No sweat, we’ve got this. That’s what we thought when the monkeypox outbreak emerged in May. After all, as an orthopoxvirus, it’s similar to smallpox and so we already have a vaccine — two, in fact. There is also a treatment, it’s generally not deadly, and, as a DNA virus (as opposed to an RNA one like SARS-CoV-2), it’s unlikely to mutate much.
But monkeypox has proved more stubborn than many thought, and governments have been slow to roll out vaccines. We spoke about the reasons why we must stay vigilant.
Therese Raphael: A third monkeypox case in a U.S. child was just reported in New York state. And a dog in Paris caught monkeypox from one of its owners, suggesting the virus can spread from humans to animals. But last month the World Health Organization figures were pretty clear that more than 99% of the cases they tracked in a handful of countries came from men having sex with men. What’s going on now? Should we be more worried?
Sam Fazeli: The latest data from the U.S. Centers for Disease Control and the U.K.’s Health Security Agency still suggest that the virus is overwhelmingly being transmitted among men who have sex with men, although as you say there have been rare cases in children and adults who have not been involved in sexual activity.
What has worried me a little is the case of a U.S. man who had traveled to the U.K. and contracted monkeypox without sexual contact, 14 days after attending a “large, crowded outdoor event” involving a few hours of close contact with others. His symptoms — diffuse skin lesions and pustules not involving the genitals — suggest infection through skin-to-skin contact. But it is important to note that he was on HIV pre-exposure prophylaxis and may have had a disregulated immune system given a recent syphilis infection, and a smaller amount of virus may have been enough to start an infection.
Still, it suggests the risk of spread in such settings. That’s worrying when you think about the start of the school year and the social activity that involves.
TR: What do we know about whether the virus spreads via surfaces?
SF: What we know is that the amount of virus needed to cause an infection is quite high, especially as humans are not the preferred hosts for this virus. As such, it is unlikely that there is enough virus on a given surface such as bedding to infect someone else.
We also know from a recent report that although viral DNA was found in 70% of the specimens taken in the household of two infected individuals, no live virus was found. This suggests that the risk of infection from surfaces may be low, though the individuals had reported cleaning the surfaces they thought might be contaminated, so that might have helped kill any live virus.
TR: What do you make of the animal transmission risk and what precautions should people take?
SF: As noted above, humans are not the natural host for monkeypox virus, which despite its name, originated in rodents. So animals for sure can be infected. The fact that there is now evidence that dogs can also be infected suggests that those who have pets and have active infections must make sure their animals are also kept away from others. Also, whether monkeypox can be transmitted back from pets to humans is not known.
TR: In Washington, D.C., officials are rolling out second vaccine doses, but using only one-fifth of the vaccine — the so-called intradermal method — because vaccine supplies are so low. Is this as effective as getting a full dose?
SF: It’s worth remembering that the vaccine that is being used most, Jynneos from Bavarian Nordic, is a vaccine against smallpox and has never been tested against monkeypox in humans. The data supporting its potential to prevent monkeypox disease is from animal studies. But the smallpox vaccine was essentially delivered intradermally, so there is good precedence for this.
TR: We also have a therapy, tecovirimat, made by Siga Technologies. How effective has that proved to be?
SF: We don’t yet have enough data. The drug was developed for smallpox but is available on a “compassionate use basis” for the treatment of monkeypox.
TR: I want to try to unpack whether we’re winning or losing here. We started tracking monkeypox when the outbreak appeared in May. Since then, more than 14,000 Americans have been infected, more than 16,000 in Europe and some 39,000 globally. The U.S. declared monkeypox a national health emergency in August, not long after the WHO declared it an international public health emergency.
Outbreaks in the U.K., Germany and in some parts of New York and Canada have slowed, however. In terms of the speed of spread and even mutations, are we getting on top of the virus?
SF: I think we definitely can get on top of it, especially given that transmission is still mostly among a particular population. A concerted effort to vaccinate the most at-risk is really important, as is the continued public health management of the situation through awareness campaigns. If we fail, and the virus takes hold among the broader community, or mutates in a way that gives it a better ability to infect humans, then we will facing a much tougher task than we are now.
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ABOUT THE WRITERS
Therese Raphael is a columnist for Bloomberg Opinion covering health care and British politics. Previously, she was editorial page editor of the Wall Street Journal Europe.
Sam Fazeli is senior pharmaceuticals analyst for Bloomberg Intelligence and director of research for EMEA.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
