The Monkeypox outbreak in the United States has been spreading at a surprising pace. According to several reports, the number of cases has been severely underestimated.  One of the reasons might be related to testing, as the following ture story about a scientist who thought he had monkeypox illustrates.

A scientist visits the doctor suspecting he has monkeypox. What happened next may surprise you…

The scientist thought he had monkeypox so he went to  his primary care doctor. He says “I have rectal pain and swollen glands and want a monkeypox test.” The doctor says, “this looks and sounds a lot like an STD. I’m going to test you for a sexually transmitted disease instead.” But those tests came back negative and the pain was getting worse, so the scientist went to urgent care and asked again for the monkeypox test. As you might imagine, most urgent care don’t have this test available. Monkeypox is not like strep throat.  It’s a disease that virtually no doctor in the USA has ever seen before. It’s only endemic in Africa. So the doctors at urgent care give him antibiotics to treat him instead for a bacterial infection. Well Monkeypox is viral. It doesn’t get better. It gets really bad. So bad that he can’t sleep at night. The scientist doesn’t give up, he goes to an ER at a big academic hospital in New York. He’s seen by specialists, but they don’t think it’s monkeypox either. They say they won’t test him for it. (It’s probably true that they didn’t test because they don’t have a way to test him for it and at this stage, they might have felt it wouldn’t change the treatment for his condition.) He must have been upset when a few days later, he got a rash, and its characteristic for monkeypox. When NPR published this story on May 25th, the number of cases in the entire USA was around 200 . Less than a month later, New York City alone has over 800 cases and that number is climbing.

What is monkeypox?

Monkeypox is a zoonotic virus that affects animals and humans. It’s thought that the people of Sub-Saharan Africa have been affected by Monkeypox for thousands of years. Monkeypox was first isolated in a lab from infected monkeys in the late 1950’s in Africa. In the Democratic Republic of Congo in 1970 the first humans were infected by the same virus that was identified in 1950.

Have there been prior outbreaks of monkeypox?

The first Monkeypox outbreak in the western hemisphere took place in the midwestern United States in 2003. According to the CDC, all of the 47 reported cases took place after direct contact with infected animals that were imported to the USA from Ghana.

How does it spread?

Prior to the current outbreak most infections took place after contact with infected animals and the chance of spreading between people was low. But recent evidence suggests the current strain spreads between individuals especially in the MSM population.

Are we dealing with a new more infectious strain of Monkeypox?

It’s a little concerning that the current infections are spreading more quickly and between people, that it has infected more individuals than in prior outbreaks and that it’s spreading across the globe. It’s possible that we are dealing with a new strain or that the virus has found its way into environments that make it easier to spread.

Why are we underestimating case counts?

It seems many of the cases may be falling under the radar. We don’t know how many cases there are because  we don’t have a good system of contact tracing for Monkeypox yet. It took a long time to set up this system to conduct contact tracing in COVID. Contact tracing is important to help notify people who were exposed get tested and treated more quickly.

Staying Safe

To stay safe from monkeypox you can practice some of the same procedures you learned during the coronavirus pandemic. Practicing social distancing or wearing a mask if you are in an area with high prevalence or if you are living near someone who is infected is a good start. We have also learned that this is a disease that is spreading through close physical contact between individuals. It is also being spread during intercourse, according to the New York State Department of Health, so wearing protection during intimate activities is advised.

How dangerous is Monkeypox?

Unfortunately, there is a wide range of reported mortality at this stage. There tends to be a bias towards higher mortality rates at the beginning of any outbreak. This was the case during the coronavirus pandemic which had extremely high mortality rates early on during the pandemic. While experts don’t think Monkeypox will spread like Coronavirus, no one really knows. Individuals, with multiple comorbidities, weakened immune systems as well as the elderly, young children and pregnant women are at greater risk from infection. 

Is Monekypox very contagious?

We don’t know. Monkeypox is not believed to have as high an R0 as Coronavirus, but it’s early. Initial testing done from CDC reported 30% positivity rates, suggesting it might be more contagious than we know. But those numbers may have been inflated by a limitation on tests or the populations that were tested. In other words, we need more data.

The Silver Lining

The good news is that not only is there a test, there is also a vaccine.   Monkeypox and smallpox are both part of the variola viral genus. This means that receiving a smallpox vaccine confers protection against Monkeypox.