What Happened to Monkeypox?

Why cases suddenly began to decline.

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Monkeypox samples in a California lab.Credit…Mike Kai Chen for The New York Times

By  German Lopez

Oct. 13, 2022

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A few months ago, monkeypox regularly made headlines as a major new disease outbreak. Then it largely vanished from the news.

What happened in the meantime? The virus receded: Since a peak in early August, reported monkeypox cases in the U.S. have fallen more than 85 percent through yesterday.

The rise and fall of monkeypox provide lessons on the spread of diseases — an aspect of public health that experts acknowledge we still know far too little about. Covid has made clear that much of the world was not prepared for a deadly pandemic. Monkeypox, while nowhere as dangerous as Covid, can shed light on our vulnerabilities (as my colleague Apoorva Mandavilli  explained ).

Today’s newsletter will look at why monkeypox declined, and what that might mean for future outbreaks.

Possible explanations

Ultimately, monkeypox in the U.S. has been contained to a narrow demographic, mostly gay and bisexual men with multiple partners. It was never very deadly; there were just 28 confirmed deaths globally out of  more than 72,000 reported cases. (I wrote earlier  about the virus and how it spreads.)

Daily average monkeypox cases in the U.S.

400 cases

200

June

2022

July

Aug.

Sept.

Oct.

Note: Chart shows seven-day averages through Oct. 12.

Source: Centers for Disease Control and Prevention

By The New York Times

Four factors explain monkeypox’s decline, experts said. First, vaccines helped slow the virus’s spread (despite a  rocky rollout ). Second, gay and bisexual men  reduced activities , such as sex with multiple partners, that spread the virus more quickly.

The third reason is related: the Pride Month effect. Monkeypox began to spread more widely around June, when much of the world celebrated L.G.B.T.Q. Pride. Beyond the parades and rallies, some parties and other festivities involved casual sex. As the celebrations dwindled, so did the increased potential for monkeypox to spread.

And finally, the virus simply burned out. Monkeypox mainly spreads through close contact, making it harder to transmit than a pathogen that is primarily airborne, like the coronavirus. “Because of that, monkeypox is a self-limiting virus,” Apoorva told me. That made it less likely to grow into a larger outbreak.

Much of this explanation may sound familiar after more than two years of Covid: A virus can be tamed by vaccines and behavioral changes.

Unclear communication

Another factor worth emphasizing: public health communication. During Covid, officials have sometimes given  unclear or misleading guidance because they did not trust the public with the truth.

A similar phenomenon played out with monkeypox. Some officials were cautious about explicitly labeling monkeypox as a greater risk to gay and bisexual men and asking them to reduce risky sexual activities, out of fear of stigmatizing a population that already faces discrimination over AIDS.

New York City’s health department initially opposed recommending that gay and bisexual men reduce their number of sexual partners, arguing that L.G.B.T.Q. people have had “their sex lives dissected, prescribed and proscribed in myriad ways.” (Internally, the agency debated  whether that was the right response.) Those concerns stopped officials from clearly communicating the dangers to the population most at risk.

Eventually, public health officials began tailoring their warnings toward gay and bisexual men. In late July, the World Health Organization’s director general  said  that men who have sex with men should consider limiting their number of sexual partners. The  C.D.C.  and  New York City’s health department  echoed the guidance.

And it appeared to work: Monkeypox cases began to decline. That shift in public messaging enabled two of the four factors I explained earlier, as officials targeted gay and bisexual men for vaccine drives, and men who have sex with men limited riskier activities.

But the clearer guidance came after weeks of criticism, exposing a habit of unclear messaging that keeps the country vulnerable to health crises.

Unpredictable viruses

For all we do know about monkeypox’s decline, there is much we don’t know. We are still in “the cave ages” in understanding the spread of viruses, Michael Osterholm, an epidemiologist at the University of Minnesota,  has said.

Much of that lack of knowledge is related to the unpredictability of human behavior. Scientists can map viruses down to the atomic level but have a hard time guessing what people will do at any given point. And people are the ones spreading viruses, whether it’s Covid at Christmas parties or monkeypox at Pride celebrations.

That uncertainty opens the possibility that monkeypox could spread again. People most in danger of contracting the virus may skip the vaccine because its spread has slowed, or they could resume risky activities too soon, before cases are low enough to stop another outbreak. Or another major event, like next year’s Pride Month, could bring monkeypox back.

And the virus still regularly spreads in western and central Africa, where it was first found in humans and has never been fully contained — putting it one flight away from the U.S. or Europe. “I don’t see any progress on addressing that,” said Dr. Céline Gounder, a senior fellow at the Kaiser Family Foundation. (The U.S. is working with Japan to distribute more vaccine doses globally,  Politico reported yesterday.)

The good news: This year’s outbreak has made officials take monkeypox more seriously. So if it does come back, the country may be more prepared to deploy vaccines and take other steps to fight it. But success depends on how people react.

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