Let’s Take Monkeypox Seriously
It’s adapting to humans. We have a safe vaccine. Let’s offer it voluntarily to those most at risk, like gay men, Africans in the modern diaspora and health workers, and head off the possibility that it becomes another AIDS.
Monkeypox is on the move. We’re still very much in the “fog of war” period with this potential epidemic, but it’s acting as if it’s adapting better to humans. As we’ve seen with Covid, that’s bad news.
Without panicking, we should take it seriously. (Maybe The New York Times could treat it as front-page news.) And we should aggressively use the tools we have to slow it down. Although that sounds obvious, our new hypersensitivity about vaccines will make it controversial.
We are still in the fog. We don’t know exactly how this mis-named rodent virus is transmitting now or how far it has spread.
Most journalists seem to be in “Don’t worry — it’s not Covid” mode. But with 100 cases found in two weeks in a dozen countries across Europe and North America and as far away as Israel and Australia, I’m not that sanguine. It has an incubation period of up to 21 days, so there could be thousands before this outbreak is under control — assuming we can bring it under control.
Some will dismiss that count as merely the result of more vigilance. In 2016, some experts tried to say that about Zika, claiming the Brazilians had just never correctly counted microcephaly cases before. They were wrong.
Monkeypox is also a serious disease. The Congo Basin clade has a fatality rate of nearly 10 percent, the West African clade is between 1 and 4 percent fatal. In an epidemic outside Africa, those figures will probably drop. Mild or asymptomatic cases are no doubt often missed in Africa, which would lower the fatality rate. Also, the virus — like measles — is probably more often fatal to malnourished kids than it would be to well-fed Americans. But take no comfort — any disease within shouting distance of 10 percent fatality that becomes more transmissible is a disaster.)
And those who recover definitely suffer. They can feel miserable with fever and pox for a month. (We should also assume there will be “long monkeypox,” since many viruses have lingering effects in some victims.)
Although we know little, we do have an inkling of who’s most at risk. And — amazingly — we already have tens of millions of doses of a vaccine, because we made it against smallpox, an older and nastier relative. We also have a treatment.
Why don’t we move fast and preemptively, before the virus mutates to be even better at human-to-human transmission?
Most of the newly diagnosed have no previous known risk factors: They have not visited Africa. They aren’t exotic pet dealers or prairie dog owners (see below). Most have not knowingly touched anyone with pox.
Also, in a new twist, many of them are gay men, often diagnosed at STD clinics. That immediately raises a new question: Has monkeypox morphed into a disease transmitted through sex? (Or perhaps kissing? If so, why isn’t it, like mono, rampant on college campuses?)
Naturally, that has revived old memories. Forty years ago, a mystery disease turned up in gay men in America and Europe that ultimately turned out to be a virus that came from African chimpanzees, made the jump to humans — probably via hunters who cut themselves butchering chimps. It expanded widely but silently in Africa and then made its way — probably via Haiti and definitely via semen and blood — into several networks in the West: men who had sex with men, blood-transfusion recipients (including hemophiliacs, who died in great numbers), drug injectors who shared needles and sex workers.
I am not saying this is a repeat of AIDS. But, like AIDS and other once-novel pathogens, it will take us time to gauge the risks. AIDS is not a “gay disease” — that’s a Western prejudice. In other countries, it affects other risk networks. We don’t yet know enough about monkeypox to answer even the most basic questions, like: Is it in semen? Is it in blood? Is it in saliva? Is in droplets? Do condoms protect? Is anal sex riskier than vaginal sex? How about oral sex? Kissing? Hugging? Breathing? Bedsheets?
European C.D.C. reports mention “genital lesions.” Anal sex raises H.I.V. risks because of micro-tears; but genital lesions transmit many diseases. No one yet knows enough to say: “Whew. I’m safe.”
What I am saying is that, as viruses get better at infecting humans, the infection routes they sniff out are unpredictable. For 50 years, we thought Ebola was transmitted only by blood, vomit and feces, and then in 2015 we discovered that it could be transmitted by sex. We thought Zika was transmitted only by mosquitoes, and then in 2016, we discovered that it too could be transmitted by sex. Conversely, 40 years ago, we initially feared AIDS might be spread by kissing or sharing forks and spoons, and we turned out to be wrong.
Going forward, we will undoubtedly sometimes be wrong about monkeypox, and we should be prepared to change our minds. (Let’s not repeat the “Fauci lied about masks” nonsense. Fauci, like any good scientist, changed his advice as we learned more.)
Meawhile, let’s fight it. Britain is already giving smallpox vaccine to close contacts of cases and the European C.D.C. is recommending the same tactic.
That’s a start, but known contacts is a tiny pool of protected people. It seems far too conservative an approach in the face of a growing threat.
Why don’t we offer the vaccine voluntarily to all gay men who contemplate having sex with strangers? We should probably also offer it to all sex workers of all genders. Why? Because if you have sex with anyone you don’t know well enough to say, “Uh, before we begin, can I check your body for sores?” then you are are already in the high-risk group for H.I.V., gonorrhea, syphilis, chlamydia, herpes and hepatitis. And it’s looking like monkeypox is worming its way into those sexual networks.
Some will be outraged and shout, “You’re suggesting we use gay men as guinea pigs!”
To which I would reply: “Yes, I am. And if I were a gay man born after 1972 who hadn’t already had three smallpox shots (see below) and I was having sex with strangers, I’d volunteer to be one of those guinea pigs. Why? Because this isn’t a blind alley — this is a new, much safer version of an old vaccine that saved millions of lives. We know more than we did when we started offering PrEP, and PrEP is a lifesaver. Plus, I’d be contributing to science. I think it’s worth the risk.”
We may also soon want to offer the vaccine — again, on a voluntary basis — to emergency room doctors and nurses, paramedics, police officers and so on — anyone who might theoretically come in contact with a monkeypox victim.
With enough volunteer takers, we can quickly build up an even bigger safety database and calculate the true risk-benefit ratio of the new vaccine and decide where to go from there. If the outbreak fades out, we can return it to the freezers. If it spreads, we can start offering it to more and more people at risk — which ones will depend on how it spreads. Given the source, and the history of known cases, it’s likely that Africans in the modern diaspora (ie, still going back and forth) could be next at bat.
The ultimate step should be to attack the pox at its source — central and west Africa. Initially, we might require that everyone flying to or from countries with circulating monkeypox, starting with the Democratic Republic of Congo, be vaccinated. That’s going to be unpopular, especially when it expands to include countries like Nigeria, which has many more Americans with family ties. But I don’t mean we should single out Africans. I mean vaccinating business executives, tourists, aid workers, journalists, everyone who gets on a plane. The risk to them — and their families — will be reduced.
Controlling the disease inside Africa itself will be a multi-year effort requiring many billions of dollars. But it ultimately must be done or we will face more outbreaks like this one as the virus roams human populations and gets better and better at targeting our cells.
We’ve had close calls before. We had a serious monkeypox scare in 2003. A Texas dealer in exotic species imported a shipment of 762 rodents from Ghana, including giant Gambian pouched rats, tree squirrels, rope squirrels, porcupines, dormice and striped mice. The pouched rats were shipped to a pet warehouse in Illinois and stored near 200 prairie dogs that were later shipped to pet stores all over the eastern half of the country.
The first inkling there was a problem was a three-year-old boy in Wisconsin getting a high fever and a rash after being bitten by the family’s new prairie dog. The child’s parents also got the rash. Quick thinking by state health officials identified the virus and issued an alert.
It was two more months of frantic searching for those 200 prairie dogs and the humans who bought them (sometimes at unregistered pet fairs, just like guns) before the outbreak was declared over. By the time it was, 71 humans had been infected — half were laboratory confirmed, the rest were “probables” based on symptoms and exposure. Two had become seriously ill. Of the prairie dogs that were traced and necropsied, 94 had the virus. So did some pouched rats, dormice and squirrels in the original shipment.
Because none of those infected humans had zero contact with any prairie dogs, the C.D.C. concluded that there was no confirmed human-to-human transmission in that outbreak.
Still, it was bad news all around — one strain of the virus proved itself capable of infecting five different mammalian species, including humans. We now have confirmed H2H transmission.
And, if you’re a New Yorker, consider this: how would you like to see this disease reach our rodent population? Rats with monkeypox are an animal reservoir we really don’t want to face. We’d never eradicate it. (In 1899, plague reached this country via San Francisco; it’s still here — circulating in prairie dogs.)
There was another close call last July, when a passenger on a flight from Nigeria to Atlanta and on to Dallas turned out to be infected with the 10-percent-fatal strain. More than 200 people in 27 states had to be quarantined for observation because they had sat close to him, used or cleaned the same airplane bathroom, had driven him to the hospital or had other fleeting interactions. Luckily, no one got infected. (This was mid-2021 — everyone on the plane was masked.) That’s encouraging — but just one known case teaches us next to nothing.
In its report last April on the Texas case, the C.D.C. noted that there have been nine travel-related cases from Nigeria to various countries. They seemed to be hinting that Nigeria’s urban epidemic is out of control and maybe some measures to protect Americans from it should be taken. But the C.D.C. is not exactly known for political courage in the early stages of epidemics. In 2016, it fumfered around for more than two weeks before advising pregnant American women to avoid travel to Caribbean countries with rampant Zika transmission, even though the threat to fetuses was abundantly clear and it was the height of the post-Christmas travel season.
This brings us to the vaccines, why they’re safe, and why we should be inspired to pursue even more safety data. Eradicating smallpox in 1980 was one of history’s public health triumphs. Nonetheless, the vaccine we used was one of the most dangerous ever invented. It was a live, weakened virus similar to smallpox that was not injected, but pricked into the skin. (The skin has many more immune cells than shoulder muscles do, so you are more likely to “get a take.”) But the blister and scab confirming that “take” could sometimes turn necrotic in people with eczema, and even require amputation. In people with suppressed immune systems, it could spread and cause what was essentially a case of smallpox; in very rare cases, people died. And if the blister pressed against another person’s open wound or mucous membrane, the virus might jump, putting them at risk.
(Had we not eradicated smallpox by 1980, observed Dr. David L. Heymann, a former W.H.O. and Public Health England official who fought smallpox, Ebola and even monkeypox in Africa, we never would have. AIDS emerged in 1981, and the old vaccine could have been deadly in anyone with untreated H.I.V.)
But risk is relative. With smallpox still circulating, that “unsafe” vaccine was worth using. From the 1940’s to 1980, the world’s governments gave out millions of doses.
I was born in 1954. According to my mother’s meticulous notes, I got that unsafe vaccine three times: when I was 9 months old (her notes say “it took”); then when I was 8 years old and again at 13.
I survived, I don’t even have a scar — and I’m probably immune to monkeypox, or at least to dying from it. If the virus did go pandemic, I’d ask for a booster, but I’m still probably much better protected than you if you were born after 1972, when we stopped vaccinating Americans against smallpox.
That old vaccine is defunct. In 2007, the F.D.A. approved a replacement, ACAM2000, for the strategic national stockpile, in case weaponized smallpox was ever released on the world. In 2019, the F.D.A. approved an even newer and safer vaccine, Jynneos, from Bavarian Nordic in Denmark. It does not replicate in human cells and was meant for immune-compromised populations that could not take ACAM2000. According to the company, they shipped 30 million frozen doses to the U.S. and are now making millions more freeze-dried ones.
Jynneos was efficacy-tested in monkeys before they were given lethal doses of monkeypox; it saved almost all of them. It was also tested in American soldiers (who were not deliberately given monkeypox, of course); they developed twice the protective antibodies of those given ACAM2000. It was safety-tested in 22 studies in almost 8,000 people in the U.S., Germany and Mexico, including hundreds with H.I.V. or skin diseases that would make them ineligible for the old vaccines. Less than one-tenth of one percent got serious adverse reactions, and those were close to the same low rates as in the placebo groups, so the vaccine was judged to be quite safe.
Given those odds, I’d happily take it if monkeypox began to spread. But I’m probably in a very low-risk group, and it makes more sense for me to focus on keeping my Covid risk low. However, if I were gay, or Nigerian-American — or if I were still traveling to Africa for The New York Times every year — I’d probably lobby for my chance to get it now. I’d rather take a small risk than see this spread further.