Monkeypox, once a relatively obscure virus endemic to Africa, has become a global threat, infecting more than 20,000 people in 75 countries and prompting the World Health Organization to declare a global emergency.
On Thursday, the states of New York and San Francisco declared states of emergency. But even as the national tally approaches 5,000 cases and experts warn that containment is slipping, federal health officials have not followed suit.
One reason: This virus — unlike the coronavirus — is a known enemy, officials say. Doctors understand how it spreads, and there are now tests, vaccines and treatments.
But for scientists, the accumulating research paints a more complex and challenging picture. The virus remains a mystery in some important ways, not exactly behaving in ways researchers have seen during sporadic outbreaks in African countries.
Scientists are racing to answer three specific questions that will determine how quickly monkeypox can be stopped — if it can be stopped at all.
How exactly does the virus spread?
At the beginning of the outbreak, health officials claimed that the virus was spread through respiratory droplets released when an infected person coughed or sneezed, and through close contact with pus-filled skin lesions or bedding and other contaminated materials.
It was all true. But it may not be the whole picture.
More than 99 percent of people infected so far are men who acquired the virus through intimate contact with other men, according to the Centers for Disease Control and Prevention. Only 13 women and two young children had been diagnosed with monkeypox as of July 25.
Researchers have found the virus in saliva, urine, feces and semen. It is unclear whether these fluids can be infectious and, in particular, whether the virus can be transmitted during sex in ways other than close skin-to-skin contact. But the pattern of spread so far across sexual networks has researchers wondering.
However, it is clear that monkeypox does not spread easily and has not yet spread to the rest of the population. The average person is not at risk from store-bought clothes, for example, or from a passing interaction with an infected person, as some social media posts suggest.
What you need to know about the monkeypox virus
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What is monkeypox? Monkeypox is a virus similar to smallpox, but the symptoms are milder. It was discovered in 1958 after an outbreak in monkeys kept for research. The virus was found mostly in parts of central and west Africa, but in recent weeks it has spread to dozens of countries and infected tens of thousands of people, mostly men who have sex with men. On July 23, the World Health Organization declared monkeypox a global emergency.
I’m afraid I might have monkey pox. What should I do? There is no way to get tested for monkeypox if you only have flu-like symptoms. But if you start to notice red lesions, you should contact an urgent care center or your primary care doctor, who can order a monkeypox test. Isolate at home as soon as you develop symptoms and wear high-quality masks if you need to come into contact with others for medical care.
What is the treatment for monkeypox? If you do get sick, treating monkeypox usually involves controlling the symptoms. Tecovirimat, an antiviral drug also known as TPOXX, can sometimes be used in severe cases. The Jynneos vaccine, which protects against variola and monkeypox, can also help reduce symptoms, even if taken after exposure.
I live in New York. Can I get the vaccine? Adult men who have sex with men and have had multiple sexual partners in the past 14 days are eligible for the vaccine in New York, as are close contacts of infected people. Eligible people who have diseases that weaken the immune system or who have a history of dermatitis or eczema are also strongly encouraged to get vaccinated. People can book an appointment through this website.
According to the CDC, people without symptoms cannot spread monkeypox. But at least one study found the virus in men who had no symptoms. The pattern of symptoms also differs from that seen in previous outbreaks.
In Africa, some people became ill after touching infected animals, consuming wild animal meat, or using medicinal products produced by the animals. They often develop fever and body aches, followed by a characteristic rash first on the face, palms and soles, and then all over the body. Babies and pregnant women appear to be at the highest risk of severe symptoms.
In the outbreak outside Africa, many patients have no fever or respiratory symptoms at all, and the rash is often limited to a few lesions in the genital or rectal area that can easily be confused with various sexually transmitted infections.
Britain has now changed its official description of monkeypox to include lesions in the mouth as well as anal or rectal pain and bleeding. Some scientists speculate that the presentation of the disease in Western countries may accurately reflect the natural course of the virus.
Is one dose of the vaccine enough?
Jynneos, the safer of the two monkeypox vaccines, is made by Bavarian Nordic, a small company in Denmark. Supplies were severely limited, and the Biden administration moved slowly to acquire additional doses as the virus spread.
Federal officials have now ordered nearly seven million doses, which will arrive in batches over the coming months. So far, the administration has sent about 320,000 doses to the states. The Food and Drug Administration said Wednesday it had approved another 800,000 doses, but it was unclear when they would be distributed.
Jynneos should be administered in two doses 28 days apart. But some cities, including Washington and New York, are withholding second doses until more are available, emulating a strategy adopted by Britain and Canada.
Federal health officials advised against delaying second doses. But in studies, one shot of Jynneos seems to protect for up to two years. If this finding holds true in the real world, then delaying additional vaccines could help officials contain the outbreak by immunizing more Americans.
Britain withheld second doses of the Covid vaccine early in the pandemic when supplies were low, noted Tinglong Dai, an expert on vaccine supply at Johns Hopkins University. “The benefit of prioritizing the first doses outweighs the risk,” he said.
There may not be much choice as the criteria for participation expands and riskier people seek photos. Some jurisdictions have already expanded the groups eligible for immunization to include sex workers, patients of sexual health clinics, and clinicians and other employees who may be exposed to the virus on the job.
In Rhode Island, Emily Rogers, a 29-year-old medical anthropologist, said she was able to call the local health department and get an appointment “very, very quickly.”
Ms. Rogers qualified for the shot because she sometimes has sex with men at high risk of monkeypox infection. No one questioned her eligibility. “They weren’t weird about it at all — it was a very smooth process,” she said.
Because of the shortage, the vaccine is only available as a preventative measure, although it can ease symptoms if given within days of exposure.
David Baldwin, 45, a music professor in New York, is eligible for vaccination only because doctors do not believe he is already infected. (His initial symptom was rectal pain.) “As a result, I think I never developed any lesions on my body,” he said.
How well does drug treatment work?
In 2018, the FDA approved a smallpox treatment drug called tecovirimat, or TPOXX, based on data from animal studies. There is only limited data on its use in humans.
Supply is not a problem: the national stockpile contains about 1.7 million doses. Yet the drug was difficult to obtain, and this meant that uncertainty about how well and for whom the drug worked continued, even as the number of cases increased.
Because tecovirimat is not approved specifically to treat monkeypox, it can only be prescribed through a cumbersome “drug investigation protocol,” which until recently required doctors to send the CDC detailed reports, a diary kept by patients to record their progress and photos of the lesions.
With so many hurdles, many clinics don’t offer tecoxiramit at all; even doctors in well-funded institutions could only treat two or three patients a day.
Nephi Niven Stogner, 39, sought help for monkeypox symptoms on July 8. He was in excruciating pain and tried to get tecoxiramit, but was told that others were sicker and needed it more.
While waiting for the medicine in isolation, three new lesions popped up on his back. “It’s like your sentence is being extended,” he said.
Mr. Stogner finally received his first dose on July 21. Within 24 hours, his “lesions went from swollen and red to flat, dark spots,” he said.
Such delays prompted the CDC to relax the rules for access to tecovirimat. The agency now requires fewer patient visits, samples and forms and allows doctors to evaluate patients virtually.
Wider use should mean that scientists and health officials will gain a better understanding of the drug’s efficacy. The new requirements will help the CDC “determine whether and how well this drug works in monkeypox patients,” noted Kristen Nordlund, a spokeswoman for the agency.
The National Institute of Allergy and Infectious Diseases is planning a clinical trial of tecorimat in adults with monkeypox infection, including people living with HIV, that could begin this fall. The agency is partnering with Siga Technologies, which makes the drug, for another trial in the Democratic Republic of Congo, where the virus has been a longtime scourge, also expected to start this fall.
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