It may soon be too late to end the global monkeypox epidemic.
“We’re missing the window to contain this outbreak,” Boghuma Titanji, an infectious disease physician and virologist at Emory University in Atlanta, said at a July 21 seminar sponsored by Harvard Kennedy School’s Belfer Center for Science and International Affairs.
On July 23, World Health Organization Director Tedros Adhanom Ghebreyesus declared the global monkey outbreak a public health emergency of international concern, the organization’s highest alert status. The WHO committee assessing the issue was split on whether the outbreak is an international emergency, but Ghebreyesus decided sufficient conditions were met to warrant designation.
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Monkeypox has infected more than 15,700 people since early May, according to Global.health (SN: 5/22/26). As of July 22, more than 2,800 cases have been reported in the United States, according to the US Centers for Disease Control and Prevention.
“While I am declaring an international public health emergency, this is an outbreak that is currently concentrated among men who have sex with men, especially those with multiple sexual partners,” Ghebreyesus said in a statement. “That means it’s an outbreak that can be stopped with the right strategies in the right groups.”
Monkeypox has caused outbreaks in parts of Africa for decades, Anne Rimoin, an epidemiologist at the UCLA Fielding School of Public Health, told the Harvard seminar. But the virus has been “ignored by the global health community”. Monkeypox has been “giving us warning signs” for years in Congo, Nigeria and other parts of West Africa, but it has only received attention since cases outside the continent began to emerge, Rimoin said.
According to Titanji, there has been no concerted global effort to contain the virus, which is related to smallpox. Each country is left to set its own policies.
This has led to differences. Well-resourced countries have at least had access to tests, vaccines and medications, which can help limit the spread of the virus or the severity of the disease. Resource-poor nations often lack this access and have limited ability to track or control the virus. The continued spread of the monkey in low-resource countries could leave places that manage to contain an initial outbreak vulnerable to reintroduction, Jay K. Varma, director of the Cornell Center for Pandemic Prevention and Response in New York, said at the seminar. The WHO’s emergency declaration could lead to a more concerted international effort that could use more resources to contain the spread of the virus.
Even for the wealthiest countries, sustaining the outbreak is a challenge. Questions abound about how the virus is transmitted and whether vaccines and treatments – once people have access to them – can stop the spread. Although the disease can be difficult to diagnose, testing is often difficult and missed diagnoses can lead to more cases.
Most cases of monkeypox in the world have been among men who have sex with men. Of 528 people infected with the virus in 16 countries, 98 percent were gay or bisexual men, researchers reported July 21 in the New England Journal of Medicine.
In some countries with outbreaks, “gay men are criminalized,” Science magazine correspondent Kai Kupferschmidt said at the seminar. In those countries, “people can’t get good information about not getting infected and they can’t access health care if they get infected. In those countries, it’s really hard to even see the problem,” he said.
Ghebreyesus called on all countries “to work closely with communities of men who have sex with men, to design and deliver effective information and services, and to take measures that protect the health, human rights and dignity of affected communities.” Stigma and discrimination can be as dangerous as any virus,” he said in a statement.
Doctors may also miss monkey cases because of the unusual presentation of the disease in this outbreak compared to earlier outbreaks. For example, in the NEJM study, only a quarter of patients had monkeypox lesions on their faces and only 10 percent had sores on their palms or soles. These parts of the body have been some of the most affected in other outbreaks.
Instead, 73 percent of the people in the study had lesions on the anus and genitals, and 55 percent on the trunk, arms, or legs. Some people also had injuries to their mouths and throats. Most people in the study had fewer than 10 lesions, and 54 people had only one lesion on their genitals, making it even easier to confuse it with herpes or syphilis.
Seventy people in the study were admitted to the hospital. Of these, 21 were hospitalized for pain, mainly severe rectal pain. Others had eye injuries, kidney damage, heart inflammation or throat inflammation that prevented them from taking in fluids.
These complications are consistent with what health officials in the United States have seen. “While the mortality seems very low, which is high, the morbidity has been far greater than any of us expected,” Mary Foote, medical director of the New York City Department of Health and Mental Hygiene, said in a sponsored news release on July 14. Infectious Diseases Society of America.
“A lot of people with this infection are really suffering, and some may be at risk of permanent damage and scarring. We see a lot of people with symptoms so severe that they can’t go to the bathroom, urinate or eat without excruciating pain,” Foote said.
A small number of women and children also contracted monkeypox during the outbreak. Two children in the United States have been diagnosed with mumps, CDC Director Rochelle Walensky said on July 22 in an interview with the Washington Post. The two children were social contacts of men who have sex with men, he said.
A child in the Netherlands who had no contact with anyone infected with the virus also contracted monkeypox, researchers reported July 21 in Eurosurveillance. His case raises the possibility that monkeypox can spread undetected in communities more widely than previously thought.
“I don’t think it’s surprising that we occasionally see cases of gay, bisexual or other non-men who have sex with men. The social networks we have as humans means we interact with many different people,” Jennifer McQuiston, deputy director of the CDC’s Division of High Impact Pathogens and Pathology, said at a July 22 White House news conference.
Exactly how the Dutch child became infected is a matter of speculation. Monkeypox is usually spread between people through close contact with infected people or through close contact with clothing, bedding, or towels used by people with the disease. Viral DNA analysis showed that the boy is not related to the known cases in the Netherlands. He traveled to Turkey in June and may have been infected there or while traveling.
The boy has very low levels of IgA antibodies, which help protect the mucous membranes and prevent infections there. Low levels of antibodies can make you susceptible to respiratory infections. People can become infected with monkeypox through droplets shed by infected people during close face-to-face interactions such as close conversation, kissing, or medical examinations. But infection patterns clearly indicate that monkeypox is not airborne like COVID-19 or other respiratory viruses, Kupferschmidt said.
The details of how monkeypox is spread are still unknown. For example, researchers do not know whether the virus can be sexually transmitted as a sexually transmitted disease. Researchers have found evidence of viral DNA in semen, saliva, urine and faeces, but this may be inactive traces of the virus. To date, no researchers have reported finding infectious viruses in genital bodily fluids that can be exchanged during sex. It’s also unknown whether contamination through mucous membranes during sex can hide the virus from later catching it, Rimoin said.
Scientists are questioning whether the monkeypox virus has mutated or simply found a social-sexual niche that allows the virus to spread more efficiently among gay and bisexual men, Titanji said. There may be different patterns of transmission in historically affected countries and in affected countries requiring different strategies to stop the spread, he said.
Researchers also need to conduct good studies to learn how vaccines and therapeutics work and under what conditions they work, Rimoin said. The WHO’s emergency declaration includes recommendations to increase testing and surveillance and increase research into vaccines, treatments and other measures to contain the virus.
One thing is clear, said Rimoin. “We’re giving this virus room to run like never before.” People have passed the money, leaving others to work on the monkey problem, he said. But now, “it’s everyone’s problem to solve.”
