[A new viral outbreak is testing whether the world has learned
anything from COVID.] [[link removed]]

SO, HAVE YOU HEARD ABOUT MONKEYPOX?  
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Ed Yong
May 19, 2022
The Atlantic
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_ A new viral outbreak is testing whether the world has learned
anything from COVID. _

, The Atlantic

 

Yesterday afternoon, I called the UCLA epidemiologist Anne Rimoin to
ask about the European outbreak of monkeypox—a rare but potentially
severe viral illness with dozens of confirmed or suspected cases in
the United Kingdom, Spain, and Portugal
[[link removed]].
“If we see those clusters, given the amount of travel between the
United States and Europe, I wouldn’t be surprised to see cases
here,” Rimoin, who studies the disease, told me. Ten minutes later,
she stopped mid-sentence to say that a colleague had just texted her a
press release: “Massachusetts Public Health Officials Confirm Case
of Monkeypox.
[[link removed]]”

The virus behind monkeypox is a close relative of the one that caused
smallpox but is less deadly and less transmissible, causing symptoms
that include fever and a rash. Endemic to western and central Africa,
it was first discovered in laboratory monkeys in 1958—hence the
name—but the wild animals that harbor the virus are probably
rodents. The virus occasionally spills over into humans, and such
infections have become more common in recent decades
[[link removed]]. Rarely, monkeypox
makes it to other continents, and when it does, outbreaks “are so
small, they’re measured in single digits,” Thomas Inglesby, the
director of the Johns Hopkins Center for Health Security, told me.
The only significant American outbreak
[[link removed]] occurred in
2003, when a shipment of Ghanaian rodents spread the virus to prairie
dogs in Illinois, which were sold as pets and infected up to 47
people, none fatally. Just last year, two travelers independently
carried the virus to the U.S. from Nigeria
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infected no one else.

The current outbreaks in Europe and the U.S. are different and very
concerning. The first case, which was identified in the United
Kingdom on May 7
[[link removed]],
fit the traditional pattern: The individual had recently traveled to
Nigeria. But several others hadn’t recently been to endemic
countries, and some had had no obvious contact with people known to be
infected. This suggests that the monkeypox virus may be
surreptitiously spreading from person to person, with some number of
undetected cases. (The incubation period between infection and
symptoms is long, ranging from five to 21 days
[[link removed]].)
“It’s uncommon to see this number of cases in four countries at
the same time,” Inglesby said. (The count is now 11: Since we spoke
on Wednesday, monkeypox has also been confirmed in Sweden, Italy,
Germany, Belgium, France, Canada, and Australia.)

These monkeypox outbreaks are also unique because … well …
they’re occurring in the third year of a pandemic_, _“when the
public is primed to be more acutely aware of outbreaks,” Boghuma
Kabisen Titanji, a physician at Emory University, told me. “I
don’t think that’s necessarily a good thing.” When it comes to
epidemics, people tend to fight the last war. During the West African
Ebola outbreak of 2014, American experts had to quell waves of undue
paranoia
[[link removed]],
which likely contributed to the initial downplaying of
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coronavirus. Now, because the U.S. catastrophically underestimated
COVID, many Americans are panicking about monkeypox and reflexively
distrusting any reassuring official statements. “I don’t think
people should be freaking out at this stage,” Carl Bergstrom of the
University of Washington told me, “but I don’t trust my own gut
feelings anymore, because I’m so sick of all this shit that I tend
to be optimistic.”

Monkeypox, then, is a test of the lessons that the world has (or
hasn’t) learned from COVID. Can we better thread the needle between
panic and laxity, or will we once again eschew uncertainty in a
frantic quest for answers that later prove to be wrong?

To be clear, monkeypox isn’t COVID—they’re different diseases
caused by different viruses with markedly different properties. COVID
was completely unfamiliar when it first appeared, but monkeypox is a
known quantity, and experts on the virus actually exist. One of them,
Andrea McCollum of the CDC, told me that based on existing studies,
monkeypox doesn’t spread easily, and not over long distances through
the air. It transmits via contaminated surfaces or prolonged proximity
with other people, which is why most outbreaks have been small, and
why people have mostly transmitted the disease to either household
members or health-care workers. “This isn’t a virus that, as far
as we’re aware, would really take off in a population like COVID,”
she said. “It really requires close contact for human-to-human
transmission.”

Of course, we have heard that before. In early 2020
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many experts claimed that COVID spread only via contaminated surfaces
or close-splashing droplets—hence the six-feet rules and hygiene
theater. Now it is widely accepted that the disease spreads
through smaller and farther-reaching aerosol particles
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the importance of ventilation and masks. But that doesn’t mean
history is repeating with monkeypox. A 2012 study
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that the virus can persist in aerosols for several days—but that was
under artificial laboratory conditions, and persistence is just one
small part of the infection process.  Chad Roy, an aerobiologist at
Tulane University School of Medicine who led that study, told me that
compared to the SARS-CoV-2 coronavirus, monkeypox is "an altogether
different virus and the risk of natural transmission by aerosol far
less likely.” And the fact remains that past monkeypox outbreaks
have been inconsistent with a virus that travels as easily as the
coronavirus. “Monkeypox does not scream ‘airborne’ at me;
COVID-19 did,” Linsey Marr, an aerosol expert at Virginia Tech, told
me.

Then again, Marr is less certain about monkeypox than she was about
COVID. And Titanji notes that our knowledge of monkeypox is based on
just 1,500 or so recorded cases
[[link removed]], as of 2018.
“I’ve seen a lot of people writing as if everything we know about
monkeypox is definitive and finalized, but the reality is that it is
still a rare zoonotic infection,” she said. For that reason,
“I’m in Team Cautious,” she said. “We can’t use what
happened with previous monkeypox outbreaks to make sweeping
statements. If we’ve learned anything from COVID, it’s to have
humility.”

For decades, a few scientists have voiced concerns that the monkeypox
virus could have become better at infecting people—ironically
because we eradicated its relative, smallpox, in the late 1970s. The
smallpox vaccine incidentally protected against monkeypox. And when
new generations were born into a world without either smallpox or
smallpox-vaccination campaigns, they grew up vulnerable to monkeypox.
In the Democratic Republic of Congo, this dwindling immunity meant
that monkeypox infections increased 20-fold
[[link removed]] in the three
decades after smallpox vanished, as Rimoin showed in 2010. That gives
the virus more chances to evolve into a more transmissible pathogen in
humans. To date, its R0—the average number of people who catch the
disease from one infected person—has been less than 1, which means
that outbreaks naturally peter out. But it could eventually evolve
above that threshold, and cause more protracted epidemics, as
Bergstrom simulated in 2003
[[link removed]]. “We saw
monkeypox as a ticking time bomb,” he told me.

This possibility casts a cloud of uncertainty over the current unusual
outbreaks, which everyone I spoke with is concerned about. Are they
the work of a new and more transmissible strain of monkeypox? Or are
they simply the result of people traveling more after global COVID
restrictions were lifted? Or could they be due to something else
entirely? So far, the cases are more numerous than a normal monkeypox
outbreak, but not so numerous as to suggest a radically different
virus, Inglesby told me. But he also doesn’t have a clear
explanation for the outbreak’s unusual patterns—nor does anyone
else.

Answers should come quickly, though. Within days, scientists should
have sequenced the viruses from the current outbreaks, which will show
whether they harbor mutations that might have changed their
properties. Within weeks, European epidemiologists should have a
clearer idea of how the existing cases began, and whether there are
connections between them. As for the U.S., McCollum told me that she
is standing by for more cases. The day after we spoke, another
suspected case was announced—a patient being cared for at Bellevue
Hospital in New York City
[[link removed]].

The U.S. is, of course, in a better position with monkeypox than with
COVID. Although the nation hadn’t planned for a coronavirus
pandemic
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it has spent decades thinking about how to handle smallpox
bioterrorism. The two cases of monkeypox in 2021 provided handy test
runs for those plans, which are now unfolding smoothly. For example,
the case in Massachusetts was identified when the patient’s
physician, having reviewed reports from the U.K., called the state’s
public-health department on Tuesday. Within 12 hours, the department
had collected and tested the patient’s samples. The next day, more
samples arrived at the CDC, which confirmed monkeypox. “All of that
worked really well,” McCollum said. “We’re a fairly well-oiled
machine.”

Also, there’s already a vaccine. One smallpox vaccine
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85 percent effective at preventing monkeypox and has already been
licensed for use against the virus. And as another bioterrorism
precaution, stockpiles of three smallpox vaccines are large enough
“to vaccinate basically everyone in the U.S.” Inglesby said. And
though monkeypox patients usually get just supportive care, a possible
treatment does exist and has also been stockpiled: Tecovirimat, or
TPOXX
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was developed to treat smallpox but would likely work for monkeypox
too.

Monkeypox may also be less deadly than is frequently claimed. The
oft-cited fatality rate of about 10 percent applies to a strain that
infected people in the Congo Basin. The West African strain, which
several of the current cases have been linked to, has a fatality rate
closer to 1 percent—and that’s in poor, rural populations. “We
haven’t seen fatalities in people who’ve had monkeypox in
high-resource settings,” Rimoin said.

Still, as COVID has shown, even when a disease doesn’t kill you, it
can hardly count as “mild.” Monkeypox might not take off in the
way that COVID did, but for those who get it, it remains a
“substantial illness,” McCollum said. “If individuals are sick,
they’re often sick for two to four weeks. It’s urgent to identify
people early, get them treatment, and identify contacts.” It helps
that one common symptom is an obvious rash, which looks like an
extreme version of chickenpox. But unlike chickenpox, the monkeypox
rash is usually preceded by a fever, the lesions are initially more
painful than itchy, and the lymph nodes are often inflamed. “The
constructive thing to do is to make sure that the public is aware of
what monkeypox looks like,” Titanji said.

For that reason, she added, it’s important to avoid stigmatizing
infected people. Many of the current cases are in men who identify as
gay, bisexual, or men who have sex with men—an unusual pattern not
seen in previous monkeypox outbreaks. That has raised questions about
a new route of transmission, but sex obviously involves prolonged
close contact, which is how the virus _normally _spreads. As COVID
showed, early narratives about a disease
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prematurely harden into accepted lore. And if those narratives turn
into stigma, they could stop people from coming forward with symptoms.

Communication might prove to be one of monkeypox’s hardest
challenges, as it has been with COVID. “We need leaders who are
saying, ‘Here’s what we know; here’s what we don’t know;
we’ll find out; and we’ll be back tomorrow,’” Inglesby said.
But some leaders have lost credibility during the recent pandemic,
while others are being drowned out by armchair experts who have
amassed large followings. “All of a sudden, everyone’s an expert
in monkeypox,” Titanji said.

_Ed Yong [[link removed]] is a staff
writer at The Atlantic. He won the Pulitzer Prize for Explanatory
Reporting for his coverage of the COVID-19 pandemic._

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