Photo: Pablo Blasquez Dominguez (Getty Images)
Monkeypox is here and spreading. The dozens of cases in several countries we told you about last month are already over a thousand worldwide, with 35 reported in the United States. But the United States almost certainly has more cases than statistics suggest, and there is reason to suspect that we are already screwing up the response to the epidemic in ways that will make it feel unfamiliar.
We are not testing enough
During the first few months of the COVID pandemic, when we had the chance to limit the virus only if we could locate all the cases and their contacts, testing was extremely insufficient. Many people who have had the virus have never been tested for it, and people who have wanted a test may not always be able to. The way we knew in the beginning that the virus was spreading unnoticed was that there were unrelated cases in the United States. The genetics of different groups in an epidemic may indicate that the virus must have spread unnoticed for some time.
Here’s what happens here: There are small groups of smallpox cases that are genetically different enough to know that there must be many more than the 35 reported cases in the United States. So many cases need to remain undetected.
One of the reasons for insufficient testing is that people who have monkeypox may not realize they have it. Monkeypox lesions are usually widespread throughout the body. In the current outbreak, sometimes a person may have lesions in only one part of the body and may even have one lesion. When that happens, you don’t think, “Oh my God, this must be monkeypox,” you think, “ha, I wonder what that spot is.” And you may or may not go to the doctor.
Doctors also don’t necessarily look for monkeypox and may not recognize it at first. It is not a common disease in the United States (or many other areas where it is prevalent) and the symptoms of this outbreak do not always follow the sequence of the textbook. You would usually expect a fever first, then a rash; but some of the known cases have received the rash before the fever. Some people have lesions only in the anal or genital area, which can look confusing like STIs such as herpes or syphilis. (Molecular microbiologist Joseph Osmundson has compiled an information sheet that includes pictures of anal and genital lesions from monkeypox.)
So the first hurdle in testing is that not enough tests are done in the first place. Testing for monkeypox involves collecting secretions or scabs from the lesions and sending them to one of several specific laboratories. Former FDA commissioner Scott Gottlieb tweeted that the current difficulty is the lack of sampling.
But if awareness improves, we may soon face a bigger problem: the capacity to test laboratories. There is currently a network of 74 laboratories that can test for orthopoxviruses and can process approximately 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 smallpox, are rare. If the test is positive for orthopoxvirus, the CDC will perform additional tests to confirm that it is monkeypox.
People with monkeypox (or orthopoxvirus suspected to be monkeypox) must be isolated for 21 days, and in the meantime, health authorities will contact, monitor and offer vaccines to the affected person and his or her close contacts. There are also antivirals that can be useful. But the vaccine has 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. More than one, in fact: Smallpox vaccination dates back hundreds of years, and there are still several modern vaccines. (Smallpox was declared exterminated worldwide in 1980, the only human virus to have this honor.) People could sometimes have fatal reactions to some of the older smallpox vaccines, so those who use a live virus – not considered monkeypox.
There is a vaccine in the United States that is licensed for use against monkeypox. It is known as MVA (for Modified Vaccinia Ankara) and its brand name here is Jynneos. It does not reproduce in humans, but still elicits an immune response against smallpox. According to a 1988 study, vaccination was 85% effective against monkeypox transmission – but this was a small study and we do not know if it is the efficacy we can expect from the current vaccine and the current strain of monkeypox.
We also don’t know if we will have enough. The U.S. Strategic National Reserve says they have 36,000 doses and have ordered another 36,000. The company that makes the vaccine also has many recent orders from other countries, for obvious reasons, and they plan to ship small batches to different countries, so everyone can get vaccinated quickly.
This is not enough vaccine to start vaccinating everyone, so the current strategy is ‘ring vaccination’, in which the vaccine is given to people who have been in close contact with a person who is known to have monkeypox. . (Monkeypox vaccine can also be given to a person with monkeypox, as it can reduce the severity of the disease if caught early enough.) But contact tracking is not perfect, and in very recent cases people do not have names or information about contact for all their close contacts. Another possible strategy would be to offer the vaccine to everyone in high-risk groups, which currently include men who have sex with men. So far, this strategy is being tested only in Canada.
People no longer understand how it is transmitted
Many of the latest cases are in men who have sex with men. This has led some people to believe that it is sexually transmitted, such as HIV or other STIs; I’ve already seen posts on social media from people who don’t understand this and say that you can only catch monkeypox by having sex with someone who has it.
Knowing that the virus is sexually transmitted, it is helpful to know if sexual transmission is the main way the virus is spread, as in HIV. But we know that monkeypox can spread through close contact of any kind, including contact with an infected person’s lesions or their respiratory droplets (such as coughing or sneezing) and possibly even aerosols.
And on that note: the CDC briefly issued a recommendation for passengers to wear masks to avoid contracting monkeypox, and then dropped that recommendation, saying it was “confusing.” Can monkeypox be transmitted by air? Perhaps! But if you’re worried about catching a virus while traveling, you should still wear a mask. We already know that masks (especially well-fitting N95-style masks) are effective in protecting us from COVID, and the incidence of COVID is increasing again – not that they have ever disappeared. So, yes, wear a mask. But also be vigilant about the symptoms of monkeypox and don’t be afraid to ask for a test or vaccine if you think you have monkeypox or may have been exposed.
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