Opinion: This Monkeypox Outbreak Is Different Than the Ones We‘ve Seen Before


The monkeypox outbreak is quickly becoming a hot topic across every news outlet now. Nearly 150 confirmed or suspected monkeypox cases have been reported across 14 countries —i.e., the U.K., Portugal, Spain, the U.S., Canada, Sweden, Italy, France, Belgium, Australia, Germany, Netherlands, Israel, and Switzerland — as of today. And more are likely to come.

Some of the cases, but not all, are linked to recent travel from Nigeria, where monkeypox is endemic. But little did many know that the same incident occurred one year ago during mid-2021 when Covid was surging.

The monkeypox then-and-now

In a letter to the Journal of Medical Virology — Re‐Emergence of monkeypox amidst delta variant concerns: A point of contention for public health virology?” — Sarwar et al., from Larkin Community Hospital in Florida, the U.S. has warned about the spread of monkeypox in the U.K. and U.S in mid-2021:

On July 17, 2021, a case was reported to the World Health Organization from the Dallas city of Texas in the United States. The patient had traveled from the United States to Nigeria on June 25, 2021, when he started having fever, vomiting, and a mild cough followed by a rash during his stay…On July 15, the Center for Disease Control and Prevention confirmed the disease to be positive for the West African clade of monkeypox virus [source here].
Similarly, an outbreak of three cases of Monkeypox was also reported between May 25, 2021, and June 15, 2021, in the UK. The first case traveled from Nigeria to the UK on May 8, 2021, and developed a rash after 2 days…On May 25, 2021, the West African clade of monkeypox was confirmed by [PCR]. Subsequently, on May 29, 2021, and on June 15, 2021, two other family members were also diagnosed with the same disease and treated [source here and here].

Since then, the scientific community and media have turned silent about the monkeypox spread until these few days. Why?

Apparently, the monkeypox outbreak in countries where it isn’t endemic seems to come and go.

When the travel-related monkeypox case was detected in the U.S. in July 2021, the WHO reported that it was the first incident since 2003. Before that, at least 7 incidents of travel-related monkeypox cases occurred since 1978 in the U.S. In other non-endemic countries, at least 6 such cases were reported in Israel (2018), Singapore (2019), and the U.K. (2018, 2019, and 2021).

But what about now? Is the currently spreading monkeypox the same as we encountered before? The situation so far says no.

The previous monkeypox outbreak in non-endemic countries was only limited to a few individuals, i.e., fewer than 10, at a given time. And then it died out due to its poor transmission capacity; hence, poor media coverage.

But today, nearly 150 suspected or confirmed monkeypox cases had been reported. That’s over a 10-fold increase than before at a given point in time.

“With several confirmed cases in the United Kingdom, Spain and Portugal, this is the largest and most widespread outbreak of monkeypox ever seen in Europe,” Germany’s armed forces’ medical service said on 20 May 2022.

Something is odd about its mode of transmission

Previously, monkeypox spread via close-contact respiratory droplets or bodily fluids from coughing or sneezing, which is relatively good news compared to the aerosol competency of SARS-CoV-2, the Covid-19 virus.

Respiratory droplet’s transmission mode is much slower than aerosol’s since respiratory droplets fall to the ground and do not linger in the air.

The monkeypox now should theoretically retain its respiratory droplet’s transmission mode. Its sequenced genome from a recent case in the U.K. reveals that it belongs to the West African clade with a 1% case fatality rate. So, it’s not a new type of monkeypox virus.

But there seems to be something else behind its drastic rise in transmission compared to the previous monkeypox outbreaks.

“[Monkeypox] transmission this time is puzzling experts, because a number of the cases in the United Kingdom — nine as of May 18 [2022]— have no known connection with each other. Only the first case reported on May 6 had recently traveled to Nigeria,” Reuters reported. “As such, experts have warned of wider transmission if cases have gone unreported.”

Similarly, Nature news stated, “for monkeypox to be detected in people with no apparent connection to one another suggests that the virus might have been spreading silently — a fact that Andrea McCollum, an epidemiologist who heads the US Centers for Disease Control and Prevention poxvirus team calls “deeply concerning”.”

It’s deeply concerning because tracking asymptomatic (no symptom) transmission is much more complicated than symptomatic ones. And the monkeypox we know before doesn’t tend to spread asymptomatically.

Some suspect that the current monkeypox cases were transmitted sexually among gay or bisexual men. But the evidence for this is preliminary. After all, sexual contact also means close bodily contact. And the previous monkeypox wasn’t known as a sexually transmitted disease like HIV/AIDS.

There’s also a possibility that the monkeypox virus could be airborne, as Dr. Eric Feigl-Ding — an epidemiologist and Chief of COVID Task Force at the New England Complex Systems Institute, who is one of the earliest scientists to sound the alarm for Covid-19 — cautioned in a tweet:


*Referenced Study: Verreault et al. (2012). Susceptibility of Monkeypox virus aerosol suspensions in a rotating chamber. Journal of Virological Methods.

The CDC also admits that monkeypox could spread via airborne or contact.

But “to be clear, this is a study done in an artificial chamber with device that can aerosolize virus particles. It simulates respiratory aerosols but not “real world” per se,” Dr. Feigl-Ding added. “But we should take PRECAUTIONARY PRINCIPLE- just like we should have from the beginning with coronavirus.”

With little immunity in countries where monkeypox isn’t an endemic, the WHO further warns that monkeypox cases spread further, especially when it’s summer season in Europe, where people socialize in groups more often.

What now?

When unsure, err on the side of caution; that’s the precautionary principle.

That means keeping up to date with reliable news on monkeypox and not falling prey to misinformation, disinformation, or hype, as well as being more careful in public — e.g., wearing a mask — if monkeypox is detected therein.

Nobody knows for sure how the current monkeypox situation will turn out. A few possibilities are:

  • Just end anti-climatically due to poor transmission rate or prompt public health actions to contain the monkeypox spread.
  • Develop into a small or moderate outbreak in several countries.
  • Develop into a full-fledged pandemic across multiple countries.

People will have opinions; some will be right, and some will be wrong. But experts believe that the last of these three is highly unlikely. But then again, it might very well become a reality if nothing is done to control it.

Thankfully, we are not unprepared medically. We still have smallpox vaccines that are ~85% effective against monkeypox. We also have anti-virals against monkeypox. And we have experience dealing with Covid — face masks, indoor air ventilation, physical distancing, and contact tracing — which, if applied properly, could suppress monkeypox transmission as well.

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