Cory Franklin and Robert A. Weinstein
Monkeypox is a viral disease, distantly related to its far more deadly cousin, smallpox. So far this year, it has been discovered in dozens of countries that are generally not familiar with monkeypox, with about 113 cases in the U.S., 15 of them in Illinois.
First documented in people in Africa in 1970, monkeypox has probably been circulating in central and west Africa for decades. It gained its name because it was originally discovered in monkeys.
The current version of monkeypox does not spread easily; spread appears to require close contact, in particular sexual contact, with an infected individual. The mortality rate is currently in the range of 3% to 6%, according to the World Health Organization, and to date there have been no recorded fatalities this year in the U.S. So no worries, right?
Yes and no.
The threat monkeypox poses to the general U.S. population is quite small. It is much easier to control an outbreak of this disease than it has been for COVID-19, which is transmitted through the air and behaves more insidiously because it can spread before symptoms appear. Moreover, when contracted, monkeypox is generally mild. Flu is the bench mark we have been using to gauge COVID-19, and this generation of monkeypox is less dangerous than the flu by orders of magnitude. Although this spate of monkeypox is more widespread globally than any previous outbreak, it seems unlikely it will become the cause of our next major pandemic.
The danger lies not in the current iteration of the disease but in what it could threaten in the future. A previous small outbreak of monkeypox in the U.S. in 2003 was caused by the importing of small pet mammals into the country from Africa. (The rodents transmitted it to prairie dogs, which then transmitted it to people.) There was no evidence then of person-to-person spread. The director-general of WHO now says: “The global outbreak of monkeypox is clearly unusual and concerning. The virus is behaving unusually from how it used to behave in the past. But not only that, it’s also affecting more and more countries.”
The monkeypox outbreak is an illustration of how quickly an infectious disease — bacterial, viral or parasitic — can jump from animals to humans. The transition to humans may be through the food we eat, the water we drink, the air we breathe or simply through direct contact with animals.
Once an animal disease has made the transition to humans, it can easily relocate anywhere in the world in hours via jet travel, especially if it initially presents with few signs or symptoms. Moreover, as COVID-19 demonstrated, the possibility the infectious agent will mutate into new strains is ever present. One of the things we got wrong about COVID-19 early in the pandemic was our belief that any variants would take a long time to develop.
This puts great pressure on public health officials here in the U.S. and worldwide to respond quickly once a potential threat emerges. In theory, a coordinated approach between the WHO and every country sounds ideal. In practice, that was another lesson learned from COVID-19 — each country sees the risk differently and responds in its own way.
To add to this, just as Russian writer Leo Tolstoy observed that every unhappy family is unhappy in its own way, every potential infectious threat requires its own response. Nevertheless, some things remain true, no matter the situation.
Public health must provide good surveillance in every country, with teams of trained observers watching for the first sign of an outbreak anywhere. Along with this should come reliable data reporting from trustworthy sources. There should be precise identification of the offending agent as early as possible including prompt identification of the specific molecular gene patterns. Early in the COVID-19 pandemic, the U.S. was slow to map the virus’s genetic sequences. That made it hard to identify emerging variants.
In preparing Americans for monkeypox, WHO and U.S. officials should combine these approaches with efficient communication among countries and better messaging to the public than we saw with COVID-19. As the situation on the ground changes, as it always does, it will require flexible responses. Finally, of course, there is humility. Another lesson from early in the pandemic: We thought we knew more than we did and underestimated, and continue to underestimate, Mother Nature.
Throughout history, the worst pandemics — influenza, smallpox, cholera, bubonic plague, AIDS and now COVID-19 — have been global scourges that have killed millions and devastated societies. Monkeypox is not that, but the current outbreak is an urgent warning that as far as infectious diseases are concerned, the world continues to shrink — quickly.
In the words of the ancient Chinese writer and philosopher Sun Tzu, “Plan for what is difficult while it is easy, do what is great while it is small.”
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