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Monkeypox: what we know so far

As more cases of monkeypox are reported in new areas globally, disease surveillance, contact tracing and prevention will be key to controlling this outbreak and others in the future.

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Monkeypox: what we know so far
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It's important to remember that monkeypox is highly unlikely to become a global pandemic like Covid-19.

That doesn’t mean authorities shouldn’t act quickly. Although the current strain appears to be mild, monkeypox can cause severe disease and, rarely, even death.

"What we’ve learned from the Covid-19 pandemic is that our best, most effective public health responses to outbreaks come from rapid research to understand the disease, thorough disease surveillance, access to real-time data and cooperation between nations and public health organisations."

Peter Hart

Senior Research Manager, Microbial Communities and Reservoirs

Wellcome

At this early stage of the current monkeypox outbreak, contact tracing can break the chains of transmission and, if done well, should be highly effective at preventing the situation from escalating.

Should we be concerned about how quickly monkeypox is spreading? 

We should be concerned, but not alarmed. The number of cases and their locations indicate a degree of community transmission in multiple countries, many of which have never recorded monkeypox cases.  

Monkeypox is endemic to several regions in Africa, but it has appeared in other countries before. Usually this has been isolated cases or outbreaks closely connected to travel to Africa or the international pet trade, as was the case in an outbreak in the US in 2003.  

What’s different about this outbreak is that, at the time of writing (27 June 2022), 4,147 confirmed cases have been found in 29 countries in Europe, the Americas the Middle East and Australia, far from the countries of Central and West Africa where monkeypox is endemic.

Unusually, most cases so far have been concentrated in a specific community – those who identify as gay, bisexual, or other men who have sex with men (MSM). We don’t fully understand the reasons for this, and further research is needed to understand why this community is particularly affected.

It's important that engagement with the community is conducted in a productive manner and stigmatising actions or narratives avoided. Stigmatising monkeypox or any other infection runs counter to the goals of public health, making prevention of escalation much harder.

Could monkeypox become endemic to new regions? 

Unlike the coronavirus that causes Covid-19, monkeypox is not thought to be infectious during a person’s incubation period, meaning people are not thought to spread the disease if they don't have symptoms. It also requires close contact to spread. Combined, these factors are likely to limit how widely the disease is transmitted.   

However, it can infect different animal species. There is a worry that monkeypox could become endemic in new parts of the world, particularly in areas with poor disease surveillance, if it manages to become established in animal populations. 

So, while it’s unlikely that monkeypox will become the next pandemic, if it were to enter new animal populations there is a small but real risk that we could see further outbreaks outside of its historically endemic range.

The World Health Organisation ruled out declaring monkeypox a global emergency on Saturday 25 June 2022.

However, WHO director-general Dr Tedros Adhanom Ghebreyesus said he was “deeply concerned” about the outbreak, adding it was an “evolving health threat” that he and colleagues were “following extremely closely”.

Now, scientists need to better understand the origins of this outbreak and whether the virus itself has changed. This information should come to light as more genomic sequences become available.

Are there treatments or vaccines for monkeypox?  

We already have key tools to control the disease – effective vaccines and treatments. These were primarily developed to control smallpox, not monkeypox, so research to understand how well these work against monkeypox is a priority in the current outbreak.

Although data is limited, it’s thought the smallpox vaccine provides 85% protection against monkeypox. The NHS (National Health Service) in the UK is already using it for close contacts of those who have tested positive. Many governments have historically maintained stockpiles of smallpox vaccine for emergency use, which are now being accessed to combat the spread of monkeypox. The USA, EU, UK and others have also requested additional purchases of vaccines.   

Vaccines prevent infection, but we also need drugs or treatments for people who are sick with monkeypox. Because the disease is so rare, it’s difficult to test drugs in the real world. However, a drug called tecovirimat or 'TPOXX' has been shown to be safe and effective in animal studies at treating disease. This is now being used on a limited level in those who get sick, which allows us to further understand how effective it is for treating people.

The expanded use of TPOXX and the smallpox vaccine in preventing and treating monkeypox is an important opportunity to collect data on the effectiveness of these tools. Improved knowledge on these may stop the disease spreading and could also help the African countries where the disease is endemic to better prepare for future outbreaks.

What actions should governments be taking? 

Now is the time for careful surveillance and rapid research. A robust disease surveillance system is what first detected community spread of monkeypox in the UK, and researchers and governments rapidly began to communicate and share data to better understand the spread between countries.

Public health authorities must work with local communities to continue monitoring the spread of the virus, break chains of transmission and ensure that any changes to transmission or severity are identified.  

Reacting to the WHO decision not to declare Monkeypox a Public Health Emergency of International Concern, Professor Gordon Dougan, Director of Infectious Diseases at Wellcome, said

“Governments do not need to wait for an official declaration to begin acting in a coordinated and measured way.

"Where cases have been identified, rapid public health responses such as enhanced disease surveillance, contact tracing, and self-isolation will be crucial. But with the virus continuing to spread, all countries must step up, integrate their preparations, and help those with limited capability."

As the last two years have made clear, building robust systems of cooperation are vital if we are to prevent infectious diseases from escalating. Information from contact tracing, genomic studies and vaccine and therapeutic use must be shared across nations and public health bodies to inform development and use of future interventions and understand how this outbreak began.

"While higher income countries are now paying attention to this outbreak, monkeypox has been affecting people in West and Central Africa for decades. In the age of international travel and a changing climate, strengthened epidemic preparedness benefits us all. Emerging infectious diseases are a global issue, not limited to endemic countries."

Peter Hart

Senior Research Manager, Microbial Communities and Reservoirs

Wellcome

This article was first published on 1 June 2022.

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