Well, we have another one of these to talk about. With a new disease in the news, it’s an appropriate time to discuss monkeypox. I will detail what monkeypox is, how it compares to Covid-19, and what both diseases can tell us about the governmental and social response to disease outbreaks.
The Disease
Monkeypox virus is a species of virus in the same family as smallpox and cowpox. First seen in humans in 1970, the virus infects humans and several species of monkeys and rodents. The ability to infect other species makes monkeypox far harder to contain and manage, as even a largely vaccinated population will have trouble reaching herd immunity if unvaccinated individuals can become infected from animals. The virus can spread from animal to human via bites, scratches, eating infected meat, or contact with infected bodily fluids or surfaces contaminated with such fluids. The virus spreads between humans primarily through skin-to-skin contact or through infected surfaces and materials, such as shared bedding or utensils, putting the family and nurses of infected patients at higher risk. Airborne spread through respiratory droplets is also possible, though this too is limited to prolonged, face-to-face contact. Typically, symptoms take between 5 and 21 days to appear, starting with flu-like symptoms and swollen glands. Within a few days, lesions begin to appear on the face and limbs. These lesions disappear within ten days and symptoms abade within two to four weeks. Complications such as pneumonia, sepsis, or stillbirths may occur. Mortality rates can be as high as 10% without treatment, particularly for young or immunocompromised patients, but is nearly zero for healthy adults with proper treatment.
The majority of monkeypox cases occur in West Africa and the Congo Basin, where the virus is endemic due to the presence of reservoir species and a lack of sanitation and vaccine access. Previous cases of monkeypox in other parts of the world were in recent travelers from endemic regions, the healthcare providers of these infected travelers, or from infected animals imported from these endemic regions. The R0 of monkeypox has historically been less than 1, so these outbreaks didn’t make it more than one generation before dying out. This recent outbreak marks the first time there has been significant person-to-person spread of monkeypox outside of these endemic regions. The first recognized case outside of West Africa was in May of this year in London, and as of July there have been over 16,000 recognized cases worldwide. Also, the symptoms of this new strain of monkeypox are different from previous strains of the virus. Those infected with this strain are less likely to see fever-like symptoms but more likely to see lesions, particularly in the genital region. Whether this is because of differences in the virus or differences in how the virus spreads outside the original endemic regions (particularly as an STI) is still being researched. But this change in symptoms has meant that monkeypox has been more likely to be misdiagnosed, creating an obstacle for combating this epidemic.
The good news is that monkeypox isn’t nearly the cause for concern that Covid is. The new R0 of monkeypox is still being determined, but data suggests it is between 1.15 and 1.26, lower than that of most seasonal flu strains. Much of this transmissibility comes from the virus’ long incubation period, meaning a patient will have time to infect many people before realizing they are sick. But the fact that monkeypox is only spread through close contact (sex, kissing, shared food and utensils, touching the clothing or linens of an infected person) dampens the virus’ ability to become a severe epidemic like Covid-19. As I said before, there have been 16,000 recognized cases of monkeypox globally outside of the endemic regions. To put that in perspective, my home of Fairfax County, Virginia has seen more than 20,000 Covid-19 cases in the past two months. As of this entry’s publication, there have been only five confirmed deaths from monkeypox since the outbreak began, all of which were in the original endemic regions. Unless one has unprotected sex or shares a house with a monkeypox patient, they are highly unlikely to become infected themselves and one is almost guaranteed to recover.
Why this outbreak is happening right now is still being researched. One noteworthy thing about this specific strain is that it has over fifty mutations distinguishing it from its most recent ancestor (cataloged in 2018). Researchers are studying these mutations to determine if any of them have increased the transmissibility of the virus. But monkeypox is a type of virus that mutates far slower than other types of viruses, only one or two new mutations per year, so this is an astronomically high number of mutations to acquire in only a short time. One possible explanation being explored relates to how all of these new mutations are the same specific type of mutation, one that is linked to interactions with certain enzymes in the human immune system. Scientists have speculated that this might mean that these mutations are the result of an uptick in interactions between monkeypox and the human immune system, i.e., more people getting monkeypox. If this hypothesis is correct, it would mean that this increase in mutation rate is caused by an increase in infection rates, not the other way around. (That, or the mutation rate increases the transmissibility which increases the mutation rate in a vicious cycle) If this is true, this uptick in cases has been happening for years, spreading quietly within the endemic regions of West Africa and the Congo Basin before bursting onto the world stage when Covid quarantine measures ended. If this is the case, what caused the initial rise in cases is still to be determined.
Another possible explanation for this initial rise is linked to some of the best news about this outbreak. As I mentioned earlier, monkeypox is closely related to smallpox. This is not to say the two diseases are equally deadly; smallpox had an R0 of 3 and a mortality rate of 30%. But this relationship between the two viruses means that the smallpox vaccine is roughly 85% effective against monkeypox. The number of monkeypox infections in West Africa and the Congo Basin have risen 20-fold since the 1990s, and it’s been suggested that this is because the global vaccination rate against smallpox has dropped off since smallpox was eradicated in 1980. The drive to eradicate one of the worst diseases in human history meant a massive push to distribute vaccines in the developing world which would have also suppressed monkeypox, and the rise in cases since then could be because people born after 1980 typically aren’t vaccinated against smallpox. But this is all to say that we already have an effective vaccine against monkeypox and this vaccine is already being given to those who’ve potentially been exposed to it.
Lessons to be Remembered
While the process for dealing with monkeypox is straightforward in theory, it has so far proven to be challenging for some very familiar reasons. Monkeypox vaccines exist and are currently being manufactured, but distributing them has proven a challenge. The United States has over a million doses of smallpox vaccine in storage in case of bioterrorism, but these vaccines weren’t released to the public for almost two months due to delays with FDA inspections. These vaccines aren’t yet being distributed to everyone; just like with smallpox, a system called ring vaccination is being used. When one person tests positive for monkeypox, vaccines are distributed to everyone that person had contact with in order to stop the virus from spreading further. But even this is proving difficult due to a shortage of vaccines, and most clinics don’t have the resources to perform the contact tracing needed to track down potentially exposed people before they too become symptomatic. Testing has also been slow, with no non-laboratory tests currently existing and too few labs being contracted to run samples. Between this lack of testing and efficient contact tracing, the exact spread of the virus is currently unknown, with the exact number of cases possibly being far larger than what has been reported. And some scientists have pointed out that given that monkeypox was on the rise in the endemic regions in sub-Saharan Africa over the past decade, this outbreak should probably have been predicted.
I’m sure most of you have gleaned my point already; a pathogen made it to the United States where poorly-managed logistics allowed it to spread far more effectively than it should have. Testing availability has been insufficient, government agencies have been slow to communicate with each other, and too much onus has fallen on individual clinics and healthcare workers to deal with the crisis. These are not the only comparisons between this outbreak and the Covid-19 pandemic, which speak to some broader systemic problems. To be fair, many of these were problems of the early Covid-19 pandemic which were eventually ironed out as health agencies built up new protocols and routines. And again, monkeypox isn’t nearly as big a problem as Covid. But mistakes like this early in a disease outbreak can translate to the outbreak being worse overall, with the risk of monkeypox becoming endemic in other parts of the world being the worst-case scenario. Why such similar failures happened in two concurrent outbreaks needs to be studied and learned from.
Finally, there’s the topic of who is at the greatest risk. So far, the majority of monkeypox cases have been among gay or bisexual men, with many of the earliest cases being exclusively in this demographic. This has led to monkeypox being compared to HIV/AIDS, though this is not an apt comparison. The two viruses are in different viral realms, making them less closely related than humans are to bacteria.* Monkeypox does not cause a persistent infection, being cleared completely from the body after symptoms end. HIV spreads less easily than monkeypox, given it cannot survive outside of the human body and thus can only spread through direct fluid exchange. Why monkeypox is more common among men who have sex with men is currently unknown as there isn’t a known biological mechanism to explain this disparity. Further research is being done, but if you will forgive a brief tangent, the comparison between these two diseases necessitates we all remember a very important lesson of history.
The fact that HIV/AIDS was pigeonholed as a ‘gay disease’ (as well as a disease among drug users and the impoverished) made fighting it an uphill battle for the first few years of the epidemic. The Reagan Administration actively refused to fund HIV research while everyone from politicians to news media actively avoided discussing the epidemic. While the CDC recognized AIDS as a public health crisis in 1982, they only received the federal funding to combat it in 1985. By this time, there had been 13,000 confirmed deaths by AIDS in the United States alone. As I mentioned before, a slow response in the beginning of an outbreak can result in more cases overall. Exactly how many deaths could’ve been prevented by an additional three years of response is unknowable, but some estimates have placed this total in the millions. And despite the prejudices that caused these deaths, roughly a third of new HIV cases aren’t gay or bi men. While I won’t rant about the morality of these actions (though I could), I hope I’ve given insight into how this bigotry had significant practical implications as well, turning HIV/AIDS into a worse epidemic for everyone.
AIDS was a worst-case scenario for bigotry against an at-risk group worsening an epidemic response, but it’s far from the only case in history. Anti-asian discrimination was a significant problem during the height of the Covid-19 pandemic, and how this bigotry translated to policy decisions is still being debated. During the 1900 outbreak of bubonic plague in San Francisco, strict quarantines were enforced for Chinese immigrants, but not for whites. (PBS documentary if you wish to learn more) During the 1916 outbreak of polio in New York City, recent Polish and Italian immigrants were blamed for the outbreak and barred from leaving the city, even though polio had been present in the region for decades and wealthy people were actively leaving for Long Island. Almost every epidemic in history has been used to justify discrimination against common targets, usually recent immigrants who supposedly brought the disease and against the impoverished who tended to get sick first. Casting a disease as ‘foreign’ can be used to fearmonger against outsiders as well as to downplay the risk to insiders. And it usually leads to bad public health policies because no matter where a disease comes from or who is at the most risk, everyone is susceptible. The history of bigotry in public health crises is an old one and a topic far larger than this entry. Fortunately, the government response to monkeypox has not been like that of HIV, with the CDC deliberately tailoring its messaging to avoid stigmatizing monkeypox as a ‘gay disease’ while still keeping at-risk groups informed. The activism surrounding HIV/AIDS actually did lead to greater communication between epidemiologists and the communities they’re working to protect, hopefully preventing these kinds of policies in future outbreaks. At the very least, this is a lesson we appear to be learning.
Since I began writing this piece, the WHO has declared monkeypox to be a public health emergency due to its sudden and unexpected spread. This was apparently a very close decision, with the WHO’s director general being the tie-breaking vote for the first time in the agency’s history, but it does mean that more resources will be dedicated to testing and vaccinating vulnerable populations. The worst-case scenario for monkeypox is that it spreads enough to become an endemic disease in other regions, thus never going away completely. The likelihood of this happening is still being debated, with what sources I’ve found saying this probability is low, but still high enough to be worrisome. Ultimately, monkeypox is not the threat that Covid-19 was and still is. Numbers are still low and individual risk is extremely manageable. As with Covid, the best thing to do is to listen to health experts and keep abreast of the situation. Right now, it’s best to be alert, but not outright afraid.
For More Details
https://www.scientificamerican.com/article/what-we-know-about-the-rise-in-monkeypox-cases-worldwide/
* This is a very oversimplified statement as the relationships between different viral species is less straightforward than those between living cells. That said, HIV and monkeypox are very different on a biochemical level, so any similarities between them are largely coincidental.
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