Monkeypox: how worried should you be?

Not very. At least not yet.

Monkeypox is not a new disease. It has been around for a while and has never caused a global pandemic. It is viral disease endemic in tropical rainforest areas of central and west Africa.

The World Health Organization has a wonderful outbreak report with details that were accurate as of May 21 on its spread outside of Africa to non-endemic countries.

No deaths have been reported to date. However, the extent of local transmission is unclear at this stage, as surveillance has been limited. There is a high likelihood of identification of further cases with unidentified chains of transmission, including in other population groups. With a number of countries in several WHO regions reporting cases of monkeypox, it is highly likely that other countries will identify cases.

The situation is evolving and WHO expects there will be more cases of monkeypox identified as surveillance expands in non-endemic countries. So far, there have been no deaths associated with this outbreak. Immediate actions focus on informing those most at risk for monkeypox infection with accurate information, stopping further spread and protecting frontline workers.

What is the natural reservoir of monkeypox?

Contrary to the name, it might not be monkeys where it was first spotted.

Various animal species have been identified as susceptible to monkeypox virus. This includes rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates and other species. Uncertainty remains on the natural history of monkeypox virus and further studies are needed to identify the exact reservoir and how virus circulation is maintained in nature.

Multiple draft genomes of the monkeypox virus from those who have been infected during the current outbreak are now available.

It is likely that the virus has spread from a single origin and that it belongs to the less severe West African clade.

The WHO notes that “in recent times, the case fatality ratio has been around 3–6%.”The Congo clade is more severe, but overall estimates range from 1-10%.

In Africa, monkeypox is usually transmitted from an animal (often a rodent, and not a monkey) to a human. Mutations in the past have led to greater human to human transmission.

Monkeypox clinically looks like smallpox but is less severe and less contagious. Smallpox, which has been successfully eradicated, is closely related to monkeypox.

But monkeypox is not SARS-CoV-2, and it is certainly not smallpox.

The smallpox vaccine used during eradication programs protects against monkeypox. I would guess that those of us who got a smallpox vaccine as an infant would have some protection even now against monkeypox.

The increase in monkeypox cases in recent years could be due to lower population immunity to smallpox after it was eradicated. In Africa, it occurs mostly in kids who never got the smallpox vaccine.

Monkeypox spreads from respiratory droplets, direct contact, and surfaces. According to the WHO, “Monkeypox virus is transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding.” The need for direct physical contact for spread also seems to indicate why outbreaks are usually short-lived. In the current outbreak, a high proportion of those infected are men who had sex with other men.

There’s a theoretical but unknown risk of airborne transmission. N95 masks prevent spread when near someone who is infected. Luckily, people aren’t contagious until they’re symptomatic. This is a crucial point to remember and why stopping spread is much easier than with a virus that spreads when patients are asymptomatic.

Symptom onset is usually within 1-3 weeks of exposure and can last from 2-4 weeks.

Fever, rash, and often swollen lymph nodes are the main symptoms, though other complications can result in serious cases. The rash typically starts in the mouth, then radiates to the face, and then arms and feet. PCR tests offer molecular validation.

There are also drugs like cidofovir, brincidofovir, and tecovirimat that have activity against monkeypox. They also work against smallpox. The smallpox vaccine, particularly the newer generation vaccine JYNNEOS by Bavarian Nordic is effective for monkeypox. Vaccines can also be used prophylactically in people who are exposed but don’t show symptoms yet.

There was spread in 2003 in the U.S. that was linked to infected African rats that had been imported. Nearly 50 people were infected, though no one died. Monkeypox has not typically spread well from humans to other humans (unlike smallpox and SARS-CoV-2, for example).

That’s why despite being endemic to parts of Africa and multiple international exposures, spread has historically been limited.

In fact, most international spread in the past has been from infected animals. In the current outbreak, most spread is human to human often with no travel to Africa

This is the most intriguing and worrying aspect of monkeypox — the possibility that it has spread for a while and has evolved some new biological characteristics that enhance cryptic transmission.

More work will shed light on this. But right now, risk in the general population remains very very low.

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Killing children’s curiosity.

My column last week for Hindustan Times was on how school and the burden of expectations turn children into uninventive drones and how we as adults can rekindle the wonder of childhood once again.

Psychologist Margaret Donaldson writes in “Children’s Minds” that there is a mismatch between school and children’s minds. Inquisitiveness is stifled and learning becomes an act of parroting facts. Children become fearful of failing, of being mocked, and of giving wrong answers.

Even before infants can talk, they have the tools to navigate the world. Children are “scientists in the crib.” And by the time they enter primary school, they are attuned to asking “how” and “why” hundreds of times a day.

Schools should be actively equipping children with critical thinking skills and fostering their innate curiosity. Sadly, what happens in school is as relatable as it is disappointing. In our school system, the worth of a child is reduced to how well he or she does on exams.

Frank Keil is a professor of psychology and director of the Cognition and Development Lab at Yale. For ~50 years he’s researched how people understand the world. Keil has included his insights in his super new book, Wonder: Childhood and the Lifelong Love of Science.

“Wonder is an exuberant, joyous embrace of puzzles that we encounter in our everyday lives. These puzzles launch cycles of question-asking, exploration, and discovery,” writes Keil. He laments that very few adults retain a sense of wonder from their early childhood.

Keil gives as one example the differences in books that children enjoy that are filled with probing questions that ask “how” and “why” and the books that make bestsellers lists for grown-ups which (when nonfiction “science”) include fads, quack treatments, and pseudoscience

“When wonder is stifled and demotivated, it can lead to cognitive decay that makes us all more susceptible to misleading cognitive biases, misinformation, and the blind following of consensus,” writes Keil. It’s a fantastic must-read book. But unfortunately the people who need to read it the most, won’t read it.

We see the detrimental effects of the lack of curiosity everyday all around us with anti-science narratives that hamper our ability to navigate a chaotic world full of microbes, unpredictable weather, rising pollution, and diminishing forests.

In my own life, my own sense of curiosity and wonder were beaten out of me by an unforgiving school system. We were told to place value not on actual learning but on “cracking” tests. That became our only goal.

It was in this system that I learned that what I needed to do was to “commit and vomit”. I needed to uncritically commit to memory facts presented in textbooks (which had often not been updated in decades) and vomit these facts from my brain on to sheets of paper on exam day.

We survived the system. But what happened to our sense of curiosity?

As machines take over routine jobs, creativity and curiosity which are marketable attributes will become more highly valued in the workplace too. But we are churning out mindless human drones.

Some experts think a reason most adults do not foster the curiosity of childhood is we spend most of our time on very specific goals like financing a house or finding a better-paying job. Asking big questions isn’t a priority and so there’s no time or mental bandwidth for it.

A second reason is that while our mental toolbox grows, we become less receptive to new ideas. We focus on the minutiae of everyday life. Devoid of the bright-eyed wonder of childhood, we begin to take the world around us for granted.

So, what’s the cure? Actively nurturing curiosity.

Adults tend to see things as they are, as the way they’ve always been, and as they should be. Children ask why the universe is the way it is and not in a myriad of other possible ways.

If your spend an hour with a curious child you’ll realize how much we’ve come to take the world for granted and how little we actually know about it. They will shake you to the core with their questions. Children ask the best questions… why the moon exists, why a virus infects one person and not others, why life exists on one planet and not on another, how the universe formed, and what will happen to life on Earth when humans are gone, for example.

And instead of treating children as inferior versions of adults that need to be shaped to fit our narrow mindsets, let’s learn from them how ask “how” and “why” questions from first first principles again.

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Endnotes

I’ve been traveling quite a bit recently. Here are two digital postcards from my most recent trip to Napa Valley in California. I got clear skies both ways.

And this is the Green River in Utah cutting through Canyonlands National Park — my favorite National Park in the US (in fact I like it more than Grand Canyon, Bryce, or Yosemite)

Stay well, friends.