It may be too late to prevent monkeypox from becoming endemic in the US and Europe

We failed to contain the monkeypox outbreak, and we may have missed an opportunity to prevent the disease from becoming endemic — and a permanent threat — in the US and Europe.

Monkeypox is spreading rapidly around the world, particularly in the United States and Europe. With cases doubling about every two weeks, there is a growing risk that monkeypox will become an enduring problem in countries where outbreaks were previously rare and minor.

In other words, smallpox is on the verge of becoming endemic in many new places. When that happens, it could become very difficult to eradicate. Monkeypox, which causes fever and skin rash and is fatal in very few cases, is becoming another disease that people have to worry about constantly.

There are two routes to endemicity for smallpox. If the virus infects enough people fast enough to outpace authorities’ efforts to trace transmission and vaccinate those at risk, it could become human-endemic. “We’re already getting there,” James Lawler, an infectious disease expert at the University of Nebraska Medical Center, told The Daily Beast.

The good news with this type of endemicity is that it is not to have be permanent. Reversing human endemicity is difficult, yes — but it is possible. “If it only spreads in humans, eventually it can be controlled through vaccination and natural immunity,” Amesh Adalja, a public health expert at the Johns Hopkins Center for Health Security, told The Daily Beast.

But monkeypox was originally a “zoonotic” animal virus. It circulates in rodent and monkey species in West and Central Africa, where outbreaks in human populations are common.

If smallpox finds a home in some animal species in North America or Europe — say, squirrels, rats, or prairie dogs — it will be next to impossible to eradicate them regionally. “Game over,” Lawler said. Smallpox will likely surround us forever, just waiting for opportunities to spread from animals to humans. Outbreaks will be frequent and large, just as they are now in West and Central Africa.

To be clear, smallpox is not yet endemic in humans or animals in the United States or Europe. But the trends are not encouraging. “I share the concern of other scientists about containment and the virus becoming endemic in our U.S. rodent population,” Stephanie James, director of a virus testing lab at Regis University in Colorado, told The Daily Beast.

Officials noted the current outbreak, which was a relatively mild strain of West African smallpox, after diagnosing a British traveler returning from Nigeria in early May. Smallpox spread through close physical contact, including sex, and soon accompanied travelers on airplanes bound for far and wide lands. Doctors diagnosed the first US case on May 27.

But it is now obvious that the first diagnosed Smallpox cases in Europe and the US were not the first cases. On June 3, the US Centers for Disease Control and Prevention announced it had found genetic evidence of American smallpox cases that predated the first cases in Europe in May.

The rapid spread of monkeypox among humans is a preventable tragedy. But it can get a lot worse.

Because of the similarity between smallpox symptoms and the symptoms of some common STDs, such as herpes, doctors may not have noticed or reported these previous infections at first. “The virus disguised itself as a sexually transmitted infection and has been secretly spreading for several months,” Adalja explained.

The virus had a large lead, which explains why months later it’s still ahead of intensified efforts to contain it. There were 20,638 confirmed cases in 77 countries as of Wednesday, according to the CDC. That’s an increase from less than 10,000 cases two weeks ago. The World Health Organization has counted five smallpox-related deaths in non-endemic countries.

What’s frustrating for epidemiologists is that, in theory, we had all the tools we needed to quickly contain a smallpox outbreak. Thanks to COVID, health workers around the world are better than ever at contact tracing. Vaccines and therapies that work for smallpox also work for monkeypox. There is a proven strategy: diagnose cases, isolate and treat those infected, vaccinate their family, friends and colleagues.

And educate the public — especially the highest-risk groups, including men who have sex with men.

But so far the strategy is not working. Part of the problem lies with the virus itself, Lawler said. “The disease is unlike the monkeypox we’ve seen in the past. I don’t think we know why – probably a combination of virus, hosts and environment.”

Most of the time it’s our fault. Too many doctors misdiagnosed cases of smallpox as herpes or another sexually transmitted disease. Both the WHO and the CDC have waited too long to classify the smallpox outbreak as a public health emergency and to mobilize resources. The WHO declared an emergency on July 23. The CDC is expected to do the same over the next few days.

Authorities are deploying more vaccines and therapies and stepping up testing. Still, the clinics, which are on the frontline of public health in the US, need more of everything. More tests. More vaccines and therapies. More money for public relations. The US National Coalition of STD Directors recently surveyed 100 clinics and found that half did not have the capacity to deal with the monkeypox outbreak.

“We’re still going too slow,” Lawler warned. And he added, “We still dismiss the possibility of the unexpected.” Including the increasing likelihood of smallpox spreading to squirrels or rats.

Federal authorities appear at a loss to deal with “reverse zoonotic” human-to-animal transmission. To prevent animal endemics, you must identify smallpox in a species, kill the infected animals, and then closely monitor the remaining population to ensure you have eliminated all viruses.

But it’s not clear who should take the lead in federal healthcare. “The operational response to zoonotic diseases falls within that gray area,” Lawler said. The CDC maintains a website that describes smallpox symptoms in pets and livestock and explains where to send samples for diagnosis. The Department of Agriculture’s Animal and Plant Health Inspection Service monitors diseases in animals. Especially cattle.

APHIS could not or would not confirm that it tests animals for monkeypox. The agency referred The Daily Beast to the CDC, which did not respond to an email seeking comment. If there is a lead agency for detecting smallpox in animals, that agency doesn’t seem willing to take responsibility.

The rapid spread of monkeypox among humans is a preventable tragedy. But there can still be one a lot of worse. With hard work and some luck, it’s still possible to contain and eventually eliminate the human outbreak.

But when American or European rodents get smallpox, the outbreak will escalate into something far worse. A newly endemic disease. One that is next to impossible to eradicate.

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