By now, you’ve probably seen a headline or two talking about outbreaks of monkeypox, which have been cropping up … well, all over the place, actually.
But while news articles – and the images that accompany them – can be scary, should we really be all that concerned? Are we about to see a new pandemic? Are we all going to die? And, frankly, what even is monkeypox anyway?
What is monkeypox?
“The name ‘Monkeypox’ is a misnomer,” said Michael Skinner, Reader in Virology at Imperial College London. “It’s primarily a disease … of small African animals including rodents.”
So why the misleading name? The first examples of the disease were found in monkeys in the late 1950s – but in 1970, the first case was reported in a human.
“Like humans, monkeys sometimes acquire infection from the small animals,” Skinner explained – in fact, one of the larger recent outbreaks outside of Africa was in the US in 2003, in which 73 people caught the infection from prairie dogs.
While you may have seen some alarming statistics about the disease having a mortality rate of one in ten, the reality is more complex.
“Virologists recognize two strains of monkeypox virus,” Skinner said. “The Congo strain is more severe (up to 10 percent mortality) and probably more transmissible in humans than the West African strain.”
But it’s the West African strain that’s responsible for these latest cases, and for that virus “mortality is estimated at about one percent,” Skinner pointed out. That’s still not great – it’s comparable to the mortality risk of COVID, in fact, which has already killed many millions of people – but it’s a lot more reassuring if you happen to start showing symptoms.
And on that note …
What are the symptoms of monkeypox?
So what should we look out for? Symptoms begin a week or two after infection, explained Sanjaya Senanayake, a specialist in Infectious Diseases and Associate Professor of Medicine at the Australian National University (ANU), and the first signs of illness are usually similar to those of other viral infections.
“Following infection, after a 7–17-day incubation period, there is a flu-like illness with high fevers for a few days before the rash appears,” Senanayake said. “It is quite an extensive rash that lasts for up to four weeks and can lead to permanent disfigurement.”
“Pneumonia, diarrhea, and eye involvement can occur,” he added – though “the death rate is low.”
Like other poxviruses, the rash that comes with monkeypox can look like flat lesions or large fluid filled blisters. With monkeypox, though, the pocks are usually concentrated on the face, arms, and legs rather than the trunk of the body.
While monkeypox resembles smallpox in its presentation – a deadly disease that killed millions of people every year before we vaccinated it off the face of the planet in 1980 – it’s less contagious and much less deadly than its predecessor, the WHO explains.
How is monkeypox spread?
Here’s the good news: as far as we know, monkeypox is not very transmissible.
“The disease is caused by the monkeypox virus, which is endemic in various countries in Africa but has caused outbreaks elsewhere before,” said David Tscharke, Head of the Department of Immunology and Infectious Diseases at ANU, and a poxvirus specialist.
“In the past, these outbreaks into human populations have been limited because the spread of monkeypox between people is not very efficient,” he explained.
That’s because transmission requires close contact with an infected person. “We’ve seen infection of close family or household members and carers in hospitals,” Skinner said.
“Transmission does rely on close contact,” he added, “so the wider population is not at any significant risk.”
There are a few potential transmission methods, Skinner explained: “Depending on the stage of infection, close range respiratory or droplet transmission can probably occur,” he said. “Direct contact with lesions will probably transmit the virus, which might enter by the mouth. When the lesions have healed, the scabs (which might carry infectious virus) can be shed as dust, which could be inhaled.”
It isn't generally considered a sexually transmitted disease but the UK's most recent cases have been predominantly among gay and bisexual men, so the UK Health Security Agency has noted it can be passed on through sex by skin-to-skin contact.
Are there treatments for monkeypox?
When SARS-CoV-2, the virus that causes COVID-19, first cropped up at the end of 2019, the world was taken by surprise. But that’s not the case with monkeypox: “It was first identified in humans in 1970, in Africa,” explained Raina MacIntyre, Head of the Biosecurity Program at the Kirby Institute at the University of New South Wales, and an expert in influenza and emerging infectious diseases. “It is a re-emerging disease that's been causing very large outbreaks in Nigeria and DRC since 2017.”
And that means we’re much better prepared than we were with COVID: “There are effective vaccines against monkeypox,” MacIntyre said, such as the second and third-generation smallpox vaccines – “both live virus vaccines using the vaccinia virus,” she noted.
“The third generation vaccines do not replicate in the body and can be used in immunocompromised people,” she added. “There are also effective antivirals against smallpox. It would be wise to ensure we have these and enough of both types of vaccines, together with regulatory processes to use them against monkeypox.”
Existing smallpox vaccines are known to be as much as 85 percent effective against monkeypox. The US currently has enough stockpiled “to vaccinate basically everyone” in the country, according to Thomas Inglesby, the director of the Johns Hopkins Center for Health Security, in The Atlantic, while the UK is now offering a smallpox vaccine to high-risk healthcare workers and others who have been potentially exposed to the virus.
While there are no specific treatments for the infection, studies suggest the smallpox vaccine “can even be effective when given after an exposure to the virus” Tscharke noted. Like many experts, he recommends a strategy known as “ring vaccination” to counter the spread of monkeypox. Rather than mass vaccination, this is where health authorities identify contacts of infected people and vaccinate them pre-emptively – the same technique as was used to eradicate smallpox.
Will monkeypox become a pandemic?
After a quarter-decade spent under various levels of lockdown, it’s natural to wonder: are we about to see another pandemic? But again, monkeypox isn’t COVID – and experts say there’s no need to panic just yet.
“While the new clusters of monkeypox cases in the UK and Europe need to be monitored, there is no cause for panic,” said Fasséli Coulibaly, Associate Professor at the Monash University Biomedicine Discovery Institute and Department of Molecular Biology.
“There are several reasons for this. First, the mode of transmission of viruses from this family does not present the explosive spreading power of respiratory viruses like SARS CoV-2 and influenza virus,” he explained.
What’s more, the structure of poxviruses make them, somewhat paradoxically, easier to combat than other viruses. They “are among the most complex viruses infecting humans,” Coulibaly said, as well as “experts at subverting defense systems put up by their host.”
But with that complexity comes drawbacks: “they are a bit like the elephants of the virus world,” Coulibaly said. “Their structure and replication make them easier to aim at than smaller, moving targets. Indeed, decades of basic research have revealed a few chinks in their armor.”
The sudden uptick in the number of infections across the world, from the UK to the US and Australia, may be evidence of a mutation making transmission easier – and researchers are already hard at work investigating whether that’s the case – but many scientists suspect there may be a less obvious factor at play.
“Our research shows that the waning of immunity from smallpox vaccination may be contributing to the increasing outbreaks of monkeypox – it is more than 40-50 years since mass vaccination ceased,” MacIntyre pointed out.
Prof. Coulibaly echoes the hypothesis: “Why these cases have emerged now in Europe is not known yet,” he said. However, he added, “it is clear … that the virus has been circulating more actively in central and West Africa for decades as immunity to poxviruses conferred by the smallpox vaccine is waning in the general population.”