We Are Not Ready for Monkeypox

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Monkeypox is here, and it’s spreading. The couple of dozen cases in a few countries that we told you about last month are now up to over a thousand cases worldwide, with 35 reported in the United States. But the U.S. almost certainly has more cases than the statistics suggest, and there is reason to suspect that we’re already fucking up the response to the epidemic in some ways that will feel uncomfortably familiar.

We aren’t testing enough

For the first few months of the COVID pandemic, when we had the chance to contain the virus if only we could locate all the cases and their contacts, testing was woefully inadequate. Plenty of people who had the virus were never tested for it, and people who wanted a test couldn’t 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 not related to each other. The genetics of different clusters of a disease outbreak can show that the virus must have been spreading undetected for a while.

That’s what’s beginning to happen here: There are small clusters of monkeypox cases that are genetically different enough from each other that we know there must be far more than the 35 reported U.S. cases. So a lot of cases must be going undetected.

One reason for under-testing is that people who have monkeypox may not realize that they have it. Normally, monkeypox lesions are widespread across the body. In the current outbreak, sometimes a person may only have lesions in one part of the body, and may even have a single lesion. When that happens, you don’t think, “oh my god, this must be monkeypox,” you think, “huh, I wonder what that spot is.” And maybe you’ll see a doctor, or maybe not.

Doctors also aren’t necessarily looking for monkeypox, and might not recognize it at first. It’s not a common disease in the U.S. (or in many of the other areas where it’s spreading) and the symptoms in this outbreak don’t always follow the textbook sequence. Normally you would expect a fever first, and then the rash; but some of the known cases got the rash before the fever. Some people have the lesions only in the anal or genital area, which may look confusingly similar to STIs like herpes or syphilis. (Molecular microbiologist Joseph Osmundson has put together a fact sheet that includes photos of anal and genital monkeypox lesions here.)

So the first obstacle in testing is that not enough tests are being done in the first place. Testing for monkeypox involves collecting secretions or scabs from the lesions, and sending them to one of a few specific laboratories. Former FDA commissioner Scott Gottlieb tweeted that the current bottleneck is the lack of sampling.

But if awareness gets better, we may soon run into a bigger problem: labs’ testing capacity. Currently there is a network of 74 labs that can run a test for orthopoxviruses, and they can process an estimated 7,000 tests per week. Monkeypox is the only orthopoxvirus of concern at the moment, since smallpox has been eradicated and other viruses in the family, like cowpox, are rare. If a sample tests positive for orthopoxvirus, the CDC will do further testing to confirm that it is monkeypox.

People with monkeypox (or orthopoxvirus that is suspected to be monkeypox) are supposed to isolate for 21 days, and in the meantime, health authorities will contact-trace, and offer vaccines 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 well it works

The good news about the vaccine is that we already have one. More than one, actually: Smallpox vaccination dates back hundreds of years, with several modern vaccines still available. (Smallpox was declared to be eradicated worldwide in 1980, the only human virus to have that honor.) People could occasionally have fatal reactions to some of the older smallpox vaccines, so those—the ones that use live virus—aren’t being considered for monkeypox.

In the U.S., there is one vaccine that is licensed for use against monkeypox. It’s known as MVA (for Modified Vaccinia Ankara) and its brand name here is Jynneos. It doesn’t replicate in humans, but it does still trigger an immune response against smallpox. According to a 1988 study, vaccination is 85% effective against monkeypox transmission—but that was a small study and we don’t know if that’s the efficacy we can expect from the current vaccine and the current strain of monkeypox.

We also don’t know if we’ll have enough of it. The U.S. Strategic National Stockpile says they have 36,000 doses and have ordered 36,000 more. The company that makes the vaccine also has lots of recent orders from other countries, for obvious reasons, and they plan to ship out small batches to the various countries so that everybody can start vaccinating quickly.

That’s not enough vaccine to start vaccinating everybody, so the current strategy is “ring vaccination,” in which vaccine is offered to people who were close contacts of a person known to have monkeypox. (Monkeypox vaccine may also be given to the person with monkeypox, since it can reduce the severity of illness if caught early enough.) But contact tracing isn’t perfect, and in many recent cases, people didn’t have names or contact information for all their close contacts. Another possible strategy would be offering the vaccine to everybody in high-risk groups, which currently include men who have sex with men. So far, that strategy is only being tried in Canada.

People are already misunderstanding how it’s transmitted

Many of the recent cases have been in men who have sex with men. This has led to some people assuming that it’s sexually transmitted, like HIV or other STIs; I’ve already seen social media posts from people misunderstanding this and saying that you can only catch monkeypox from sex with somebody who has it.

Knowing that a virus is sexually transmitted is helpful to know if sexual transmission is the main way that virus spreads, like with HIV. But we know that monkeypox can spread with close contact of any kind, including contact with an infected person’s lesions, or with their respiratory droplets (like from a cough or sneeze) and possibly even with aerosols.

And on that note: The CDC briefly published a recommendation that travelers wear masks to avoid catching monkeypox, and then took down that recommendation saying that it “caused confusion.” Can monkeypox be airborne? Maybe! But if you’re concerned about catching a virus when you travel, you should be wearing a mask anyway. We already know that masks (especially well-fitting N95 style masks) are effective at protecting us against COVID, and COVID cases are on the upswing again—not that they ever went away. So, yes, wear a mask. But also be on the lookout for symptoms of monkeypox, and don’t be afraid to ask for a test or a vaccine if you think you have monkeypox or may have been exposed.


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