On Thursday, New York State and San Francisco declared their own states of emergency. But even as the national tally approaches 5,000 cases and experts warn that containment is slipping away, federal health officials have not followed suit. One reason: This virus — unlike the coronavirus — is a known enemy, officials say. Doctors understand how it spreads and there are already tests, vaccines and treatments. But for scientists, the accumulating research paints a more complex and challenging picture. The virus remains a mystery in some important ways, not quite in ways that researchers saw during sporadic outbreaks in African countries. Scientists are struggling to answer three questions in particular that will determine how quickly monkeypox can be stopped—if it can be stopped at all.
How exactly does the virus spread?
At the beginning of the outbreak, health officials argued that the virus spread through respiratory droplets emitted when an infected person coughed or sneezed, and through close contact with pus-filled skin lesions or contaminated bedding and other materials. All this was true. But it may not be the whole picture. More than 99 percent of people infected so far are men who acquired the virus through close contact with other men, according to the Centers for Disease Control and Prevention. Only 13 women and two young children had been diagnosed with monkeypox on 25 July. The researchers found the virus in saliva, urine, feces and semen. It is unclear whether these fluids can be infectious and, in particular, whether the virus can be transmitted during sexual intercourse by means other than close skin-to-skin contact. But the pattern of spread so far, through sexual networks, has left researchers wondering. It is clear, however, that monkeypox does not spread easily and has not yet spilled over into the rest of the population. The average person is not at risk from store-bought clothing, for example, or from a fleeting interaction with an infected person, as some social media posts have suggested.
What you need to know about monkeypox virus
Card 1 of 7 What is monkey pox? Monkeypox is a virus similar to smallpox, but the symptoms are less severe. It was discovered in 1958, after outbreaks in monkeys kept for research. The virus was found mainly in parts of Central and West Africa, but in recent weeks it has spread to dozens of countries and infected tens of thousands of people, the vast majority of them men who have sex with men. On July 23, the World Health Organization declared monkeypox a global health emergency. I’m afraid I might have smallpox. What should I do? There is no way to test for monkeypox if you only have flu symptoms. But if you start to notice red lesions, you should contact an urgent care center or your primary care doctor, who may order a monkeypox test. Isolate at home as soon as you develop symptoms and wear high-quality masks if you must come into contact with others for medical treatment. What is the treatment for monkey pox? If you do get sick, treatment for monkeypox generally involves managing the symptoms. Tecovirimat, an antiviral drug also known as TPOXX, may occasionally be used for severe cases. Jynneos vaccine, which protects against smallpox and monkeypox, can also help reduce symptoms, even if taken after exposure. I live in New York. Can I get the vaccine? Adult men who have sex with men and who have had multiple sexual partners in the past 14 days are eligible for vaccine in New York, as well as close contacts of infected people. Eligible individuals who have conditions that weaken the immune system or have a history of dermatitis or eczema are also strongly encouraged to get vaccinated. People can book an appointment through this website. According to the CDC, people without symptoms cannot spread monkeypox. But at least one study detected the virus in men who showed no symptoms. The pattern of symptoms has also diverged from that seen in previous outbreaks. In Africa, some people became ill after touching infected animals, eating bushmeat, or using medicinal products made from the animals. They often developed fever and body aches, followed by a characteristic rash first on the face, palms and soles, then all over the body. Infants and pregnant women appeared to be at the highest risk of severe symptoms. In the outbreak outside Africa, many patients have no fever or respiratory symptoms at all, and the rash is often limited to a few lesions in the genital or rectal area, which can easily be mistaken for various sexually transmitted infections. Britain has now amended its official description of monkeypox to include lesions in the mouth, anal or rectal pain and bleeding. Some scientists have hypothesized that the presentation of the disease in Western countries may accurately reflect the natural course of the virus.
Is one dose of the vaccine enough?
Jynneos, the safer of the two monkeypox vaccines, is made by Bavarian Nordic, a small company in Denmark. Supplies have been severely limited and the Biden administration has moved slowly to obtain additional doses as the virus has spread. Now, federal officials have ordered nearly seven million doses, which will arrive in batches over the coming months. So far, the administration has sent about 320,000 doses to states. The Food and Drug Administration said Wednesday it had approved another 800,000 doses, but it was unclear when they would be distributed. Jynneos is supposed to be given in two doses 28 days apart. But some cities, including Washington and New York, are holding back second installments until more are available, mimicking a strategy adopted by Britain and Canada. Federal health officials have advised against postponing the second dose. But in studies, a single shot of Jynneos appears to be protective for up to two years. If this finding holds true in the real world, then delaying additional shots may help officials contain the outbreak by immunizing more Americans. Britain stopped second doses of the Covid vaccine early in the pandemic when supplies were low, noted Tinglong Dai, a vaccine supply expert at Johns Hopkins University. “The benefit of prioritizing the first doses outweighs the risk,” he said. There may not be many options as eligibility expands and more people at risk seek shots. Some jurisdictions have already expanded the groups eligible for immunization to include sex workers, patients of sexual health clinics, and clinicians and other employees who may be exposed to the virus on the job. In Rhode Island, Emily Rogers, a 29-year-old medical anthropologist, said she was able to call the local health department and make an appointment “very, very quickly.” Ms. Rogers qualifies for the shot because she sometimes has sex with men who are at high risk of contracting monkeypox. No one questioned her eligibility. “They weren’t weird about it at all – it was a very smooth process,” he said. Because of the shortage, the vaccine is offered only as a preventative measure, although it can alleviate symptoms if given within days of exposure. David Baldwin, 45, a music teacher in New York, qualified for vaccination only because doctors did not think he was already infected. (His original symptom was rectal pain.) “As a result, I think I never developed any damage to my body,” he said.
How well does drug therapy work?
In 2018, the FDA approved a drug to treat smallpox called tecovirimat, or TPOXX, based on data from animal studies. There is only limited data on its use in humans. Supply is not a problem: The national stockpile contains about 1.7 million doses. However, the drug has been difficult to obtain, and this has meant that uncertainties about how well and for whom the drug works remain even as the number of cases increases. Because tecovirimat is not approved specifically to treat monkeypox, it can only be prescribed through a burdensome “drug investigation protocol” that, until recently, required doctors to send the CDC detailed reports, a journal kept by patients for to record their progress and photos of the damage. With so many obstacles, many clinics did not offer tecovirimat at all. Even doctors in well-funded institutions could only treat two or three patients a day. Nephi Niven Stogner, 39, sought help for monkeypox symptoms on July 8. He felt excruciating pains and tried to take tecovirimat, but was told that others were sicker and needed it more. While he was waiting for the medicine in isolation, three new lesions appeared on his back. “It’s like getting your sentence extended,” he said. Mr. Stogner finally got his first dose on July 21. Within 24 hours, “his lesions went from swollen and red to flat, dark spots,” she said. Such delays have led the CDC to ease the rules for accessing tecovirimat. The organization now requires fewer patient visits, samples and forms and allows doctors to assess patients virtually. Wider use should mean that scientists and health officials gain a better understanding of the drug’s effectiveness. The new requirements will help the CDC “determine whether and how well this drug works in monkeypox patients,” noted Kristen Nordlund, a spokeswoman for the agency. The National Institute of Allergy and Infectious Diseases plans a clinical trial of tecovirimat in adults with monkeypox infection, including people living with HIV, which may begin this fall. The agency is working with Siga Technologies, which makes the drug, on another trial in the Democratic Republic of Congo, where the virus is a long-standing scourge, also expected to begin this fall.
