The news media coverage of the current monkeypox outbreak might bring you to believe we have the next ominous contagion bearing down on humanity now that COVID-19 is in afterglow. Pandemic crises are political and financial windfall opportunities for media as well as political leaders who have now learned to expand their authority… as well as a celebrity opportunity for public health “expert” officials. The public is now on to this, learning to be skeptical and cautious about what they are being messaged with the latest “alert”. It is a great disgrace of my profession that few to no practicing physicians have confronted misinformation and disinformation on publicized medical issues being exaggerated and misrepresented, counter to what the established science can support.
So, I will speak out on monkeypox.
Yes, there is an outbreak with many cases in multiple countries, emerging this past month. What is to be made of this? A new pandemic? Not at all. A few facts will explain the reality.
The monkeypox virus was first discovered in 1958 in some laboratory Rhesus monkeys. The first human case of monkeypox was seen in 1970, just as the smallpox vaccine was being retired. Until recently, almost all cases have been in Central and West African countries. In other words, monkeypox has not caused widespread, international epidemics for over 50 years. Why just Africa? Most likely because cases there have been mostly associated with eating infected monkey meat. Other reservoirs have been prarie dogs and rodents. The point is, it mostly has remained a local infectious disease. I will get back to a more detailed conclusive perspective on this outbreak at the end. However, I want to shift to some brief facts about the monkeypox infection that must be understood to conclude anything, rationally.
- The monkeypox virus is closely related to smallpox virus (a disease eliminated from the world 60 years or so ago). The monkeypox (MP) virus is a DNA virus. Such viruses vigorously self-repair genetic mutations that are inevitable with viral replication, and so they do not characteristically spin-off variants (as do RNA viruses, like influenza and COVID-19), leading to adapting to their hosts to become more transmissible and able to live in their hosts (just ill humans). This single fact is central to the idea that MP outbreaks should be self-limited, once the diagnosis is recognized and sick individuals and their contacts are isolated.
- MP manifests as fever, exhaustion, bodyaches, mouth sores, and a rash that starts on the face and then spreads out to the torso and limbs and palms. The skin lesions start as spots, then bumps, then blisters, and then pustules (pus-filled blisters). It also causes swollen lymph glands, distinguishing it from smallpox.
- MP transmission is by short-range respiratory droplets, rash-associated body fluids, and contaminated bedclothes. The current MP is notably mostly infection of gay individuals who attended “rave” events in Europe as well as other gatherings that featured polygamous sexual activity. MP is not a traditional sexually transmitted infection, rather instead correlated with the prolonged, close physical contact with sex.
- One other critical fact about MP transmission- it does not occur in patients until they have symptoms. So, the rampant spread of COVID, because it was being shed by those carrying the virus, but not ill with it, will not occur with MP. The arrival of the virus is announced by sickness, allowing prompt patient isolation as they become contagious. Finally, MP is not quickly and casually acquired- it requires somewhat prolonged, close exposure to an ill person.
- How dangerous is MP? It is a somewhat slow illness that tends to course over 2-4 weeks. Death rates have ranged between 1-10%. In comparison, smallpox death rates were about 30%. However, these numbers come from the Central African countries where it has been endemic. Frankly, these are medically backward countries with generally impoverished people with limited access to intensive, expert medical care. It is highly likely that the death rate would be many times lower in a “westernized” medical care system.
- Treatment: Currently, treatment would focus on supportive care and possibly vaccine administration to mobilize the immune system with protective MP antibody against the virus early in the course of the illness since the time-course of illness is over several weeks. Smallpox and monkeypox vaccines are effective against MP, but are under restricted access (stockpiled by the U.S. government for use in bioterrorism scenarios).
At this time the vaccine might be released to MP patients, close patient contacts, and healthcare professionals. They will not be released to the general public as a universal preventive like COVID vaccine, because the science does not support MP as a dangerous, widespread, propagating, highly communicable disease.
There are anti-viral agents applicable to smallpox and MP, but MP is usually a miserable, but temporary, illness and these medications bring significant toxicity risk, so they would only be used in the MP extraordinary case of life-threatening MP. To date, no one has died from MP in this outbreak.
All these facts suggest MP will not spread easily or widely as those initially exposed and ill will be promptly quarantined and then the illnesses will resolve. The virus will not mutate into variants, adapting to humans.
It is most likely that the current outbreak is a public health phenomenon of mass exposure of a limited social demographic group engaged in communal and/or polygamous sex with someone having brought MP from its endemic origin in Central Africa. Join this to the fact that anyone born after 1970 did not receive smallpox vaccine, and so does not have some immunity to MP, and the current MP outbreak should be a one-time MP perfect storm of susceptible individuals with behavior that set them up for infection with no lasting effects after several months of the initial cases proceeding through illness and recovery with them and their close contacts under quarantine. Smallpox was declared eradicated in 1980 and MP has been steadily increasing since then. The World Health Organization states that 40 years ago about 80% of the world population was vaccinated against smallpox (lending partial immunity against MP), now only 30%. The worldwide spread can be explained by their travel to concentrate in large numbers at special events, and then return with the MP virus to their countries of origin.
Edward R. Rensimer, MD
Director, International Medicine Center