The Spread of Monkeypox in a ‘Shared Global Space’

In this video, Boghuma Titanji, MD, PhD, of Emory University School of Medicine in Atlanta, discusses various issues surrounding the current monkeypox outbreak, including high-risk groups, avoiding stigma, and the potential for a broadened endemic range.

The following is a transcript of her remarks:

Monkeypox outbreaks have happened recently in non-endemic countries around the world. As of today, the WHO [World Health Organization] is reporting about 1,500 cases of monkeypox occurring in 33 countries, which are in non-endemic parts of the world for this particular infection.

Of the 1,500 cases reported so far in non-endemic countries, these cases have predominantly clustered in men. I think there have only been three cases reported in women. These have been mostly men who have sex with men or identify as gay or bisexual, and they are connected through common or shared social networks.

So it is important that we highlight that there are emerging higher-risk groups, but it’s also important to remind everyone that monkeypox doesn’t only infect men who have sex with men; men who are gay or who are bisexual. Absolutely anyone can get the infection. It is exposure with close contact, bodily fluids, contaminated clothing or bedding of individuals who have an infection, or exposure to the rash, and close contact with a rash, that can get you exposed and possibly develop a potential infection.

So it’s important to highlight the groups that are most affected currently so that they are aware, and we can find cases, and offer the interventions that are important to stop transmission, but also important to not stigmatize because anyone can be infected.

We have known that monkeypox is a virus that infects humans for over 50 years. Actually, the first case was identified in humans in 1970 in the Democratic Republic of Congo. Since that time, there have been multiple outbreaks happening in West and Central African countries where the infection is thought to be endemic, because the reservoir animals predominate in those geographies.

We know that through time, the case numbers have increased in those settings. It’s likely a combination of factors that have led to this: both growth in population; change in climate; closer interactions with the animal reservoir as populations encroach on the environments of the animals that we share our environments with; and also, as some have postulated, a decline in immunity from smallpox, because the smallpox vaccination offers a certain degree of cross protection from infection with other avipoxviruses.

So we have known that there was the potential threat for outbreaks to emerge and outbreaks to grow. This has been happening. Actually this year alone, we have almost recorded 1,500 cases of monkeypox in the Democratic Republic of the Congo — almost to the same degree as the totality of the number of cases now being reported in non-endemic countries. But this has not attracted the same level of attention because, primarily, before the current outbreaks, this was predominantly affecting populations of individuals who not only live in very remote parts of the endemic countries, but who also are poor and not necessarily prioritized on the global health priority list in terms of things that we need to address and dedicate more funding towards tackling.

One of the big concerns with the ongoing outbreaks in non-endemic countries is the realistic possibility that we could see transmission not only between humans, but actually from humans to their pets and subsequently to other wild animals in non-endemic geographies. And the risk that that carries is that you could basically have a situation where monkeypox runs the risk of broadening its endemic range, because then it establishes itself in animal reservoirs in previously non-endemic countries. Then you run into a cycle where occasionally we will start seeing sporadic spread from animals back into humans and vice versa. The risk of that really is, once an infection, a viral infection like monkeypox, establishes itself in an endemic fashion, it makes it a lot more challenging to eliminate or eradicate.

The current monkeypox outbreak coming right in the middle of a global pandemic in its third year, it really encounters a general population that is traumatized from just having lived through, and is still actively living through, the effects of a zoonotic virus that has really had tremendous impact on all of humanity for the last 3 years. What that has done, while there is a more heightened sense of awareness when outbreaks occur and people are more curious to learn about new outbreaks, there is also a certain degree of exhaustion and also the sense that ‘Oh, here we go again. We are coming out from one outbreak, we’re going into another.’ And those are all very understandable responses to have.

While the ongoing monkeypox outbreaks are concerning and need to be taken very seriously, they are not going to cause the next pandemic. It’s quite a different outbreak. It is a different virus.

We do know more about this virus than we knew about SARS-CoV-2 when it first emerged, and we also have a wealth of literature from previous outbreaks that have happened in Africa to draw from on what we need to do to actually interrupt transmission chains, and stop these outbreaks when they do occur. So I think we are starting from a point where we feel, I think people should feel a little bit more comfortable in the tools that public health has to tackle these outbreaks in an appropriate manner so that they don’t become a more consequential problem.

Most human viral pathogens originate from zoonotic viruses: HIV, SARS-CoV-2, and now monkeypox. And this is far from being the last one that we will encounter. I think it’s very important for us as global citizens to come out of our bubble and really realize that we are in a shared global space, and that awareness should translate into more advocacy for truly global responses to global threats, even before they happen.