Speaker 1: Hey everyone, just a content morning here. The first hand
Speaker 1: account does describe the death of an infant, and so
Speaker 1: if you would like to fast forward past that part,
Speaker 1: we recommend jumping ahead about two minutes.
Speaker 2: The patient was a nine month old boy who became
Speaker 2: ill with fever on August twenty second, nineteen seventy, and
Speaker 2: two days later developed a rash. He was admitted to
Speaker 2: Basankusu Hospital on September one. On examination, it was recorded
Speaker 2: that the lesions were hemorrhagic, although they showed a centrifugal
Speaker 2: distribution typical of smallpox. Crusts were collected for laboratory examination.
Speaker 2: The rash lasted about two weeks. During the scabbing stage,
Speaker 2: the patient developed otitis and mastoiditis, as well as enlarged,
Speaker 2: painful cervical nodes, which were subsequently incized and drained. The
Speaker 2: patient recovered and was about to be discharged, but on
Speaker 2: October twenty third, he developed measles and died six days later.
Speaker 2: The child had never been vaccinated. That's a tough one, because.
Speaker 3: Yeah, yeah, that's horrible. Yeah.
Speaker 1: So that is a case description of the first known
Speaker 1: human case of monkey pox, and it is from a
Speaker 1: paper by Ladinige at all from nineteen seventy two titled
Speaker 1: a Human Infection Caused by monkey Pox virus in Boston,
Speaker 1: KUSU Territory, Democratic Republic of the Congo.
Speaker 3: Ooh yeah, yeah, yep. Hi, I'm erin Welsh and i'm
Speaker 3: erin Allman Updike.
Speaker 1: And this is this podcast will Kill You and.
Speaker 2: Today we're covering monkey pox.
Speaker 1: Long awaited, much requested, here it is.
Speaker 4: Yeah.
Speaker 2: Yeah, monkey pox has obviously been making a lot of
Speaker 2: headlines lately, so a lot of you have asked for
Speaker 2: us to do this episode.
Speaker 3: We're very excited to.
Speaker 2: Dig in and deliver this episode to you because this
Speaker 2: is a very interesting virus and it's spreading in a
Speaker 2: way that we have really never seen before, which is
Speaker 2: fascinating and also potentially kind.
Speaker 1: Of terrifying, absolutely kind of terrifying. Yeah, and we know
Speaker 1: that during the last and ongoing pandemic COVID, many of
Speaker 1: you came to really appreciate our Anatomy of a Pandemic
Speaker 1: mini series for updates.
Speaker 4: And information about.
Speaker 1: What was going on and how the science was constantly changing.
Speaker 1: So that's kind of what we wanted to do here.
Speaker 2: But not a mini series specifically, hopefully not hopefully not
Speaker 2: hopefully not, but we did want to give you background
Speaker 2: on what we knew about this virus going into the
Speaker 2: current outbreak and where things stand with monkey pox today
Speaker 2: as far as we know.
Speaker 1: Yeah, And of course, the fact that this is an
Speaker 1: ongoing outbreak makes it trickier to pack in all of
Speaker 1: the super up to date info in a more deep
Speaker 1: dive research podcast like ours, And we learned that difficulty
Speaker 1: with this episode all too well because we actually initially
Speaker 1: recorded this episode in early June, June ninth to be precise, yep.
Speaker 1: But then in the week and a half that it
Speaker 1: took to edit and put it all together, so so
Speaker 1: much changed, and we didn't want to put that out
Speaker 1: and leave you with more questions than answers.
Speaker 2: Yeah, So we decided to give ourselves a little bit
Speaker 2: of time to get caught back up with monkey pocks
Speaker 2: and then record the current event section as close to
Speaker 2: the release date as possible so that we're giving you
Speaker 2: the most up to date information that we can.
Speaker 1: But since this is a virus that we've known about
Speaker 1: for quite some time, much of the biology and history
Speaker 1: section hasn't changed from that first recording, and those parts
Speaker 1: of the episode come directly from that first recording on
Speaker 1: June ninth, while this intro that you're listening to right
Speaker 1: now now and the current event section is from July sixth,
Speaker 1: twenty two.
Speaker 2: Well, can we tell you Aaron's editing is just magic.
Speaker 3: I'm sure you'll never know.
Speaker 4: You probably will.
Speaker 1: But ultimately the purpose of this episode is to give
Speaker 1: you a solid background on monkey pos how we have
Speaker 1: known this virus to act in the past, the history
Speaker 1: of its identification, and what past outbreaks can tell us
Speaker 1: about this current one. And finally we'll bring you up
Speaker 1: to speed on how things have progressed with this current
Speaker 1: outbreak in twenty twenty two.
Speaker 2: And speaking of this current outbreak, one more thing that
Speaker 2: we wanted to bring up before we get started on
Speaker 2: this episode, and that is the naming of this virus. So,
Speaker 2: as this outbreak and the number of headlines about it
Speaker 2: has grown over the past many weeks, this increased attention
Speaker 2: has generated a lot of discussion over the potentially problematic
Speaker 2: naming of this virus and its two clades. For one thing,
Speaker 2: as we'll talk a lot about, monkey pox is a misnomer,
Speaker 2: and it's also against World Health Organization guidelines to name
Speaker 2: diseases after animals or people or jobs, or food or places,
Speaker 2: because it can lead to discrimination and stigma.
Speaker 1: Which brings us to the second prong of the bad
Speaker 1: naming of monkey pox, as we'll get into again later.
Speaker 4: This virus can.
Speaker 1: Be classified into two clades or strains or subtypes of
Speaker 1: the virus, which are currently called and have historically been called,
Speaker 1: the West African clade and the Central African or Congo
Speaker 1: Basin clade, which is where they were first identified. And
Speaker 1: of course, if you've listened to this podcast before, you'll
Speaker 1: know that naming a disease or virus or clade a
Speaker 1: virus after a place is also not a good practice.
Speaker 4: It can lead to discrimination and stigma.
Speaker 2: And today a lot of the discussion that's ongoing about
Speaker 2: the naming of monkey pox and its clades is not
Speaker 2: just like, hey, this isn't good names, but it's also like, hey,
Speaker 2: let's actually fit.
Speaker 3: And come up with some new names.
Speaker 2: So it's very likely that within the next weeks or months,
Speaker 2: I don't know, monkey pox and its clades will have
Speaker 2: completely different names than what we are using today. But
Speaker 2: that hasn't happened yet, and so to avoid confusion, in
Speaker 2: this episode, we'll be using the names that the virus
Speaker 2: and the disease have historically gone by, which is monkey
Speaker 2: pox and the historic clad names. All right, Yeah, with
Speaker 2: all that behind us, I do believe it's quarantin any time.
Speaker 4: It's quarantine anytime. What are we drinking this week?
Speaker 3: We're drinking more Pox on the Rock.
Speaker 1: So all the way back in twenty seventeen, twenty seventy unbelievable,
Speaker 1: Episode three was on smallpox and it was our very
Speaker 1: third quarantin ye, and we call very third and we
Speaker 1: called it on the Rocks, and you know what, we
Speaker 1: just figured we'll stick with that. It's a classic more
Speaker 1: pox on the rocks, even though we have done other
Speaker 1: pox viruses, but.
Speaker 3: Yeah, but not like a pox named pox virus.
Speaker 4: That's you know, that's true.
Speaker 3: Yeah.
Speaker 2: I also have to say that the smallpox episode was
Speaker 2: one of my favorites of all time, and I still
Speaker 2: to this day think that Smallpox on the Rocks is
Speaker 2: one of our best quarantining names. So I love that
Speaker 2: we get to just sort of bring it back to
Speaker 2: life here.
Speaker 1: More Pox on the Rocks, and basically more Pox on
Speaker 1: the Rocks is take your favorite liquor of choice or
Speaker 1: liquor substitute of choice there's a lot of non alcoholic spirits,
Speaker 1: which is super cool. Pour it over some rocks, maybe
Speaker 1: add a little bit of citrus or a couple dashes
Speaker 1: of your favorite bitters, and it's it's really up to
Speaker 1: you what.
Speaker 4: You want to make it.
Speaker 3: Clink it in your glass and.
Speaker 1: We will post the full recipe for more poks on
Speaker 1: the rocks, the most complicated of recipes, as well as
Speaker 1: the non alcoholic placy burrita on our website This podcast
Speaker 1: will Kill You dot Com, as well as on all
Speaker 1: of our social media channels.
Speaker 2: On our website, This podcast will Kill You dot Com,
Speaker 2: you can find everything that you'd hope to find on
Speaker 2: a podcast website. You can find merch you can find
Speaker 2: our Patreon, you can find our Goodreads list, you can
Speaker 2: find a link to our music from Bloodmobile and all
Speaker 2: of the sources from all of our episodes. You can
Speaker 2: find transcripts. There is just so much there.
Speaker 4: There's no end to what you can find.
Speaker 1: Uh huh Okay, So, with this long intro out of
Speaker 1: the way, I feel like there's no possible way that
Speaker 1: there's more business to cover.
Speaker 4: So let's get started.
Speaker 2: Let's take a quick break and then get into the
Speaker 2: biology of this virus, monkey pox and smallpox and cowpox
Speaker 2: and many other animal named pox viruses are as we
Speaker 2: learned in our smallpox episode.
Speaker 3: In fact, pox viruses.
Speaker 4: Stands to reason right well.
Speaker 3: If they aren't tall though.
Speaker 2: They belong to a family of viruses called the pox
Speaker 2: Veri dae, specifically in the orthopox virus genus. So orthopox
Speaker 2: viruses and all pox viruses in general are pretty large viruses.
Speaker 2: They're generally shaped like bricks or like big chunky oval shapes.
Speaker 2: They have an envelope that surrounds them, and they have
Speaker 2: this very large, linear, double stranded DNA genome. And we
Speaker 2: on this podcast have covered the most famous pox virus, smallpox.
Speaker 3: We have way long time ago, now, huh.
Speaker 2: That virus is known as variola virus, and thanks to
Speaker 2: vaccination campaigns as well as the fact that that was
Speaker 2: a human specific pox virus, smallpox was eradicated in was
Speaker 2: it nineteen eighty that it was declared eradicated?
Speaker 5: Yep?
Speaker 3: Yeah.
Speaker 2: And then you may also remember we covered another pox virus,
Speaker 2: mix oma virus, although that is in a different genus,
Speaker 2: the late pory pox virus genus.
Speaker 4: I got a kick out of something about maxomma.
Speaker 3: Virus tell me.
Speaker 4: So I kept stumbling.
Speaker 1: Across these papers on monkey pox where the name Frank
Speaker 1: Fenner was either an AWF or mentioned in a reference
Speaker 1: to like another paper, and I was like, that name
Speaker 1: sounds so familiar, and he was like one of the
Speaker 1: big researchers who studied mixcellovirus and wrote the book, the
Speaker 1: textbook that I read for that episode, And so I
Speaker 1: just got a really fun kick out of that.
Speaker 3: I love that when episodes intertwine.
Speaker 4: Yeah, exactly, excellent.
Speaker 2: So the majority of poxviruses, especially today, I'm really just
Speaker 2: focusing on this orthopox virus genus since we're talking about
Speaker 2: monkey pox.
Speaker 3: These are not.
Speaker 2: Human specific viruses. So, like I mentioned some of them
Speaker 2: at the top, there's smallpox, camel pox, cowpox, the vaccinia
Speaker 2: virus which is what was used to make the smallpox vaccine,
Speaker 2: which includes various strains like buffalo pox and rabbit pox,
Speaker 2: and then the one we're going to focus on today
Speaker 2: that is the subject of all the media forevor currently
Speaker 2: monkey pocks. But all of these various animal based names
Speaker 2: are slight misnomers because they might lead you to believe
Speaker 2: that they only infect that particular animal.
Speaker 4: Or that they come from that particular animal.
Speaker 2: Exactly, but that's not the case. But in the case
Speaker 2: of monkey pocks, the name is a real misnomer because
Speaker 2: while it was first identified from monkeys, evidence suggests that
Speaker 2: it's rodents and not monkeys, that are the primary natural
Speaker 2: reservoir for this particular virus. And just like many of
Speaker 2: the other orthopox viruses, monkey pocks can have a relatively
Speaker 2: broad host range. And what these broad host ranges mean
Speaker 2: is that sometimes these various viruses can spill over from
Speaker 2: their animal hosts into us humans, and that is what
Speaker 2: listeners of this podcast will be very famili You're with
Speaker 2: is often called a zoonotic pathogen. These are transmitted from
Speaker 2: animals to humans via spillover events, and anyone who listened
Speaker 2: to our smallpox episode one hundred million years ago remembers
Speaker 2: that this is a thing.
Speaker 3: Because of cowpox.
Speaker 2: Cowpox is what helped serve as one of the first
Speaker 2: examples of a type of vaccination that was it. Edward
Speaker 2: Jenner Aaron, uh huh, I feel so proud that I
Speaker 2: remembered that inoculated people with cowpox to protect them against smallpox.
Speaker 3: And this example.
Speaker 2: Illustrates a couple of really key characteristics that I wanted
Speaker 2: to highlight upfront about orthopox viruses because they'll be important
Speaker 2: throughout this episode, and that is a that these pox
Speaker 2: viruses can infect a wide range of potential hosts depending
Speaker 2: on the virus, and that infection with one pox virus
Speaker 2: often confers at least some degree of cross protection against
Speaker 2: other virus species.
Speaker 4: Crucial crucial information.
Speaker 2: Very very crucial, And so when it comes to monkey
Speaker 2: pos let's focus on that for now, this is not
Speaker 2: a completely new virus. We've known since nineteen seventy that
Speaker 2: it has the potential to both be a zoonotic illness
Speaker 2: as well as occasionally cause small outbreaks that do include
Speaker 2: person to person transmission. But today, what's happening currently in
Speaker 2: twenty twenty two is by far the most person to
Speaker 2: person transmission that we've seen, and we'll get into that
Speaker 2: later on, but I just kind of wanted to set
Speaker 2: the stage that we've known about monkey pox and its
Speaker 2: ability to infect humans for quite some time and in
Speaker 2: the past, like prior to the nineteen eighties, because a
Speaker 2: lot of the human population was vaccinated against smallpox, humans
Speaker 2: possessed some degree of protection against monkey pocks, and today
Speaker 2: that's really, for the most part no longer the case
Speaker 2: because the vast majority of people are not being vaccinated
Speaker 2: against smallpox anymore since it's been eradicated. But let's get
Speaker 2: into monkey pocks, shall we. Yeah, So, the disease that
Speaker 2: monkey pox causes is actually similar in a lot of
Speaker 2: ways to smallpox, although it is substantially less virulent. So historically,
Speaker 2: the way that we've understood the transmission of monkey pox
Speaker 2: is actually very similar to the transmission of smallpox, and
Speaker 2: that is by close contact with either the rash itself,
Speaker 2: which we'll talk about in a minute, or by respiratory
Speaker 2: droplets that are full of virus, and potentially by very
Speaker 2: short range aerosols, because this is a virus that can
Speaker 2: persist in the environment for a little bit longer than
Speaker 2: other viruses. And I meant to try and find an
Speaker 2: exact number for you, Erin, because I thought you might ask.
Speaker 3: I don't have a.
Speaker 2: Number, Okay, But it's more environmentally stable, for example, than
Speaker 2: like a coronavirus. Interesting, and like smallpox, monkeypox also has
Speaker 2: a potentially rather.
Speaker 3: Long incubation period.
Speaker 2: Yeah, it's usually in the range of ten to fourteen days,
Speaker 2: but it can be as short as a week. It
Speaker 2: could be even longer than a couple of weeks. And
Speaker 2: in general, as far as we understand, people don't become
Speaker 2: infectious until the development of the rash.
Speaker 3: Oh okay, yeah, so let's talk about what the symptoms
Speaker 3: look like, shall we? Mm hmm.
Speaker 2: Most people who get infected with monkey pos will start
Speaker 2: off feeling cruddy. They'll get fever, they'll have malaise, they'll
Speaker 2: start to feel very sick for at least one or
Speaker 2: two days before the development of this rash. Also, very commonly,
Speaker 2: people might also notice swelling in the lymph nodes, maybe
Speaker 2: the lymph nodes under your chin, maybe behind your ears,
Speaker 2: maybe in your groin, maybe in your armpits. This lymphatenopathy,
Speaker 2: as it's called, could be anywhere. And then after one
Speaker 2: or two days of this generalized feeling really sick is
Speaker 2: when the rash itself typically begins. And the rash of
Speaker 2: monkey pocks looks a lot like the rash of smallpox,
Speaker 2: and it follows a very classic series. It begins as
Speaker 2: these small two to five millimeters flat to maybe mildly raised,
Speaker 2: little bumps. They're called macules and papules.
Speaker 3: That's the beginning, okay.
Speaker 2: And it tends to start in what's called as centrifugal
Speaker 2: and I'm sorry, I feel like I'm pronouncing that word wrong.
Speaker 2: Rash anyway, This means that the rash tends to start
Speaker 2: on the extremities, especially the head, and then the arms
Speaker 2: and the legs, and then it spreads inwards.
Speaker 5: Huh.
Speaker 2: This is the same way that smallpox tends to start.
Speaker 2: It's more concentrated on the head, the extremities, and then
Speaker 2: it spreads to the rest of the body inwards. And
Speaker 2: that's in contrast to what are sometimes called centripetal rashes,
Speaker 2: which start primarily on the trunk and then spread outwards.
Speaker 2: A great example of this is something like chicken pox.
Speaker 4: That's so interesting.
Speaker 2: There's a lot of different ways that rashes spread. You
Speaker 2: might remember when we talked about measles and rubella. They
Speaker 2: start on the head and then spread downward. That's called
Speaker 2: cephalocadad spread. Rosola is another virus that tends to start
Speaker 2: on the neck and trunk and then spread up to
Speaker 2: the face and out to the extremities. But like not
Speaker 2: in exactly the same way as something like chicken pox would.
Speaker 3: There's a lot it's interesting.
Speaker 4: Is it just different tissue tropisms or what.
Speaker 3: That's a great question.
Speaker 2: I don't actually know, Okay, yeah, or if it's just yeah,
Speaker 2: I don't know. This is a really good question. That'll
Speaker 2: be a fun whole episode. It's just like rash distributionshes.
Speaker 4: I love that.
Speaker 3: That would be.
Speaker 2: Fun actually, So it spreads in that way. But then
Speaker 2: this rash does progress through very similar phases as the
Speaker 2: smallpox rash. So they start out as those flat or
Speaker 2: slightly raised maculo papules. Then they become even more raised
Speaker 2: and fill with fluid. These are known as vesicles. Then
Speaker 2: these vesicles will start to form into these puss filled,
Speaker 2: taut pustules, and then these pustules will crust over and
Speaker 2: then eventually slough off and often leave a scar behind.
Speaker 2: So this process from papule to vesicle to pushtule to scab,
Speaker 2: this is a long process. Just like with smallpox. It
Speaker 2: generally takes between fourteen to twenty one days, so two
Speaker 2: to three weeks. And what's interesting is that, unlike something
Speaker 2: like chicken pox, what tends to happen is that all
Speaker 2: of this rash progresses through those phases at the same time. Huh,
Speaker 2: So all of your rash is papules and then they
Speaker 2: all around the same time transformed to vesicles to pushtules,
Speaker 2: et cetera, whereas with chicken pox and other herpes viruses
Speaker 2: you often see vesicles in like different stages of healing,
Speaker 2: so you'll have some that are crusting, some that are vesicles,
Speaker 2: et cetera.
Speaker 1: Yeah, I'm really trying to resist just saying like why
Speaker 1: why how?
Speaker 3: Why?
Speaker 4: Why? Why? Yeah?
Speaker 2: Yeah, it's really good questions. I don't know, Aaron, It's
Speaker 2: really interesting, especially when it comes to the details of
Speaker 2: the virology of this virus and the path of physiology.
Speaker 2: I'll just warn you, we don't know much. We really don't, right, Yeah,
Speaker 2: But in contrast to smallpox, this is where we get
Speaker 2: to the good parts about monkey pox. We don't tend
Speaker 2: to see a lot of the more severe forms, especially
Speaker 2: if you remember listening through our smallpox episode and I
Speaker 2: read over it to remind myself how horrific smallpox is.
Speaker 2: Oh yeah, the most severe form, the heemorrhagic form that
Speaker 2: we describe in that episode, doesn't tend to happen. That
Speaker 2: hasn't really been seen to happen with monkey pox.
Speaker 3: Which is very good.
Speaker 2: But that being said, case fatality rates have been shown
Speaker 2: in some cases to still be relatively high. There are,
Speaker 2: as it turns out, and I know you'll talk a
Speaker 2: little more about aaron, two different clades of this virus,
Speaker 2: and one of them seems to be more virulent, where
Speaker 2: the case fatality rate is estimated on average to be
Speaker 2: about ten percent, actually really high.
Speaker 4: In unvaccinated individuals.
Speaker 2: Exactly in unvaccinated individuals, and then in the other clade,
Speaker 2: the fatality rate is usually estimated at about three and
Speaker 2: a half percent, which again is still really high.
Speaker 3: But is much much less than smallpox.
Speaker 4: Right.
Speaker 1: Yeah, I was surprised at how high the case fatality
Speaker 1: rates were.
Speaker 4: Much had no idea.
Speaker 2: I did not realize that either. I thought that it
Speaker 2: was much lower. And it's interesting because it really does
Speaker 2: vary depending on what outbreak you're looking at, and it
Speaker 2: probably really varies how much data was collected in all
Speaker 2: of these different cases.
Speaker 3: So we'll see when we get to what's happening today.
Speaker 1: Yeah, I think there are other factors to like the
Speaker 1: number of confirmed cases first and suspected, and then the
Speaker 1: other thing too, I think is access to healthcare, because
Speaker 1: a lot of the deaths that seemed to happen seem
Speaker 1: to be secondary causes.
Speaker 2: Right, even in our first hand account, right, this poor
Speaker 2: nine month old survived infection with monkey pox, but then
Speaker 2: was left unfortunately susceptible to another infection.
Speaker 3: So yeah, it's it's.
Speaker 2: Very especially with the way that these pustules can break open,
Speaker 2: you are very susceptible to overlying bacterial infection of this rash. Yeah, yeah,
Speaker 2: so that tends to be the symptoms of monkey pocks.
Speaker 2: Most people do recover with relatively little long term effects
Speaker 2: except for scarring, which, given how prevalent this rash can
Speaker 2: be on the face, can be pretty significant, But generally
Speaker 2: don't tend to see a lot of long term like
Speaker 2: other problems that arise from monkey pocks when people survive. Okay,
Speaker 2: And like I said, when it comes to the path
Speaker 2: of physiology, I don't have a ton of detail to
Speaker 2: give you aarin. I was trying to look into a
Speaker 2: lot of specifics and try and compare and contrast this
Speaker 2: pox virus to smallpox. But I guess in our early
Speaker 2: seasons I didn't talk about pathophysiology a lot because I
Speaker 2: didn't even mention it in the smallpox episode. But this virus,
Speaker 2: when we get infected right through direct contact with the
Speaker 2: virus that is contained in these pustules. I think that's
Speaker 2: important for everyone to know. And these pustules can be
Speaker 2: present in our mouth, they can be present in the genitals,
Speaker 2: they can be present on mucus membranes, but also throughout
Speaker 2: our skin. And this virus, once it then gets into
Speaker 2: a new host body, seem to have a pretty wide
Speaker 2: tissue tropism. So they replicate in our skin cells, but
Speaker 2: they also replicate in our lymphatics, which is why you
Speaker 2: see that lymphatinopathy. And then they've also been shown to
Speaker 2: replicate in and a lot of the cells that usually
Speaker 2: help clear out bacteria and viruses, like our macrophases. And
Speaker 2: another interesting thing is that the more severe clade of
Speaker 2: these viruses seem to replicate in an even wider variety
Speaker 2: of tissues, including the genito urinary tract, the respiratory tract,
Speaker 2: and even the GI tract. And so, while we don't
Speaker 2: fully understand and there's probably underlying genetic basis to the
Speaker 2: difference in virulence between these two clades, and we don't
Speaker 2: really know the details, it's quite possible, based on what
Speaker 2: we know about the difference in potential tissues that they infect,
Speaker 2: that that's part of that virulence. Right, If you have
Speaker 2: a virus that's infecting basically wider variety of your tissues,
Speaker 2: you're more likely to get sick, You're more likely to
Speaker 2: get more severely sick, and then that's leading to a
Speaker 2: higher case fatality rate.
Speaker 4: That makes sense. Yeah, And so in terms of I.
Speaker 1: Just can't resist monkey pox versus smallpox, Yeah, does smallpox
Speaker 1: also have pretty wide tissue tripism?
Speaker 2: Yeah, I believe it's very similar. One thing that I
Speaker 2: think is very interesting that's quite different between monkey pox
Speaker 2: and smallpox is this lymphatenopathy. These swollen lymph nodes happen
Speaker 2: in like over ninety five ninety eight percent of cases
Speaker 2: of monkey pox, and they don't happen at all with smallpox.
Speaker 2: But it's not because smallpox isn't able to replicate in
Speaker 2: these tissues. Some people think it's actually because we're mounting
Speaker 2: a better immune response to the monkey pox than we
Speaker 2: did to smallpox.
Speaker 1: Right, smallpox is just evading our immune system a little exactly.
Speaker 2: Ok.
Speaker 3: Yeah, Yeah, Yeah.
Speaker 2: That's also something that differentiates this disease from veriicella chicken
Speaker 2: pox historically. And when I say historically, I don't mean
Speaker 2: like like Aaron's history.
Speaker 3: Section, not.
Speaker 4: From twelve hundred BC.
Speaker 2: No, No, I just mean like in past outbreaks, veriicella
Speaker 2: is often cited as the other disease that's most difficult
Speaker 2: to distinguish from monkey pocks. But there are a few
Speaker 2: pretty solid distinguishers. One is that initial fever, which is
Speaker 2: pretty rare with chicken pox. When it is present, it's
Speaker 2: usually doesn't last as long, and it's not as severe
Speaker 2: as a fever, Like most people don't get as sick
Speaker 2: from chicken pox as they get from monkey pox. Okay,
Speaker 2: And then I already talked a little bit about the
Speaker 2: differences in the progression of that rash where they might
Speaker 2: progress in different stages with vericella, and all the stages
Speaker 2: progress at the same time with monkey pox, but with veriicella.
Speaker 2: With chicken pox, it also progresses much more rapidly, right
Speaker 2: Like chicken pox is a much shorter duration in general.
Speaker 2: And then there's that lymphatenopathy, those swollen lymph nodes that
Speaker 2: are really common in monkey and really uncommon in chicken pox.
Speaker 4: It's so interesting.
Speaker 2: Yeah, chicken pox not a pox virus, right, Yeah, see
Speaker 2: our chicken pox episode.
Speaker 4: What type of virus is it?
Speaker 3: Aaron it's a herpes virus eric.
Speaker 2: But yeah, so it does definitely complicate the picture though,
Speaker 2: because they can look very similar in some cases, especially
Speaker 2: if you have never seen a monkey pox case and
Speaker 2: you don't know what you're looking for. Yeah, Aarin, that's
Speaker 2: the biology.
Speaker 1: Uh wow, Okay.
Speaker 3: Was that enough? Did you want more?
Speaker 4: I guess?
Speaker 1: I guess My biggest questions really have to do with
Speaker 1: what's going on today, and so maybe maybe we'll address
Speaker 1: some of those when we get to the current events section.
Speaker 3: We will that.
Speaker 2: So everything that I just described is classic monkey pox.
Speaker 2: This is monkey pox as we have understood it until today.
Speaker 2: What we'll talk about and what we're seeing today is
Speaker 2: in fact quite different than monkey pox.
Speaker 3: That we've seen in the past. So we'll get to that.
Speaker 2: But first, Aaron, can you tell me where the heck
Speaker 2: this came from?
Speaker 3: And like how we got to where we're going to
Speaker 3: get to today.
Speaker 4: I'm so glad you asked.
Speaker 3: Uh.
Speaker 1: Yeah, I will get to that right after this break.
Speaker 1: So again, I just want to preface the history of
Speaker 1: monkey pox by mentioning that when talking about the history
Speaker 1: of this disease, is a big part of that story
Speaker 1: has to do with the different clades of this virus
Speaker 1: and how they have occurred in different epidemics over the
Speaker 1: past decades. And even though these names are likely to
Speaker 1: be changed in the future, and for good reason, naming
Speaker 1: diseases after places.
Speaker 4: Can lead to othering in stigma.
Speaker 1: Like we've already mentioned, they haven't been changed yet, and
Speaker 1: so I'll be using the names that they have been
Speaker 1: called historically, which is the West African and Central African
Speaker 1: or Congo basin clades or subtypes.
Speaker 4: All right, the history of monkey pox.
Speaker 1: Yeah, Aaron, you are definitely not alone in wondering where
Speaker 1: did this virus come from? And how did we get
Speaker 1: to where we are today. Yeah, it seems likely that
Speaker 1: a good chunk of the world is very curious about
Speaker 1: the same thing. And I'll include myself in that. And
Speaker 1: in reading for this episode, I found out that where
Speaker 1: is the biology or maybe more specific the clinical manifestations
Speaker 1: of monkey pox and smallpox maybe similar in a lot
Speaker 1: of ways, their histories and importantly ecologies are incredibly different. Yeah,
Speaker 1: and again I'll point you towards our smallpox episode to
Speaker 1: get more detailed info about the history of this devastating disease.
Speaker 1: But for the purposes of this monkeypox episode. I think
Speaker 1: it'll be enough for me to say that smallpox ranks
Speaker 1: up there as one of the deadliest diseases of humans
Speaker 1: of all time, both in terms of the case fatality
Speaker 1: rate as well as the sheer number of people it
Speaker 1: has killed. In the twentieth century alone. Smallpox is estimated
Speaker 1: to have killed between three hundred million to five hundred
Speaker 1: million people.
Speaker 2: In the twentieth century alone, and it was eradicated in
Speaker 2: nineteen eighty Yeah.
Speaker 4: And declining in many places of starting long before then.
Speaker 3: Wow.
Speaker 4: Yeah.
Speaker 1: Smallpox has helped to topple civilizations, change the outcome of wars,
Speaker 1: and it has shaped humanity in really innumerable ways, both
Speaker 1: trivial or seemingly trivial and monumental, like from makeup trends
Speaker 1: to the development of vaccines, giving vaccines their name. Part
Speaker 1: of me wishes, like a small part of me wishes
Speaker 1: that we hadn't covered smallpox yet, because I feel like
Speaker 1: I did not give it the detailed, deep dive that
Speaker 1: it deserved, although I can't bring myself to re listen.
Speaker 1: But also the other part of me is relieved that
Speaker 1: we have that massive disease already under our belts. In
Speaker 1: any case, smallpox was one of the most notorious and
Speaker 1: impactful diseases ever to have infected humanity, and emphasis on
Speaker 1: was because, like we talked about, it's also one of
Speaker 1: the most incredible success stories in public health. Smallpox is
Speaker 1: one of two diseases to have ever been eradicated, though
Speaker 1: fingers crossed will be adding at least one more to
Speaker 1: that list soon dracunculiasis maybe, and it remains as of
Speaker 1: June twenty twenty two, the only disease of humans.
Speaker 4: To have been eradicated.
Speaker 1: Check out our Renderpest episode to learn more about the
Speaker 1: other disease that has been completely wiped off this planet.
Speaker 1: Throughout the nineteen sixties and nineteen seventies, public health agencies
Speaker 1: around the world participated in a tremendous coordinated campaign to
Speaker 1: determine where smallpox still lurked and to stop the chain
Speaker 1: of transmission through vaccination, and as we've talked about, their
Speaker 1: massive efforts paid off. In nineteen eighty, the world was
Speaker 1: declared free of smallpox, and vaccination against this virus slowed
Speaker 1: and ceased. But out of the ashes of smallpox emerged
Speaker 1: another pox virus, the same one that's been making headlines lately.
Speaker 1: Of course, I'm talking about monkey pox, monkey pox.
Speaker 4: How did people.
Speaker 1: First recognize this virus, where had it been hiding, how
Speaker 1: long ago did it evolve, and why was it showing
Speaker 1: up just as smallpox was disappearing?
Speaker 3: Yeah, Aaron, Yeah.
Speaker 1: So these are the questions that I'm hoping to get
Speaker 1: answered for you in this history section. Starting with evolutionary history.
Speaker 1: Although the monkey pox virus was first identified in only
Speaker 1: nineteen fifty eight, it's been around for much longer than that.
Speaker 1: Researchers put the origin of this virus at around twenty
Speaker 1: five hundred years ago, give or take a few hundred years,
Speaker 1: with the West African clade that's the less virulent clade
Speaker 1: showing up only six hundred years ago at least according
Speaker 1: to one estimate. So yes, it's been around longer than
Speaker 1: nineteen fifty eight, but it's not a terribly terribly old virus. Yeah,
Speaker 1: and neither is the smallpox virus, really, which estimates put
Speaker 1: as a little older, maybe like thirty four hundred years
Speaker 1: ago or so, which is actually more recent than what
Speaker 1: I said in our smallpox episode, which I just said
Speaker 1: very generically, Oh, around ten thousand years ago when humans
Speaker 1: first domesticated animals and began settling in larger groups, and
Speaker 1: definitely smallpox needed that sort of crowd setting in order
Speaker 1: to spread. But in any case, here's the correction five
Speaker 1: years later. Initially, before these more precise evolution date estimates,
Speaker 1: researchers suspected that the monkey pox virus could be the
Speaker 1: ancestor of the smallpox virus, since they cause similar disease
Speaker 1: and the monkey pox virus has a wider host range.
Speaker 1: The smallpox virus has a smaller genome and just infects humans,
Speaker 1: and so some researchers thought that maybe it had lost
Speaker 1: some of those genes that had allowed it to infect
Speaker 1: more species, to trade off infectivity for humans. But it
Speaker 1: turns out that monkey pox is neither the ancestor nor
Speaker 1: a descendant of the smallpox virus. It likely evolved from
Speaker 1: the cowpox virus, Okay, And it was a relief to
Speaker 1: learn that because not like personally speaking, but I think,
Speaker 1: you know, scientifically speaking, because one of maybe, yeah, because
Speaker 1: one of the key characteristics of smallpox that made eradication
Speaker 1: possible was the lack of a wildlife reservoir, and if
Speaker 1: smallpox had evolved from monkey pox once, then scientists felt
Speaker 1: like it might be possible for it to happen again,
Speaker 1: to become once again specifically adapted to humans and transmission
Speaker 1: from human to human.
Speaker 3: Right like a smallpox two point zero.
Speaker 1: Exactly, But thankfully that isn't the case. I mean, of course,
Speaker 1: it could become more adapted to humans given the opportunity,
Speaker 1: but at least it hasn't happened before. So like, maybe
Speaker 1: the road map isn't as clear. Okay, anyway, So if
Speaker 1: monkey pox has been around for thousands of years, why
Speaker 1: did it take so.
Speaker 4: Long for us to notice it? I have a guess,
Speaker 4: what is your guess?
Speaker 3: Because smallpox existed.
Speaker 1: That's exactly what I have. Smallpox stole the show. Yeah,
Speaker 1: smallpox was Marcia and monkeypox was Jan.
Speaker 3: Oh, poor Jan.
Speaker 1: By the mid twentieth century, we had gotten a lot
Speaker 1: better at being able to actually visualize and isolate and
Speaker 1: culture viruses, which had been tricky before due to their
Speaker 1: tiny size, and so scientists by then knew what a
Speaker 1: smallpox virus looked like, as you said, a big brick
Speaker 1: shaped virus. They had also found other pox viruses as well,
Speaker 1: some very host specific like mixomavirus and others that had
Speaker 1: these wide host ranges, and like you said, Aaron. The
Speaker 1: naming trend for many of these pox viruses was to
Speaker 1: name it after the animal you first isolated it from,
Speaker 1: assuming that that species was the reservoir or the natural host.
Speaker 1: And I put in some fun ones here, and I
Speaker 1: realized as I was like reading for the episode today
Speaker 1: that I saw in the transcript from smallpox because I
Speaker 1: couldn't listen to it, that you had done the same thing.
Speaker 4: But we have just a little bit of overlap.
Speaker 1: Which is fun Oh, cow pox, camel pox, mule deer pox,
Speaker 1: salmon pox, nile crocodile pox, and so on.
Speaker 4: Those were just a few of them that I grabbed.
Speaker 2: Oh, that's funny erin because in the last one I
Speaker 2: definitely said dolphin pox, and you asked me if there
Speaker 2: was fish pox, and I was like, ah, it seems
Speaker 2: like there should be fish pox. So then you said
Speaker 2: salmon pox.
Speaker 4: I love dpox.
Speaker 1: Yeah, And so this naming convention was how monkey pox
Speaker 1: got its name. In nineteen fifty eight, a few crab
Speaker 1: eating macaques at a polio vaccine research institute started getting
Speaker 1: sick about two months after their arrival from Singapore. Some
Speaker 1: of these monkeys started showing signs of a pox like illness, fever, pustules,
Speaker 1: swollen lymph nodes. Only about twenty percent of the monkeys
Speaker 1: showed any signs of illness, although the virus was found
Speaker 1: in the kidneys of some asymptomatic monkeys, suggesting the potential
Speaker 1: for a latent infection.
Speaker 4: Okay, the outbreak ended pretty.
Speaker 1: Soon after it began, but not four months later, another
Speaker 1: newly arrived batch of monkeys, also from Singapore, held in
Speaker 1: a completely different room, also came down with this pox
Speaker 1: like virus. This time, about thirty percent showed signs of infection.
Speaker 1: The researchers published their observations and suggested that this pox
Speaker 1: like disease could be caused by a previously unrecognized pox virus.
Speaker 1: Maybe perhaps we should call it monkey pox virus.
Speaker 4: Maybe we should maybe.
Speaker 1: This first recorded outbreak of monkey pox at an animal
Speaker 1: facility was quickly followed by more. The next year, monkeys
Speaker 1: of several different species came down with the infection at
Speaker 1: a research institute in Philadelphia, and then a couple of
Speaker 1: years after that, monkey pox popped up in the primate
Speaker 1: colony of the Walter Reed Army Institute of Research in Washington,
Speaker 1: d C. Interestingly, this outbreak hinted at what would later
Speaker 1: be seen in human infections of monkey pox. Several monkeys
Speaker 1: got sick from the disease, but the ones that died
Speaker 1: had been previously irradiated for some research project, suggesting that
Speaker 1: this virus posed a greater risk for immunosuppressed hosts.
Speaker 3: Ah.
Speaker 1: The pattern of monkey pox breaking out in places where
Speaker 1: animals were held in crowded conditions continued, as you might expect,
Speaker 1: with cases popping up in more more animal research facilities
Speaker 1: as well as the Zoological Garden in Rotterdam, Netherlands in
Speaker 1: nineteen sixty four, which was the first time that monkey
Speaker 1: Pops failed to live up to its name exclusively. I
Speaker 1: guess you could put it okay, like, essentially, during the
Speaker 1: zoo outbreak, I tried to be clever.
Speaker 4: It didn't work. And not only did a bunch.
Speaker 1: Of primate species become infected orangutang's gorillas, squirrel, monkeys, macas, gibbons, marmosets, wow,
Speaker 1: but so did other non primate species such as giant anteaters.
Speaker 1: Oh no, and they those anteaters were apparently at like
Speaker 1: the source of the outbreak, igniting the outbreak. Really yeah,
Speaker 1: even though they're definitely not thought to play a role
Speaker 1: in the natural history of this virus in the wild.
Speaker 1: The mortality rate from this outbreak was much higher than
Speaker 1: had been previously seen. Eleven of the twenty three affected
Speaker 1: animals died, including six of nine arrenguitanks. Oh god, I know,
Speaker 1: but more than just showing that this virus could be
Speaker 1: very deadly and had a wider host range than previously thought,
Speaker 1: what the zoo outbreak demonstrated was that crowding, multi species mixing,
Speaker 1: and stress provided the perfect conditions for the transmission of
Speaker 1: this and likely other viruses. We just keep learning this
Speaker 1: lesson Throughout these early outbreaks. The warning bells for potential
Speaker 1: spillover into humans were also sounding, given that monkey pox
Speaker 1: virus was clearly showing it could infect a number of
Speaker 1: different species, but so far it was just sort of
Speaker 1: like a faint ringing of bells, since none of the
Speaker 1: animal handlers or research technicians at any of these outbreak
Speaker 1: sites had gotten sick with the virus. Early papers describing
Speaker 1: these outbreaks no noted that perhaps monkeypox was simply not
Speaker 1: infectious to humans, but they did also point out that
Speaker 1: all of the people who had come into contact with
Speaker 1: infected animals had been vaccinated against smallpox ah yep. In
Speaker 1: these papers, they acknowledged that it was possible that monkey
Speaker 1: pox could potentially infect an unvaccinated person, but that remained
Speaker 1: hypothetical until nineteen seventy. For the first six or seven
Speaker 1: years of the nineteen sixties the smallpox eradication campaign.
Speaker 4: It wasn't doing too hot.
Speaker 1: Funding was limited, projects were understaffed, and smallpox cases didn't
Speaker 1: seem to be dropping. But by the end of the
Speaker 1: decade things had really turned around as funding started to flow,
Speaker 1: agencies began working together, and people got a better sense
Speaker 1: of the scope of the problem. The smallpox eradication campaign
Speaker 1: wasn't just about vaccinating every last person. It was identifying
Speaker 1: where the virus was still circulating so that you could
Speaker 1: concentrate your efforts in those regions, in those communities, And
Speaker 1: so a big part of smallpox eradication involved surveys to
Speaker 1: see where smallpox was or wasn't. If someone walked into
Speaker 1: a clinic with a rash or a lesions all over
Speaker 1: their body and a fever, that would send up an
Speaker 1: alert for a smallpox crew to come out see if
Speaker 1: it was smallpox, and if it was conduct contact tracing
Speaker 1: and vaccinate those who were unvaccinated, essentially stop the chain
Speaker 1: of transmission, and that practice worked really well. Smallpox rates
Speaker 1: had plummeted by nineteen seventy when one of these alerts
Speaker 1: of a possible case came in from the Waka Bokeeka
Speaker 1: region of Basunkusu Territory in the DRC. The last significant
Speaker 1: outbreak of smallpox in the region had happened in nineteen
Speaker 1: sixty eight, so two years prior and since then maybe
Speaker 1: a few suspected cases, but nothing for sure. When public
Speaker 1: health officials arrived to check out this alert, they found
Speaker 1: two suspected cases of smallpox. One ended up being chicken pox,
Speaker 1: but the other, the nine month old boy that you
Speaker 1: heard about in our first hand account, looked very much
Speaker 1: like he had smallpox, and as was protocol, his doctor
Speaker 1: took specimens to verify that it was indeed very ola virus.
Speaker 4: Except it wasn't.
Speaker 1: It was monkeypox virus, which until this point had not
Speaker 1: been seen in humans. Initially, the reaction to the news
Speaker 1: of a human monkey pox case seemed almost mixed or uncertain.
Speaker 1: Was this something to be concerned about or was it
Speaker 1: just a fluke? Did we only catch it because we're
Speaker 1: actively looking for smallpox and this happens to look like smallpox.
Speaker 1: That may be true, but it definitely wasn't a fluke
Speaker 1: because throughout the rest of the nineteen seventies, human monkey
Speaker 1: pox cases popped up sporadically and over a wide geographic
Speaker 1: range in the DRC Liberia, Nigeria, Ivory Coast, Sierra Leone,
Speaker 1: and although the total case count was low at around
Speaker 1: the thirties to forties between nineteen seventy and nineteen seventy nine,
Speaker 1: it was enough for researchers to draw some patterns.
Speaker 4: One of these patterns.
Speaker 1: Was that human to human transmission seemed very low, most
Speaker 1: of the people infected had direct contact with an animal source.
Speaker 1: Another was that it seemed to predominantly affect children, those
Speaker 1: young enough.
Speaker 4: To have not gotten the smallpox vaccine.
Speaker 1: And a third was that there seemed to be a
Speaker 1: substantial difference in disease severity between the West Africa cases
Speaker 1: and the Central Africa cases, with infected individuals in Central
Speaker 1: Africa experiencing much worse illness and a higher risk of death.
Speaker 1: Like you discussed aaron between like one to five percent
Speaker 1: for the West Africa clade compared to around ten percent
Speaker 1: of the Central Africa clade. Yeah, But perhaps the most
Speaker 1: alarming pattern that researchers were observing was the fact that
Speaker 1: cases seemed to be on the rise. In nineteen eighty
Speaker 1: smallpox was declared eradicated, which meant almost no one was
Speaker 1: getting vaccinated any longer, although surveillance still continued in many
Speaker 1: places for a few years, rooting out those suspected smallpox
Speaker 1: cases that often ended up being chicken pox or more
Speaker 1: and more likely monkey pox. Like you talked about, Aaron,
Speaker 1: the smallpox vaccine provides cross protection against other orthopox viruses,
Speaker 1: including monkey pox, and with the smallpox vaccination campaign coming
Speaker 1: to an end, that meant a great later and greater
Speaker 1: proportion of the population was susceptible to monkey pocks. And
Speaker 1: the increase in cases over the eighties and into the nineties,
Speaker 1: and the changing epidemiology of these outbreaks challenged the assumptions
Speaker 1: previously made about this virus, like human to human transmission
Speaker 1: being uncommon, or that young children were most susceptible, or
Speaker 1: that monkeys were the natural reservoirs for this virus. From
Speaker 1: nineteen eighty to nineteen eighty six, surveillance identified three hundred
Speaker 1: and thirty eight probable and confirmed cases of monkey pox
Speaker 1: in the DRC alone, which was the country with by
Speaker 1: far the largest number of cases. The case fatality rate
Speaker 1: of unvaccinated individuals was around nine point eight percent, The
Speaker 1: average patient age was getting older and older, and human
Speaker 1: to human transmission was much likelier, with during the nineteen
Speaker 1: eighties twenty eight percent of cases likely having gotten it
Speaker 1: from an infected individual another human. Actually observing human to
Speaker 1: human transmission was alarming, but researchers crunched the numbers and
Speaker 1: came to the conclusion that a monkey pox outbreak could
Speaker 1: not be sustained without repeated introductions from a primary animal source.
Speaker 1: I think the lesson here might be, let's just be
Speaker 1: careful with these assumptions and rules, because after a few
Speaker 1: quiet years in the late nineteen eighties and early nineteen nineties,
Speaker 1: monkey pox made an appearance in nineteen ninety six to
Speaker 1: nineteen ninety seven in the DRC, when it led to
Speaker 1: about eighty eight confirmed cases. In this outbreak, seventy percent
Speaker 1: of infected individuals reported coming into contact with another human case,
Speaker 1: while only twenty seven percent had known contact with an animal.
Speaker 1: So that changed very quickly and very disturbingly, and the
Speaker 1: infection chains were getting longer too.
Speaker 4: It wasn't just you got infected.
Speaker 1: From an animal and you gave it to one other
Speaker 1: person in your household and it stops with them. Now
Speaker 1: it seemed more possible for them to pass it on
Speaker 1: and pass it on and so on down the line.
Speaker 1: And a big reason for this change was, of course,
Speaker 1: vaccination status.
Speaker 4: In nineteen eighty.
Speaker 1: About eighty percent of the global population was vaccinated against smallpox.
Speaker 2: Wow, Eric, I know, do we have numbers like that
Speaker 2: for any other vaccine like currently?
Speaker 4: It's a good question.
Speaker 1: I'm sure that the I'm sure you could compile them,
Speaker 1: but like ready to grab numbers.
Speaker 3: No, that's impressive.
Speaker 1: Yeah, well that number is yeah, has dropped.
Speaker 4: Wow, and dropped logically so, logically so.
Speaker 1: And today less than thirty percent of the global population
Speaker 1: is vaccinated against smallpox.
Speaker 2: Does that mean like including the people who were vaccinated
Speaker 2: forty years ago and who knows if they even have
Speaker 2: any immunity?
Speaker 4: Right?
Speaker 1: Yeah, Okay, yeah, I guess I should say has been vaccinated. Yeah,
Speaker 1: And we stopped vaccinating for good reason. Smallpox was no
Speaker 1: longer around, and when the threat of a disease is
Speaker 1: less than like potential side effects from a vaccine, the
Speaker 1: risk calculation changes like.
Speaker 2: Yeah, and the original smallpox vaccine had a lot of
Speaker 2: potential side efficce.
Speaker 4: It did it did.
Speaker 1: After this outbreak in the DRC in nineteen ninety six
Speaker 1: to nineteen ninety seven, sporadic cases of monkey pox continued
Speaker 1: to pop up in West and Central Africa, but the
Speaker 1: next big cluster happened in a very unexpected place.
Speaker 2: I love it.
Speaker 4: It is so I could not believe my eyes when
Speaker 4: I was reading this.
Speaker 1: On May twenty fourth, two thousand and three, a three
Speaker 1: year old girl from Wisconsin was hospitalized with an unexplained
Speaker 1: fever and rash. Can you think of anything else that
Speaker 1: was going on in two thousand and three in the
Speaker 1: public health sphere?
Speaker 2: I sure can, Aaron, how about SARS, COVID one.
Speaker 1: SARS, Kobe one timing?
Speaker 4: I could not, I know, believe it.
Speaker 3: It's Aaron, listen, I know. So.
Speaker 4: Yeah.
Speaker 1: People were understandably a bit freaked out by this unexplained
Speaker 1: febrile illness.
Speaker 4: I think we can all relate to that.
Speaker 1: But her symptoms didn't really fit with SARS. Talking with her,
Speaker 1: mom called up a few more likely suspects because it
Speaker 1: turns out that the girl and her family had recently
Speaker 1: attended a swap meet for exotic animals, and they came home.
Speaker 4: With a prairie dog that they have purchased.
Speaker 3: I can't okay, I'll let you finish.
Speaker 4: Yeah, yeah, yeah.
Speaker 1: This prairie dog was intended to be a pet, and
Speaker 1: some days later, the prairie dog, doing what wild animals do,
Speaker 1: bit the girl.
Speaker 4: Later that day, the.
Speaker 1: Animal started showing signs of illness, discharged from the eyes,
Speaker 1: enlarged lymph nodes, and skin leasions. A few days later,
Speaker 1: the prairie dog died. Oh gosh, yeah, I can't imagine
Speaker 1: how terrifying. And a few days after that, the girl
Speaker 1: was admitted to the hospital. So diseases from prairie dogs.
Speaker 1: You're probably thinking plague and tulamia. Yeah, and that's certainly
Speaker 1: what the doctors thought, but the bacterial cultures came up negative.
Speaker 1: The girl recovered, and the doctors were left with no
Speaker 1: clear answers until the girl's mother became ill.
Speaker 4: Also.
Speaker 1: This gave them an opportunity for more testing, which revealed
Speaker 1: ta da monkey pox virus.
Speaker 3: Monkey pox.
Speaker 1: I now what like how at this point the virus
Speaker 1: had only been detected in West and Central Africa, and
Speaker 1: no human cases had occurred outside of the regions outside
Speaker 1: of like some travel cases. So naturally, public health officials
Speaker 1: began investigating this swap meat right like where let's find
Speaker 1: the other prairie dogs as prairie dog was hanging out with,
Speaker 1: and they turned up a surprising number of cases of
Speaker 1: monkey pox linked to the swap meat Wow. By the
Speaker 1: end of July, so the first case was May twenty fourth,
Speaker 1: forty seven confirmed or suspected cases of monkey pox had
Speaker 1: been detected in Wisconsin, Illinois, and Indiana.
Speaker 3: Wow Midwest the Midwest showing strawn.
Speaker 1: It turns out that an exotic animal distributor in Illinois
Speaker 1: had gotten a shipment of animals from Ghana via Texas.
Speaker 1: This shipment consisted of about eight hundred small mammals oh my,
Speaker 1: including species known to be associated with monkey pox, such
Speaker 1: as rope squirrels and trees squirrels. Public health officials tested
Speaker 1: these animals and found that sure enough, several of them
Speaker 1: were infected with monkey pox, including some Gambian rats that
Speaker 1: had been sent to Illinois where they were kept in
Speaker 1: close proximity to the prairie dogs that were sold to people.
Speaker 3: And there you go, and there you go monkey pox.
Speaker 4: Monkeypox.
Speaker 1: Interestingly, as of twenty twenty one, no human cases of
Speaker 1: monkey pox.
Speaker 4: Have been reported from Ghana.
Speaker 1: Huh, but it's probably circulating there among wild animals, at
Speaker 1: least as far as I could find.
Speaker 3: I actually did.
Speaker 2: I knew that I have that on my list, huh,
Speaker 2: as well as Ghana, But there it has only been
Speaker 2: identified in animals.
Speaker 4: Yeah, huh yeah.
Speaker 3: Interesting.
Speaker 1: Yeah, But this outbreak in the Midwest US clearly showed
Speaker 1: how easy it was for monkey pox to spill over
Speaker 1: into humans, and it led to a band by the
Speaker 1: CDC on the importation of any African rodents, live or dead,
Speaker 1: into the US. Yes.
Speaker 4: Wow.
Speaker 1: Another alarming lesson from this outbreak was how many species
Speaker 1: the monkey pox virus can infect. Yeah, like prairie dogs,
Speaker 1: which likely hadn't ever been exposed to it before.
Speaker 2: Yeah, and clearly got very sick from it and died
Speaker 2: very sick.
Speaker 1: I mean, can you imagine if the virus had gotten
Speaker 1: out into a wild population, I know, prairie dogs, it
Speaker 1: could have just run rampant and exposed a lot of
Speaker 1: other animals that it just could have been like go
Speaker 1: on and on and on and this I want to say,
Speaker 1: is absolutely still a risk today with widespread travel and
Speaker 1: transport of not just animals creating opportunities for spillover into humans,
Speaker 1: but also spillback from humans into wild animals.
Speaker 4: Yeah, just important to keep in.
Speaker 3: Mind, yep.
Speaker 1: Into the two thousands and twenty tens, monkey pox cases
Speaker 1: continued to climb, and the average age of those infected
Speaker 1: climbed with it Eightian age in the nineteen seventies of
Speaker 1: a person who was infected was four years old, in
Speaker 1: the twenty tens it.
Speaker 4: Was twenty one.
Speaker 1: Human to human transmission became more common, probably for the
Speaker 1: same reason that the average age was increasing, a decline
Speaker 1: in smallpox vaccination, and alongside an increased incidence in areas
Speaker 1: where monkey pox is naturally circulating, there have also been
Speaker 1: higher rates of travel or imported cases, where people travel
Speaker 1: from an endemic country to a non endemic one and
Speaker 1: bring back monkey.
Speaker 4: Pox with them.
Speaker 1: Although most of the cases of monkey pox have historically
Speaker 1: taken place in the Democratic Republic of Congo and are
Speaker 1: from the Central African clade, the West African clade is
Speaker 1: not far behind, with a large outbreak in Nigeria and
Speaker 1: twenty seventeen to twenty eighteen, This outbreak consisted of one
Speaker 1: hundred and twenty two confirmed or probable cases and a
Speaker 1: case fatality rate of six percent.
Speaker 4: Wow.
Speaker 3: That's quite high.
Speaker 4: It's quite high.
Speaker 1: So it seems high based on what we know about
Speaker 1: the West African clade. But it turns out that several
Speaker 1: of the people who died were immuno compromised and others
Speaker 1: had developed sepsis from secondary bacterial infections, and I think
Speaker 1: another was like an infant. And so I think this
Speaker 1: really highlights how crucial again, how crucial access to healthcare is,
Speaker 1: because if you compare this to.
Speaker 4: The outbreak in the Midwest, no one died.
Speaker 3: No one died. Yep.
Speaker 4: Yeah.
Speaker 1: And also about this outbreak in Nigeria, the last reported
Speaker 1: case of monkey pocks before this happened thirty nine years before.
Speaker 2: Wow.
Speaker 4: So yeah.
Speaker 3: Interesting.
Speaker 1: I also want to point out that the case numbers
Speaker 1: I've mentioned with these previous outbreaks may still seem like
Speaker 1: low numbers, right, one hundred and twenty two cases, eighty
Speaker 1: eight cases, forty seven cases, But those are just the
Speaker 1: confirmed numbers. Generally speaking, suspected can be much much higher.
Speaker 1: Since the few dozens of cases reported in the nineteen seventies,
Speaker 1: rates of monkey pocks have shot up at least tenfold,
Speaker 1: but likely much higher. In the two thousands, there were
Speaker 1: over ten thousand suspected cases of the Central African clade,
Speaker 1: and that nearly doubled the following decade to nearly nineteen thousand.
Speaker 3: Wow.
Speaker 1: In twenty twenty there were an estimated six thousand, two
Speaker 1: hundred and fifty seven in the DRC alone.
Speaker 2: Wow, that's way more than I expected.
Speaker 1: Arin me too, And I don't know, like I think
Speaker 1: that the numbers. I get your frustration often with these
Speaker 1: in the current events sections where I like, I don't
Speaker 1: know the numbers and numbers aren't good ye, And there
Speaker 1: is a lot of discrepancy between confirmed and suspected, And
Speaker 1: so I think it's difficult to get a handle on
Speaker 1: how many of those suspected, how many of those nineteen
Speaker 1: thousand are likely to actually be monkey pox keypox compared
Speaker 1: to like chicken pox or something.
Speaker 3: I know it's a huge, huge discrepancy.
Speaker 4: It is.
Speaker 1: But what we do know for sure, even if we
Speaker 1: don't have the best handled on numbers, we do know
Speaker 1: that cases are going up. This is not just an
Speaker 1: artifact of reporting or better surveillance. This is a real
Speaker 1: and concerning increase, and part of what makes it so
Speaker 1: concerning is how much we still don't know about this virus.
Speaker 1: I mean, and don't get me wrong, we know a lot.
Speaker 1: People have studied this virus for years. We have a
Speaker 1: vaccine specific to monkey box. We're well ahead of the
Speaker 1: game compared to how we were with SARS, Kobe two
Speaker 1: and COVID at the start of the pandemic, But there
Speaker 1: are still huge gaps in our knowledge. For instance, the
Speaker 1: reservoir species it's been found in some wild animals, such
Speaker 1: as Thomas's rope squirrel, a tree squirrel, the Gambian pouched
Speaker 1: rat a Soodi mangabae. But we still don't know for
Speaker 1: sure the primary source of many of these outbreaks, or
Speaker 1: even if there is just one reservoir species compared to several,
Speaker 1: whether the West African clade has a different ecology or
Speaker 1: reservoir species compared.
Speaker 4: To the Central African one, et cetera.
Speaker 1: The ecology in general of this virus is not well understood,
Speaker 1: which makes it difficult to predict when and where outbreaks
Speaker 1: might occur, what time of year, what region, and so on.
Speaker 1: People have done some really cool ecological niche modeling, trying
Speaker 1: to look for patterns in where past cases have occurred
Speaker 1: to see if we can get a framework for.
Speaker 4: Where future ones might happen.
Speaker 1: But we still have a long way to go, Like
Speaker 1: the knowledge gaps are just almost too great, And crucially,
Speaker 1: we need to consider this disease from a one health perspective.
Speaker 3: Yeah we do.
Speaker 4: We'll never get sick of saying that.
Speaker 3: Nope.
Speaker 1: Researchers have pointed to four primary reasons for monkey pocks
Speaker 1: reemergence and outbreaks, several of which are very much one
Speaker 1: health aligned. Number one increased contact between humans and wildlife
Speaker 1: due to habitat encroachment from urbanization and hunting. Number two,
Speaker 1: wildlife trade, especially of rodents. Number three ecological and climate
Speaker 1: shifts bringing animals and humans closer together. And number four
Speaker 1: increased proportion of population that is not vaccinated against smallpox.
Speaker 1: I would also like to add a fifth reason, and
Speaker 1: that is increased global travel.
Speaker 4: So I'm really.
Speaker 1: Curious, Aaron, to hear you bring us up to speed
Speaker 1: on this ongoing monkey pox epidemic, and maybe a question
Speaker 1: that I feel like we haven't asked in a long time.
Speaker 4: How scared we need to be?
Speaker 3: Yeah?
Speaker 2: We haven't asked that in a very long time. Let's
Speaker 2: take a quick break and I'll see if we can.
Speaker 2: I don't know come to an answer.
Speaker 3: So just as a reminder, all.
Speaker 2: Of that that you heard, the history and the biology
Speaker 2: section were recorded on June ninth, twenty twenty two. Today
Speaker 2: we are recording on July sixth, twenty twenty two.
Speaker 3: So that is how up to date our data is.
Speaker 3: Let's get into it, shall we.
Speaker 2: Prior to this current outbreak that's ongoing, monkey pox was
Speaker 2: considered endemic in a number of countries across Central and
Speaker 2: West Africa. In these countries, the World Health Organization collects
Speaker 2: data from an integrative Disease Surveillance and Response system, that's
Speaker 2: what it's called, which is still in place and was
Speaker 2: in place prior to this current outbreak.
Speaker 3: And I want to kind.
Speaker 2: Of emphasize here that in these endemic areas, every year
Speaker 2: there are both confirmed and even greater numbers of suspected
Speaker 2: cases of monkey pocks, and very often there are deaths
Speaker 2: that occur every year.
Speaker 3: So I kind of want to.
Speaker 2: Just say that upfront, because although this current outbreak that's
Speaker 2: making headlines is important and it is worthy of these headlines,
Speaker 2: monkey pox was also important even before this outbreak, and
Speaker 2: we shouldn't only care about diseases when they infect people
Speaker 2: in Europe or in the US. I think it's very
Speaker 2: easy to ignore infectious as well as chronic diseases that
Speaker 2: seem to only affect people living far away or in
Speaker 2: rural areas or impoverished areas, et cetera.
Speaker 4: Yeah.
Speaker 3: Absolutely, Yeah, So that's up top.
Speaker 2: But this outbreak is still very significant, so let's get
Speaker 2: into the details of it. I believe that I mentioned
Speaker 2: this earlier in this episode, but I'll reiterate that any
Speaker 2: single case of monkey pocks that was detected outside of
Speaker 2: previously considered endemic countries is considered an outbreak. All it
Speaker 2: takes is one case. And the vast majority of cases
Speaker 2: that we have seen prior to this, like you discussed
Speaker 2: in the history section era and have been either small
Speaker 2: geographically or very small numerically, like associated with travel or
Speaker 2: something like that. And today, very new things are happening.
Speaker 2: So this outbreak that is going on between May and
Speaker 2: so far July of twenty twenty two. Ongoing was first
Speaker 2: reported to the World Health Organization on May thirteenth, when
Speaker 2: two confirmed and one probable case were reported, all from
Speaker 2: a single household in the UK, and then two days later,
Speaker 2: on May fifteenth, four more confirmed cases were all reported.
Speaker 2: All these all of a sudden and these cases, through
Speaker 2: all of the investigation that people could do, seemed to
Speaker 2: have been acquired in the UK and were not related
Speaker 2: to any travel, especially any travel to endemic areas or
Speaker 2: any other travel associated cases.
Speaker 1: So no one knows the ultimate origins necessarily of monkey pocks.
Speaker 1: But those were just the first reported cases, not necessarily
Speaker 1: the first cases cases exactly.
Speaker 2: So as we see these numbers pile up, it turns
Speaker 2: out that there were likely many other cases that people
Speaker 2: became symptomatic with much earlier than May thirteenth, But this
Speaker 2: was just the first that were reported to the World
Speaker 2: Health Organization.
Speaker 4: Gotcha?
Speaker 3: Yeah?
Speaker 2: Now since May, since that time, these case reports have
Speaker 2: been piling up. Yeah. By May twenty first, it was
Speaker 2: ninety two confirmed cases by May twenty six, two hundred
Speaker 2: and fifty seven. By June eighth, before our last recording,
Speaker 2: over one thousand confirmed cases in twenty nine countries, And
Speaker 2: now at the time of this re recording July sixth
Speaker 2: over six thousand cases have been confirmed in fifty eight
Speaker 2: countries and.
Speaker 1: Just to clarify, those countries are countries where monkey pox
Speaker 1: has not been known to happen previously.
Speaker 2: Well, here's where things get a little bit confusing, okay,
Speaker 2: And the importance of surveillance and good data to begin
Speaker 2: with is really exemplified. So, between January and June of
Speaker 2: twenty twenty two, in the World Health Organization African Region,
Speaker 2: where this is an endemic disease, there have been several thousand,
Speaker 2: over fifteen hundred suspected cases, but just over seventy confirmed cases.
Speaker 2: And so now as of July, the World Health Organization
Speaker 2: is not reporting those separately. They're counting everything in this
Speaker 2: year as all part of this outbreak.
Speaker 3: If that makes sense, I see.
Speaker 2: Okay, So that number six thousand includes in both endemic
Speaker 2: and non endemic countries, and the majority of these cases
Speaker 2: in this current outbreak, about eighty percent have been reported
Speaker 2: in the World Health Organization European Region.
Speaker 4: Gotcha.
Speaker 3: Yeah.
Speaker 2: It's also important to note that in this outbreak there
Speaker 2: has only been one death reported, which happened in Nigeria. However,
Speaker 2: there had been over sixty deaths that were suspected to
Speaker 2: be due to monkey pocks but were not confirmed. Those
Speaker 2: happened in endemic regions before May of this year, Okay,
Speaker 2: And so it seems like both for streamlining of data reasons,
Speaker 2: but also to reduce this stigmatization and idea that there
Speaker 2: is separate things going on in endemic countries and non
Speaker 2: endemic countries. Right now, the world health organizations reporting only
Speaker 2: confirmed cases at this point and deaths only due to
Speaker 2: confirmed cases, and everything is part of this outbreak, if
Speaker 2: that makes sense once it's a confirmed case.
Speaker 4: Yeah.
Speaker 2: And so obviously this outbreak with these numbers and in
Speaker 2: the number of countries that we are seeing is drastically
Speaker 2: different from any monkey Pock's outbreak that we have seen before,
Speaker 2: and it's in a number of different ways. So what
Speaker 2: I want to do is kind of go over some
Speaker 2: of the ways besides just the numbers and the geographic
Speaker 2: spread in which this outbreak is different and see if
Speaker 2: I can answer some of the questions as to why.
Speaker 3: Yeah, I'll do my best.
Speaker 2: So first, in this particular outbreak, the disease seems to
Speaker 2: be presenting in some cases with a rather different clinical
Speaker 2: presentation than that classic presentation that I described in the
Speaker 2: biology section, So some people seem to not be reporting
Speaker 2: quite as much of the constitutional symptoms. Those are things
Speaker 2: like fevers, malaise, overall feeling really sick. Some people don't
Speaker 2: have those at all, and people seem to have lesions
Speaker 2: in some cases at least in different stages of development
Speaker 2: at the same.
Speaker 1: Time, which is very interesting.
Speaker 3: So fascinating to me.
Speaker 2: And that's like we talked about something that's more typical
Speaker 2: of like a vericella, a chicken pox, but very much
Speaker 2: not typical of what we've seen with monkey pox or
Speaker 2: other pox viruses in the past. Another thing that's different
Speaker 2: is a lot of people are being identified through sexual
Speaker 2: health or primary healthcare clinics presenting with lesions primarily in
Speaker 2: the genital and perianal region. They are classic monkey Pocks
Speaker 2: looking lesions, but starting on the genitals rather than the
Speaker 2: head or mouth like we've seen in the past, and
Speaker 2: in some cases they aren't always spreading to the entire body.
Speaker 1: I think these differences are really interesting because what I'm
Speaker 1: very curious about is whether whether these represent new characteristics
Speaker 1: of a new manifestation of this disease or just things
Speaker 1: that we previously haven't captured in past outbreaks because surveillance
Speaker 1: maybe was not that high and it was sort of
Speaker 1: like unless you had a clear case of monkey pocks
Speaker 1: then yeah.
Speaker 2: Yeah, that is the exact question that everyone is trying
Speaker 2: to answer. We don't have a full handle on it,
Speaker 2: but I'll get into a little bit more detail that
Speaker 2: helps us get there.
Speaker 1: I have a quick question though, before we do that.
Speaker 1: So we have a vaccine for monkey pox.
Speaker 3: Which just jumping ahead on all my thing.
Speaker 1: I know, I know, I know, but this is about
Speaker 1: sort of like outbreak control. So when somebody is diagnosed
Speaker 1: with monkey pocks, what happens to them, like in terms
Speaker 1: of the treatment that they get, the care that they get,
Speaker 1: and then public health wise, what happens to their contacts.
Speaker 3: Yeah, excellent question.
Speaker 2: So, first, if somebody presents to their clinic with things
Speaker 2: that look like monkey pox, especially now that everyone is
Speaker 2: aware that this is a thing that's happening, ideally, samples
Speaker 2: from these lesions are going to be taken and they're
Speaker 2: going to be tested to see if it is truly
Speaker 2: monkey pox. If it is, there is treatment that's available.
Speaker 2: There is an anti viral that was very recently approved
Speaker 2: for treatment of smallpox as well as monkey pocks. So
Speaker 2: especially if someone is very, very sick, then hopefully they
Speaker 2: would have act to that kind of antivirals. I truly
Speaker 2: don't know what the status of antiviral access is across
Speaker 2: the world, and I suspect it's relatively limited since it's
Speaker 2: a pretty new anti viral and historically this disease has
Speaker 2: not been so prevalent, but they do exist. Then isolation
Speaker 2: is going to be really important, so a person should
Speaker 2: avoid contact close contact with other people, especially contact with
Speaker 2: the lesions themselves. And then is when comes the real
Speaker 2: like what we call boots on the ground epidemiology, where
Speaker 2: epidemiologists will come in and say, okay, let's go over
Speaker 2: everywhere that you've been, everywhere that you've traveled in the
Speaker 2: preceding two to three weeks most likely, since this is
Speaker 2: a relatively long incubation period, virus everyone that you've been
Speaker 2: in contact with, everyone that you've maybe lived with or
Speaker 2: shared a bed with, or just been in very close
Speaker 2: contact with. And then those people will be contacted to
Speaker 2: see if they've developed a any symptoms and also just
Speaker 2: to be made aware that A if they have symptoms,
Speaker 2: they should isolate and b they should be on the
Speaker 2: lookout for symptoms. The last piece of that puzzle is
Speaker 2: that people who were very very.
Speaker 3: Likely to have been exposed.
Speaker 2: It is also possible to do what's called post exposure
Speaker 2: prophylaxis with a vaccine. So we have two different vaccines
Speaker 2: that are available, and you can do vaccination. I've seen
Speaker 2: different reports, but up to a number of days after
Speaker 2: exposure and potentially drastically reduce the risk that you would
Speaker 2: go on to get infected.
Speaker 4: Okay, cool, thank you.
Speaker 1: Yes, I know it was jumping ahead, but I just
Speaker 1: wanted to have like in my head, yeah, step one,
Speaker 1: step two, step three, what does this look like?
Speaker 2: Yeah, like what actually happens?
Speaker 3: Yeah, that's a good question.
Speaker 5: Where were we We were in talking about symptoms and yeah,
Speaker 5: so yeah, those are all the symptoms that are a
Speaker 5: little different.
Speaker 2: Some symptoms, like the lymphatinopathy, seem pretty consistent, and plenty
Speaker 2: of people are still presenting with relatively classic looking monkey pox,
Speaker 2: so that's important to point out in very good news reporting.
Speaker 2: The overall fatality rate has been exceedingly low compared to
Speaker 2: what we've seen in a lot of other cases and outbreaks.
Speaker 2: So far, only one confirmed death from monkey pocks, and.
Speaker 1: Is that likely due to just access to healthcare, Well.
Speaker 2: That probably plays a big role, but all of the
Speaker 2: samples that we have been able to identify so far
Speaker 2: come from that West African We know that's not a
Speaker 2: good name, but the West African strain, which is much
Speaker 2: less virulent, and this one in particular seems to be
Speaker 2: even less so. When it has caused outbreaks in the past,
Speaker 2: it's actually had a more rate of like less than
Speaker 2: one percent. Okay, so this strain in particular seems to
Speaker 2: have a much lower mortality rate, much less varulent, So
Speaker 2: that's very good news. Yeah, So I think a lot
Speaker 2: of people probably have the question, and you kind of
Speaker 2: asked it a little bit aarin already, and that is
Speaker 2: like why like why is this spreading so rapidly? Like
Speaker 2: how can this outbreak be so much bigger than any
Speaker 2: that we've seen before? And there's kind of a lot
Speaker 2: of different possibilities. So is it because, like I described,
Speaker 2: the symptoms seem to be a lot more mild, So
Speaker 2: are people spreading it more easily because they just don't
Speaker 2: realize that they're infected?
Speaker 3: Maybe we don't really.
Speaker 2: Know, because, like you said, we don't maybe have the
Speaker 2: best data to begin with to know how much was
Speaker 2: this virus potentially circulating undetected? Across the globe potentially, right.
Speaker 2: Another possibility is is this particular virus different than other strains?
Speaker 2: Is this particular strain more infectious or more easily transmitted,
Speaker 2: especially from person to person? Is maybe maybe we don't
Speaker 2: really know.
Speaker 3: We do have some pretty limited.
Speaker 2: Data just about what we know about how different this
Speaker 2: particular strain is from a very closely related one that
Speaker 2: had caused a few cases in twenty eighteen twenty nineteen
Speaker 2: that were mostly travel associated. So this particular virus is
Speaker 2: closely related to that one which caused a number of cases,
Speaker 2: but it has at least fifty new mutations that have
Speaker 2: not been seen before or we're not present in that
Speaker 2: twenty eighteen twenty nineteen cases.
Speaker 4: Okay, questions here?
Speaker 1: Okay number one, Sorry, I know you were in taking
Speaker 1: a breakfaice. I will continue on and I can't stop
Speaker 1: myself from interruptn.
Speaker 4: Okay, this is a DNA virus.
Speaker 3: That's my next sentence erin oh perfect.
Speaker 4: So A that's a high mutation rate for a DNA virus.
Speaker 2: Right, sure, is Aaron, It's about like a way higher
Speaker 2: I think we would have estimated. So this is like
Speaker 2: fifty mutations in about three to four years. We would
Speaker 2: expect probably like one to two or so a year.
Speaker 4: Oh okay, but mom, uh b or two. I don't
Speaker 4: know what I started with.
Speaker 3: Uh huh.
Speaker 1: Do we have available data to kind of look at
Speaker 1: that same trend with other monkey pock strains in the past.
Speaker 2: Fascinating question Erin as far as I can tell, I
Speaker 2: don't think so.
Speaker 1: Okay, or at least we don't have We haven't done
Speaker 1: the genomic analysis right.
Speaker 3: Not yet, not yet.
Speaker 2: But there's a lot of thought just based on I think,
Speaker 2: not only perhaps the mutations that we're finding, but also
Speaker 2: just you know, comparing the mutations in this virus to
Speaker 2: the way that other viruses mutate, especially zoonotic viruses. Remember
Speaker 2: that this has primarily been a you know, animal to
Speaker 2: human spillover type virus. So there is thought that perhaps
Speaker 2: this is the result of micro evolution, so small changes
Speaker 2: to be better adapted to evade our human immune response,
Speaker 2: essentially getting more specific to infecting humans.
Speaker 1: Okay, so these are not necessarily just random mutations, These
Speaker 1: are actually functional potentially.
Speaker 2: Yeah, potentially, Yes, that's kind of the thought, because that
Speaker 2: would help explain like why now, right, if this virus
Speaker 2: you know, picked up these mutations that made it really
Speaker 2: easy to be transmitted. Then it makes sense it's gonna
Speaker 2: transmit a lot more efficiently.
Speaker 4: I mean, it makes sense. But that doesn't make it
Speaker 4: any less.
Speaker 3: No, it's it makes them a lot more scary.
Speaker 2: But on the flip side, it does again seem to
Speaker 2: be a very very low mortality rate compared to most
Speaker 2: other strains that we've seen.
Speaker 4: Plus we have treatment and vaccine.
Speaker 2: Plus we have treatment and vaccines. The other thing that
Speaker 2: is different about this outbreak that's very important for us
Speaker 2: to talk about for a lot of reasons, is that,
Speaker 2: especially very early in this outbreak in May and June,
Speaker 2: when cases were rolling in, these cases were primarily being
Speaker 2: reported in men who have sex with men. That's the
Speaker 2: public health terminology. And when we are in an outbreak situation,
Speaker 2: a new disease, what have you, it is really really
Speaker 2: important to get information as accurate as we have it
Speaker 2: out and available to the public as quickly as we can,
Speaker 2: so that public health agencies are aware, so that clinicians
Speaker 2: and health systems can be aware and be on the lookout,
Speaker 2: so that if more active surveillance needs to be enacted,
Speaker 2: it can be And so when there are epidemiological characteristics
Speaker 2: that link cases together, such as in these early reports
Speaker 2: of quote in individuals who self identify as men who
Speaker 2: have sex with men. This is important information because it
Speaker 2: can help us inform both groups or individuals who are
Speaker 2: at risk, as well as the public health infrastructure at large,
Speaker 2: how to react and how to reduce overall risk.
Speaker 1: Right.
Speaker 2: That's imperative information. The problem is especially because of our
Speaker 2: society's obsession with othering and ostracizing people in general, as
Speaker 2: well as the historic and continued marginalization of gay men,
Speaker 2: bisexual men, transgender and gender queer in individuals, many of
Speaker 2: whom are going to fall into this category of men
Speaker 2: who have sex with men. Because of this particular dynamic
Speaker 2: at play, it's very easy to make it seem as
Speaker 2: though this is another problem which can lead to a
Speaker 2: lot of stigmatization. And not only is that problematic, but
Speaker 2: it also makes it really easy to miss a lot
Speaker 2: of potential transmission.
Speaker 3: Right, and the World.
Speaker 2: Health Organization agrees that that is very likely what has
Speaker 2: been happening, based on the rapidity with which we have
Speaker 2: seen case numbers rise and how long the incubation period
Speaker 2: is for this disease. This is something that's been circulating
Speaker 2: for some time but is now being diagnosed.
Speaker 1: I feel like you use epidemiological characteristics of a disease
Speaker 1: patterns of an infectious disease to prevent it from spreading
Speaker 1: further and to control, But it seems like what can
Speaker 1: often happen and what does happen is instead of using
Speaker 1: those to tell you, okay, who might most be at risk?
Speaker 4: How can we best use this information to control?
Speaker 1: Instead, it's like putting blinders on and being like, oh,
Speaker 1: we only are going to look for it.
Speaker 2: In these individuals, right, or we're going to say, well,
Speaker 2: I'm definitely not at risk because that's not me. I
Speaker 2: don't fit into that bucket. Yeah right, and that's it's
Speaker 2: just not good.
Speaker 4: Yeah.
Speaker 2: So yes, in this particular outbreak, people who identify as
Speaker 2: men who have sex with men were possibly some of
Speaker 2: the first to be exposed, or at least the first
Speaker 2: one is to pay.
Speaker 3: Attention and notice a rash and go and get it
Speaker 3: checked out.
Speaker 2: And that is still important information for us to have.
Speaker 2: And what's interesting is that the question that has been
Speaker 2: raised a lot because of this particular route of transmission
Speaker 2: is the question of is monkey pox and STI is
Speaker 2: this a sexually transmitted disease now, And the answer is
Speaker 2: essentially no, not really, because as far as we know,
Speaker 2: this is still a disease that is transmitted the way
Speaker 2: that monkey pox has always been transmitted, and that is
Speaker 2: by close contact. Sexual contact is one type of close contact,
Speaker 2: but any sharing of things like clothes or bedding, any
Speaker 2: touching of skin, lesions and potentially respiratory droplets or very
Speaker 2: close range aerosols, given that this virus can be in
Speaker 2: the saliva or lesions could go undetected in the mouth,
Speaker 2: really is what it comes down to, the same way
Speaker 2: that they can be undetected on the genitals. So there's
Speaker 2: a lot of questions of like is this a sexually
Speaker 2: transmitted disease, And in some ways it's an interesting and
Speaker 2: important question, like is this virus particularly being housed in say,
Speaker 2: serve coal secretions or in semen or something like that.
Speaker 2: But what it boils down to is that we know
Speaker 2: that it's the viral particles in these lesions that are
Speaker 2: on your skin that are infectious. Yeah, And because sexually
Speaker 2: transmitted infections are often very highly stigmatized, I think it's
Speaker 2: pretty important to push back against that in this case,
Speaker 2: especially early on when we really don't know the full
Speaker 2: extent of this epidemic, pandemic, what have you. Yeah, yeah, Aarin,
Speaker 2: that's what's going on as far as we know. We
Speaker 2: already talked about everything that we're doing to kind of
Speaker 2: prevent it and help prevent the spread. A lot of
Speaker 2: that is making the public aware, and so hopefully we're
Speaker 2: helping with that at least a little.
Speaker 4: I have one last question for you.
Speaker 1: Give it to me erin how scared do we need
Speaker 1: to be?
Speaker 2: Yeah, we haven't asked that question in so long. I
Speaker 2: would say this is something that the public health powers
Speaker 2: that be are taking very seriously and are working really
Speaker 2: really hard to interrupt this chain of transmission. But overall,
Speaker 2: for most of the eight billion people in this world,
Speaker 2: this is still something that at this point is pretty
Speaker 2: low risk. Overall, it is transmitted in a much more
Speaker 2: limited manner than something like SARS COVID two, for example.
Speaker 2: It's also generally a self limited disease in terms of severity.
Speaker 2: We have not seen mortality like we saw and are
Speaker 2: still seeing.
Speaker 3: With COVID for example. But it is also.
Speaker 2: Spreading a lot more rapidly. And one of the things
Speaker 2: that I think about is if it makes its way
Speaker 2: into wild or domestic animal populations, it could definitely establish
Speaker 2: and become an endemic disease worldwide. Same thing if this
Speaker 2: virus has really become very well adapted to humans and
Speaker 2: is now just being very easily transmitted person to person.
Speaker 3: So it is a big deal. For those reasons.
Speaker 1: It seems like there is cause for concern and there
Speaker 1: is cause for hope. Yeah, and I guess the future
Speaker 1: will tell us how we should have been feeling in
Speaker 1: retrospect at this moment.
Speaker 2: I think maybe, I think that people are really paying
Speaker 2: a lot of attention, and so for me, that gives
Speaker 2: me a lot of hope.
Speaker 3: Yeah.
Speaker 1: Yeah, Well, maybe we'll be back with a miniseries.
Speaker 3: Oh I hope not.
Speaker 4: I hope not too. I really hope not.
Speaker 2: Actually, A twive this week in Virology has been doing
Speaker 2: a lot of updates. So if people are interested, especially
Speaker 2: in like really deep dives on the virology of this,
Speaker 2: they've got the dates. It's another podcast check it.
Speaker 4: Out for sure.
Speaker 3: Good wreck well then well sources.
Speaker 1: Speaking of sources, I have several a bunch, but I'm
Speaker 1: just going to shout out too. One on monkey pocks
Speaker 1: virus evolution by Babkin at All from twenty twenty two
Speaker 1: called an Update of orthopox Virus Molecular Evolution. And then
Speaker 1: there was a great paper from twenty twenty two in
Speaker 1: plus Neglectrotropical Diseases called the Changing Epidemiology of Human monkey
Speaker 1: pos a Potential threat.
Speaker 3: A systematic review can confirm that's a great paper.
Speaker 4: It's a great paper.
Speaker 2: I also had quite a number of papers one that
Speaker 2: I liked for the clinical aspect. There was a few,
Speaker 2: but one in particular was just called human monkey pox
Speaker 2: and it was in Clinical Infectious Diseases from twenty fourteen.
Speaker 2: There is a very interesting paper with more detail about
Speaker 2: the specific strain that is causing this outbreak. It's a
Speaker 2: pre print from Nature Medicine twenty twenty two too. Obviously
Speaker 2: I will link to that as well as the World
Speaker 2: Health Organization page where they are posting all of their
Speaker 2: disease outbreak news updates. But you can also follow them
Speaker 2: on Twitter for very rapid fire updates on the state
Speaker 2: of monkey pox today.
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Speaker 1: And thank you to you listeners. We hope that you
Speaker 1: found this episode helpful.
Speaker 4: I hope so informative.
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Speaker 4: Truly, truly, truly.
Speaker 1: Okay, Well, until next time, wash your hands.
Speaker 3: You filthy animals.
Speaker 1: Um um