It has been a mere nine weeks since the United Kingdom announced it had detected four cases of monkeypox, a virus endemic only in West and Central Africa. In that time, the number of cases has mushroomed to nearly 13,000 in over 60 countries throughout Europe, North and South America, the Middle East, new parts of Africa, South Asia, and Australia.
The growth in cases and the geographic spread has been rapid and relentless.
Now, even as global health officials race to curb spread of the virus, most experts polled by STAT said they don’t believe it will be possible to contain it.
“I think we missed that train at this point,” said Gary Kobinger, director of the Galveston National Laboratory at the University of Texas Medical Branch and a member of an expert committee that advises the World Health Organization’s Emergencies Program.
The view is equally grim from clinics that diagnose sexually transmitted infections, which have been on the frontlines for monkeypox detection given that the virus is primarily spreading among men who have sex with men in the United States, U.K., and a number of other countries.
“The STI field is preparing for the long haul here,” said David C. Harvey, executive director of the National Coalition of STD Directors, an organization that represents sexual health clinics. “We think, unfortunately, that monkeypox may become endemic among the MSM community.”
Not everyone is categorical — or pessimistic.
Rochelle Walensky, director of the Centers for Disease Control and Prevention, and Rosamund Lewis, the World Health Organization’s technical lead on monkeypox, expressed the belief that with a lot of effort, transmission in the population of men who have sex with men can be stopped.
“I do think it’s still possible. I am so not giving up yet,” said Walensky, who described herself as someone who is in general “pretty optimistic” but who is not “an eternal optimist.”
She noted that when speaking of the prospects for containment, she was talking about the situation in the U.S. — which of course is only one of the countries that will need to stop transmission if the outbreak is to be contained.
Walensky’s optimism in this case derives from the fact that, to date, the virus appears to be spreading mainly within a defined community — one that has mobilized to get out the word of the risk its members face.
“Within this community there was a lot of high-risk [exposures] before we were able to test enough, educate enough, both on the provider side and the patient side. And there’s a lot of that happening right now,” Walensky said.
Lewis was more cautious in her assessment.
“Maybe optimistic is not quite the right word,” she said in an interview from Geneva, where the WHO is headquartered. “I think it can be done, but I’m not necessarily optimistic about it. Because for it to be done requires that all countries pull out all the stops. And that includes countries and jurisdictions that don’t have a case yet.”
Critics of the containment efforts are legion, arguing in social media platforms and published commentaries that access to testing has been inadequate, rollout of vaccine has been too slow, the public health communications have been too tentative. In an effort not to repeat the errors of the early days of HIV, some of the early messaging around monkeypox wasn’t specific enough about who was at most risk.
Others bemoan the fact that the world allowed itself to get in this position in the first place. It’s been clear for the past few years that monkeypox transmission has changed — and not for the better — in Nigeria, one of the countries where the virus lives in rodents and small animals. There have been more cases, and a number of exported cases have landed in the U.K., the U.S., Israel, and Singapore. It was only a matter of time.
“The probability of containment is diminishing daily,” said Anne Rimoin, a monkeypox expert at the University of California, Los Angeles. “It’s really unfortunate because we do have the tools. This is not an unknown virus. … We have vaccines that are already available, even vaccines with indications for monkeypox. Therapeutics. And we know what’s needed to be done.’’
At the same time, there are significant challenges, not the least of which is the fact that two and a half years into the Covid-19 pandemic, public health workforces around the globe are running on fumes.
“I think it’s a daunting task for the countries. And it’s on top of the last [Covid] wave, BA.5. So we are all over our heads,” said Agoritsa Baka, principal expert for emergency preparedness and response at the European Centre for Disease Prevention and Control in Stockholm.
Baka noted that for a while this spring, she was involved in the response to three health emergencies — the ongoing pandemic, the burgeoning monkeypox situation, and the investigation into unexplained cases of severe hepatitis in young children. Fortunately, the latter has been taken off her plate.
“We are piling up one difficult outbreak on top of a pandemic and I think it is too much for the public health services and authorities all over. I think this is the trickiest part,” she said.
There are other innate challenges. People who contract monkeypox are infectious until all their lesions heal, a process that can take several weeks. During that time, they should be in isolation, but that’s a big ask, said Jay Varma, director of the Cornell Center for Pandemic Prevention and Response at Weill Cornell Medicine.
“Most people can’t even spend five days … in isolation for Covid,” he said. “Financially, can they do it?”
Varma is among the people who think global containment of the outbreak is out of reach.
“Globally, the cat is out of the bag,” he said. “Given how in so many parts of the world men having sex with other men is so heavily stigmatized and the places where these people would normally want to seek care for other sort of sexual-related issues are so poorly resourced and the access to biomedical interventions is going to be so limited … I find it very unlikely that you will get to a stage where this is not a disease that isn’t a global disease, as opposed to one concentrated in Central and West Africa.’’
Contact tracers have struggled to find people who may have been exposed to the virus. That would likely have always been true for an infection that is being spread primarily through sexual contact, as appears to be the case with this outbreak. For myriad reasons, people aren’t always willing to share full details of their sex lives. The fact that some men who have sex with men prefer not to be identified as bisexual or gay adds to the complexity, as does the reality that in some countries, gay sex is illegal. And some of the men who have contracted monkeypox don’t know the names of all of their sexual partners.
Some jurisdictions initially thought to offer monkeypox vaccination to contacts of known cases, so called post-exposure prophylaxis. But as the difficulties of contact tracing became apparent, it became clear that approach alone wouldn’t work. Early on, the city of Montreal began to offer vaccine to men who had sex with men who were likely to have more than one sexual partner. Other places, like New York City, have followed suit, offering vaccine to men who have sex with men who have multiple partners or anonymous sex. This approach, called pre-exposure prophylaxis, is effectively trying to stop spread by depriving the virus of susceptible people.
Mathematical modeling conducted for the European Centre for Disease Control and Prevention suggested that if 90% of diagnosed cases are successfully isolated so they don’t transmit to others and contact tracers can find about half of a case’s regular contacts and about 10% of their non-regular contacts (the former being household contacts and a small number of regular sexual partners while the latter being people with whom contact is more fleeting) and if 80% of people who are offered vaccine on a pre-exposure basis agree to be vaccinated, there’s about a 75% chance of containing the outbreak.
There are a lot of ifs in that equation. Baka, one of the authors of the work, said it suggests effective deployment of monkeypox vaccine should make a big difference “if we do it right. But then we would need enough vaccine.”
Therein lies the rub. Monkeypox vaccine is in short supply globally and will be for months to come.
In New York, the city’s health department’s website began accepting bookings at 6 p.m. Friday for 9,200 new vaccination appointments. They were all snapped up by 6:07 p.m.
By the end of July, the U.S. expects to have taken possession of just over 1 million doses of the vaccine, enough to fully vaccinate 500,000 people. (New York has already indicated it will only give people one dose until it is assured it has adequate supply.) But most other countries will be without.
“Right now we just don’t have nearly enough vaccine to even begin to have a measurable impact on widespread global transmission,” said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy. “There’s going to be a lot of frustrated people who want to get vaccine where it won’t be available.”
Osterholm believes the only way to have contained this outbreak would have been to prevent it — by vaccinating the people who had never been vaccinated against smallpox in the dozen or so countries in West and Central Africa where monkeypox is traditionally found, he said. (Smallpox vaccination, which was stopped decades ago when smallpox was eradicated, offers cross-protection against monkeypox.)
Once the virus started spreading in Europe and beyond, he believes the battle was lost. “I think at this point you’d expect to see case numbers go up dramatically over the course of the next several months, in part due to improved surveillance, access to diagnostics, and of course the community spread of infection.”
Osterholm is especially worried — Rimoin shares his concern — about the prospect that people might spread monkeypox to animals in the new parts of the world where the virus is now circulating. Rodents and small mammals — things like squirrels and prairie dogs — are highly susceptible to this virus. If “reverse zoonoses” occur, the virus could become entrenched in countries far beyond the dozen or so in West and Central Africa where monkeypox has been traditionally found.
“Once that happens, we’ll never be able to put the genie back in the bottle,” said Osterholm. “That will be an endemic area, likely forever.”
Baka said she believes the growth of new cases can be slowed, though she worries another type of Covid fatigue — the public’s keen desire to return to pre-pandemic life — is contributing to containment challenges. “I’m a little bit scared with the summer. Because I see a lot of people traveling. Everything is crazy.’’
Rimoin said the world needs to think about what it’s willing to tolerate in terms of a poxvirus getting a much bigger global footprint. Varma agreed, saying that while the disease seems to be milder than previously feared — there have been no deaths to date outside of the endemic countries — past experience should have taught us that when old viruses emerge in new places, we typically learn they have tricks we haven’t anticipated.
He pointed to the fact that a virus spread by mosquitos, Zika, can both be transmitted by sex and can cause profound birth defects when passed from a pregnant woman to her fetus, or that Ebolavirus can lodge in parts of the body where the immune system can’t root it out, leading to recurrent infection in rare cases or transmission via sex.
“We learn things new and none of them ever turn out to be good,” he said.
Though she’s clearly concerned the outbreak may not be stoppable, Rimoin gets frustrated with that line of talk. The fight needs to continue, she insisted.
“We’re losing daylight here. Whether or not we’ve completely lost the battle, I think that’s a little fatalistic. But this is not going to be a black-and-white issue. We may not be able to control it completely, but that doesn’t mean we completely throw up our hands and say: ‘That’s it.’”
Still, she admitted: “This is not going to be a short-term battle.”
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