Electron microscope image of monkeypox viral particles.

Public health experts are on edge because of recent monkeypox outbreaks. Several countries, including the U.S., have reported cases of the viral infection recently. There have been no deaths reported so far. It is possible that something has changed about the virus or its relationship to humans that is making it more transmissible than before.

Countries with reported monkeypox cases

The UK, Canada, Spain, Portugal, Italy, Sweden, and the U.S. have documented cases of monkeypox. There have been 13 suspected cases in Canada of a Massachusetts resident who recently traveled there. Seven people are thought to have contracted it in the UK, with the first case thought to have been contracted in Nigeria.

The first documented case of monkeypox in Africa was in the 1970s. It's a zoonotic disease, meaning that infections are usually transmitted from animals to humans, rather than between people. Andrew Pavia is an infectious disease doctor at the University of Utah. There is no clear answer as to why this is happening.

Human to human spread has been limited in the past. We don't know if it is spreading more easily from person to person. I am not aware of any evidence to support that idea yet, but that is one possible explanation, according to Pavia.

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What is monkeypox virus?

Monkeypox is caused by a member of the poxviruses family. The only human germ that has been fully eradicated so far is the smallpox virus. Monkeypox causes a rash that starts in the face and spreads throughout the body with flu-like symptoms.

People are usually sick for about two weeks after exposure, and it takes one to three weeks for symptoms to start. There are cases in the UK that appear to be caused by a less virulent version of the virus, with a fatality rate closer to 1%.

“Given what we know today, there is no reason to panic or for most people to have any worries, but it is early days, so that may change.”

If the monkeypox outbreak grows into a bigger threat, we could use some of the available tools. Smallpox vaccines can be given after exposure to prevent illness, so they can be used as a part of a strategy to short-circuit an outbreak. There are approved antivirals that work against poxviruses.

Why is monkeypox spreading now?

It is possible that the virus has evolved to make it more infectious. Jo Walker, an infectious disease epidemiologist and modeler at the Yale School of Public Health, believes that the increased spread could be related to the victory over smallpox.

The eradication of smallpox was achieved through the efforts of a global mass vaccine program. Poxviruses cause cross-immunity to other viruses, and the weakened virus in the classic smallpox vaccine isn't even smallpox. The buffer of immunity may have stopped the spread of monkeypox. Our collective protection has waned over time, possibly allowing monkeypox to spread more widely, without needing to change in any important way.

A patient with monkeypox lesions.

The decline in immunity is not due to waning immunity at the individual level, but due to people with immunity dying, and people without immunity being born.

Walker notes that some researchers have long warned about monkeypox or similar viruses someday filling in the niche left behind by smallpox, and some have argued that it is a major factor in why the germ made a reappearance in Nigeria after four decades of zero reported cases.

There is a chance that a mystery animal is to blame for seeding these outbreaks. The largest known outbreak of monkeypox in the U.S. in 2003 was traced back to contact with prairie dogs.

There is evidence of human-to-human transmission in some of these cases. In the UK and Spain, the majority of infections have been found in young gay and bisexual men. Monkeypox can theoretically survive in the environment in aerosol particles intact, as suggested by other research.

Pavia said that getting to the bottom of the monkeypox mystery will require classic medical detective work. Epidemiologic investigations will try to figure out the type of contact that resulted in people's infections and the number of infections that seem to spring up from each index case. In the lab, scientists will be looking for genetic changes in the virus samples taken from patients, or testing out whether the infections behave differently in model animals.

There is no reason to panic or worry, but it is early days, so that may change.