar to STIs like herpes or syphilis. (Molecular microbiologist Joseph Osmundson has compiled a fact sheet with photos of monkeypox lesions in the anal and genital areas here.)
So the first obstacle to testing is not doing enough testing at all. Testing for monkeypox involves collecting secretions or scabs from the 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 as awareness improves, we may soon encounter a bigger problem: test capacity. There is currently a network of 74 labs that can perform an orthopoxvirus test and they can process an estimated 7,000 tests per week. Monkeypox is currently the only orthopoxvirus of concern because smallpox has been eradicated and other viruses in the family, such as cowpox, are rare. If a sample tests positive for orthopoxvirus, the CDC performs further testing to confirm it is monkeypox.
People with monkeypox (or orthopoxvirus suspected to be monkeypox) are told to isolate for 21 days, and meanwhile Health authorities will trace contacts and offer vaccinations to the affected person and their close contacts. There are also antivirals that may be helpful. But the vaccine brings with it another problem.
We have a vaccine but we don’t know how well it works
The good news about the vaccine is that we already have one. Actually more than one :SVaccination against smallpox is on the decline hundreds of years, when some modern vaccines still exist. (Smallpox was declared globally eradicated in 1980, the only human virus to have had that honor.) Humans could occasionally have fatal reactions to some of the older smallpox vaccines, so those — those using live viruses — aren’t considered for monkey pox.
There is a vaccine approved for use against monkeypox in the United States. It is known as MVA (for Modified Vaccinia Ankara) and its brand name here is Jynneos. It does not replicate in humans, but nevertheless elicits an immune response against smallpox. According to a 1988 study, the vaccine is 85% effective against transmission of monkeypox — but that was a small study and we don’t know if that’s the effectiveness we can expect from the current vaccine and the current strain of monkeypox.
We don’t know if we’ll have enough of it either. The US Strategic National Stockpile says they have 36,000 cans and have ordered another 36,000. The company that makes the vaccine also has many new orders from other countries, for obvious reasons, and plans to ship small batches to the different countries so everyone can start vaccinating quickly.
That’s not enough vaccine to start vaccinating everyone, so the current strategy is “ring vaccination,” where the vaccine is offered to people who have had close contacts with a person known to have monkeypox is. (Monkeypox vaccine can also be given to the person with monkeypox because it can reduce the severity of the disease if caught early enough.) However, contact tracing is not perfect, and in many recent cases people did not have names or contact information for all of their close contacts. Another possible strategy would be to offer the vaccine to everyone in risk groups, which currently includes men who have sex with men. So far, this strategy is only being tested in Canada.
People already misunderstand how it is transmitted
Many of the recent cases have involved men who have had sex with men. This has led some people to assume it is sexually transmitted, like HIV or other STIs; I’ve seen social media posts from people who misunderstood this and said the only way to get monkeypox is to have sex with someone who has it.
Knowing that a virus is transmitted sexually is helpful in knowing if sexual transmission is the main way the virus spreads, as with HIV. But we do know that monkeypox can spread through close contact of any kind, including contact with an infected person’s lesions or with their respiratory droplets (such as from coughing or sneezing), and possibly even with aerosols.
And on that note: TThe CDC briefly issued a recommendation that travelers should wear masks to avoid monkeypox, and then accepted this recommendation said it “caused confusion”. Can monkeypox be airborne? Maybe! But if you’re worried about catching a virus while travelling, you should wear a mask anyway. We already know that masks (especially well-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 watch out for monkeypox symptoms and don’t be afraid to ask for a test or vaccine if you think you have or have been exposed to monkeypox.
