As of Wednesday, there have been over 2,300 cases of monkeypox reported in the United States. The spread of the virus—which can cause painful, disfiguring lesions and possible blindness—has triggered a great deal of fear in the wake of the nation’s mishandling of COVID-19. That fear was only exacerbated when a graphic circulated around social media suggesting that monkeypox spreads easily through the air and can only be stopped by a medical-grade respirator rather than the type of masks that have become so familiar.
People have a right to be scared. And considering that we’re still in the middle of a pandemic that we’re apparently not even trying to contain, they have a right to be skeptical about anything they’re hearing when it comes to a disease spreading across the nation.
But much of what’s being shared online at the moment falls into the categories of click bait and scaremongering. Monkeypox is a real threat, but it is not a “start wearing a class-three isolation suit on the subway” kind of threat. Not only is airborne monkeypox not something you should be concerned about, but there are very effective ways to prevent the spread of this disease … thanks to its relatives.
Here’s a story you probably don’t know. In July 2015, a woman went to her doctor in Fairbanks, Alaska, out of concern over a number of small sores on her hands and some body-wide muscle aches. After a few tests at a local hospital, it was determined that the woman was infected with an orthopoxvirus, the kind of virus that contains most of the diseases that have historically been called a “pox.” What’s more, this was a never before seen virus, a novel orthopoxvirus that was given the name “Alaska pox.”
The discovery of a novel virus in the same family as variola, the virus behind smallpox, which was responsible for 300 million deaths in the 20th century alone, was obviously concerning. However, over the next six years, the total number of Alaska pox cases grew to … four.
Alaska pox, as it turned out, likely can’t spread person to person and is spread by coming into contact with one of the many animals that people in Alaska seem to get involved in handling. Seven years later, we’re still not sure which animal that may be. This is a good example of how a disease may be novel, it may be closely related to a disease with the highest kill count in history, and it can still be essentially harmless. In this case, even the small lesions caused by the disease seem to heal up neatly in a couple of weeks.
Smallpox is the greatest killer in the history of mankind. Alaska pox is a temporary inconvenience to a few people. And, big surprise, most pox viruses fall somewhere in the middle, with most of those that can affect people being a lot closer to the Alaska pox pole.
So what do we know about monkeypox?
As far as pox virus go, monkeypox is actually pretty bad. It can cause very serious lesions anywhere on the body that leave the kind of disfiguring scars that helped make pox viruses so dreaded in the past. Those lesions can be painful. They can cause blindness when they occur in the area of the eyes. If you know someone with a bad case of shingles, think about that. Only worse. Somewhere between 1% and 4% of those infected, usually young children or adults with compromised immune systems, will die from the disease (and yes, that’s a broad range). While monkeypox can be bad, most cases of monkeypox are much milder—it can come and go with few symptoms.
It’s absolutely true that monkeypox can be spread by respiratory droplets. It can also be spread by contact with respiratory droplets or fluids from lesions left behind on surfaces, and the virus can remain viable on surfaces for a period of days. Maybe even weeks.
However … most of the warnings, and most of the information on that scaremongering graphic that’s been going around, don’t have much connection to how monkeypox actually spreads person to person. The cautions on that image and many of those that get relayed in the media come from past experience in handling monkeypox outbreaks … among monkeys. Anyone who has read Richard Preston’s fascinating and terrifying book The Hot Zone has some idea of how monkeys, especially those used in medical testing, are treated and housed, and how difficult it can be to contain some really damn scary bugs when they began to spread among rooms of angry, highly-stressed, feces-flinging, pee-spreading, bitey little primates who most definitely did not want to be part of your damn experiment in the first place.
It should be absolutely no surprise that health officials recommend much more serious gear for entering a room with racks of sick monkeys than for your afternoon run to Sav-a-Lot. Do not feel like it’s time to switch from your N95 mask to something Dustin Hoffman might have worn in Outbreak.
The biggest problem with monkeypox isn’t that it’s spread through the air, and it’s definitely not sex—gay or otherwise. It’s simply that monkeypox is mostly spread through contact, and that the period of infection is so, so long. Basically, someone can spread monkeypox as long as they have lesions, which can be a period of weeks. They may even be able to spread the disease a week or two after the last dried and ugly scab drops away.
The number of cases now known in the United States is exactly the kind of thing that can be handled through contact tracking and quarantine. The problem is the length of that quarantine. The length of symptoms averages around three weeks, but can run to a couple of months. People who have been diagnosed with monkeypox should be isolated through that period, with a good seven to 10-day safety margin after the last lesion has cleared. And every surface in the house needs a heavy duty bleach-y cleaning before anyone else touches anything.
The number of monkeypox cases in the U.S. is also definitely at the level where local, state, and federal agencies can, and should, be providing housing options for those infected so that they can not only get adequate treatment, but remain isolated safely. Except in Florida, of course, where Gov. Ron DeSantis is surely drafting an executive order that monkeypox patients be added to every classroom.
The fact that case counts doubled in the U.S. over the last week is absolutely cause for concern. Monkeypox can be deadly, it can be horrific even it’s not deadly, and children are one of the groups who suffer most from infections.
The good news here is that:
1) You are extraordinarily unlikely to catch monkeypox through the air unless you’re really face to face with someone who is infected,
2) Orthopoxviruses of all kinds tend to be “nonevasive.”
These are DNA viruses, and most are very simple (variola viruses have just 200 to 500 base pairs). That means that not only are specific vaccines against monkeypox pretty much 100% effective, but vaccines against any other pox virus are also expected to be highly effective in preventing monkeypox. Compared to the 30,000 rung ladder of COVID-19’s RNA, these viruses tend to be much more stable, much easier to stop. A vaccine against an orthopoxvirus doesn’t just stop severe infection, it stops an infection from even getting started.
This is, after all, how vaccination got started in the first place. Back in 1796, English physician Edward Jenner did an impressive bit of detective work. He realized that “skin like a milkmaid” wasn’t just a saying, but that the young women who grew up working in dairies actually did have smooth skin, unblemished by the pox scars that were then so common. He put this observation together with the realization that milkmaids often caught the mild disease cowpox, which usually just caused sores on the hand, in their childhood. Jenner realized that this was apparently protecting them from the disfiguring and deadly infection of smallpox.
He then did what any good scientist of the day would do when he didn’t have a handy roomful of caged monkeys: Jenner turned a 9-year-old boy into a test subject. The good doctor first took material from a sore on the hand of a milkmaid, made a few scratches into the arm of his gardener’s son, and rubbed in that good old pus. Then he waited a few months, and purposely exposed the kid to smallpox. The boy did not develop smallpox.
Anyway, most people today have not been vaccinated for smallpox. That’s because the effectiveness of smallpox vaccine, and the nonevasive nature of the virus, allowed us to drive that bastard to extinction. But smallpox vaccine is still available, so it is possible to conduct campaigns of vaccination, especially in areas where there have been outbreaks.
There is also a vaccine specifically developed for monkeypox, the Jynneos vaccine, 190,000 doses of which have been dragged out of the Strategic National Stockpile to administer to those in close proximity to known cases. More of this vaccine will definitely be needed, and more is coming, but the manufacturing rate is low because there’s never been much demand.
Monkeypox can also be treated with antiviral drugs.
It is highly unlikely that monkeypox is going to explode into a nationwide epidemic, or worldwide pandemic. Good evidence for this can be found in the fact that monkeypox is already endemic in several nations in Africa, but it has rarely been responsible for more than a few clusters of disease in any year. There have been past outbreaks, including in the U.K. and the U.S., but none of them really amounted to much. (A 71-case cluster in the United States back in 2003 began with a girl who was bitten by a prairie dog. Don’t f**k with prairie dogs.)
When COVID-19 first appeared, it had a basic reproductive rate—that R0 number—of about 2.5. As each new and more infectious variant has appeared, that number has marched steadily upward. The R0 of the latest omicron variants is estimated to be a truly terrifying number somewhere above 18. COVID-19 may now be the most infectious disease we know.
Monkeypox has an estimated R0 of 0.8 to 1.0. Meaning that on average, a person with monkeypox infects one other person. An R0 value like this means that a spread of a disease can definitely be stopped before it becomes widespread—if authorities will practice good case tracing and people will cooperate in effective quarantine.
Should you be concerned? Yes. That’s an absolutely reasonable response. Should you be concerned that the United States is about to see a second COVID-level pandemic even before we finish with the first one? Also yes … but not monkeypox. It’s clear we’re going to be living with COVID-19 for years or decades, because both individuals and governments seem to have accepted that 200,000+ people dying each year and millions acquiring a long-term disability is a peachy price for being able to enjoy date night at Applebee’s.
We will face some new fast-spreading disease where every passing day could mean millions of lives. Monkeypox isn’t it.
Wear a mask outside your home, more for COVID-19 than for monkeypox. Wash your hands. If you know that some people in your area have been infected, take that into account and think about wearing disposable gloves or diligently using bleach-based wipes on things like that grocery cart handle. But don’t start shopping NASA surplus for leftover moon suits. Unless you just want one. Those things are cool.