Health experts agree: the outbreak could soon be labeled a pandemic, if it isn’t already. And the situation is likely to get worse before it gets better. More infections, more deaths, more chance of smallpox mutating. “We’re in uncharted territory with this outbreak … and still early in the event,” James Lawler, an infectious disease expert and Wiley colleague at the University of Nebraska Medical Center, told The Daily Beast. The latest figures from the US Centers for Disease Control are startling. The CDC recorded 9,647 infections as of July 11. This is a fourfold increase compared to just a month ago. “It’s shocking after everything we’ve learned with COVID-19, we’ve let another virus escalate to this point. “ —Lawrence Gostin, Georgetown University The virus, which causes a rash and fever and can be fatal in a very small percentage of cases, is found in 63 countries—57 of which typically do not have monkeypox outbreaks. Cases are concentrated in West and Central Africa – where the virus is endemic – as well as in Europe, where the current outbreak first began in May. But the US also has a staggering number of cases: 865 in 39 states, according to the CDC. That’s five times more than a month ago. “Monkey pox is clearly a global health emergency,” Georgetown University global health expert Lawrence Gostin told The Daily Beast. “It has been simmering in small pockets in Central and West Africa for decades, but until now there have been no non-travel-related cases in the rest of the world. It is now found in almost every region of the world and is spreading rapidly.” The death rate, mercifully, is still low. As of July 4, the latest date for which data is available, the World Health Organization had recorded just three deaths in the current outbreak. Health workers examine passengers arriving from abroad for symptoms of monkeypox at the Anna International Airport terminal in Chennai on June 3, 2022.
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Three out of 9,647 – or 0.03 percent – is a far lower death rate than the West and Central African countries have apparently suffered from their own smallpox outbreaks in recent decades. The worst African outbreaks, involving a strain of the virus endemic to the Congo River basin in Central Africa, have resulted in official death rates of up to 10 percent. But the more viruses spread, the more they mutate — often in ways that make them deadlier. As monkeypox spreads faster than health authorities can contain it, the greater the risk that it will spawn new, more dangerous variants, potentially increasing the death toll. Monkey pox is mainly transmitted through close physical contact, especially sexual contact. However, it is not a sexually transmitted disease. He’s just taking advantage of the skin-to-skin contact that comes with sex. The virus can also travel short distances in spit, though probably not far enough to qualify as “airborne.” Officials first noticed the current outbreak, involving a relatively mild West African strain of smallpox, after they diagnosed it in a UK traveler returning from Nigeria in early May. On a ride to Europe, the virus spread quickly through physical contact. David Hayman, who headed the WHO’s emergency department, said men who attended raves in Spain and Belgium “amplified” the outbreak – apparently through close, sometimes sexual, contact with other men. After that, the virus accompanied travelers on planes headed for distant lands. Doctors diagnosed the first case in the US on May 27. But it is now clear that the first cases of smallpox diagnosed in Europe and the US were not the real first cases. On June 3, the CDC announced that it had found genetic evidence of smallpox cases in the US that preceded the first cases in Europe from May. Doctors may not have noticed or reported these earlier cases at first because of the similarity between the symptoms of smallpox and the symptoms of some common sexually transmitted diseases such as herpes. In other words, today’s outbreak started, and spread, without anyone realizing it at first. The virus had a big head start, which explains why, months later, it still has the upper hand. “By the time we recognized affairs were happening, we were already behind,” Lawler said. Early diagnosis is the key to quickly containing a dangerous virus. If officials know where the virus is concentrated in the early days of an outbreak, they can isolate infected people, conduct contact tracing to identify vulnerable populations, and develop treatments and vaccines to treat the infected and protect the uninfected. (Luckily for us, widely available smallpox vaccines work just fine against smallpox.) With the most likely vectors of infection cut off by early intervention, the virus withers and disappears—before it can mutate into some new variant that might, say, be more contagious or even evade vaccines. This should have happened in April or even earlier, but it didn’t because the WHO, CDC and other health organizations didn’t even know there was a smallpox outbreak. The current, rapid spread is the consequence of this initial failure. Signs from Toronto Public Health offer resources and information about monkeypox at the annual Dyke Walk in downtown Toronto.
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The worst outcome is not hard to imagine. Ten thousand cases could quickly blossom into a hundred thousand cases. Then a million. Various experts and agencies disagree on the exact definition of a “pandemic,” but it’s increasingly likely that the smallpox outbreak qualifies now—or will in the coming weeks. At that point, the world will face simultaneous pandemics. The WHO carefully avoided using the p-word to describe the smallpox outbreak. The CDC did not immediately respond to a query That’s wrong, Lawler said. “We certainly can’t make ‘pandemic’ declarations for every disease outbreak that crosses multiple international borders without becoming the boy who cried wolf,” he admitted. But, he added, “I would argue that we should have learned some humility about emerging viruses by now.” If the word “pandemic” grabs people’s attention and highlights the growing danger, use it. The silver lining is the very low death rate in the current smallpox outbreak. This could be a statistical anomaly resulting from a huge number of deaths in previous African epidemics. “I’m not sure we have a full grasp of the denominator of cases that are actually happening in West Africa,” Lawler pointed out. It means that it is likely that smallpox deaths in Africa were spread over a much larger number of infections than we thought at the time. It’s also possible that we’re seeing a happy side effect of a smallpox outbreak that mainly affects wealthier communities. “Monkey pox is now being diagnosed in urban populations where more people have access to health care facilities,” Blossom Damania, a virologist at the University of North Carolina at Chapel Hill, told the Daily Beast. In any case, we should not be complacent. Smallpox like all viruses treats every infected person like a laboratory. An opportunity to try new things, learn and change. Each additional infection increases the chance of new variants emerging. As COVID has proven time and time again, new variants mean new risks. Greater transmissibility, severity or vaccination – or a combination of all three. There is still time to prevent the worst-case scenario of millions of cases and potentially thousands of deaths. The WHO, CDC and other health agencies must redouble efforts to educate doctors and speed up diagnoses — and then move faster to isolate and treat infected people and vaccinate those around them. “If we can get enough vaccine to high-risk contacts, that will stop,” Amesh Adalja, a public health expert at the Johns Hopkins Center for Health Security, told The Daily Beast. COVID has reminded us how bad a virus outbreak can get. Then came monkeypox to remind us of our strong tendency toward complacency, even in the midst of an ongoing health crisis. “It’s shocking that, after everything we’ve learned with COVID-19, we’ve let another virus escalate to the point of becoming a global health emergency,” Gostin said. To catch the fast-moving pox, what we need now—more than anything else—is a new sense of urgency.
