Technically, Monkeypox Already IS a Pandemic

2018 monkeypox case in Britain, from Lancet Infectious Diseases

There are now almost 800 confirmed or suspected cases of monkeypox outside of Africa — up from a handful in early May. The W.H.O. just raised the threat level, saying it posed a “moderate risk” to global health.

Technically, monkeypox already is a pandemic. It meets the definition the W.H.O. previously used: “Sustained human-to-human transmission of a novel pathogen in two or more W.H.O. regions.”

(True, it’s not “novel” since it was discovered in 1958, but it’s novel outside of Africa. Don’t underestimate old pathogens that discover new horizons. Measles, smallpox and tuberculosis were old news to Columbus and the conquistadors when they brought them to the New World, but they went on to wipe out 90 percent of their new hosts.)

Also: most of the countries reporting cases now have a history of honest reporting. Many that have not yet done so have histories of coverups during their outbreaks of AIDS, SARS, bird or swine flus or Covid: Russia, India, Indonesia, China and many countries in Africa and the Middle East. Also, not every country handles new PCR tests well. This outbreak may be much bigger than we realize.

The W.H.O. and the C.D.C. are still being reassuring, saying monkeypox “can be contained.” But they said that about Covid too — for two full months — until it was clear that it could not. Every day, the W.H.O.’s director-general, Tedros Adhanom Ghebreyesus, would say: “There is a window of opportunity to contain this virus. But that window is closing.” On March 11, it closed — he declared Covid a pandemic.

On Monday, a W.H.O. official used the same “window of opportunity” line and hedged when asked if it would go pandemic, saying only: “We don’t know but we don’t think so.”

(The agency retired its official definition of a pandemic in 2009 because journalists complained it was being too persnickety: H1N1 swine flu was all over North and South America and the Caribbean, but the W.H.O. wouldn’t call it a pandemic because the Western Hemisphere is all one W.H.O. region. In 2020, as Covid spread, a W.H.O. spokesman said the agency would not revive the word “pandemic” since on January 30, they had declared the virus a “public health emergency of international concern.” But the world didn’t pay enough attention, so they upped the ante in March. Watch for that pattern.)

This pandemic — or whatever it ends up being called — won’t be anything like Covid. It can’t move that fast. But it seems to be moving fast enough to elude ring vaccination, which is the current containment plan.

If each case has 200 contacts, as the case in Boston did, the virus could run rings around contact-tracers and vaccinators. (Most of the 200 were doctors and nurses, not sexual partners.)

Because smallpox vaccine is considered an anti-terrorism agent, the government is being cagey about how many doses it has. The official line is “more than enough,” but there is no breakdown. If there are 100 million doses of the old ACAM2000 vaccine, that’s an excellent start — but that vaccine has some very rare but very bad side effects. It is also contraindicated for many people with common conditions like heart ailments and pregnancy.

The newer Jynneos vaccine is much safer — and easier to inject — but right now the government will not specify how many unexpired doses it owns. “More than 1,000,” the last figure given out by the C.D.C., is clearly not enough. That number is not accurate, according to a government figure who spoke on condition of anonymity but declined to give the true number.

Another drawback: full vaccine immunity takes six weeks — two shots a month apart plus two weeks until antibodies kick in. If we’re going to protect health workers — especially at clinics catering to gay men — we should start right now.

What’s particularly worrying is the semi-silent way the virus is now spreading. We don’t know if there is any fully asymptomatic transmission, but there are definitely mild cases with only a few pox, and not always on obvious places like the face. Sometimes it’s confined to genitals and mouths. Also, there have been initial misdiagnoses as cold sores or chickenpox — the kind of mistake that leads to spread to family, friends, classmates, doctors and nurses.

Since I wrote a piece on May 23 saying “Let’s Take Monkeypox Seriously,” I’ve gotten some dismissive reactions, saying “it’s like AIDS — if you don’t go to gay raves, you’re fine.”

We shouldn’t be so smug.

First, AIDS isn’t a “gay disease.” Women and teenage girls make up more than half — 53 percent — of all the people infected with H.I.V. in the world right now, according to Unaids. (Most transmission in Africa and parts of Asia is heterosexual.)

Second, diseases never stay inside their first targets. Not all AIDS victims are from the Congo Basin, not all Covid victims are from Wuhan, not all syphilis victims fought at the siege of Naples.

What’s the closest analog to the way monkeypox transmits? Probably herpes.

H.I.V. jumps when semen touches blood. That’s why anal sex is more dangerous than vaginal sex: it causes micro-tears. Women are at higher risk if they have untreated STD’s or other lesions or are treated harshly during sex.

Herpes, by contrast, transmits when blister touches mucous membrane. Blister transmission is harder to contain. Virtually everyone gets oral cold sores in childhood — that’s the herpes virus. Almost 600,000 Americans a year contract genital herpes — the scarlet H on the cover of Time magazine in 1982. It’s twice as common among women as among men — and even condoms don’t completely protect because they don’t cover the peri-genital area.

Any fatality rate in a disease that might be as transmissible as herpes is scary.

(As has been pointed out to me, the weakness in this analogy is that monkeypox lasts only for weeks, while herpes is a chronic, relapsing disease; victims can infect others for years. That should reduce the danger, but not eliminate it. Also, new viruses often surge in a naive population.)

Of the nearly 800 cases compiled by www.global.health, less than one percent are in women (but many case don’t specify sex). However, it’s still early days.

Thus far, no one has died. Outside of Africa, the West African strain appears to be less than one percent fatal, since we have treatments and the vaccines are partially protective if given quickly after infection. But that doesn’t mean people can’t still get quite sick.

Case descriptions just published in Lancet Infectious Diseases of the treatment of seven monkeypox cases in Britain between 2018 and 2021 are discouraging. Three of the seven were female, one was a baby girl. Four were infected in Nigeria, one was a health care worker infected by a patient in Liverpool, one was father-to-baby-to-mother.

All seven recovered, but they were hospitalized for 10 to 39 days. Only one of two antivirals approved for smallpox worked: Brincidofovir did not seem to help and had to be stopped because it threatened to cause liver damage. Only one patient got tecovirimat, but it did seem to speed her recovery.

Except for the baby, all were in their 30’s or 40’s, too young to have been vaccinated against smallpox. Two reported serious pain from deep or ulcerated lesions that kept them hospitalized longer. All had pox on multiple parts of their body, although photographs with the study suggested that many pox were subtle, not big and scary. Several patients had detectable virus in their nose for three weeks, although it wasn’t clear that it infected that way. One patient had a relapse six weeks later after having sex for the first time; the lymph glands in his groin swelled. The study’s authors speculated that there might be a genital reservoir for the virus.

Management of the seven cases was “challenging,” the authors said, even in a wealthy country like Britain.

Public health authorities, as usual, are tiptoeing around the fact that the disease started in Africa, is rampant in Nigeria and is currently mostly in gay men. They fear stigmatizing Africans, Nigerians and gay men. A good goal — but the wrong tactic, in my opinion. I agree with Jim Downs’ essay in The Atlantic: Too much politically correct caution can kill — and then you get the backlash anyway.

People at risk need to be urgently warned and protected. That’s not easy. I know from covering H.I.V. that well-educated urban gay men are connected to the medical system — and they keep abreast of the news. Poor and rural gay minority Americans are not and do not. I assume the same kind of schism exists in the modern African diaspora. This outbreak must be stopped — soon. If it is not, it could lead to discrimination, hatred and violence, as it has for Asians.

I’ve also heard experts say: “Now that all doctors are on alert, we’re going to be able to diagnose cases fast.” That’s not my experience. Many primary care physicians don’t keep up. I’ve been stunned by how much bad advice some of my friends have gotten from their doctors over the past two years about testing, quarantines, monoclonal antibodies, Paxlovid and other issues. (Not to mention the actual MDs out there prescribing ivermectin or giving people notes excusing them from vaccination — why can’t state licensing boards and professional societies crack down?)

Testing needs to speed up. It’s currently centralized at the C.D.C. — which is how we flew blind for a month and Covid got out of control in this country.

Monkeypox is currently not making big headlines. Perhaps for that to change we’ll have to wait for the first death in this wave — which seems sadly inevitable. Remember Mitchell Wiener, the Queens assistant principal who was New York City’s first swine flu death, the one that made Americans take it seriously? That was more than three weeks after the virus in Mexico became front-page news.

With an incubation period of two to three weeks and typical reporting delays, most cases were are learning about now are likely in people infected before most Americans had even heard of monkeypox. If this is going to be stopped, we need to do more, and faster. This window of opportunity is closing.

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New York Times, 1976–2021. Last beat: lead Covid reporter. 2020 Chancellor Award; 2021 NYT team Pulitzer donaldgmcneiljr1954@gmail.com

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Donald G. McNeil Jr.

Donald G. McNeil Jr.

New York Times, 1976–2021. Last beat: lead Covid reporter. 2020 Chancellor Award; 2021 NYT team Pulitzer donaldgmcneiljr1954@gmail.com

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