Monkeypox outbreaks: 4 key questions researchers have | Hacker News Reader

Monkeypox outbreaks: 4 key questions researchers have

nature.com

42 pointsrntn68 comments

Something interesting I’ve observed a lot (on Twitter, so take it with a grain of salt) is an attitude of “monkeypox isn’t exclusively a gay disease, and associating it with gay people is homophobic”. I’ve even seen people criticising government health departments for warning gay men about the epidemic.

But the current spread _does_ appear to be, from what I’ve heard, almost exclusively amongst men who have sex with men. It’s not homophobic to state that, if that’s what’s actually happening. In fact, it’s important to inform people at risk so they can take suitable precautions.

Apparently we're not allowed to say obesity is a health risk either, so I'm not surprised about the monkeypox issue.

Apparently science needs to take a back seat to social justice now.

It is but the risk here is that this may be bad information: there’s no reason to believe it can only spread among gay men, or that it will continue to do so. And simultaneously it may be spreading elsewhere but we’re only seeing a subset of the infections because the gay community has been alerted and is looking. So if you do too much messaging about this, you’re potentially going to give people bad information. Not to mention that the last time we had a major outbreak of a “gay men’s disease” it led to some terrifically bad and discriminatory outcomes that were bad for patients and broad public health at the same time. (And no matter how much you might think the US has learned from that episode, plenty of countries still discriminate in law.)

In fact some of the cases documented so far haven't been men who have sex with men and it's not uncommon in Africa, so encouraging people to believe they're safe if they're not MSM is potentially damaging. It's much like HIV in this case, the number of heterosexuals infected with that is much higher than most straight people want to believe.

The problem with this argument is that for the public health system of a random country X that happens to be not located in Africa, the spread patterns in Africa matter very little. If you're trying to prevent the spread of a certain disease in country X, you're looking at the known spread pattern in X. And the same goes for HIV.

> there’s no reason to believe it can only spread among gay men, or that it will continue to do so

But epidemiologically, the difference between a disease that only spreads among gay men and a disease that overwhelmingly spreads among gay men is way smaller than the difference between a disease that overwhelmingly spreads among gay men and a disease that spreads with no discernible pattern at all.

Just because it can do something else as well doesn't mean that if you want to stop the spread of this as quickly as possible, you shouldn't inform your actions with all the information you know. From the public health perspective, considering the possible consequences, ignoring the information you have would be nearly criminal.

I could be true that it’s both more likely to be spread amongst men who have sex with men and that the group is more likely to be tested or see a physician.

If your hypothesis is true, we should observe an explosion of cases with upcoming pride parades?

You should look for it, but you'd need someone who's contagious at the right moment to participate in one of these events for such an explosion to happen. Given only a hundred cases or so in the world, such events do not seem to be guaranteed with monkeypox the way that they'd be, for example, with the current spread of Covid-19.

For folks who want actual expert thoughts on the recent Monkeypox cases instead of self appointed Twitter expert opinions check out the This Week in Virology podcast.

They covered it at the start of episode 902[0] and had a dedicated clinical episode with an infectious disease doc[1]

0: https://www.microbe.tv/twiv/twiv-902/

1: https://www.microbe.tv/twiv/twiv-special-monkeypox/

Questions I have for researchers:

Is this a new strain or one of the two known strains?

Are we witnessing greater human-to-human transmission than previously known?

What is the fatality rate so far of this outbreak?

The article has you covered on the first question.

>The most important insight they have gained so far is that each of the sequences closely resembles that of a monkeypox strain found in western Africa.

The wikipedia article for the current outbreak gives 0 deaths so far.

https://en.wikipedia.org/wiki/2022_monkeypox_outbreak

>Is this a new strain or one of the two known strains?

It's been confirmed that the current outbreak is the same as a 2018 outbreak of the West African clade.

>Are we witnessing greater human-to-human transmission than previously known?

This is the million $ question... it's been speculated that this outbreak originated due to some kind of (very) close contact event with dozens of people in Europe and continues to spread because of the long incubation period for monkeypox.

>What is the fatality rate so far of this outbreak?

None, so far (but it's still early).

I am not a researcher but I can answer one of your questions: it is the less-lethal strain (west African clade) but it appears that 94 nucleotide and 51 amino acid changes have occured since our sequencing of the closest strain in 2018. (That is apparently a lot by DNA virus standards, as a friend of mine who happens to be a molecularbiologist has told me.)

Waiting to hear what the gain-of-function research advocates are going to say about this (they've rather gone silent since Sars-CoV2 spread around the world). Should we be using CRISPR to modify different sections of the monkeypox genome to see if we can create as many different variants as possible so we can identify those that rapidly jump from human to human? The argument is, then we would know what to look for if we found it, because we'd have a better idea of which specific regions of the genome are involved in transmissibility...

Specious reasoning at best. The more likely result would be that a laboratory worker would get infected with such a highly-transmissible modified monkeypox, leave the lab, spread it into their local community, and from there modern transportation technology (planes, trains, automobiles, etc.) would ensure rapid spread around the world. This is not a conspiracy theory, just a rational risk assessment (and is now the most likely theory of the origin of Covid-19, like it or not).

Here's the latest scientific research on monkeypox as of 2020, from researchers based in Africa, it's up on sci-hub.se for those who want to read it, and is also a good overview:

Alakunle, E., Moens, U., Nchinda, G., & Okeke, M. I. (2020). Monkeypox Virus in Nigeria: Infection Biology, Epidemiology, and Evolution. Viruses, 12(11), 1257.

Respiratory droplets and contact with body fluids, contaminated patient’s environment or items, skin lesion of an infected person have been found to be associated with inter-human transmission. Congo Basin clade (Central Africa clade) is reported to be more virulent than West Africa clade and thereby contributes more to inter-human transmission.

The West Africa clade is apparently the one involved in this outbreak.

I don’t have any dog in this fight, but one of the points made in this article is that we don’t really understand the Monkeypox genome well enough to know which mutations might lead to greater spread or virulence. So when a new cluster pops up we can’t tell if it’s spreading due to a mutation or if it will have a greater IFR than we expect from past outbreaks. I’m not saying GoF is the right solution to this, given the risks. But it is probably one way to gather this sort of data.

The counterpoint to that argument is that there very well could be hundreds of artificially induced mutations that could give rise to extremely virulent or extremely transmissible strains, and yet that's not proof that such mutations would be at all likely to arise under natural conditions in the wild.

We have some very solid examples of independently-arising mutations in SARS-CoV-2. In fact quite a few of the Omicron mutations had been seen in other lab variants.

> and is now the most likely theory of the origin of Covid-19, like it or not

According to whom, if I may ask? It appeared to me that we know just as much about it as 2 years ago. That is to say, you can't assign a probability because there isn't really any data. But I didn't keep up with it, so I'm not sure.

One interest aspect of these various outbreaks is that we now recognize that there are a lot more negative externalities to air travel that are not being priced in.

80% of the world has never flown, 1% of frequent fliers account for half the pollution/emissions, and the global wealthy/elite are the vast majority of fliers.

The fact that air travel accelerates transmission rates of novel diseases from remote parts of the world mean that these new diseases are a manifestation of harm done by the wealthy to the poor.

These tragedies of the common can only be solved by coordinating efforts, but the geopolitical situation means that is impossible for now…

Well air travel between Russia and the west has decreased so there is that..

It's also heavily impacted travel more broadly because Russia was a popular low cost route from Europe to East Asia

This is not necessarily true. During the Spanish conquest of South America many indigenous died. It shows diseases travel equally well by boat. Maybe flight accelerates transmission, however, grounding all airplanes is not going to stop it.

This is why ships had quarantine flags. It wasn’t a perfect system, but that combined with ocean crossing being longer than the incubation period of many diseases meant they were a far less efficient disease vector.

The same result could be achieved with an enforced (men with guns, not polite suggestion) 14 day quarantine of all air travelers, flight time included. But the jet set have too much political power and prefer to spread disease.

Yeah, ask China how well this ‘15 days to stop the spread’ tactic is working out.

Imagine not being able to understand the difference between quarantining a vessel and locking down an entire city.

Hint: one significant difference is that in the latter case it’s already too late.

Imagine fantasizing you can actually lock the borders to any country that is not a continent of its own.

All these obvious plans have been tried, and failed. All that sciency talk sounds really smart, but doesn’t hold up in the real world.

Yup, air travel may accelerate disease transmission across the global, but it doesn't create something that wouldn't happen otherwise.

> ... and the global wealthy/elite are the vast majority of fliers

Are there reliable numbers about this?

Most air travel is on economy class. How are these travelers part of the "wealthy elite"?

In the context of the world population, anyone who has ever been on an airplane is a wealthy elite.

That's a little under 20% of the world's population. I agree most of them are likely to be somewhere in maybe the top 1/3, but it's not like only the top few percent have ever flown.

Globally, people who can afford airfare are a minority.

How many people live in slums around the world, or live in poverty?

The parent isn't talking about the wealthy in, eg, America. They are comparing the average American vs the rest of the world.

> Globally, people who can afford airfare are a minority.

Or a cellphone, or a car, or vaccines, but no one uses the superlative "wealthy elite" if you drive a Honda Civic because the implication is just silly.

Yeah, they do? And why is it silly to remember that you are in the top percentage points of wealth, globally? Seems like you are suggesting we should ignore the fact that most humans still live in poverty?

That view of the world is considerably out of date. Economic development in China and SE Asia generally has transformed global demographics. More than half the world's population are now middle class. The number in poverty fell from 35% in 1990 to 10.7% in 2013, again largely (but by no means solely) due to China.

https://knowledge4policy.ec.europa.eu/foresight/topic/growin....

That's the percentage of people living off $2 a day. I'm glad to see that number decreasing, but I think most Americans are making many multiples of that. The median household income here is $70k.

Let's say you make half that, and you can sometimes fly in a plane. $35k, 3 person family. You are still in the top 20th percentile globally (while considered quite poor in the States).

Does being in the top 20% make you wealthy or elite? I dunno. If you are making median income here you are probably in the top ten percent, globally. Does that make you elite or wealthy? It's subjective. I don't have a specific number. But the point still stands that you are almost to the top globally even if you are relatively poor in the States.

>That's the percentage of people living off $2 a day. I'm glad to see that number decreasing, but I think most Americans are making many multiples of that. The median household income here is $70k.

Sure, we have a long way to go to remediate global inequality, but huge strides have been made within my lifetime. Ive seen this myself in China, since my wife is Chinese. She grew up in a house her father, a factory worker, built from bricks. Ive seen it. She has a photo of herself as a girl making some of the tiles for the floor. She's now a senior nurse here in the UK, her sister is a departmental manager for a bank in China. I first visited her hometown Hohhot in 2001 and have seen it grow from empty streets because barely anyone could afford cars, to constant traffic jams. I used to count the cranes on construction sites on the way from the airport each visit, it was usually somewhere around 30.

But anyway, for now a certain degree of inequality is an unfortunate fact of life, but it's not like anyone is imposing that from on high. Grinding poverty has been the common state of humanity for thousands of years, it's not like the lives of the ancestors of the remaining 11% in poverty were dramatically better a hundred years ago, or a thousand. It's only with globalised trade, technological diffusion, and investment powered economic development that a majority of humanity have a chance to achieve a stable and comfortable quality of life.

> How are these travelers part of the "wealthy elite"?

Ask the folks living on $1/day.

This is a valid point - air travel certainly can lead to the rapid global spread of infectious disease - but there's a counterpoint, for example the smallpox eradication program would likely have been impossible without the use of air travel as well. Here's a great overview of that campaign by its main director:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3720050/

Lessons from the eradication of smallpox: an interview with D. A. Henderson (2013)

> These tragedies of the common can only be solved by coordinating efforts, but the geopolitical situation means that is impossible for now

Which efforts need to be coordinated?

> The fact that air travel accelerates transmission rates of novel diseases from remote parts of the world mean that these new diseases are a manifestation of harm done by the wealthy to the poor.

How new/novel? Early 1900s? 1960s? 1980s? 2000s?

> One interest aspect of these various outbreaks is that we now recognize that there are a lot more negative externalities to air travel that are not being priced in.

Are all positive externalities priced in? How do the scales weigh positive and negative externalities? Seems like air travel also does a lot of good.

The tracker I've been watching shows pretty explosive growth over the past week.

https://bnonews.com/monkeypox/

The total population of top 3 countries only is 118200000. That's a hundred and eighteen million two hundred thousand people.

Total number of cases in all countries as of now sits at 448. I don't think that can be called "a pretty explosive growth" by any means.

Stop spreading the media scare.

It was 7 people last week. 7 -> 450 is a big jump up. Until r values stabilize, it's reasonable to keep an eye on it.

It is possible that monkeypox, like CoVID, can be asymptomatic in healthier individuals. But now that we’ve gone through Covid we have a lot of less healthy people and these people present with symptomatic disease.

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