We blew our chance to quickly contain monkeypox. Now the dangerous virus is spreading fast all over the world.
Health experts agree: the outbreak could soon qualify as a pandemic, if it doesn’t already. And the situation is likely to get worse before it gets better. More infections, more deaths, more chances for the pox to mutate.
“We are in uncharted territory with this outbreak… and still early in the event,” James Lawler, an infectious disease expert and a colleague of Wiley at the University of Nebraska Medical Center, told The Daily Beast.
The latest figures from the US Centers for Disease Control are starting. The CDC tallied 9,647 infections as of July 11. That’s a fourfold increase compared to just a month ago.
“It is shocking after all we learned with COVID-19, we have let another virus escalate to this point.
— Lawrence Gostin, Georgetown University
The virus, which causes a rash and fever and can be fatal in a very small percentage of cases, is in 63 countries—57 of which don’t usually have any monkeypox cases.
Cases are concentrated in West and Central Africa—where the virus is endemic—as well as in Europe, where the current outbreak began in May. But the US is logging a starting number of cases, as well: 865 in 39 states, according to the CDC. That’s five times as many as a month ago.
“Monkeypox is clearly a global health emergency,” Lawrence Gostin, a Georgetown University global-health expert, told The Daily Beast. “It has simmered in small pockets in Central and West Africa for decades, but until now there have been no cases unrelated to travel in the rest of the world. Now it is in virtually every region of the world and spreading rapidly.”
The death rate, mercifully, is still low. As of July 4, the most recent date for which figures are available, the World Health Organization had recorded just three deaths in the current outbreak.
Three out of 9,647—or .03 percent—is a much lower death rate than West and Central African countries apparently suffered in their own pox outbreaks in recent decades. The worst African outbreaks, involving a strain of the virus that’s endemic to the Congo River Basin in Central Africa, have resulted in official death rates as high as 10 percent.
But the more viruses spread, the more they mutate—often in ways that make them deadlier. As long as monkeypox spreads faster than health authorities can contain it, the greater the risk it’s going to spawn new, more dangerous variants, potentially driving up the death toll.
Monkeypox mostly spreads through close physical contact, especially sexual contact. It’s not a sexually transmitted disease, however. It just takes advantage of the skin-to-skin contact that accompanies sex. The virus can also travel short distances on spittle, although probably not far enough to qualify as “airborne.”
Officials first noticed the current outbreak, involving a relatively mild West African strain of the pox, after diagnosing a UK traveler returning from Nigeria in early May. Hitching a ride to Europe, the virus spread quickly through physical contact.
David Heymann, who formerly headed the WHO’s emergencies department, said that men attending raves in Spain and Belgium “amplified” the outbreak—apparently through close, sometimes sexual, contact with other men.
After that, the virus accompanied travelers on planes heading for countries far and wide. Doctors diagnosed the first US case on May 27.
But it’s apparent now that the first diagnosed pox cases in Europe and the US weren’t the real first cases. On June 3, the CDC announced it had found genetic evidence of US pox cases that predated the first cases in Europe from May.
Doctors may not have noticed or reported these earlier cases, at first, owing to the similarity between pox symptoms and the symptoms of some common sexually transmitted diseases such as herpes. In other words, the current outbreak began, and expanded, without anyone noticing at first.
The virus had a big head start, which helps to explain why, months later, it still has the advantage. “By the time we recognized that cases were happening, we were already behind,” Lawler said.
Prompt diagnosis is the key to containing a dangerous virus quickly. If officials know where the virus is concentrated in the early days of an outbreak, they can isolate infected people, conduct contact-tracing to identify vulnerable populations and deploy therapies and vaccines and to treat the infected and protect the uninfected. (Lucky for us, widely available smallpox vaccines work just fine against monkeypox.)
With its likeliest infection vectors cut off by early intervention, the virus withers and disappears—before it can mutate into some new variant that might, say, be more contagious or even evade vaccines.
That’s what should have happened back in April or even earlier, but didn’t because the WHO, CDC and other health organizations didn’t even know a pox outbreak was happening. The current, rapid spread is the consequence of that initial failure.
The worst outcome isn’t hard to imagine—10,000 cases could quickly bloom into 100,000 cases. Then 1 million. Various experts and agencies disagree over the precise definition of “pandemic,” but if the pox outbreak doesn’t already qualify, it’s increasingly likely that it will in the weeks to come. At that point, the world will be contending with simultaneous pandemics.
The WHO for one has studiously avoided using the p-word to describe the pox outbreak. The CDC did not immediately respond to a query
This is a mistake, Lawler said. “We certainly cannot make ‘pandemic’ declarations about every disease outbreak that crosses multiple international borders without becoming the boy who cries wolf,” he conceded.
But, he added, “I would argue that we should have learned some humility in the face of emerging viruses by now.” If the word “pandemic” gets people’s attention and underscores the growing risk—use it.
The silver lining is the very low death rate in the current pox outbreak. That could be a statistical anomaly resulting from a huge overcount of deaths in earlier African outbreaks. “I am not sure we have a full grasp of the denominator of cases that actually occur in West Africa,” Lawler pointed out. Meaning, it’s possible that pox deaths in Africa were spread out across a much bigger number of infections than we realized at the time.
It’s also possible we’re seeing a happy side-effect of a pox outbreak mostly affecting richer communities. “Monkeypox is now being diagnosed in urban populations where more people have access to health-care facilities,” Blossom Damania, a virologist at the University of North Carolina at Chapel Hill, told The Daily Beast.
Either way, we shouldn’t get complacent. The pox, like all viruses, treats every infected person like a laboratory. A chance to try new things, learn and change. Every additional infection increases the likelihood of new variants emerging. As COVID has repeatedly demonstrated, new variants mean new risks. Greater transmissibility, severity or vaccine-evasion—or a mix of all three.
There’s still time to prevent the worst-case scenario of millions of cases and potentially thousands of deaths. The WHO, CDC and other health bodies must double down on efforts to educate doctors and speed up diagnoses—and then move more quickly to isolate and treat infected people and vaccinate those around them. “If we can get enough vaccine into high-risk contacts, this will cease,” Amesh Adalja, a public-health expert at the Johns Hopkins Center for Health Security, told The Daily Beast.
COVID reminded us how bad a viral outbreak can get. Then monkeypox came around to remind us of our strong tendency toward complacency, even amid an ongoing health crisis. “It is shocking that, after all we have learned with COVID-19, we have let another virus escalate to the point of becoming a global health emergency,” Gostin said.
To catch up with the fast-moving pox, what we need now—more than anything—is a fresh sense of urgency.