We failed to get on top of the monkeypox outbreak and we may have missed the chance to stop the disease becoming endemic—and a permanent threat—in the U.S. and Europe.
Monkeypox is spreading fast all over the world, especially in the United States and Europe. With cases doubling every two weeks or so, there’s a growing risk that monkeypox will become a permanent problem in countries where, before, outbreaks were rare and small.
The pox is, in other words, close to becoming endemic in a lot of new places. If that happens, it might become very difficult to eradicate. Monkeypox, which causes a fever and rash and is fatal in a very small number of cases, will become yet another disease that people have to worry about all the time.
For the pox, there are two paths to endemicity. If the virus infects enough people fast enough to outpace authorities’ efforts to trace transmission and vaccinate at-risk individuals, it might become endemic in people. “We are getting close to this already,” 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 hard, yes—but it’s possible. “If it’s just spreading in humans it can be controlled—eventually—through vaccination and natural immunity,” Amesh Adalja, 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 in rodent and monkey species in West and Central Africa, where outbreaks in the human population are frequent.
If the pox finds a home in some animal species in North America or Europe—say, squirrels, rats, or prairie dogs—it’ll be all but impossible to eradicate regionally. “Game over,” Lawler said. The pox will be all around us, probably forever, just waiting for opportunities to spread from animals to people. Outbreaks will be frequent and big, just like they are now in West and Central Africa.
To be clear, the pox is not endemic in people or animals in the United States or Europe—yet. But the trends aren’t encouraging. “I do share the other scientists’ concern of containment and the virus becoming endemic in our U.S. rodent population,” Stephanie James, the head of a viral testing lab at Regis University in Colorado, told The Daily Beast.
Officials first noticed the current outbreak, involving a relatively mild West African strain of the pox, after diagnosing a U.K. traveler returning from Nigeria in early May. Spreading through close physical contact including sex, the pox soon accompanied travelers on planes heading for countries far and wide. Doctors diagnosed the first U.S. case on May 27.
But it’s apparent now that the first diagnosed pox cases in Europe and the U.S. weren’t the real first cases. On June 3, the U.S. Centers for Disease Control and Prevention announced it had found genetic evidence of American pox cases that predated the first cases in Europe from May.
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Monkeypox’s rapid spread in people is a preventable tragedy. But it can still get a lot worse.
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Doctors may not have noticed or reported these earlier infections, at first, owing to the similarity between pox symptoms and the symptoms of some common sexually transmitted diseases such as herpes. “The virus was masquerading as a sexually transmitted infection and had been spreading clandestinely for several months,” Adalja explained.
The virus had a big head start, which helps to explain why, months later, it’s still staying ahead of intensifying efforts to contain it. There were 20,638 confirmed cases in 77 countries as of Wednesday, according to the CDC. That’s up from fewer than 10,000 cases two weeks ago. The World Health Organization has counted five pox-related deaths in non-endemic countries.
What’s frustrating to epidemiologists is that, in theory, we had all the tools we needed to swiftly contain a pox outbreak. Thanks to COVID, health workers all over the world are better than ever at contact-tracing. Vaccines and therapies that work for smallpox also work for monkeypox. There’s a proven strategy: diagnose cases, isolate and treat the infected, vaccinate their family, friends and co-workers.
And educate the public—especially the highest-risk groups including men who have sex with men.
But so far, the strategy isn’t working. Part of the problem is with the virus itself, Lawler said. “The disease is different than the monkeypox we have seen in the past. I don’t think we know why—probably a combo of virus, hosts and environment.”
Mostly, it’s our fault. Too many doctors misdiagnosed pox cases as herpes or some other STD. The WHO and the CDC both waited too long to designate the pox 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 deploying more vaccines and therapies and boosting testing. Even so, the clinics that are on the public-health front line in the U.S. need more of everything. More tests. More vaccines and therapies. More money for community outreach. The U.S. National Coalition of STD Directors recently surveyed a hundred clinics and found that half lacked the capacity to deal with the monkeypox outbreak.
“We are still going too slowly,” Lawler warned. And, he added, “we are still dismissing the possibility of the unexpected.” Including the increasing likelihood of the pox spreading to squirrels or rats.
The feds seem to be at a loss to deal with “reverse zoonotic” people-to-animal transmission. To prevent endemicity in animals, you have to detect pox infections in a species, cull the infected animals then closely monitor the remaining population to be sure you eliminated all the virus.
But it’s not clear who in the federal health establishment should take the lead. “Operational zoonotic disease response falls in this gray area,” Lawler said. The CDC maintains a website describing pox symptoms in pets and livestock and explaining where to send samples for diagnosis. The Department of Agriculture’s Animal and Plant Health Inspection Service monitors disease in animals. Especially livestock.
APHIS couldn’t, or wouldn’t, confirm it’s testing animals for monkeypox. The agency referred The Daily Beast to the CDC, which did not respond to an email seeking comment. If there’s a lead agency for detecting pox in animals, that agency doesn’t seem eager to take responsibility.
Monkeypox’s rapid spread in people is a preventable tragedy. But it can still get a lot worse. With hard work and a little luck, it’s still possible to contain and eventually eliminate the human outbreak.
But if American or European rodents catch the pox, the outbreak will escalate into something much worse. A newly endemic disease. One that’s all but impossible to eradicate.
