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Image: Toby Morris
Image: Toby Morris

ScienceAugust 22, 2022

Siouxsie Wiles and Toby Morris: What to know about monkeypox

Image: Toby Morris
Image: Toby Morris

Monkeypox is far less dangerous than Covid-19, but a severe lack of vaccines and lingering homophobic stigma are putting the brakes on attempts to eliminate it. Siouxsie Wiles explains where we’re at with help from illustrator Toby Morris.

With the WHO recently declaring the monkeypox outbreak a  public health emergency of international concern, and Burnett Foundation Aotearoa and the Green Party calling on the New Zealand government to adopt an elimination strategy for the disease, here’s what you need to know.

Eliminating monkeypox doesn’t mean lockdowns and closed borders

Let’s just get this clear right at the start. Eliminating monkeypox won’t take the same blunt measures we needed to eliminate Covid-19. Monkeypox is not as infectious, doesn’t spread in the same way, and a vaccine exists, albeit one that’s globally in very short supply right now. Elimination means getting at risk people vaccinated, making it easy for people to get tested and to self-isolate, and using contact tracing to break any chains of transmission.

Now that’s out of the way, here’s a little more about this latest public health emergency.

Monkeypox has nothing to do with monkeys

Monkeypox got its name after causing a smallpox-like disease in monkeys at a Danish research institute in 1958. The virus was isolated from the infected monkeys and found to be closely related to the one that causes smallpox. They called it monkeypox virus which is now often referred to as MPXV, by scientists and medical professionals at least. I’ll come back to this later, but it’s worth remembering that thanks to a global vaccination effort, smallpox was declared eradicated in May 1980.

The first human monkeypox case described (at least in the scientific literature) was in a baby in what is now the Democratic Republic of Congo (DRC) in Africa in 1970. The baby wasn’t infected by contact with an infected monkey, but like the monkeys, by exposure to another animal. It’s thought the natural reservoir for the monkeypox virus might be rodents.

There are at least two distinct versions of the monkeypox virus that cause disease in people. Think of these like the delta and omicron variants of the Covid-19 virus. Similar but different. These were known as the West African clade and the Congo Basin clade. As part of their efforts to ensure the naming of viruses, variants, and diseases doesn’t cause offence to any cultural or ethnic groups, and to minimise any negative impact on trade, travel or animal welfare, the WHO has just announced that the Congo Basin clade will now be known as Clade one (I) and the West African clade as Clade two (II). They also announced that the virus causing the current outbreak is Clade IIb. A group of experts are currently deciding whether a name change for monkeypox the disease is needed, and if so, to what.

Monkeypox – the early years

A good summary of all the monkeypox cases before this current outbreak was published in February in the open access journal PLOS Neglected Tropical Diseases. Reviewing the literature, Eveline Bunge and colleagues found there were sporadic cases of monkeypox, mainly in the DRC, but also in a few other African countries during the 1970s, 1980s, and 1990s. After that monkeypox became endemic in the DRC. The country went from 511 cases in the 90s to over 10,000 probable cases between 2000 and 2009 and then almost 19,000 between 2010 and 2019. Bunge and colleagues also report how the disease changed from being found in young children in the 1970s to young adults in the 2010s. Because most cases in the DRC are probable rather than lab confirmed (it takes precious resources to confirm infections and sequence the virus), it’s not clear whether all recent cases in the DRC have been caused by Clade I.

The first reported human monkeypox cases outside of Africa were in the USA in 2003 when 47 people were infected by pet prairie dogs. The prairie dogs had picked up the virus from infected rodents imported from Ghana for the exotic pet trade. These were infections with the Clade II monkeypox virus.

Clade II popped up again in 2017, this time causing an outbreak in Nigeria. According to one paper about that outbreak, in one hospital at least, the cases were mostly in young men, and many had oral and genital lesions. As the authors noted, it was plausible that the virus may have transmitted through “close skin to skin contact during sexual intercourse”.

Until recently, there had also been a few monkeypox cases in Israel, the UK, and Singapore related to travel to Nigeria.

Monkeypox now

At the end of their paper, Bunge and colleagues wrote: “Monkeypox is gradually evolving to become of global relevance. Surveillance and detection programs are essential tools for understanding the continuously changing epidemiology of this resurging disease.”

How right they were.

In early May, the UK public health agency reported cases of monkeypox in England that had no documented history of travel to Africa. They were causes by Clade II MPXV. By early June there had been over 300 confirmed cases in the UK. Here we are in August, and there have now been more than 41,000 confirmed cases in 94 countries. At the time of writing, we have had four cases in New Zealand.

How monkeypox spreads

MPXV is much more difficult to pass on than, for example, the virus behind Covid-19. All the contact tracing data so far shows that transmission happens between people with intensive close or household contact, including people caring for people with monkeypox like family members or healthcare staff.

Like with smallpox, MPXV causes painful virus-filled open lesions. The virus spreads through close skin-to-skin contact with someone with open lesions. That could be through sex, but it could also be through activities like playing a contact sport, or even breastfeeding. Because some people get lesions in their mouth, the virus may be transmitted through droplets from close and prolonged face-to-face contact. That’s why it’s a good idea for people with oral lesions to wear a mask if around others. The virus may also transmit via contact with heavily contaminated surfaces or objects, like bedding and towels. There’s just been a case of a dog catching it that way, by sleeping in the same bed as its owners.

Just because someone has been exposed to or has monkeypox, doesn’t mean they are gay or bisexual

It’s worth remembering that many infectious diseases spread through social networks. Those networks can consist of households, workplaces, and communities of people with shared lived experiences.

Right now, monkeypox is mostly circulating within the very tight knit community of gay and bisexual men and they need our support to get through this. But, under the right conditions, it could have emerged in any community.

Here in Aotearoa New Zealand, we’re almost famous for how interconnected we all are. We are the embodiment of “six degrees of separation” (or “six degrees of Kevin Bacon” if you are a movie fan), the idea that all people are six or fewer social connections away from each other.

In this global outbreak, cases have been documented to sometimes pop up among other communities. That means that just because someone has monkeypox, or is asked to isolate as a close contact, doesn’t mean they are gay or bisexual.

This is important, because stigma and prejudice surrounding homosexuality can stop people seeking a test or treatment, getting vaccinated, or self-isolating if they need to. Because of how connected we all are, we need everyone with monkeypox or who has been exposed to monkeypox to come forward for testing. That’s the only way we’ll break chains of transmission and stop the virus jumping into other social networks.

In other words, stigma isn’t just bad for people with monkeypox, it’s bad for all of us.

Empty ampoules of Bavarian Nordic’s monkeypox vaccine Imvanex / Jynneos. (Photo: Sven Hoppe/picture alliance via Getty Images)

What to look out for

Monkeypox often starts with one or more of the generic signs of a viral infection we are all now so familiar with – a headache, fever, chills, tiredness, muscle aches, or swollen lymph nodes. After a few days people may start to get a rash. In some people it’s just a few spots in one or two areas of the body, especially around the genitals and mouth. In other people it’s more widespread. The spots then become fluid-filled blisters which can be extremely painful.

Keep a watch out for symptoms, especially if you’ve been overseas recently. If you get blisters or a rash, isolate yourself, including from your pets, and get in touch with your healthcare provider or a sexual health clinic to get tested. That’ll involve having some swabs taken and sent to a lab for PCR to look for the virus.

Most people with monkeypox will recover in two to four weeks without medical treatment. Hydrocolloid acne treatments can help soothe the rash. However, the disease can be much more serious in immunocompromised people. Sadly, 12 people have died in the outbreak so far.

I said earlier there is a monkeypox vaccine, but that it’s currently in short supply. The US has secured most of the current doses so it’s probably best just to consider it unavailable for now. That’s because there is only one small company, Denmark’s Bavarian Nordic, that holds the patent and manufactures the vaccine. Their manufacturing facility is currently out of action because they are making changes that will mean they can make other vaccines. They’re not expecting to bring it back online until the end of the year and have said they won’t start making any new monkeypox vaccine doses until next year. The WHO and other pharma companies have offered to help increase production, but it sounds like those offers haven’t been taken up. This piece on Health Policy Watch is well worth a read. It’s a pretty damning review of the current situation.

Where did this outbreak come from?

It turns out that the chances of a global monkeypox outbreak have been increasing for years, in part thanks to our eradication of smallpox. The smallpox vaccine also protects against other related viruses like monkeypox. With smallpox eradicated, we’ve not had a smallpox vaccine on the routine vaccine schedule for 40 years. The global population was about 4.4 billion in 1980. It’s now almost 8 billion. That means there are well over 3 billion of us now without any immunity and the rest with waning immunity. It’s clear from the growth in monkeypox cases in the Democratic Republic of Congo that waning protection against related pox viruses was becoming a problem.

A comparison of viral sequences suggests that the Clade IIb monkeypox virus causing the current global outbreak jumped from animals to humans sometime in 2016 and has been transmitting under the radar for a few years. One reason it may have been transmitting undetected in Nigeria is because homosexual activity is prohibited there under the Criminal Code Act and the Same Sex Marriage (Prohibition) Act 2013. The maximum penalty is 14 years’ imprisonment. It’s also criminalised at the state level through Sharia law. The maximum sentence there is death by stoning.

As for why we’re experiencing a global monkeypox outbreak now? That’s a good question. It could be related to the Covid-19 pandemic, or the timing could be completely coincidental.

The virus that causes monkeypox doesn’t care about our sexuality. It’s just found an efficient way to transmit between people. We can’t allow stigma to make this outbreak any worse than it already is. That means we all need to put judgement and assumptions aside and make sure our rainbow communities have all resources they need.

That way they’ll stay safe from monkeypox, and they’ll also protect us all from a wider outbreak.

Keep going!