Monkeypox is 'out of the box' and has Europe on edge

BARCELONA — For decades now, experts believed monkeypox would simply stay put in Africa. This May, the zoonotic virus proved the fallacy of that idea, appearing in 23 countries — many of them in Europe —prompting the World Health Organization to declare Sunday that it was a “moderate” global public health risk.

“It’s an unusual situation,” Dr. Sylvie Briand, director of Pandemic and Epidemic Diseases Department at the WHO, said during a webinar on Monday. “Before, we had [monkeypox] only in certain countries. Now it’s out of the box.”

An electron microscope image showing both oval-shaped and round monkeypox virions.
A 2003 electron microscope image shows mature, oval-shaped monkeypox virions and immature, spherical virions obtained from a sample of human skin. (Cynthia S. Goldsmith, Russell Regner/CDC via AP)

The sudden increase in cases in Europe, where the U.K. and Spain have so far recorded 300, is prompting health authorities to issue alerts, warning sexually active populations, particularly those who engage in high-risk activities, to be on the lookout for symptoms. The U.K. has also urged those who are ill with monkeypox to abstain from intimate relations, to have no contact with pets and to not leave their homes for a month.

Officials in the U.K., which on Tuesday confirmed 179 cases, and Spain, where the Health Ministry on Monday announced it has 120 cases, are recommending smallpox vaccines for close contacts of those already infected, believing that a vaccine for the related virus given within four days of exposure can minimize monkeypox symptoms.

Click image for more graphics from the World Health Organization.
Click image for more graphics from the World Health Organization.

But Dr. Daniel Lopez-Acuña, the former director of crisis management at the WHO, told Yahoo News that “we will not need vaccinations of the general public,” since the disease will probably not affect large swaths of the population. That’s encouraging, given that smallpox was eradicated in 1980 and supplies of smallpox vaccines are scarce. (The good news is that health officials say people older than 45, most of whom were vaccinated against smallpox, may be far less likely to contract monkeypox.)

Beyond the case numbers in Europe, which are shooting higher than most African countries where monkeypox is endemic, what the recent outbreak is underscoring is that human-to-human transmission is indeed possible — and that human sexual contact is now what is spreading the disease, as opposed to contact with wild animals.

According to Spanish health officials, two of the believed “amplification events” that helped spread monkeypox across Europe took place in Spain. One was at a popular, and now shuttered, gay sauna in Madrid that was reportedly linked to at least 20 infections. Another occurred in the Canary Islands, the Spanish territory off Africa, which hosted a 10-day gay pride event in early May that 80,000 attended, and that resulted in cases in other European countries, including Denmark and Slovenia.

Francesco Vaia talks to reporters.
Francesco Vaia, director of Spallanzani Infectious Disease Hospital in Rome, at a press conference on May 20. Vaia said three cases of monkeypox have been confirmed at the hospital. (Andrew Medichini/AP)

“But it’s not a gay disease — the transmission could have happened at a business conference or a political rally,” Dr. Roger Paredes, chief of the Infectious Diseases Department at Barcelona’s Germans Trias i Pujol Hospital, told Yahoo News. It is being transmitted through close skin contact, Paredes added, and is just as likely to be passed by heterosexuals.

In fact, close physical contact of many sorts — including talking closely for a prolonged period and perhaps even dancing — could transmit the disease, which can spread through respiratory droplets as well as skin touching skin, and via clothing and bedding.

Health experts now believe monkeypox may have been spreading for months or even years, previously going unrecognized and only now presenting itself in substantial enough numbers to warrant global alerts.

“At the beginning, some practitioners were confused, thinking this could be a manifestation of a complicated syphilis [case], a manifestation of another novel disease or even an extreme expression of genital herpes,” said Lopez-Acuña.

That the disease is making itself known just before summer — with its music festivals, big bashes and extended travels — makes the issue more difficult, as does the fear of stigmatizing those who show symptoms. “We need to identify cases, take good care of them and make sure they isolate,” said Paredes, “and then do contact tracing,” which is key to controlling the spread.

A patient's arms and torso covered with lesions and sores caused by monkeypox.
The arms and torso of a patient with lesions due to monkeypox in Democratic Republic of the Congo in 1997. (AP)

What’s more, since lesions from this outbreak tend to show up in “the nether regions,” according to Dr. Rosamund Lewis, the WHO’s leading monkeypox expert, some people who have it may not even know. “You may have these lesions for two to four weeks [in the genital and perianal regions], so they may not be visible to others, but you may still be infectious,” she said on Monday.

Further complicating matters is the recommended one-month quarantine period for those infected. “That’s hard to maintain,” said Paredes. “People do not usually stay at home for one month without leaving.”

Many believe, nevertheless, that this outbreak can be contained if people with monkeypox identify themselves to medical professionals and commit to self-isolation, and if their contacts are rapidly traced. “Collectively, the world has an opportunity to stop this outbreak,” said Lewis. “There is a window.”

But if it isn’t halted soon, some experts, including Lopez-Acuña, believe monkeypox could make its way onto the roster of sexually transmitted infections, even though it’s not, by definition, an official sexually transmitted disease. He shrugs off the “whole debate of whether it’s an STD or not” as a matter of semantics. “The fact is the dominant mechanism of transmission in these recent outbreaks in Europe has been sexual,” he said.

The hands of a monkeypox patient with healing sores.
The hands of a monkeypox patient who displayed the characteristic rash during its recuperative stage in 1997. (AP)

That monkeypox is being transmitted through sex is no huge surprise to American epidemiologist Dr. David Heymann, currently a professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine. The Centers for Disease Control and Prevention sent him to Africa as the main investigator of monkeypox in the 1970s, when it was largely a disease seen in children. Three years ago, he chaired a seminar at the London think tank Chatham House that examined sharply accelerating monkeypox rates in Africa — increases attributed in part to more frequent global travel, growing numbers of the population who hadn’t been vaccinated against smallpox, and even flooding that brought humans and wild animals into closer proximity.

One curious idea that emerged at the seminar was “an observation that some people with monkeypox have genital lesions,” he told Yahoo News. “And there was a hypothesis that they could transmit monkeypox if there was close contact in the genital area.” Now that hypothesized mode of transmission seems to be exactly what is spreading the disease through skin-to-skin contact, although it's unclear if the exchange of bodily fluids may also transmit it.

In fact, even though monkeypox has been seen in humans for over 40 years, there are still a number of unknowns in this current outbreak. “Pets,” for one, said Paredes, “are quite an unknown territory. There is potential transmission to pets, but our main epidemiological worry is if pets get infected and they go outside and meet with other pets” — thereby increasing the animal reservoir of potential carriers. The safety of places like public swimming pools is likewise “uncertain,” he said, although people with monkeypox should stay isolated at home regardless, he added.

A gloved hand points to a graph on a computer screen.
A computer screen at the Hospital Ramon y Cajal in Madrid shows positive test results for monkeypox. (Carlos Lujan/Europa Press via Getty Images)

But for right now, at least, health officials are relieved that what is circulating widely is the West African strain of monkeypox and not the much more serious Central African strain, which is the one most likely to be shown in photographs accompanying reports, according to Heymann, who noted that the Central African strain is “beginning to spread from person to person. And it’s quite a threat.” That strain may prove fatal for 10% of those who acquire it, according to the WHO. Heymann attributes that strain’s absence in Europe to the fact that those who get it are “extremely ill” and less likely to travel.

While emphasizing that monkeypox “is not going to be like COVID — it’s not going to be a superspreader disease that everybody can get everywhere,” Paredes said that health authorities want to nip it in the bud. “The big question,” he added, “is whether monkeypox will become endemic in Western countries or not. That depends on how well we do our jobs in the upcoming few weeks.”

Though the risk to the general public may not be high, Lopez-Acuña suggests that measures put in place to combat COVID may benefit those who want to absolutely minimize all risk of encountering monkeypox. These include wearing masks, social distancing and staying clear of settings with crowds. Despite a renewed sense of freedom in Spain (where indoor COVID mask mandates were lifted only in late April), an attitude that may have promoted more sexual activity, he noted that 4,000 Spaniards died from COVID in the past two months.