Monkey Pox

I keep getting asked the same question again and again; is this outbreak of monkey pox a real threat, or is this another case of overstated and weaponized public health messaging? I am going to save my answer to this question for the end of this article and instead focus on what monkey pox is, the nature and characteristics of the associated disease, what we know and don’t know.

The monkeypox virus, which originates in various regions of Africa, is related to SmallPox (Variola), which are both members of the genus Orthopoxvirus. However, it is important to understand that Variola (major or minor) is the species of virus which is responsible for the worst human disease caused by the Orthopox viruses. For example, Cowpox, Horsepox, and Camelpox are also members of this genus, none of which are a major health threat to humans, and one of which (Cowpox) has even been (historically) used as a Smallpox vaccine. My point is that just because Monkeypox is related to Smallpox, this does not in any way mean that it represents a similar public health threat. Anyone who implies otherwise is basically engaged in or otherwise supporting weaponized public health-related propaganda. In other words, spreading public health fearporn.

Monkeypox was first identified in 1958 in colonies of monkeys, and the first human case of the virus was identified in 1970 in the Democratic Republic of the Congo. Most likely this was just the first case identified, as people living in Africa have been in contact with monkeys and the other Monkeypox animal hosts for millennia. The “West African” monkeypox clade (clade = variant) circulating outside of Africa at this time causes a milder disease compared to the closely related virus found found in other regions of Africa (Congo clade).

The symptoms of monkeypox are somewhat similar to, but much milder than smallpox disease. The general clinical presentation of the disease caused by the West African monkey pox clade virus involves Influenza-like symptoms — fever, body aches, chills — together with swollen lymph nodes. A rash on the palm of the hand is often observed. In the latter stage of the disease, which may last for up to a month or more in some cases, may involve small lesions which develop a crust, and which can result in a small depigmented scar. There is no evidence of asymptomatic transmission. In other words, current medical knowledge indicates that it is only spread by person to person contact between an uninfected individual and someone who already has symptoms of the disease. Therefore, disease spread can be readily controlled by classical public health interventions such as contact tracing, temporary quarantine of those who have had physical contact with someone who is infected, and longer term quarantine of those who develop symptoms. Essentially all of the current cases in the west which we are seeing in the news are among men who have sex with men, and appear to be due to close physical contact. Monkeypox is endemic in many parts of Africa, and is a “zoonotic” virus, meaning it can be transmitted from a variety of animals (not just monkeys) to humans. Initial animal to human transmission followed by limited human to human transmission is probably the cause of the sporadic cases typically observed in Africa. Chicken pox, which is highly transmissible, is not part of the genus Orthopoxvirus, despite that name “pox.” Once again for emphasis, Cowpox and Camelpox are also in the genus Orthopoxvirus, and they are not particularly pathogenic when contracted by humans; just because Monkeypox is a “pox” virus in the genus Orthopoxvirus, does not mean it is particularly deadly.

Monkeypox is a double stranded DNA virus, which means that due to the double stranded nature of DNA each of the two strands act as a “check” on the other during replication. As a consequence of this “error checking”, this and other DNA viruses mutate much more slowly than RNA viruses do. Over time, DNA virus genomes are relatively stable. This means that, unlike SARS-CoV-2 (COVID) or influenza, Monkeypox is unlikely to rapidly evolve to escape either naturally acquired or vaccine induced immunity. For the purposes of making a vaccine, this makes it a much easier target that say, a rapidly evolving RNA Coronavirus such as SARS-CoV-2, the virus which causes COVID-19. Furthermore, from an immunological point of view, the various Orthopox viruses often are cross-protective. In other words, if you have been vaccinated with a smallpox vaccine, or previously infected by Cowpox, Camelpox, or Monkeypox, you are highly likely to be quite resistant to disease caused by the Monkeypox virus which is now being (quite rarely) reported in non-African countries.

Current data indicate that Monkeypox is not very infectious in humans – it has a low Ro (perhaps below 1), which is the term used to describe how efficiency an infectious disease can spread from human to human. Again, this is super good news for containment. An Ro of <1 generally means that (even in the absence of social distancing of other containment measures), for every person already infected, on average less than one other person will become infected. For comparison purposes, the Omicron variants of SARS-CoV-2 have an Ro in the range of 7 to 10. A virus with an Ro of less than one can be easily contained with the standard public health methods discussed above. A virus with an Ro of 7-10 essentially cannot be contained and will rapidly spread throughout the world, as we have seen with the Omicron variants. In the case of a virus with an Ro around 1 or less, traditional infectious disease containment methods such as contact tracing, identification and isolation of infected individuals can be all that is needed to control the virus. Now the fact that Monkeypox is being spread from human to human (rather than only arising from contact between a person and an infected animal) is not such good news, but since this transmission appears to be from very close contact, this means that it can be easily contained without resorting to a general population vaccination campaign. In this type of setting, if there is a significant outbreak, vaccination is often restricted to just the health care and/or first responder personnel most likely to be in contact with an infected person. Using a vaccine to help that containment via either “ring” vaccination or wide-spread vaccination strategies is generally unnecessary, and may even be counterproductive, depending on the safety of the vaccine – keeping in mind that no drug or vaccine is perfectly safe.

Let me take a moment to tell a personal story to illustrate this point. After the 9-11 events including the anthrax letters, I took a job involving clinical development of a wide range of biodefense vaccines under a US Department of Defense (DoD) contract (issued to Dynport Vaccine Company). One of the vaccine indications we worked on was for prevention of Smallpox. The Vice President of the United States at the time, Mr. Dick Cheney, was advocating for widespread vaccination against smallpox because it was thought that there was something like a 1% chance of a bioterror attack involving reintroduction of smallpox into the United States. The existing live attenuated smallpox vaccine began to be deployed throughout the United States to healthcare workers and first responders. Then multiple reports of vaccine-caused damage began to circulate. I was tasked with looking into historic DoD smallpox vaccine campaign records concerning these types of “adverse events”. Adverse events after administration of this live attenuated vaccine were well known, and generally fell into two categories. In some cases, a small subset of young warfighters and recruits had some previously undetected immunologic defect which resulted in them developing an ongoing infection by the live attenuated vaccine virus that was being used at the time. The other group developed more subtle symptoms including what now appears to have been vaccination-associated myo- and pericarditis – typically ascribed to an autoimmune process. These problems were known risks back when smallpox vaccination was common (and smallpox had not been eradicated) and therefore no surprise when the same vaccine was redeployed in the present. But smallpox had been eradicated, and Mr. Cheney’s worst case scenario never happened. Those who were vaccinated and damaged to protect against a non-existent threat provide a great example illustrating a completely upside down risk benefit ratio. All risk, no benefit. And, appropriately, the smallpox vaccination campaign was halted.

Key takeaway: this is not influenza or COVID – this virus mutates slowly, it is not highly infectious, naturally acquired immunity is potent and long lasting, and Orthopox vaccines are usually cross protective. The risk of immunologic escape is very, very low. And the spread of this virus can be readily stopped by simple, inexpensive classical public health measures. If it were otherwise, we would already have experienced a pandemic of Monkeypox decades ago.

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