The Monkeypox Outbreak, Explained : Short Wave The White House officially declared monkeypox a public health emergency in the United States last week. More than 7,500 cases of the virus have been confirmed since it began spreading across the country in May.

Today's show: Health reporter Pien Huang on how the outbreak began, how it gathered steam and whether monkeypox is on track to become an endemic disease in the United States.

Check out more of NPR's reporting on monkeypox:
- Monkeypox: The myths, misconceptions — and facts — about how you catch it
- He discovered the origin of the monkeypox outbreak — and tried to warn the world
- How we talk about monkeypox matters. Experts offer ways to reduce stigma

How Monkeypox Became A Public Health Emergency

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EMILY KWONG, HOST:

You're listening to SHORT WAVE from NPR.

THOMAS LU, HOST:

Hey, Short Wavers. Producer Thomas Lu here with health reporter Pien Huang. So, Pien, you've been covering monkeypox for several weeks now, watching cases escalate and escalate.

PIEN HUANG, BYLINE: And since the first case in the U.S. was detected in Boston in May, it's been found in 48 states, and case counts are booming.

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UNIDENTIFIED PERSON #1: This morning, a Massachusetts man is in isolation after being diagnosed with the first case of monkeypox in the U.S. this year.

UNIDENTIFIED PERSON #2: ...Also at social gatherings as the agency reports more than 7,500 cases of monkeypox nationwide. The CDC is also requesting...

UNIDENTIFIED PERSON #3: We urge every American to take monkeypox seriously and to take responsibility to help us tackle this virus.

LU: And the U.S. has declared a public health emergency in response to the disease, which, for anyone who doesn't know, is caused by a virus related to smallpox.

HUANG: Right, though it's much less deadly and less transmissible.

LU: And the response is giving people some deja vu, like it's COVID all over again or even early HIV/AIDS days.

HUANG: Right. And that's because right now it's most prevalent among gay and queer folks and their sexual networks, primarily men who have sex with men. And based on the limited data we have, it also seems to be hitting communities of color and HIV-positive people harder. And public health officials, at least in the U.S., have been criticized for a slow, bureaucratic response.

LU: Today on the show, how the monkeypox outbreak got started, how it gathered steam and whether it can be stopped now. You're listening to SHORT WAVE, the daily science podcast from NPR.

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LU: Pien, let's start by learning more about monkeypox. Could you tell us what it is and where it came from?

HUANG: Yeah, well, the global outbreak right now is really changing what we thought we knew. So monkeypox is a disease that's been around for a long time. And before this outbreak, the most common understanding of it was that it was endemic to some countries in Africa but not really seen elsewhere. You know, you would usually see spillover events from animals, maybe some household transmission. And it was really found in certain regions of the world where people hunt and eat bushmeat, had contact with animals. And our colleague Michaeleen Doucleff spoke with Dr. Dimie Ogonia. He's a Nigerian doctor who diagnosed the first known case of the strain five years ago. And he tried to warn the world about it.

DIMIE OGONIA: They brought my attention to it - a young boy. He had skin lesions that appeared very unusual, very large, affecting the face and all over the body. The suspicion of monkeypox just came up.

HUANG: That was the first case of monkeypox in Nigeria in almost 40 years. And over the next few months, many more cases cropped up, and he started noticing a pattern. A lot of the cases were being found in young, middle-class men who lived in cities. Many of them were men who had sex with multiple partners or with sex workers. So he realized that it was spreading pretty effectively between people, probably through sexual contact. And he tried to warn the medical establishment that monkeypox was spreading from person to person in this new way, but he says that people didn't want to hear it.

LU: And then earlier this year, cases started cropping up in countries where the virus isn't typically found, mostly among communities of men who have sex with men.

HUANG: Yeah. Now we're in a situation with more than 27,000 cases globally, and a quarter of those cases are in the U.S. Now, there have been a few cases in women and children, but most of the cases that we have data for - I'm talking about 98, 99% of the cases in the U.S. - most of those cases have been in the community of gay, bisexual men who have multiple partners among their sexual networks.

LU: Clarify for me - is monkeypox an STD?

HUANG: Well, it's definitely behaving like a sexually transmitted disease, even though it's not being officially classified by the World Health Organization or the CDC as that. You know, an STD is defined as a disease that's primarily spread through sexual contact, and that's what we're seeing with monkeypox right now. It is possible to be spread through other ways, not very easily, but it can spread through prolonged face-to-face contact as well or touching the virus repeatedly on surfaces, introducing it into the body that way. So I currently think of it and, you know, doctors that I've spoken to have sort of thought of it as kind of an STD-plus. It's spreading through sex but not exclusively, even though that is the main way that it's spreading right now.

LU: Got it. Thanks for the clarification. Currently, the U.S. has the largest detected outbreak. What's the situation here?

HUANG: Yeah. The U.S. has surpassed countries like Spain and the U.K., and they're now leading with over 7,000 cases. And even then, experts say it's an undercount. You know, for the first two months of the outbreak, from - through May and June, testing was really limited. Then in July, it started to become easier to get tested. Doctors could order them through major commercial labs. But in this country, we're still only testing people with active lesions.

LU: Because that's what the CDC recommends. Anyone with a rash that could be monkeypox, get tested.

HUANG: Yeah. I mean, the virus can also show up in saliva and other bodily fluids, which would be a quicker and easier way to test for it, but right now the FDA says they're sticking with testing people with active lesions 'cause they say there's not enough evidence for the other testing methods. So that effectively means that someone is pretty far into the infectious period by the time they can even get tested.

LU: Gotcha. So talking about testing is making me think about the other important tools that we've used to fight another public health emergency, COVID. I'm thinking treatments and vaccines. Where are we on those fronts?

HUANG: Well, unlike with COVID, we did start with an advantage here. We had vaccines and treatments that have been developed against pox viruses over many years. And theirs seemed to work against monkeypox as well, although how well they work is a question that they're still working out in real time.

LU: And there's also a shortage of the vaccine. I know some cities, like Chicago and here in D.C. and New York, the health department is rationing it out, making appointments just for the first dose of the vaccine without knowing when they can have people come back for their second dose, right?

HUANG: Yeah. The government has 1.1 million vaccine doses on hand that they're sending out to states. But since each person is supposed to get two doses, that only covers half of the population that the CDC says is at the highest risk. Now, the FDA is considering a strategy called dose sparing, where a smaller amount of the vaccine is injected into the skin. They say that it might be just as effective, though it's a little harder to administer. So if they do go ahead with this, what's considered one dose now would be stretched to five.

And the reason they're considering this is because the vaccine supply has been so limited, and it's due to a series of oversights. And, you know, The New York Times reported that there used to be 20 million doses in the strategic national stockpile, but those expired. The U.S. government has been slow to request doses and to place additional orders, so other countries have been prioritized ahead of the U.S. Now, all told, the U.S. government does expect to have 7 million doses by the middle of 2023. But in the meantime, the outbreak is really surging right now.

LU: And, Pien, ideally, there would be a vaccine so widespread that it covers the whole population to create herd immunity and stop spread. But many people in the gay and bisexual male community, the priority population at the moment, are still waiting to get it. And I know that there's a pretty wide range of symptoms. Some people get mild cases with just one or two lesions. Some people get more serious cases where they have lesions in different parts of their body or internal lesions even, which can be excruciating. And some people get complications or are in such pain that they land at the hospital.

HUANG: Yeah, that's right, Thomas. I mean, there is a range in the course of disease, and it's not exactly clear what the breakdown is. But for people with more serious cases, you know, if they have lesions in the genitals or anus, for instance, there's an antiviral pill called Tecovirimat or TPOXX, and that is a two-week course of pills that can stop the virus from spreading from cell to cell. There's 1.7 million courses in the strategic national stockpile, and it was developed against smallpox and approved based on animal data. So it's never been tested against disease in a lot of people, and it's not clear right now how well it works against monkeypox. But I've been hearing from patients and doctors, anecdotally, that it's helping people heal a lot more quickly.

Still, in order to access TPOXX, there's a specific process that doctors have to go through with the CDC, with local health departments, to prescribe it. And what I'm hearing is that these extra hurdles are making it hard for patients to find a doctor that's willing to prescribe it, even when they clearly qualify based on the CDC's guidelines.

LU: Pien, this is reminding me a lot of kind of the early COVID days, right? I mean, we started the outbreak, the monkeypox outbreak, with a full toolbox of vaccine treatments and tests, but there's still access issues.

HUANG: You know, a lot of people would agree with you on that. Take Dr. Melanie Thompson. She's a longtime HIV doctor in Atlanta, and she tells me that the same mistakes are being repeated over and over again because they're caused by structural problems with the way that our health care system is set up.

MELANIE THOMPSON: For one thing, we don't have a unified health system, so many people don't have access to routine health care. Our public health systems have been underfunded by - for decades, and they have been decimated by COVID.

HUANG: Thompson said that for individuals, ideally, people with monkeypox would isolate at home until they're no longer infectious. But a lot of people face stigma, or they face losing their jobs if they try to stay home for two to four weeks. So if a person can't put food on the table or pay their rent, they're going to make choices that don't put public health first. And another thing she told me was that instead of being more prepared at this particular moment, the public health system is more depleted and broken than it was before because of the pandemic.

LU: So where does that leave us? What's next for this outbreak?

HUANG: Unfortunately, more people are going to get monkeypox. Cases are rising quickly. They've gone from 700 to 7,500 in the past month. And the country is still playing catch-up with the virus. Because of lags with testing and then with rolling out vaccines, we really don't know how big this outbreak is, and very few people are protected. There's also big gaps in the data collection. The federal government doesn't actually know how many vaccines or treatment courses have gone out or to whom, though they said that declaring a public health emergency will make it easier for them to start collecting this data from states.

And there's also big open questions we're behind on, like is it spreading from people without symptoms? How well do the vaccines work at preventing sickness and spread? Still, Dr. Ali Khan, a public health dean at the University of Nebraska, says the disease generally takes a lot of close contact to spread.

ALI KHAN: Do not go wash your vegetables because somebody with, you know, monkeypox may have touched, you know, the apples. So this isn't I went to the restaurant and got infected or - you know, this isn't casual contact. The data is pretty clear. This requires pretty close, intimate skin-to-skin contact with somebody who's infected.

HUANG: Getting out vaccines, treatments and education on how to prevent it should be enough to get the virus under control. But Larry Gostin, a public health law professor at Georgetown, says that requires a lot more urgency right now.

LARRY GOSTIN: The stakes are huge. You know, the window for containing monkeypox in the United States and globally is very narrow, and it's closing. And so if we don't get it under control, we'll have endemic monkeypox in the United States for many years to come.

HUANG: And it's not just clearing the disease from the U.S. You know, with COVID, with monkeypox, what we're seeing is what global health experts have been telling us all along - that diseases don't respect borders. And until we wipe out the disease everywhere, it's a threat to people everywhere.

LU: Pien, thank you so much for this overview.

HUANG: You're welcome.

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LU: This episode was produced by Chloee Weiner, edited by Rebecca Ramirez and fact-checked by Rachel Carlson. Michaeleen Doucleff also contributed to this reporting. The audio engineer for this episode was Stu Rushfield. Our programming higher-ups are senior director Beth Donovan and senior vice president of programming Anya Grundmann. I'm Thomas Lu. Thanks for listening to SHORT WAVE from NPR.

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