Monkeypox is spreading rapidly throughout the world, especially in the United States and Europe. With cases doubling roughly every two weeks, there is a growing risk that monkeypox will become a permanent problem in countries where, previously, cases were rare and small. Smallpox is, in other words, close to becoming endemic in many new places. If this happens, it can become very difficult to eliminate. Monkey pox, which causes a fever and rash and is fatal in a very small number of cases, will become yet another disease that people have to constantly worry about. For smallpox, there are two paths to endemicity. If the virus infects enough people quickly enough to overwhelm authorities’ efforts to detect transmission and vaccinate those at risk, it can become endemic in humans. “We’re already close to it,” James Lawler, an infectious disease specialist at the University of Nebraska Medical Center, told The Daily Beast. The good news with this type of endemicity is that it doesn’t have to be permanent. Reversing human endemicity is difficult, yes, but it is possible. “If it’s just spreading to people, it can be controlled — eventually — 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 “zoonogenic” animal virus. It circulates in rodent and monkey species in West and Central Africa, where outbreaks in the human population are frequent. If smallpox finds a home in certain animal species in North America or Europe—say, squirrels, rats, or prairie dogs—it will be nearly impossible to eradicate regionally. “Game over,” Lawler said. Smallpox will be all around us, probably forever, just waiting for opportunities to spread from animals to humans. Outbreaks will be frequent and large, as they are now in West and Central Africa. To be clear, smallpox is not endemic to humans or animals in the United States or Europe—yet. But the trends are not encouraging. “I share the concern of other scientists about containment and that the virus is becoming endemic in the US rodent population,” Stephanie James, head of a virus testing lab at Regis University in Colorado, told the Daily Beast. Officials first noticed the current outbreak, involving a relatively mild West African strain of smallpox, after they diagnosed it in a UK traveler returning from Nigeria in early May. Spread through close physical contact, including sex, smallpox was soon accompanying travelers on planes bound for distant lands. Doctors diagnosed the first case in the US on May 27. But it is now clear that the first cases of smallpox diagnosed in Europe and the US were not the real first cases. On June 3, the US Centers for Disease Control and Prevention announced that they had found genetic evidence of cases of American smallpox that preceded the first cases in Europe since May. “The rapid spread of smallpox among humans is a preventable tragedy. But it could still get a lot worse.” Doctors may not have noticed or reported these previous infections at first because of the similarity between the symptoms of smallpox and the symptoms of some common sexually transmitted diseases such as herpes. “The virus was masquerading as a sexually transmitted infection and spreading secretly for several months,” Adalja explained. The virus had a big head start, which explains why, months later, it is 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 up from fewer than 10,000 cases two weeks ago. The World Health Organization has counted five smallpox-related deaths in non-endemic countries. What is frustrating for epidemiologists is that, in theory, we had all the tools we needed to quickly contain a smallpox outbreak. Thanks to COVID, healthcare workers around the world are better than ever at contact tracing. Vaccines and treatments that work for smallpox also work for monkeypox. There is a proven strategy: diagnose cases, isolate and treat the 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 isn’t working. Part of the problem is with the virus itself, Lawler said. “The disease is different from the monkeypox we’ve seen in the past. I don’t think we know why—probably a combination of viruses, hosts, and environment.” Mostly, it’s our fault. Too many doctors misdiagnosed cases of smallpox as herpes or some other STD. The WHO and CDC waited too long to declare the smallpox outbreak a public health emergency and mobilize resources. The WHO declared a state of emergency on July 23. The CDC is expected to do the same in the coming days. Authorities are developing more vaccines and treatments and stepping up testing. Even so, clinics on the front lines of public health in the US need more than anything. More tests. More vaccines and treatments. More money for community outreach. The US National Coalition of STD Directors recently surveyed one hundred clinics and found that half lacked the capacity to deal with the monkeypox outbreak. “We’re still moving very slowly,” Lawler warned. And, he added, “we still reject the possibility of the unexpected.” Including the increased possibility of smallpox spreading to squirrels or rats. The Feds seem to be struggling to deal with “reverse zoonotic” human-to-animal transmission. To prevent endemicity in animals, you must detect smallpox infections in a species, kill the infected animals, and closely monitor the rest of the population to make sure you eradicate all the virus. But it is not clear who in the federal health establishment should take the lead. “The surgical response to zoonotic disease falls into this gray area,” Lawler said. The CDC maintains a website that describes symptoms of smallpox in pets and animals and explains where samples should be sent for diagnosis. The Department of Agriculture’s Animal and Plant Inspection Service monitors animal diseases. Especially livestock. 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 primary agency for animal pox detection, that agency does not seem willing to take responsibility. The rapid spread of smallpox to humans is a preventable tragedy. But it could still get a lot worse. With hard work and a little luck, it is still possible to contain and eventually eliminate the human epidemic. But if American or European rodents contract smallpox, the outbreak will escalate into something much worse. A newly endemic disease. One that is impossible to eradicate.
