We failed to deal with the monkeypox epidemic, and we may have missed the chance to stop the disease from becoming endemic—and a constant threat—in the US and Europe.
Monkeypox is spreading rapidly throughout the world, especially in the United States and Europe. With cases doubling every two weeks, there is a growing risk that monkeypox will become a permanent problem in countries where outbreaks were previously rare and small.
In other words, smallpox is close to becoming endemic in many new places. If this happens, it can become very difficult to eradicate. Monkeypox, which causes a fever and rash and is fatal in a very small number of cases, will become another disease that people have to worry about all the time.
There are two pathways to endemicity for smallpox. If the virus infects enough people quickly enough to outpace authorities’ efforts to track transmission and vaccinate at-risk individuals, it could become endemic in humans. “We’re getting close to that,” James Lawler, an infectious disease expert at the University of Nebraska Medical Center, told The Daily Beast.
The good news with this kind of endemicity is that it doesn’t have to be permanent. Reversing human endemicity is difficult, yes, but possible. “If it only spreads in humans, it can be controlled — eventually — through vaccination and natural immunity,” Amesh Adalya, a public health expert at the Johns Hopkins Center for Health Security, told The Daily Beast.
But monkeypox was originally a “zoonotic” animal virus. It circulates among rodent and monkey species in West and Central Africa, where outbreaks in the human population are frequent.
If smallpox finds a home in some animal species in North America or Europe — say, squirrels, rats or prairie dogs — it will be nearly impossible to eradicate in the region. “Game over,” Lawler said. Smallpox will be all around us, probably forever, just waiting for opportunities to spread from animals to humans. Epidemics will be frequent and large, as now in West and Central Africa.
To be clear, smallpox is not yet endemic in humans or animals in the United States or Europe. But the trends are not encouraging. “I share the concern of other scientists about containment and the virus becoming endemic in our U.S. rodent population,” Stephanie James, head of a virus testing laboratory at Regis University in Colorado, told The Daily Beast.
Officials first became aware of the current outbreak, involving a relatively mild West African strain of smallpox, after a UK traveler returning from Nigeria was diagnosed in early May. Spread through close physical contact, including sexual intercourse, smallpox soon accompanied passengers on airplanes traveling to countries far and wide. Doctors diagnosed the first case in the US on May 27.
But it is now clear that the first diagnosed cases of smallpox in Europe and the US were not the true first cases. On June 3, the US Centers for Disease Control and Prevention announced that they had found genetic evidence of smallpox cases in America predating the first cases in Europe since May.
“The rapid spread of monkeypox among humans is a preventable tragedy. But it could still get a lot worse.
Doctors may not have noticed or reported these earlier infections at first because of the similarity between the symptoms of smallpox and the symptoms of some common sexually transmitted diseases, such as herpes. “The virus masqueraded as a sexually transmitted infection and spread secretly for several months,” Adalya explained.
The virus had a big head start, which helps explain why months later it is still outpacing intensified efforts to contain it. There were 20,638 confirmed cases in 77 countries as of Wednesday, according to the CDC. That’s up from less than 10,000 cases two weeks ago. The World Health Organization has counted five smallpox-related deaths in non-endemic countries.
What’s frustrating for epidemiologists is that, in theory, we had all the tools we needed to quickly contain the smallpox epidemic. Thanks to COVID, healthcare workers around the world are better than ever at contact tracing. Vaccines and therapies that work for smallpox also work for monkeypox. There is a proven strategy: diagnose cases, isolate and treat the infected, vaccinate their families, friends and colleagues.
And educate the public – especially the most at-risk groups, including men who have sex with men.
But so far, the strategy isn’t working. Part of the problem is the virus itself, Lawler said. “The disease is different from the monkeypox we have seen in the past. I don’t think we know why – probably a combination of virus, hosts and environment.
It’s mostly our fault. Too many doctors misdiagnosed cases of smallpox as herpes or another sexually transmitted disease. Both WHO and CDC waited too long to designate the smallpox outbreak as a public health emergency and mobilize resources. The WHO declared an emergency on July 23. The CDC is expected to do the same in the next few days.
Authorities are rolling out more vaccines and treatments and stepping up testing. However, clinics on the front lines of US public health need more than anything. More tests. More vaccines and therapies. More money to promote the community. The US National Coalition of STD Directors recently surveyed one hundred clinics and found that half did not have the capacity to handle the monkeypox outbreak.
“We’re still going too slow,” Lawler warned. And he added, “we still rule out the possibility of the unexpected.” Including the increased likelihood of smallpox spreading to squirrels or rats.
The feds can’t seem to get a handle on “reverse zoonotic” human-to-animal transmission. To prevent endemicity in animals, you must detect smallpox infections in a species, destroy the infected animals, then carefully monitor the remaining population to ensure that you have eliminated all the virus.
But it’s not clear who in the federal health care establishment should take the lead. “The operational response to zoonotic diseases falls into that gray area,” Lawler said. The CDC maintains a website describing the symptoms of smallpox in pets and livestock and explaining where to send samples for diagnosis. The Animal and Plant Health Inspection Service of the Ministry of Agriculture monitors animal diseases. Especially livestock.
APHIS could not or would not confirm that it tests animals for monkeypox. The agency referred The Daily Beast to the CDC, which did not respond to an email seeking comment. If there is a lead agency for detecting animal pox, that agency doesn’t seem ready to take responsibility.
The rapid spread of monkeypox among humans is a preventable tragedy. But it could still get a lot worse. With hard work and a little luck, it is still possible to contain and eventually eliminate an outbreak in humans.
But if American or European rodents catch smallpox, the outbreak will escalate into something much worse. A new endemic disease. One that is nearly impossible to eradicate.
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