Digitally-colorized electron microscopic image depicting a monkeypox virus particle obtained from a clinical sample. Courtesy CDC. (Getty Images)

Monkeypox: What You Actually Need to Know

A primer by Donald G. McNeil Jr.

If the byline on today’s piece is familiar to you it might be because Donald G. McNeil Jr. was the reporter who, more than any other, sounded the alarm about Covid. Or because he warned you about Zika years before. Or maybe you remember his groundbreaking work on AIDS.

Plagues are sort of McNeil’s thing.

For decades, he reported on epidemics of all kinds for The New York Times. He joined the paper in 1976 as a copy boy. Over his career, he reported from some 60 countries. Last year, he was the author of two of the 15 articles about the coronavirus pandemic that won the Pulitzer Prize for Public Service for the Times.

For reasons that will not surprise Common Sense readers, McNeil was pushed out of the paper last year. (You can read his account here.)

Needless to say, we are very proud to publish him today on monkeypox. — BW

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As if one plague weren’t enough, we now have another: monkeypox. And we’re not handling it well.

At the moment, unless you are a gay man with multiple anonymous or casual sexual partners, you are probably not at much risk. In this new non-African outbreak that began in May, most of the cases have been inside that network—at least thus far. In seven central and west African countries, there have been tens of thousands of suspected cases and hundreds of deaths attributed to the virus over the last two decades. This new outbreak has risen from a dozen cases in Portugal, Spain and Britain in mid-May to more than 12,000 in over 50 countries, from Iceland to Australia. Over 1,000 of them are in the U.S., many of them in cities like New York, Los Angeles, San Francisco and Chicago.

But there’s no guarantee it will stay inside that network. Monkeypox is transmitted by sex, by skin-to-skin contact, by towels and sheets, and possibly even by kissing or coughing by patients with sores inside their mouths. A few nurses have caught it from patients, as have family members. There’s much we don’t know about it yet. 

Some sexually transmitted diseases—like AIDS—have stayed mostly inside gay male sexual networks. (In the West, that is. In Africa, more than 50 percent of H.I.V. cases are in women and girls.) Some, like syphilis, circulate generally but are more common among gay men. Others like herpes and HPV are widespread among heterosexuals. There’s no way to know yet where monkeypox will go.

We have a vaccine—two vaccines, actually—and also a  treatment, so we are in a far better position than we were at the beginning of H.I.V., Covid or virtually any other previous epidemic. But right now, it’s still spreading fast, with the global number of cases rising by about 1,000 a day. 

If there are two effective vaccines for this disease and one solid treatment, why are we losing the fight?

I blame several factors: shortages of vaccines and tests, the initial hesitancy by squeamish health agencies to openly discuss who was most at risk, and the refusal by the organizers of lucrative gay sex parties to cancel them over the past few months—even as evidence mounted that they are super-spreader events. 

The monkeypox virus—misnamed because it normally circulates in African rodents, not simians—is related to smallpox, but it’s not nearly as lethal. The successful 25-year effort to eradicate smallpox held it in check: The smallpox vaccine also prevents monkeypox. 

But vaccination ended in 1980 because the old vaccines had some rare but very dangerous side effects. So in the 1990s, monkeypox cases began reappearing in rural Africa, mostly in children born after 1980.

In central Africa, two strains circulate: one with a fatality rate of about 10 percent, another of about one percent. It now looks as if, sometime in 2017 in southeast Nigeria, an even less lethal but more transmissible variant of the second strain emerged. It has circulated in Nigerian cities since then and a few cases were found among Nigerians traveling to Europe and the U.S. One new study suggests that variant was circulating in Europe at least as early as this past March and picking up new mutations. 

This May, it appeared among gay men, especially those who had visited four venues: the Darklands leather fetish festival in Belgium; the annual Pride Festival in Spain’s Canary Islands; a gay rave at Berlin’s Berghain techno club; and the Paraiso sauna in Madrid, which, since it had darkened cubicles for orgies, a bondage cell and a bar, was really more of a huge sex club than a spa.

Even though one “sex-positive” party after another has turned into super-spreader events, there has been no willingness by the organizers of such parties to cancel or even reschedule them until more men can be vaccinated.  June was Pride Month in New York and cases are surging in the city now. Two recent parties in San Francisco,   Electroluxx Pride and the Afterglow Blacklight Discotheque had cases linked to them. And yet more events, like Provincetown Bear Week are going forward anyway.

Outside of Africa, the disease has not killed anyone yet. But for some victims, the pain—especially from pustules inside the mouth or rectum—is so severe that it requires hospitalization. Others feel miserable for weeks; a few get permanent scars. Also, those with monkeypox are supposed to stay in isolation until all the pox crust over and the scabs fall off, which can take up to a month.

The negligible fatality rate won’t necessarily persist if the virus escapes its current network: mostly young, mostly healthy adult men. In Africa, children and pregnant women are the most likely to die from monkeypox. (Older people, by contrast, are not. Many Africans born before 1980 and most Americans born before 1972 were vaccinated as children and doctors believe they still have some residual protection.)

We have two vaccines: 

The older one, ACAM2000, approved in 2007, was made after fears were raised that Saddam Hussein had stocks of weaponized smallpox. The National Strategic Stockpile contains 100 million doses. But it has a very small risk of seriously hurting or even killing someone with undiagnosed H.I.V. or another immune-suppressive condition, or someone with widespread skin problems, such as eczema.  It also has about a one-in-500 risk of heart inflammation, which is scary but can usually be treated.

The newer one, Jynneos, made by Bavarian Nordic in Denmark and approved in 2019, is much safer. It has been tested on people with H.I.V. and with skin problems.  As of three years ago, Bavarian Nordic had supplied our Strategic National Stockpile with 28 million doses, but all those have expired. Nordic had a contract to make a longer-lasting freeze-dried version, but when this epidemic began, the stockpile held only 64,000 usable doses; another 800,000 are in bulk frozen form in Denmark. The company is currently converting them into a usable form. (According to New York magazine, the company did not do this sooner because, during the Covid pandemic, it couldn’t get the F.D.A. to inspect its new factory. The Washington Post reports that the inspection has now been done and the vaccines are being processed and loaded onto freezer planes in batches of 150,000 doses at a time.)

We also have an antiviral medicine, tecovirimat or Tpoxx, which was developed by Siga Technologies as a defense against a smallpox bioterrorism event. It also lessens monkeypox symptoms, and comes in both oral and intravenous forms. But many men are finding it hard to get because the Centers for Disease Control requires that men getting it be enrolled in a clinical trial

So where are we now?  As in all epidemics, we’re in the early “fog of war” period. We don’t have rapid tests, so we have no idea how many cases the country really has. (The current test requires swabbing a pustule—those may not appear until many days after the initial infection.) We don’t know all the ways it’s transmitted. We don’t know if there is asymptomatic transmission. And we don’t have nearly enough Jynneos vaccine. When a city like New York gets a shipment, all the appointments are gone in within minutes

I started writing on Medium about monkeypox on May 23, when most media outlets were saying either “Monkeypox? Eww!” or “Don’t worry, it’s not Covid.” I argued that we needed to take the threat seriously. 

In five subsequent articles, I’ve made some fairly strident suggestions.

First, that we talk frankly about risky gay male sex networks instead of fretting about stigmatization. Stopping an epidemic is more important than greenwashing it. Second, that this summer’s Pride celebrations for men (not the parades, the “sex-positive” after-parties) should be rescheduled until autumn, when many more men will be vaccinated and rapid tests should be available to enable testing right at the party door. Third, that we stop pretending that ring vaccination could ever work and instead offer vaccine to all men with multiple sex partners, and to all sex workers. (Vaccinating the “ring” of contacts around each case is impossible when men have anonymous sex—they don’t know who their contacts are.) Fourth, that we roll out both the Jynneos and the ACAM2000 vaccines and screen men for the risks posed by the older vaccine. Fifth, that the government offer a month’s shelter to all men who test positive so they can isolate safely under medical surveillance.  (Not all gay men live fabulous lives; some have to sell sex to eat and pay rent.)

Some of these things are finally being done, but I still don’t think we’re doing enough. 

In mid-June, the C.D.C. did finally issue warnings that were blunt about the risks of anonymous hook-ups, even mentioning fetish gear and sex toys. 

On June 23, New York City’s health department imitated Montreal and started offering vaccine to all gay men who had recently had multiple or anonymous sex partners. Other American cities followed suit. 

This is progress, but there still isn’t enough of the safer Jynneos vaccine. And the C.D.C. doesn’t think the threat yet warrants releasing the huge stockpile of ACAM2000. 

The Food and Drug Administration needs to do whatever it can to speed up access to the stocks of Jynneos owned by the U.S. government but frozen in Denmark. If they aren’t enough to stop the epidemic, some hard choices about ACAM2000 will have to be made. The F.D.A must also speed up access to Tpoxx. In an epidemic, it is unfair to demand that every suffering recipient enroll in a clinical trial in order to be treated.

Moreover, gay men—particularly the owners of businesses and organizations sponsoring parties at which sex is encouraged—are not, in my opinion, making the sacrifices needed to slow down the spread.  Their reluctance to reschedule reminds me of the early 1980s, when the owners of San Francisco’s bathhouses bitterly fought the city’s attempts to close them, cloaking themselves in the mantle of gay freedom even as their clients died of AIDS. There was just too much money to be made. For Bear Week—as in the baths 40 years ago—the sponsors now claim their events will be “educational.”  

I see the need to stop this epidemic as urgent. Helping more men avoid misery is in itself a worthy goal. But beyond that, after 50 years of progress, a serious backlash against gay rights is growing in this country: One need only read Clarence Thomas’s decision in Dobbs to get a sense. If the virus, which is already pegged a “gay disease,” keeps spreading and even kills some children or pregnant women, that will get much worse. 

For once, we have the tools to stop a budding epidemic. But we don’t yet have enough of them. We should ask men to show restraint until enough rapid tests and vaccines are ready. Then we should crush it.  

After that, for the long term, we should encourage other nations to join us in investing billions in a campaign to wipe out this virus at its source, in Africa. Not only would that save the lives of Africans—most of them children—but it’s far cheaper than having to fight this battle again and again on our soil.

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