Chill! Putting Monkeypox in Context

Please read this blog version instead of my original piece about monkeypox, published in the summer issue of Chicago Life Magazine.  Things are changing very fast in this field.  A significant share of the information cited in the first rendition has changed in the two months that have passed since I submitted it in June.  This pace of change will no doubt continue for a while.  So consider what you read below to be as up-to-date as was possible on August 20, 2022.  You can expect that numbers will grow and treatments will evolve.  But the underlying principles of the biology and epidemiology of infectious disease should hold up just fine.

As you know, for many publications there is often a significant lead time between submission and publication of a print article.  (No delay between writing and posting is one of the huge advantages of publishing a blog.)  Because monkeypox had just appeared over the horizon in America, during the interval between when I wrote the piece and when the public received information about the disease was changing ultrafast.  I called the publisher to make some serious edits a couple of weeks after I’d submitted my article in early July.  It was too late.  The edition was already at the printer.

So here, belatedly, are the edits I would have liked to have made to the piece you’re about to read below, plus a few more based on information that has come to light even since magazine’s release date in mid-July. All these changes are incorporated in this blog.

  • As of August 10 there were 14,115 total confirmed cases of monkeypox in the US.
  • Compare that to an average of 106,115 new COVID cases and 265 deaths per day and 759 deaths in the week ending August 10.
  • In the last few months there have been more than 100,000 new cases of COVID diagnosed daily.  Based on the huge number of unreported positive home tests, the actual total is much, much higher.
  • On July 23 the World Health Organization declared monkeypox a global health emergency.  The Biden Administration labeled monkeypox a public health emergency on August 4.  
  • In August the US Department of Health and Human Services said there were 1.1 million doses of JYNNEOS monkeypox vaccine on hand in the nation.  HHS has developed a clear national distribution strategy.
  • Epidemiologists and infectious disease specialists are still figuring out how the disease is transmitted from person-to-person.  How much skin-to-skin contact must there be to pass it on?  Is the disease ever contracted via the respiratory system?  Inhalation doesn’t appear to be a very likely road to infection.
  • At this time monkeypox is especially, but certainly not solely, afflicting the community of men who have sex with men.  Public health officials are very aware of the risk of stigmatizing this population, as happened with HIV, which was also transmitted by other means than gay male sex.  There is a parallel danger of lulling the rest of the population into believing they cannot contract monkeypox, thereby not protecting themselves from the virus nor recognizing it when it strikes.
  • In spite of this new slug of concerning data about monkeypox, the main point of the story remains.  The risk of contracting this disease and the relatively low level of its severity most of the time is way, way less than other epidemics human beings have faced recently, as well as in the distant past.  You ought to be aware of monkeypox but you can still chill.

BTW, Chicago Life, circulation over 100,000, is distributed quarterly with the New York Times and the Wall Street Journal as a supplement to their Sunday edition throughout the Chicago area.

Chill! Putting Monkeypox in Context

What can I tell you, well-informed reader, that you don’t already know about monkeypox?  How’s this?  CHILL!

Monkeypox is a new infectious disease (except to some Africans and certain workers in biological laboratories who’ve known about it for decades).  It poses little threat now and for the foreseeable future.  To put it in perspective, as August 10 the U.S. Centers for Disease Control reported 14,115 total confirmed cases of monkeypox in the U.S. Compare that to an average of 106,115 new COVID cases and 265 deaths per day and 759 deaths in the week ending August 10.

Monkeypox got its name after it was isolated in 1958 in colonies of sick laboratory monkeys.  Later the virus was found on the loose in Africa in humans, monkeys, rats, mice, squirrels and other mammals.  The first recorded human infection occurred in the Democratic Republic of the Congo in 1970 and in the United States in 2021.  I say “recorded” because the disease had probably been endemic in Africa for years.  It wasn’t until over 1000 human cases were counted in 30 non-African nations, beginning this May, that monkeypox gained the attention of the world’s scientists.  In July the World Health Organization declared monkeypox to be “A public health emergency of international concern( EPHEIC).”  Bad as EPHEIC may sound, it is way less concerning than a bona fide pandemic, in which incidence of an infection skyrockets at an exponential rate, as COVID did.  Estimates of fatality rates in Africa range from 1-5% of cases.  Not one person so far has died from a monkeypox infection in the USA.

The causative organism of monkeypox is a double-stranded DNA virus of the same general structure as chickenpox and smallpox.  Symptoms of infection include fever, fatigue, headaches, muscle aches, and swollen lymph nodes, typically lasting 2-4 weeks.  Around day 3 a pocky rash may begin on the face, torso, arms or legs.  Each pock starts as a little sore that turns into a bubble-like blister.  Some blisters may become more inflamed, infected and scar when they heal, sort of like chickenpox, which struck almost every American child until 1995, when widespread vaccination against that virus began here.  (I have an 1/8” diameter scar on my forehead because I didn’t listen to my mom and scratched my itchy pocks when I was 5 years old.)  About 2 per 100,000 very unlucky chickenpox patients develop brain or lung infections.  Some of them die. 

There are two monkeypox vaccines, administered in 1- or 2-shot regimen.  Manufacturers have been rapidly ramping up the supply.  There is plenty of ongoing discussion and no clear cut answers about the best way to administer the vaccine.  Scientists are testing promising anti-viral regimens.  None has been approved so far.

Meanwhile, because of similarities to the monkeypox virus, smallpox vaccine provides pretty good protection against monkeypox.  There are currently significant stockpiles of smallpox vaccine.  Most every U.S. person born before 1971, when smallpox vaccination was discontinued in the United States, bears a scar on their upper arm that attests to smallpox inoculation and estimated 85% protection from monkeypox.  Unlike highly contagious smallpox, which is easily broadcast through the air, monkeypox is only transmitted by direct contact with active pocks or by clothes worn by an infected person.  

A significant percentage of cases in this country has been acquired via sexual encounters of men with men, probably by direct contact with active pox skin lesions.  So far the virus not been found in sexual secretions.  The U.S. Centers of Disease Control has been quick to point out that gay sex is far from the only way to transmit the disease, hoping to blunt any anti-homosexual discrimination that might arise, as occurred in the 1980s in the face of the AIDS epidemic.

Unlike monkeypox, smallpox kills, disfigures or blinds many of its victims.  The disease was endemic in the Old World.  A significant portion of the loss of New World native populations resulted from their encounter with this scourge introduced by conquerors and colonizers.  

In 1794, just shy of a century before viruses were discovered, the English physician Edward Jenner performed the first vaccination against smallpox.  Thanks to ever better vaccines and persistent worldwide public health programs, smallpox has been eradicated from the face of the Earth.  The very last case was identified in East Africa in 1977.  We stopped inoculating against smallpox in the United States because the last case was seen here in 1949.  We still have a pretty good supply of the vaccine in case of germ warfare.  Several countries, including the United States, maintain repositories of active smallpox virus for possible use in biowar.  That should give you an idea of how transmissible and devastating smallpox is.

Currently both monkeypox and smallpox vaccines are reserved for people who are at risk of exposure to monkeypox through their jobs as laboratory or public health workers.  Epidemiologists are discussing creating a “ring of immunization” of people who have been in close contact with an identified patient.  Still, that’s not a lot of people.  

No matter what, we have got to keep an eye on monkeypox.  This virus or a another one that is currently simmering in humans and/or animals could mutate--as the COVID virus has been doing for more than 2 years and the influenza virus has done every year since at least the 5th Century BC, as recorded by ancient Greeks--and cause a serious epidemic among us featherless bipeds.  If COVID has taught us anything (which I sometimes doubt) it’s that we need to be forever on the lookout, monitoring every biologic agent that could conceivably infect humans, studying its molecular structure, estimating its potential for causing illness, and elucidating its modes of transmission.  The world must be prepared to respond immediately should monkeypox become a larger threat.  

For now, let the virologists, immunologists, infectious disease experts, epidemiologists, public health and policy mavens, and (god help us) politicians worry about monkeypox.  Sooner or later a new infectious disease will come along that really does merit fretting about.  In the meantime, CHILL! 
August 24, 2022
 in the
Written by
Marc Ringel, MD

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