We haven’t been able to get over the monkeypox outbreak, and we may have missed the opportunity to prevent the disease from becoming endemic – and a permanent threat – in the US and Europe.
Monkeypox is rapidly spreading around the world, especially in the United States and Europe. With cases doubling every two weeks or so, there is a growing risk that monkeypox will become a permanent problem in countries where, previously, outbreaks were rare and small.
In other words, smallpox is almost endemic in many new places. When that happens, it can become very difficult to eradicate. Monkeypox, which causes fevers and rashes and is fatal in a very small number of cases, will become yet another disease of constant concern to people.
For smallpox, there are two roads to endemism. If the virus infects people quickly enough to surpass authorities’ efforts to detect the transmission and vaccinate those at risk, it could become endemic in humans. “We’re getting close to this already,” James Lawler, an infectious disease expert at the University of Nebraska Medical Center, told The Daily Beast.
The good news with this kind of endemism is that it isn’t to have be permanent. Reversing human endemicity is difficult, yes, but it is possible. “If it only spreads in humans, it can be controlled — eventually — through vaccination and natural immunity,” Amesh Adalja, a public health expert at the Johns Hopkins Center for Health Security, told The Daily Beast.
But monkeypox was originally a “zoonotic” animal virus. It circulates in rodent and monkey species in West and Central Africa where outbreaks in the human population are frequent.
If the smallpox finds a home in some animal species in North America or Europe, for example squirrels, rats or prairie dogs, it is virtually impossible to eradicate regionally. “Game over,” Lawler said. The smallpox will be all around us, probably forever, waiting for opportunities to spread from animals to humans. Outbreaks will be frequent and large, as they are now in West and Central Africa.
To be clear, smallpox is not yet endemic to humans or animals in the United States or Europe. But the trends are not encouraging. “I share the concerns of other scientists about the containment and becoming endemic of the virus in our American rodent population,” Stephanie James, the head of a viral testing lab at Regis University in Colorado, told The Daily Beast.
Officials first noticed the current outbreak, involving a relatively mild West African strain of smallpox, following the diagnosis of a British traveler who returned from Nigeria in early May. The smallpox spread through close physical contact, including sex, and soon joined travelers on planes bound for distant lands. Doctors diagnosed the first US case on May 27.
But it is now clear that the first diagnosed cases of smallpox in Europe and the US were not the real first cases. On June 3, the US Centers for Disease Control and Prevention announced it had found genetic evidence of US smallpox cases predating the first cases in Europe as of May.
“The rapid spread of Monkeypox to humans is a preventable tragedy. But it could be much worse.”
Doctors may not have noticed or reported these previous infections at first because of the similarity between smallpox symptoms and the symptoms of some common sexually transmitted diseases such as herpes. “The virus masqueraded as a sexually transmitted infection and had been spreading clandestinely for several months,” Adalja explains.
The virus was ahead of the curve, helping to explain why months later, it continues to intensify efforts to contain it. According to the CDC, there were 20,638 confirmed cases in 77 countries on Wednesday. That’s more than less than 10,000 cases two weeks ago. The World Health Organization has counted five deaths caused by smallpox in non-endemic countries.
What’s frustrating for epidemiologists is that, in theory, we had all the tools we needed to quickly contain a smallpox outbreak. Thanks to COVID, health professionals around the world are better than ever at contact tracing. Vaccines and therapies that work for smallpox also work for monkeypox. There is a proven strategy: diagnose cases, isolate and treat the infected, vaccinate their family, friends and colleagues.
And educate the public, especially the highest-risk groups, including men who have sex with men.
But so far the strategy is not working. Part of the problem lies with the virus itself, Lawler said. “The disease is different from the monkey pox we’ve seen in the past. I don’t think we know why – probably a combination of virus, hosts and environment.”
Most of the time it’s our fault. Too many doctors have misdiagnosed smallpox as herpes or another STD. The WHO and CDC have both waited too long to declare the smallpox outbreak a public health emergency and mobilize resources. The WHO declared a state of emergency on July 23. The CDC is expected to do the same in the coming days.
Authorities are deploying more vaccines and therapies and encouraging testing. Yet the clinics that are on the front lines of public health in the US need more than that. More testing. More vaccines and therapies. More money for community work. The US National Coalition of STD Directors recently surveyed 100 clinics and found that half were unable to handle the monkeypox outbreak.
“We’re still going too slow,” Lawler warned. And, he added, “we still reject the possibility of the unexpected.” Including the increasing likelihood of the smallpox spreading to squirrels or rats.
The FBI appears unable to deal with “reverse zoonotic” human-to-animal transmission. To prevent animal endemism, you need to detect smallpox infections in a species, kill the infected animals, and then keep a close eye on the remaining population to make sure you’ve eliminated all the virus.
But it’s not clear who should take the lead in the federal health agency. “Operational response to zoonotic diseases falls into this gray area,” Lawler said. The CDC maintains a website that describes smallpox symptoms in pets and livestock and explains where to send samples for diagnosis. The Animal and Plant Health Inspectorate of the Ministry of Agriculture monitors diseases in animals. Especially cattle.
APHIS could not or would not confirm that it tests animals for monkey pox. The agency referred The Daily Beast to the CDC, which did not respond to an email asking for comment. If there is a leading agency for detecting smallpox in animals, that agency seems reluctant to take responsibility.
The rapid spread of Monkeypox to humans is a preventable tragedy. But it can still be a lot worse. With hard work and a little luck, it is still possible to contain and ultimately eliminate the human outbreak.
But if American or European rodents get the smallpox, the outbreak will escalate into something much worse. A new endemic disease. One that is nearly impossible to eradicate.