Close-up of monkeypox lesions on the arm and leg of a female child. Human infection with monkeypox-like virus in 4 year-old female in Bondua, Grand Gedeh County, Liberia. CDC's Public Health Image Library) Media ID #2329
According to the World Health Organization, there have been over 1,000 confirmed cases of Monkeypox across 29 countries — mostly in Europe and North America. The actual number of cases circulating in the population is likely much higher.
We are in the midst of an outbreak of Monkeypox, which is rarely found outside of West Africa.
My guest today, Dr. Eric Toner, is a Senior Scholar at The Johns Hopkins Center for Health Security. We kick off discussing what exactly Monkey Pox is and how spreads before having a broader conversation about ongoing efforts to contain this outbreak. As Dr. Toner explains, many of the unique qualities of Monkeypox — including that we already have an effective vaccine against it — suggests that this outbreak is very much containable.
Dr. Eric Toner [00:02:14] So monkeypox is a viral illness that is a cousin of smallpox that is native to Central and West Africa, but which has rarely caused infections outside of Africa. It’s been known since, I think, the 1950s. It’s called monkeypox because it was first identified in a monkey but monkeys are not the reservoir for the disease. The reservoir for the disease is rodents. And for the last decade or more, it has been endemic in West Africa, meaning there are constantly some cases and scattered outbreaks through West Africa, to a large extent in Nigeria but not exclusively in Nigeria. There are two main strains of monkeypox. One from the Congo region which tends to be a much more severe disease with a fairly high mortality rate of about 10%. The milder strain is the West African strain, and that is the strain that we’re all dealing with now and that historically has had a fatality rate of about 1% although in the cases that have occurred outside of Africa, the fatality rate has been nearly zero.
How does monkeypox spread?
Mark L. Goldberg [00:03:44] And what do we know about how it is spread?
Dr. Eric Toner [00:03:50] So it is primarily spread by direct physical contact with either the lesions, the pox themselves, or with bodily fluids from an infected person. So that could be respiratory droplets, saliva, or it could be other bodily fluids, so it requires close contact. It’s not something that is spread through the air over long distances. It’s not like COVID.
What is the difference between the two strains of monkeypox?
Mark L. Goldberg [00:04:24] So what accounts for the sharply divergent mortality rates for monkeypox? You said one was about a 10% mortality rate, which is really high. The other is about 1% in Africa and a mortality rate outside of Africa that is, as you said, virtually zero.
Dr. Eric Toner [00:04:45] So there is a genetic difference between the two strains, which we believe is the cause of the more severe disease in the Congo basin as opposed to the West African strain. The probable reason that mortality rates are lower in the developed world is that we have modern health care with all that comes with that in terms of ability to treat the symptoms, for IV fluids, for whatever is needed to take care of patients should they get very sick. So that probably explains the difference between the 1% mortality in West Africa traditionally and what we’re seeing now.
Has monkeypox ever spread outside of Africa before?
Mark L. Goldberg [00:05:38] And before this current outbreak, how common were outbreaks of monkeypox outside of Africa?
Dr. Eric Toner [00:05:46] It was very rare. It would happen occasionally, we had an importation of a single case of monkeypox here in Maryland not too long-ago last year, and that was a traveler from Nigeria. And so usually the cases that have occurred have been isolated cases of a traveler from an endemic area who got infected there, traveled home, and got sick and was diagnosed. Sometimes, very rarely, there would be some secondary transmission that is, somebody else in their family who had close contact might get sick but actually that was quite rare. We did have one outbreak in the U.S. couple of decades ago that was related to rodents that were imported from Africa that then infected some other rodents and eventually 47 people got infected, but they were all mild disease and there was little or no secondary transmission.
Why is this monkeypox outbreak spreading further than previous outbreaks?
Mark L. Goldberg [00:07:07] Hmm. So, this current outbreak seems much bigger, frankly, than any other outbreak outside Africa we’ve seen in many, many years. What do we know so far about how this outbreak has spread?
Dr. Eric Toner [00:07:27] Well, the current outbreak is being spread largely through close sexual contact, primarily among men who have sex with men and where the index case was, we don’t know for sure. There was an initial case in London in a man who had traveled from Nigeria, but we don’t know if that was the first case because there’s no evidence that perhaps this has been spreading longer than we initially knew. But of the thousand confirmed cases, almost all of them are young men who have sex with other men. And many of the cases are related to either parties or raves or saunas or activities in which there was sexual contact with multiple partners, unknown partners so this seems to be the primary driver of the epidemic so far. There have been a few handfuls of cases in women, primarily household contacts but so far, we are not seeing significant evidence of transmission outside of this particular network.
What is the World Health Organization (W.H.O.) doing to slow the spread of monkeypox?
Mark L. Goldberg [00:08:58] Given that the cases are so far, you know, relatively few: we have about 1000 confirmed cases but there are probably others, presumably, that are out there in the population that we don’t know about anymore. And given that, it’s relatively difficult to spread compared to something like COVID and also that its fatality rate is virtually zero, it seems to me that monkeypox right now, at least and we’re speaking on Tuesday, June 7th, seems like almost like a like a low stakes test for how we might approach containment of an emerging epidemic like this. What have we seen thus far, for example, from the World Health Organization in terms of confronting this this outbreak?
Dr. Eric Toner [00:09:51] I think the W.H.O. having learned lessons from COVID and other outbreaks, Ebola, for example, has jumped on this very aggressively. I think they are working with the 27 or 28 countries that now have cases, supporting their efforts to track cases, start investigations, do contact tracing. So, W.H.O.’s major role in this effort is primarily one of coordination and support. And in most of the countries that have been affected so far during this current epidemic outside of Africa are all relatively wealthy countries or most of them are, so they have fairly robust public health systems. And those systems are working hard to identify their cases, test them, isolate them, quarantine where that’s necessary and vaccinate. One of the advantages of monkeypox is that we have both effective vaccines and effective treatments. Most of the time, treatment is not needed but the vaccine has been administered to several thousand people so far around the world who have been in contact with people who have had identified cases.
How is the United States responding to rising cases of monkeypox?
Mark L. Goldberg [00:11:30] And so it seems like the emerging strategy is one in which health authorities seek to test suspected cases, isolate those who have confirmed positive cases and their contacts, and then maybe do that kind of ring vaccination of those who might be suspected contacts or secondary contacts of infected individuals. Are we seeing that system snap into place, say, here in the United States at a pace that suggests to you that this, in fact, will be contained?
Dr. Eric Toner [00:12:09] I am really quite confident that it will be contained and yes, the system has snapped in place, I think, very, very quickly. I think the CDC and the state health departments have done a good job of getting in and being very responsive, doing what’s needed to be done without being unduly alarmist with it. I think their messaging has been pretty good, better than their messaging around COVID, for example, which is to say there’s important information that certain people need to have, and that health care providers and public health officials need to have but it’s important to emphasize that this is not a threat to the general public, and this is not a gay disease. Rather, it is a disease that right now is affecting a particular network of people.
What is the treatment for monkeypox? Is there a vaccine for monkeypox?
Mark L. Goldberg [00:13:10] But chances are in the not-too-distant future, unless it’s successfully contained very quickly, presumably it has or will spread in many other different kinds of populations.
Dr. Eric Toner [00:13:23] Yes, I think that that is likely to be the case. I do think it can be contained fairly quickly, but if not, then it will spread. You know, it is probably a relatively easy disease to contain in contrast to HIV, for example, and certainly in contrast to COVID. For the most part, the people who are infected know they’re infected because they have symptoms, and they tend to be symptoms that would drive one to health care. So, in contrast to HIV, for example, where there are no symptoms for many years, people who are infected can be identified pretty quickly. So, I do think it’s containable. Also, in contrast to HIV, we have an effective vaccine that works even after somebody has been exposed, which is very unusual. We have very few vaccines that work after a person’s been infected but for the pox viruses, these vaccines do work if administered within a few days.
Could this outbreak of monkeypox be related to the reduction in routinely administered smallpox vaccines?
Mark L. Goldberg [00:14:36] So I’ve seen some commentary suggesting that, at least in part, this outbreak may be a consequence of the fact that the smallpox vaccine is no longer routinely administered. You know, for listeners, smallpox was eradicated in like 1980 after a massive effort by the World Health Organization, by the United Nations, by national governments. So, smallpox has been wiped off the face of the earth and so there hasn’t been a need for the routine and mass vaccinations against smallpox. And as you said, smallpox is related to monkeypox. So, do you buy that theory that a reduction in mass vaccinations of smallpox has perhaps contributed to this outbreak of monkeypox?
Dr. Eric Toner [00:15:26] I think it probably is true that with waning vaccination in the population, there’s more opportunity for the virus to be exported from Africa to other places. I think it’s also true that it probably relates to the outbreak that’s been going on in West Africa now for a number of years. In Africa they have a young population and the vast majority of people have not been vaccinated against smallpox so there’s fertile ground for this virus to spread.
Mark L. Goldberg [00:16:08] I mean, is one policy implication, therefore, that vaccinations against smallpox should be ramped up, particularly in Africa?
Dr. Eric Toner [00:16:18] I don’t think so, because the ring vaccination approach works so well. There’s no need for mass vaccination. The current vaccine that’s approved for use in monkeypox is a safe and effective vaccine but like any vaccine, there are potential side effects and potential risks. And so, I don’t think it would be justified in trying to vaccinate the entire population. Just what is being done, what should be done is vaccinating those people who have had close contact with known cases.
How far might this outbreak of monkeypox spread?
Mark L. Goldberg [00:17:02] So, you’ve sort of reassured me and I think most of the audience that this in places that are higher income, that have more robust health systems, this is very much an easily containable challenge. To what extent might monkeypox, however, be spread to countries, to health systems that are less robust, that are less strong? And what might the international community do, if anything, to support those health systems as they potentially prepare to confront monkeypox arriving within their borders?
Dr. Eric Toner [00:17:46] So I would assume that monkeypox is being exported to other regions in which it’s not endemic. So far, we’re not seeing that reported to any great extent in the information that’s being released by W.H.O. but that may be because surveillance systems aren’t yet picking it up. So, I do think it is likely that we will see more cases in other low- and middle-income countries that don’t have the same resources as the high-income countries that are mostly being affected now. I think the thing that would help the most is making sure they have vaccine available. And so W.H.O. can play an important role in helping to ensure that all countries have access to the vaccines that are effective against monkeypox.
Are there enough smallpox vaccines to aid in slowing the spread of monkeypox?
Mark L. Goldberg [00:18:54] And are there like sufficient stocks of that vaccine, to your knowledge, or is it something that could be easily ramped up in production relatively quickly?
Dr. Eric Toner [00:19:05] There are large stocks of the vaccine. Most of them are owned by the US government and to a lesser extent by other governments. Whether or not the US would be willing to donate or share those vaccines, I don’t know, but there are millions of doses that are either housed within the US national stockpile or under contract with Bavarian Nordic.
Mark L. Goldberg [00:19:38] That’s the company that creates it?
Dr. Eric Toner [00:19:40] That is the company that makes the vaccine. There are other smallpox vaccines which are made in other countries, and I don’t know about their availability. First of all, I don’t know about the stockpiles they have. I doubt that they’re very large and I don’t know anything about the ability to quickly ramp up. I suspect they can’t ramp up that quickly. You know, there’s a significant lead time in producing vaccines, particularly when they haven’t been producing them every day. They have to get a factory line going and that might involve hiring people. It’s not a just press a button and start making more of this stuff but I think there are enough vaccines to get started and probably enough to control the outbreak worldwide because this is not going to explode like COVID did. If this is not quickly contained, it will grow, but it’ll grow slowly because it’s not that transmissible, because it has a long incubation period and because people will seek health care when they get sick, even in low-income countries, and can easily be isolated. So, I’m not that worried.
Mark L. Goldberg [00:21:25] Along those similar lines of not being too worried, do the biological facts of this disease in that it spreads relatively slowly suggest to you that even in low-income countries, in low resource settings, it probably won’t present too much of a strain to health systems?
Dr. Eric Toner [00:21:46] I don’t think it’ll present a strain to health systems. What I do think can be a problem and it could even be a problem in high income countries such as the United States is in the ability to test people for it. The test is not simply a nasal swab or a blood test. It involves taking a specimen from one of the pox, one of the pustules on the skin and that has to be done carefully so that the person taking the specimen does not get infected. So, it involves wearing personal protective equipment. The specimen has to be sent typically to a regional or national laboratory in places that have the capability to do the testing normally. And it takes time and it’s expensive. And I think probably many places don’t have easy availability of that testing. They probably have to send it to something like a W.H.O. regional laboratory. So, I think testing can be a bottleneck. In the days of the smallpox program, and we didn’t, for most part, test people, we just diagnosed them by looking at them. And you can do that with monkeypox, too, if it’s a classic case but many of the cases that we’ve seen over the course of the last few weeks have not been classic cases. They’ve been fairly mild. Many have not had fever. Many have only a single lesion, a single pox, rather than being covered in them. But what we don’t know is how contagious those people are who have that very mild disease. But for other people who have the more classic presentation, you can be pretty sure of diagnosis just by looking at the patient.
Will it be easy to contain this monkeypox outbreak?
Mark L. Goldberg [00:24:09] I guess maybe one policy concern or public health concern might be that, if you do have this testing bottleneck, that if it takes a while to get a test result back, and if you are basing your decision on whether or not to vaccinate an individual or their contacts on the positive result back, that that time lag could be sort of potentially problematic.
Dr. Eric Toner [00:24:32] Yes, it could be. What I think, from a policy standpoint probably makes the most sense in a country that doesn’t have the ability to do testing readily, is just to do ring vaccination based on a clinical diagnosis, based on just examining the patient. If a physician sees a patient and in his or her judgment, it looks like monkeypox, then, you know, in the setting of an outbreak, I would advocate for doing ring vaccination even without a laboratory confirmation.
What lessons from COVID can be applied to slowing the monkeypox outbreak?
Mark L. Goldberg [00:25:17] So lastly, what lessons from COVID might be productively applied right now in this early stage of the identification of this outbreak?
Dr. Eric Toner [00:25:32] Well, I think one of the lessons is around communication and the importance of communication being clear, honest about what you know, about what you don’t know, about what you need to find out, how you’re going to find that out. I think there’s a pair of lessons about the fact that we need to have more robust testing capability even in high income countries. We learned this lesson in COVID, and I think we’re getting to learn it again now with monkeypox, that we need to have an even larger network of laboratories that can do all kinds of testing. And I think it’s yet again another lesson about the importance of public health and that we need to invest in our public health systems because public health are the people who respond to things like this.
How will we know if the efforts to slow the spread of monkeypox are working?
Mark L. Goldberg [00:26:44] Lastly, and I think I just said lastly, but lastly, lastly, this time, in the coming days or weeks or even months, are there any inflection points that you’ll be looking towards that will suggest to you whether or not indeed this outbreak is being contained or conversely, if it is being spread with abandon.
Dr. Eric Toner [00:27:10] So what I’m looking for and hope I don’t find, are lots of cases for which we cannot find a connection to known chains of transmission. That is, people who have confirmed monkeypox and they don’t know where they got it and we can’t find out where they got it because that would indicate that there’s much more disease out there and there are other chains of transmission that we don’t know about. The other thing that I would look for is a change in the demographic pattern of the patients. So, if we start seeing lots of people who are outside the network of men who have sex with men, if we start seeing many more people like that, then that would also be an indication that there’s more transmission going on outside of that network.
Mark L. Goldberg [00:28:18] Well, Dr. Toner, thank you so much for your time. This is very helpful.
Dr. Eric Toner [00:28:22] Well, you’re very welcome and thank you for having me.
Mark L. Goldberg [00:28:25] And kind of reassuring.
Dr. Eric Toner [00:28:27] Oh, well good.
Mark L. Goldberg [00:28:31] All right. Thank you all for listening. Thank you to Dr. Toner, that was great. And yeah, I am somewhat reassured by his expert take that indeed, this is eminently containable. And of course, I’ll be following the trajectory of this outbreak as events unfold in the coming weeks and months. All right. We’ll see you next time. Thanks, bye!