It is Time to Raise the Alarm on Monkeypox
With community transmission taking a foothold in the U.S., public health agencies must do more to stamp out the virus, effectively communicate the increasing risk to the MSM community and better inform the public.
Cases of monkeypox have toppled in the last 7 weeks to over to 3,500 cases worldwide in 44 countries. This latest outbreak of an emerging threat should serve as a reminder of the importance of doing something about growing epidemics in other parts of the world, including low- and middle-income countries. Surely, Covid has shown us that disease knows no boundaries. A growing outbreak is bound to create havoc in other parts of the world if left unchecked, uncontained, and uncontrolled. And that is exactly what is happening with monkeypox today.
In contrast to Covid-19, which began with a novel virus that was unknown to humankind before 2019, the virus that causes monkeypox has been documented since 1958. Researchers in Africa have been sounding the alarm on the increasing spread of monkeypox for years. There was a call for action as Nigeria’s monkeypox outbreak (that started in 2017) began to expand to present day, but it went unheeded according to Chikwe Ihekweazu, the former director general of the Nigeria Centre for Disease Control.
Preliminary data on genomic sequencing of U.S. monkeypox cases shows at least two distinct circulating monkeypox variants. Two U.S. cases with travel history to Nigeria are genetically similar to a 2021 monkeypox case seen in a Texas man who also traveled to Nigeria. The other circulating monkeypox virus is genetically similar to infections occurring in Europe. While all circulating strains of monkeypox likely have a common ancestor, the larger issue is that there may have been several introductions of the monkeypox virus to the U.S. from different parts of the world — all likely happening longer and more frequently than public health officials may have suspected. This suggests there has been undetected transmission for some time.
It is unclear just how long this outbreak has been brewing, but it seems cases of monkeypox may have been confused for more common sexually transmitted infections (STI) like herpes and syphilis as this latest outbreak has been introduced into the sexual network of men who have sex with men (MSM). Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky stated that current monkeypox cases are presenting similar to some sexually transmitted infections and could be mistaken for other diagnoses. This is likely fueling the spread of monkeypox undetected coupled with not testing enough specifically for monkeypox. What’s more, a diagnosis of an STI does not preclude a monkeypox infection. In fact, co-infections with STIs and monkeypox have been reported.
Unlike Covid-19, monkeypox does not easily spread person to person, and requires direct contact with the infected source (person or object). Current cases are largely being driven by skin-to-skin contact said WHO’s incident manager for monkeypox, Catherine Smallwood. While sexual transmission of the virus is not one of the ways it spreads, WHO is investigating recent reports from Italy and Germany which showed a small trace amount of monkeypox DNA in semen samples collected from monkeypox patients.
Monkeypox is also a fairly self-limiting disease with most people making a full recovery. 1 death has been reported so far. At the same time, it is not a benign infection and can have lasting implications for some people including skin scarring left by pox lesions and potentially secondary infections such as bronchopneumonia, sepsis, encephalitis, and infection of the cornea with ensuing loss of vision.
As cases continue to mount in the U.S., now up to 173 cases across nearly two dozen states as of June 23, some with no linkage to travel outside the country or exposure to someone who has traveled, the telltale sign of community transmission taking a foothold, here are a few reasons why we must act fast and effectively communicate the increasing risk to the public.
Most cases in the U.S. are being driven primarily among social networks of those identifying as gay, bisexual, and other men who have sex with men (MSM). Tiptoeing around the fact that this is the most at-risk group due to the introduction of the virus in this network is a disservice. Behavioral risk factors that increase ones chance of getting infected include having multiple sex partners.
Trying to balance risk communication without stigmatization is not an easy task, especially with our long history of marginalizing and discriminating against the LGBTQ community. Luckily, we are not starting from scratch and have existing trusted messengers and organizations in the community that can be leveraged, who work all year round on LGBTQ causes. We must broaden the outreach through all platforms including social media and outpatient clinics. Raising awareness is an all of the above approach.
While the current outbreak has been predominately observed among those identifying as men who have sex with men, it is not the only population that is at risk and cases among women have been reported in the U.S and around the world. Regardless of gender, people should be vigilant. Anyone can get monkeypox and spread it.
Risk to the general public is low but increasing as cases continue to stack up in the surrounding community. The best way to protect yourself is to avoid contact with anyone who has monkeypox and follow any prevention recommendations shared by your healthcare provider. You should seek medical care immediately if you develop any unexplained skin rashes on any part of your body, even if you didn’t have contact with someone who has monkeypox.
For more information on ways to prevent monkeypox, especially if you are traveling, see the CDC website. If you engage in sexual activity with multiple or anonymous sex partners, here is a CDC tipsheet to reduce your risk of getting monkeypox during sex.
It is not surprising that with the eradication of smallpox in the 1980 and the subsequent cessation of use of the smallpox vaccine (which also provided some cross protection to other poxviruses including monkeypox), we are now seeing waning population immunity. Luckily, we’re not starting from square one for monkeypox. There is 50 years of research on the clinical signs, symptoms, and disease progression of monkeypox. The U.S.’s has vaccine stockpiles which are now being deployed to those at most risk, antiviral treatments including Tecovirimat (also known as TPOXX) and Cidofovir (also known as Vistide) which are FDA authorized, and Vaccinia Immune Globulin Intravenous (VIGIV), which is FDA licensed.
The best way to prevent an outbreak from growing further and becoming an established virus (becoming endemic) is to break chains of transmission. This requires a strong and effective awareness and risk communication campaign that details prevention and risk reduction techniques to go along with tried-and-true public health interventions like testing, isolation of cases, contact tracing and offering vaccinations to those who are eligible.
New York City has recently announced it is offering the 2-dose JYENNEOS vaccine at a temporary vaccine clinic to all men 18 years and older who identify as gay or bisexual and to other men who have sex with men and have had multiple or anonymous sex partners in the last 14 days. New York is often the model for the rest of the nation, and hopefully more states will follow suit. Providing protection to the community most at-risk is essential and good public health practice.
On May 29, 2022, the World Health Organization (WHO) had increased its threat assessment of monkeypox to ‘moderate’ risk to global health. And on June 6, 2022, The CDC upgraded its travel health notice for travelers considering international travel to countries reporting monkeypox cases from “watch — level 1” to “alert — level 2.” On June 23, 2022, the WHO convened its Emergency Committee under the International Health Regulations to assess whether the outbreak represents a public health emergency of international concern with deliberation results pending.
There is a high likelihood that more cases will be found without any identified chains of transmission with the potential to spread to other populations including children, the elderly, and the immunocompromised. We must act fast. It is time to sound the alarm.
This piece was co-authored by Syra Madad, DHSc, MSc, MCP and Nicole A. Hoff, PhD, MPH. Dr. Madad is on the faculty at Boston University’s Center for Emerging Infectious Diseases Policy & Research and is Senior Director of the System Special Pathogens Program at NYC Health + Hospitals and a fellow at the Harvard Belfer Center for Science and International Affairs. Dr. Hoff is Adjunct Assistant Professor at UCLA Fielding School of Public Health.
