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Three pressing questions about monkeypox: spread, vaccination, treatment

Monkeypox, once a relatively obscure endemic virus in Africa, has become a global threat, infecting more than 20,000 people in 75 countries and forcing the World Health Organization to declare a global health emergency.

On Thursday, New York State and San Francisco declared their own emergencies. But even as the national tally nears 5,000 cases and experts warn the lockdown is slipping away, federal health officials haven’t followed suit.

One reason: This virus — unlike the coronavirus — is a known enemy, officials say. Doctors understand how it spreads and there are already tests, vaccines and treatments.

But for scientists, the accumulation of research presents a more complicated and difficult picture. The virus remains a mystery in some important ways, not behaving exactly as researchers have seen it in sporadic outbreaks in African countries.

Scientists are racing to answer three questions in particular that will determine how quickly monkeypox can be stopped – if it can be stopped at all.

Early in the outbreak, health officials said the virus was spread through respiratory droplets emitted when an infected person coughed or sneezed, and through close contact with pus-filled skin lesions or bedding and other contaminated materials.

It was all true. But that may not be all.

According to the Centers for Disease Control and Prevention, more than 99% of those infected to date are men who contracted the virus through intimate contact with other men. Only 13 women and two young children had been diagnosed with monkeypox as of July 25.

Researchers have found the virus in saliva, urine, feces and semen. It is not known whether these fluids can be infectious and, in particular, whether the virus can be transmitted during sexual intercourse by means other than close skin-to-skin contact. But the pattern of spread so far, along sexual networks, has researchers wondering.

It is clear, however, that monkeypox does not spread easily and has not yet spread to the rest of the population. The average person is not threatened by store-bought clothes, for example, or a passing interaction with an infected person, as some social media posts have suggested.

According to the CDC, people without symptoms cannot spread monkeypox. But at least one study has detected the virus in men who showed no symptoms. The pattern of symptoms also diverged from that seen in previous outbreaks.

In Africa, some people have become ill after touching infected animals, eating bushmeat or using animal-based medicines. They often developed fever and body aches, followed by a characteristic rash first on the face, palms and feet, then all over the body. Infants and pregnant women seemed most at risk of severe symptoms.

In the outbreak outside of Africa, many patients have no fever or respiratory symptoms, and the rash is often limited to a few lesions in the genital or rectal area, which can easily be confused with various sexually transmitted infections.

Britain has now changed its official description of monkeypox to include lesions in the mouth, as well as anal or rectal pain and bleeding. Some scientists have speculated that the presentation of the disease in Western countries may accurately reflect the natural evolution of the virus.

Jynneos, the safer of the two monkeypox vaccines, is made by Bavarian Nordic, a small company in Denmark. Supplies were severely constrained and the Biden administration moved slowly to acquire additional doses as the virus spread.

Now, federal authorities have ordered nearly seven million doses, which will arrive in batches over the next few months. So far, the administration has shipped about 320,000 doses to states. The Food and Drug Administration said Wednesday it had approved 800,000 more doses, but it was unclear when they would be distributed.

Jynneos is meant to be given in two doses 28 days apart. But some cities, including Washington and New York, are withholding second doses until more are available, mimicking a strategy adopted by Britain and Canada.

Federal health officials have advised against delaying second doses. But in studies, a single shot of Jynneos appears to be protective for up to two years. If this finding holds true in the real world, postponing additional injections could help authorities contain the outbreak by immunizing more Americans.

Britain withheld second doses of the Covid vaccine early in the pandemic when supplies were low, noted Tinglong Dai, a vaccine supply expert at Johns Hopkins University. “The benefit of prioritizing early doses outweighs the risk,” he said.

There may not be many choices as eligibility expands and more at-risk people seek vaccinations. Some jurisdictions have already expanded the groups eligible for vaccination to include sex workers, patients of sexual health clinics, as well as clinicians and other employees who may be exposed to the virus at work.

In Rhode Island, Emily Rogers, a 29-year-old medical anthropologist, said she was able to call the local health department and get an appointment “very, very quickly.”

Ms. Rogers qualified for the shot because she sometimes has sex with men at high risk of monkeypox infection. No one questioned his admissibility. “They weren’t weird about it at all — it was a very smooth process,” she said.

Due to the shortage, the vaccine is only offered as a preventive measure, although it may alleviate symptoms if given within days of exposure.

David Baldwin, 45, a music teacher in New York, qualified for the vaccination only because doctors did not believe he was already infected. (His initial symptom was rectal pain.) “As a result, I don’t think I ever developed any lesions on my body,” he said.

In 2018, the FDA approved a drug to treat smallpox called tecovirimat, or TPOXX, based on data from animal studies. There are only limited data on its use in humans.

Supply is not a problem: the national stock contains approximately 1.7 million doses. Yet the drug has been difficult to acquire, meaning ambiguities over quality and for whom the drug works have persisted even as the number of cases increases.

Since tecovirimat is not specifically approved to treat monkeypox, it can only be prescribed through a cumbersome “experimental drug protocol” that until recently required doctors to send to the CDC detailed reports, a diary kept by patients to record their progress and photographs of the lesions.

With so many obstacles, many clinics did not offer tecovirimat at all; even doctors in well-funded institutions could only treat two or three patients a day.

Nephi Niven Stogner, 39, sought help for symptoms of monkeypox on July 8. He was in terrible pain and tried to get tecovirimat, but was told others were sicker and needed it more.

As he waited for the medicine in solitary confinement, three new lesions appeared on his back. “It’s as if your sentence was extended,” he said.

Mr. Stogner finally received his first dose on July 21. Within 24 hours, his “lesions went from swollen and red to flat, dark spots,” he said.

These delays led the CDC to relax the rules for access to tecovirimat. The agency now requires fewer patient visits, samples and forms, and allows doctors to assess patients virtually.

Wider use should mean scientists and health officials will have a better understanding of the drug’s effectiveness. The new requirements will help the CDC “determine whether and how well this drug works for patients with monkeypox,” noted agency spokeswoman Kristen Nordlund.

The National Institute of Allergy and Infectious Diseases is planning a clinical trial of tecovirimat in adults infected with monkeypox, including people living with HIV, which could begin this fall. The agency is collaborating with Siga Technologies, which makes the drug, on another trial in the Democratic Republic of Congo, where the virus is a long-standing plague, which is also expected to begin this fall.


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