Photo: Pablo Blazquez Dominguez (Getty Images)
The monkey’s smallpox is here and spreading. The couple dozen cases in some countries we talked about last month are now more than a thousand cases worldwide, with 35 reported in the United States. But the U.S. is almost certain to have more cases than the statistics suggest, and there is reason to suspect that we are already fucking the response to the epidemic in some way that we find uncomfortable.
We are not trying hard enough
During the first months of the COVID pandemic, when we had a chance to contain the virus if we could only locate all the cases and their contacts, the evidence was sadly inadequate. Many people who had the virus were never tested, and people who wanted a test could not always get one. The way we knew at first that the virus was spreading unnoticed was that there were cases in the U.S. that were unrelated. The genetics of different groups of a disease outbreak may show that the virus must have spread undetected for a while.
Here’s what’s starting to happen here: There are small groups of cases of monkeypox that are genetically quite different from each other that we know there must be far more than the 35 cases reported in the United States. So many cases have to go unnoticed.
One of the reasons for the insufficient evidence is that people who have monkeypox may not realize they have it. Smallpox smallpox lesions are usually widespread throughout the body. In the current outbreak, sometimes a person can only have injuries in one part of the body, and may even have a single injury. When this happens, don’t think, “My God, this must be the monkey’s smallpox,” you think, “eh, I wonder what this place is.” And maybe you’ll see a doctor, or maybe not.
Doctors don’t necessarily look for monkeypox either, and they may not recognize it at first. It is not a common disease in the US (or in many other areas where it is spreading) and the symptoms of this outbreak do not always follow the sequence of the textbook. Normally, a fever would be expected first, followed by a rash; but some of the known cases had the rash before the fever. Some people have lesions only in the anal or genital area, which can seem confusingly similar to STIs such as herpes or syphilis. (Molecular microbiologist Joseph Osmundson has compiled an information sheet that includes photos of anal and genital lesions of monkeypox here.)
So the first hurdle to testing is that not enough testing is done in the first place. The monkeypox test involves collecting secretions or scabs from the lesions and sending them to one of the few specific laboratories. Former FDA Commissioner Scott Gottlieb tweeted that the current bottleneck is the lack of sampling.
But if consciousness improves, we soon run into a bigger problem: the testing ability of labs. There is currently a network of 74 labs that can do an orthopoxvirus test and can process about 7,000 tests a week. Smallpox is the only orthopoxvirus currently of concern, as smallpox has been eradicated and other viruses in the family, such as bovine smallpox, are rare. If a sample is positive for orthopoxvirus, the CDC will do more testing to confirm that it is monkeypox.
People with monkeypox (or orthopoxvirus suspected of being monkeypox) are supposed to be isolated for 21 days, and in the meantime, health authorities will track contacts and offer vaccinations to the affected person and their close contacts. There are also antivirals that may be helpful. But the vaccine brings another problem.
We have a vaccine, but we don’t know how 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, with several modern vaccines still available. (Smallpox was declared eradicated worldwide in 1980, the only human virus to have this honor.) Sometimes people could have fatal reactions to some of the oldest smallpox vaccines, so , those that use live viruses are not considered. for the smallpox of the monkey.
In the United States, there is an approved vaccine for use against monkeypox. It is known as MVA (for Ankara Modified Vaccinia) and its brand here is Jynneos. It does not replicate in humans, but still triggers an immune response against smallpox. According to a 1988 study, vaccination is 85% effective against the transmission of monkeypox, but this was a small study and we do not know if this is the effectiveness we can expect from the current vaccine and the current strain of the smallpox of the monkey.
We also don’t know if we will have enough. The U.S. National Strategic Stock says they have 36,000 doses and have ordered 36,000 more. The vaccine company also has many recent orders from other countries, for obvious reasons, and they plan to send small batches to different countries so that everyone can start getting vaccinated quickly.
The vaccine is not enough to start vaccinating everyone, so the current strategy is the “ring vaccination”, in which the vaccine is offered to people who were close contacts with a person who is known to he had smallpox from the monkey. (The monkeypox vaccine can also be given to the person with the monkeypox, as it can reduce the severity of the disease if detected early enough.) But contact tracking is not perfect and in many cases recent , people had no names or contact information. for all your close contacts. Another possible strategy would be to offer the vaccine to all high-risk groups, which currently include men who have sex with men. So far, this strategy is only being tested in Canada.
People are already misunderstanding how it is transmitted
Many of the recent cases have been in men who have sex with men. This has led some people to assume that it is sexually transmitted, such as HIV or other STIs; I’ve seen posts on social media from people who misunderstand it and say you can only catch the monkey’s smallpox for sex with someone who has it.
Knowing that a virus is sexually transmitted is useful in determining whether sexual transmission is the main route of virus spread, as is the case with HIV. But we do know that monkeypox can spread through close contact of any kind, including contact with the lesions of an infected person or their respiratory drops (such as coughing or sneezing) and possibly even with aerosols.
And on that note, the CDC briefly issued a recommendation for travelers to wear masks to avoid getting monkeypox, and then withdrew that recommendation, saying it was “confusing.” Can monkeypox be carried in the air? May be! But if you’re worried about catching a virus while traveling, 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 have ever disappeared. So yes, wear a mask. But also be aware of the symptoms of smallpox and don’t be afraid to ask for a test or vaccine if you think you have smallpox or may have been exposed.