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

We failed to bring the monkeypox epidemic under control, and we may have missed the opportunity to prevent the disease from becoming endemic – and a permanent threat – in the United States and Europe.

Monkeypox is spreading rapidly around 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 outbreaks were rare and small.

In other words, smallpox is about to become endemic in many new places. If this happens, it could become very difficult to eradicate. Monkey pox, which causes fever and rashes and is fatal in a very small number of cases, will become another disease people need to worry about all the time.

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

The good news with this kind of endemicity is that it does not have be permanent. Reversing human endemicity is difficult, yes, but it is possible. “If it’s just spreading in humans, it can be controlled – eventually – through vaccination and natural immunity,” Amesh Adalja, 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 epidemics in the human population are frequent.

If smallpox finds refuge in certain animal species in North America or Europe, for example squirrels, rats or prairie dogs, it will be virtually impossible to eradicate it regionally. “Game over,” Lawler said. Smallpox will be all around us, probably forever, just waiting for opportunities to spread from animals to humans. Epidemics will be frequent and large, just as they are now in West and Central Africa.

To be clear, smallpox is not endemic in humans or animals in the United States or Europe – yet. But the trends are not encouraging. “I share the concern of other scientists about the lockdown and the virus becoming endemic in our rodent population in the United States,” said Stephanie James, head of a viral testing laboratory at Regis University in Colorado, USA. Daily Beast.

Officials first noticed the current outbreak, involving a relatively mild West African strain of smallpox, after diagnosing a British traveler returning from Nigeria in early May. Spreading through close physical contact, including sex, smallpox quickly accompanied travelers on planes to distant lands. Doctors diagnosed the first US case on May 27.

But it is obvious now that the first diagnostic the smallpox cases in Europe and the United States were not the first true cases. On June 3, the United States Centers for Disease Control and Prevention announced that they had found genetic evidence of American smallpox cases that predated the first cases in Europe from May.

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

Doctors may not have noticed or reported these infections earlier, at first, due to 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 had been spreading clandestinely for several months,” Adalja said.

The virus had a big head start, which helps explain why, months later, it still remains one step 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 less 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 have all the tools necessary to quickly contain a smallpox epidemic. 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 infected people, vaccinate their family, friends and colleagues.

And educate the public, especially groups most at risk, including men who have sex with men.

But so far, the strategy is not working. Part of the problem is the virus itself, Lawler said. “The disease is different from the monkey pox that we have seen in the past. I don’t think we know why, probably a combination of virus, host and environment.

Above all, it is our fault. Too many doctors have misdiagnosed cases of smallpox as herpes or another STD. Both the WHO and the CDC have waited too long to designate the smallpox outbreak as a public health emergency and mobilize resources. The WHO declared an emergency on July 23. The CDC should do the same in the coming days.

Authorities are rolling out more vaccines and therapies and stepping up testing. Even so, the clinics that are on the front lines of public health in the United States need more of everything. More trials. More vaccines and therapies. More money for community outreach. The US National Coalition of STD Directors recently surveyed about 100 clinics and found that half lacked the capacity to deal with the monkeypox epidemic.

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

The federal government seems incapable of dealing with “reverse zoonotic” transmission from humans to animals. To prevent endemicity in animals, you need to detect smallpox infections in one species, cull the infected animals, and then closely monitor the remaining population to be sure you’ve cleared all the virus.

But it is unclear who in the federal health establishment should take the lead. “The operational response to zoonotic diseases falls into this gray area,” Lawler said. The CDC maintains a website describing the symptoms of smallpox in pets and livestock and explaining where to send samples for diagnosis. The Zoosanitary and Phytosanitary Inspection Service of the Ministry of Agriculture monitors animal diseases. Mostly cattle.

APHIS was unable or unwilling to confirm that it was testing the animals for monkeypox. The agency referred The Daily Beast to the CDC, which did not respond to an email seeking comment. If there is an agency responsible for detecting smallpox in animals, that agency seems unwilling to take responsibility.

The rapid spread of monkeypox in humans is a preventable tragedy. But he can still get a plot worse. With hard work and a bit of luck, it is still possible to contain and eventually eliminate the human epidemic.

But if American or European rodents catch smallpox, the epidemic will escalate into something much worse. A new endemic disease. One that is almost impossible to eradicate.

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