Monkeypox Outbreak a “Significant Event” But Not a Crisis…Yet

An expert cautions against panic but advises careful study and robust public health response.

Anne W. Rimoin, PhD, MPH, has been studying monkeypox for more than 20 years. Although her work has focused primarily on the spread of the virus in central Africa, specifically in the Democratic Republic of the Congo, she has sufficient experience with its dynamics to provide perspective on the seriousness of the threat it poses in Europe and North America.

And, while she describes the case clusters being reported in England and the United States—where, as of this writing, there has been 1 confirmed case and 6 others under investigation, according to the Centers for Disease Control and Prevention (CDC)—as a “significant event,” it is not a crisis or cause for panic.

At least not yet.

“This is a known pathogen,” Rimoin, PhD, MPH, professor, Department of Epidemiology, Gordon-Levin Endowed chair in Infectious Diseases and Public Health, director, Center for Global and Immigrant Health, director, UCLA-DRC Health Research and Training Program UCLA Jonathan and Karin Fielding School of Public Health, told Contagion. “We have vaccines, and we have therapeutics. However, we are seeing the virus move through populations in ways we haven’t seen before, so it is a situation that requires a lot of study and action.”

In addition to the known therapeutics, including tecovirimat, a study with 7 monkeypox patients published on May 24 by The Lancet Infectious Diseases revealed that the antivirals brincidofovir may also be effective at treating the disease.

The US has, in fact, seen a much larger outbreak of monkeypox—in 2003, when there were 47 people infected (with no fatalities). However, that was before the COVID-19 pandemic, which has changed the public’s view of infectious diseases and outbreaks, possibly forever.

On May 22, President Biden described monkeypox as a “concern in that if it were to spread, it would be consequential.” Still, he noted that the nation has stockpiles of the smallpox vaccine, which works against it, and that he doesn’t believe quarantines will be needed to contain its spread.

Belgium became the first non-African country to impose a quarantine on May 20, when it announced that those infected—there are 4 confirmed cases there—would be required to isolate for 21 days.

Rimoin agrees that the US hasn’t reached the point where similar measures are needed, though confirmed cases should definitely isolate. That said, due to the COVID-19 pandemic, “the public is much more familiar with tools such as contact tracing, case investigation, and quarantine and we need to leverage that and keep all of these options on the table should we need them,” she said.

So far, the CDC has warned travelers to “practice enhanced precautions,” while emphasizing that the “risk to the general public is low.” Examples of precautions include avoiding close contact with sick people, contact with dead or alive animals, and eating or preparing wild game. The agency also advises frequent hand washing and that travelers who develop monkeypox symptoms avoid contact with others.

As of May 24, cases of monkeypox have been identified in the US, Canada, Israel, and 14 European countries. The confirmed case in the US—involving a man in Massachusetts—had recently travelled to Canada, where 13 suspected cases of the virus are being investigated. As of this writing, he has been hospitalized and is in good condition, based on media reports.

In addition, New York City health officials have said that they are investigating a single “presumptive” case.

That some cases in these countries have occurred in men who have sex with men likely reflects the virus “taking advantage of close contact situations,” according to Rimoin.

“It has nothing to do with who is having sex with whom—these cases could have happened on spring break in Cancun,” she said. “As always, we have to be very careful to avoid stigmatization.”

Indeed, stigmatization can ultimately hamper scientific investigations of infectious disease outbreaks, she added, something that is vitally needed here given that “we don’t have great situational awareness of this outbreak yet.” The United Nations’ Aids agency has called some reporting on the monkeypox virus racist and homophobic.

Although anyone who has close contact with an infected person is at risk of contracting monkeypox, the good news, relatively, is that the current confirmed cases involve the “more mild, West African form” of the virus, according to Rimoin.

Countries that have had high case fatality rates during previous outbreaks have generally been low-resource settings with low access to supportive care. In addition to protecting against spread domestically, the US has an obligation to assist these countries with case investigation and smallpox vaccine access, Rimoin said.

“This outbreak is occurring at a time when we have waning population immunity to pox viruses globally,” she said. “So, biologically it makes sense, but we still need to understand what’s going on out there and why.”