Monkeying around

9 November 2022

It’s always been a cliché that bad things happen in pairs – and the arrival of monkeypox just as the Covid pandemic began to recede has done little to disprove the theory. But beyond the superficial similarities between the two illnesses, and some of the more dramatic media attention it’s enjoyed, how much do monkeypox and Covid really have in common? Andrea Valentino talks to Professor Wafaa El-Sadr of Columbia University, and Professor David Heymann of the London School of Hygiene and Tropical Medicine, to learn more.

Adangerous virus that arrived from overseas. Thousands of cases worldwide, with thousands more to follow. A rush to vaccinate vulnerable groups. Education and advice campaigns ramped up in multiple languages. A global health emergency declared by the WHO. If all this sounds familiar, it should. For the second time in just a few years, we’re facing a global health emergency that, if it hasn’t yet taken on the tenor of Covid, certainly sparks the same worried feelings. Yet beyond the headlines, what is monkeypox really, and does it pose similar risks as the pandemic that just passed?

In part, these questions are difficult to answer, if only because monkeypox has just recently transcended its African homeland and spread across the planet. But that hardly means these are questions not worth posing. In the way medical professionals and community activists can use education to fight the disease, or in the way governments have to ramp up vaccine production if they hope to successfully beat the virus, many of the challenges we faced during Covid have returned with monkeypox, and look set to stay relevant long into the future too. Even if monkeypox proves not to be as deadly or as enduring as Covid, it still has to be addressed with a public health strategy.

“It is important to keep in mind that anyone with close contact to someone with monkeypox lesions may become infected.”

Professor Wafaa El-Sadr


The jump in infections in the first week of July, without more than 6,000 known to have caught the disease.


Monkey business

Read some of the more breathless reports and you might be tempted to imagine that monkeypox is totally new. In fact, the disease, a virus that originally spread from animals to humans, has been around for years. As long ago as 1958, to give just one example, Danish scientists identified it as a distinctive disease – or perhaps that should be diseases. After all, there are in fact two strains of monkeypox, one more dangerous type originating in the jungles of the Congo basin, and a milder version further west. More to the point, both ‘clades’ of monkeypox, as they’re known officially, have long been endemic across nearly a dozen African countries. The Republic of the Congo has, for instance, recorded more than 1,000 cases in 2022 alone.

Of course, the difference now, explains Wafaa El-Sadr, is that monkeypox in more recent times has left the DRC and is infecting people in New York and London. But how did this happen? El-Sadr, a professor at Columbia University and founder of the International Centre for AIDS Care and Treatment Programs, takes up the story. “It is thought that a person who was incubating the monkeypox infection travelled from one of the endemic countries, developed the disease, and then transmitted it to others through close contact, resulting in the current outbreak in non-endemic countries.” That certainly chimes with what we know: unlike Covid, monkeypox is not airborne, instead requiring physical touch, or else contact with infected clothes or bed sheets.

Nor is that the only way that monkeypox differs from Covid. While the latter’s symptoms manifest internally – shortness of breath and flu-like symptoms – the most striking indication of monkeypox is pimply rashes on the body itself. Some of the more invisible symptoms include a fever, exhaustion and headaches. If all that sounds rather grim, the physical characteristics of monkeypox can at least be a useful way of figuring out if someone is infected.

“Whether it’s monkeypox in the genital area, or monkeypox on another part of the body, just being suspicious of anyone with open sores, making sure that you don’t come in physical contact with them, is good advice for everyone,” stresses David Heymann, a distinguished epidemiologist and former chairman of Public Health England, who is now a professor at London School of Hygiene and Tropical Medicine.

Community transmission

This last point is important – not least given the demographics that have borne the brunt of monkeypox across Europe and North America. According to a recent paper by the New England Journal of Medicine, around 95% of reviewed cases were transmitted by men during sex with other men. Yet Heymann speculates the gay community’s long and unhappy relationship with STDs is arguably at play here. Though monkeypox isn’t an actual STD, after all, Heymann hints that long traditions of self-diagnosis and check-ups mean the disease is being “amplified” by the gay community. This education-heavy approach is shadowed by actual rules. In England, to give one example, doctors are required to inform their local council or Health Protection Team if they suspect a patient has monkeypox.

Not that monkeypox – like HIV before it – is a disease only the gay community can catch. For if self-reporting is helping turn that particular group into the virus’s reluctant standard bearers, all that’s needed to be infected is close contact with infected material, or non-sexual touch with a sick individual. As El-Sadr puts it: “It is important to keep in mind that anyone with close contact to someone with monkeypox lesions may become infected.” This is gradually being borne out in the statistics. At the time of writing, the Centre for Disease Control and Prevention (CDC) reports two cases of monkeypox in children, while a Texan woman recently tested positive. That’s echoed by rising case numbers more broadly. Naturally, total cases are still dwarfed by Covid, but the first week of July nonetheless saw a 77% jump in infected individuals, with more than 6,000 people now known to have caught the disease. And that’s before you consider the many unrecorded cases that are likely to be circulating too.

Behind these alarming headlines, though, what’s the actual threat of monkeypox to the average person? Here, fortunately, there’s a spot of good news. “Based on prior information,” explains El-Sadr, “most cases tend to be mild or self-limited.” That’s amply reflected in the figures. No one in the Western world yet is known to have died from monkeypox, testament to the relative gentleness of the West African clade, the one that made the jump from Liberia, Sierra Leone and other endemic countries. In practice, most people can expect their case of monkeypox to remind them of childhood chickenpox, with those tell-tale spots completely disappearing within about a month.

Our passport out of here?

Not that we should lower our guard just yet. For as El-Sadr emphasises, monkeypox can still be dangerous for a minority. For one thing, she explains how lesions in the urethra or anus can cause severe pain, especially when urinating or defecating. Lesions in the eye can cause even nastier problems, especially for immunosuppressed individuals. That’s shadowed by broader concerns. We might have been lucky by importing the West African clade – but if the Congolese ever arrives, we risk more serious trouble. Nearly 60 people are estimated to have been killed by Congolese strain so far this year, with some researchers arguing that hundreds of deaths are going unrecorded in isolated jungle settlements.

To put it another way, what’s arguably needed in the fight against monkeypox is a response as robust and speedy as the one we eventually saw with Covid, if only to prevent a more serious outbreak in future. As a disease that spreads through close contact, in fact, that response surely begins with keeping infected individuals away from the rest of society. It also means providing people who exhibit severe disease with the treatment they need. One option is antiviral drugs, which El-Sadr stresses are effective, and which have successfully been used to attack the side effects of AIDS.

Then there’s the question of vaccines. Like with Covid, they promise to stop monkeypox in their tracks, especially since doctors already have doses at their disposal. “There is a vaccine,” says Heymann. “In fact, it’s been licensed to prevent monkeypox.” Similar to the traditional smallpox vaccine, Heymann adds this new vaccine, known as Jynneos, doesn’t replicate in the human body, making it safer for HIV-positive people who are at risk of more serious disease generally. Given that available summary surveillance data from the European Union, as well as separate reports from Portugal, Spain and England suggests that 30% to 51% of patients with monkeypox also have HIV – that’s undoubtedly good news.

“Whether it’s monkeypox in the genital area, or monkeypox on another part of the body, just being suspicious of anyone with open sores, making sure that you don’t come in physical contact with them, is good advice for everyone.”

Professor David Heymann


The number of monkeypox cases in the Republic of the Congo.


Of course – as the past few years once again make clear – getting a vaccine approved is only half the battle. The fight against monkeypox might only truly be won if doctors succeed in getting jabs into arms. In part, that’s a question of capacity. Like with Covid, governments are rushing to get doses through factory gates, with the FDA hoping to have 800,000 Jynneos shots available soon. Not that they’ll necessarily all have to be used: between careful quarantining and continuing active education of vulnerable groups, the second global health emergency of recent years could yet be stopped in its tracks, unless the Congolese clade spreads anyway.

Monkeypox symptoms manifest as pimply rashes on the body.
‘Clades’ of monkeypox have long been endemic across nearly a dozen African countries.

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