Enough distinct things happened this week in Monkeypox that it made sense to split off the information on it into a distinct post. This is probably slightly over the threshold required for doing that.

Executive Summary

WHO declares Monkeypox a public health emergency of international concern.

One could define of ‘keeping up with the news’ is when the WHO declares an emergency and you become more worried only to the extent you worry about what they are going to do next.

Thus, this does not indicate a crisis situation, or even one worse than one would have expected a few weeks ago. It is, like most monkeypox news this week (and also the majority in general), an acknowledgement of the inevitable.

Will we turn the tide soon? It briefly looked like this might have already happened, but it turned out not to be the case. I give us a reasonable chance to indeed turn the tide relatively soon, and without a broad spillover into the non-MSM community. There will of course be some cases of spread elsewhere, but my (not too confident) hunch is that the disease won’t robustly spread in most other places, and will remain mostly within MSM.

The overall case numbers are still quite low. If you are not in contact with the places this is concentrated, the whole thing is in practice fully ignorable, and would be for several additional doublings. Even after that, it would be mostly ignorable. You’d want to be aware of what to look for, but talk of major behavioral adjustments (or even speculations on things like shutting daycare centers) seem at worst highly unlikely.

Various News

When all the available vaccine slots are taken within seven minutes (as 300k doses remain parked overseas) the problem likely is not a lack of keeping up with the news. That sounds bad. Some needed perspective, however, is what our health officials do best.

Yes, I imagine not counting days makes the count smaller.

CDC numbers on case growth.

My understanding is these are cumulative numbers, which means the lack of acceleration this past week looked like excellent news. That is especially true given the expansion of testing capacity.

Later, on July 26, we had this.

That’s 700 in 4 days, versus 1k in 7 days. We continue to see a leveling off in case growth. All responses are things like ‘sigh’ but this was excellent news.

Until the next day, and, well, whoops.

Once again we are not looking so good. Metaculus is responding appropriately.

Metaculus thinks the MSM percentage of cases will end up being around 93%. Cate Hall says it seems mispriced too high. I don’t think so.

CDC director Walensky (who is finally getting her media training) says she is considered about zoonosis, where the virus would get into our animals, which would likely mean we would be stuck with monkeypox permanently. I’ve seen relatively little talk about that concern, and zero focus on reducing the chance that it happens. Then again, I have little faith in our ability to make monkeypox go to zero in humans.

Experts embrace first doses first for Monkeypox. I wonder how much of this was the debate during Covid and how much of it is that no one is paying attention so they feel permission to do something correctly.

Also, I wouldn’t ban orgies, that won’t work, but I would have been willing to say out loud that maybe they aren’t such a good idea right now. I do think failure to do that is not good for public trust.

This from CNN is the latest ‘we could have prevented this’ polemic.

The difficult truth is that this monkeypox outbreak could have been avoided. We should have paid attention to this virus decades ago. Turning a blind eye to an outbreak happening in another country is not only foolish — it’s dangerous.

I continue to not understand what practical physical proposal would have done the job. It is not as if we can go in and contain things elsewhere. It is not as if we can take the kind of countermeasures that would have prevented it from coming to the country.

Presumably the actual proposal is to have already done the necessary work decades ago to prepare for this eventuality? Get everything ready to go, know exactly how to best use our resources and all that? I still don’t see how this changes things all that much unless we would have been prepared to do mass vaccinations.

We must act fast, and we must act now.

What are we suggesting a non-blind eye would have done without decades of time? What would it do now?

I do get the argument that ‘the CDC has been preparing for smallpox for a long time and this is story-mode smallpox’ but with actual smallpox you can take very expensive in every sense countermeasures that you cannot take here. That does not mean I expect that we are prepared for smallpox and would handle it well. I expect we would handle it badly, and fixing that is a priority, but story mode without the ability to focus is not always easy.

So yes, we can point to a bunch of failures…

So, with these resources on hand, why is the US not able to contain the monkeypox outbreak?

The answer is much more complex than just a few mishaps; it is a combination of an initial narrow criteria for whom to test for monkeypox sent to a limited testing infrastructure of public health labs, challenges with doing contact tracing for multiple or anonymous sexual partners, a vaccine supply that has fallen far short of demand, lack of resources to support self-isolation of people that are positive and our tiptoeing around communicating the reality that the most at-risk population is men who have sex with men. Adding to this already calamitous situation, we are reliant on decades-old clinical information to inform our understanding of this disease, while the current outbreak is showing unusual disease presentation with atypical features.

…but that does not mean that those failures made that much difference.

What does the Biden administration propose? The useful talking points you expect.

They’re going to work on vaccinations and testing and treatment and science, even reductions of paperwork. That’s all good stuff. What’s even better is what isn’t here, which is a bunch of Sacrifices to the Gods or signaling games.

Unlike some of our other health experts who are busy, well, asking that the name of monkeypox be changed to ‘avoid stigmatizing vulnerable communities.’

(Also, that’s not the same guy who was warning against scaring people with scary stories about this ‘Covid-19’ virus during the February 2020 lunar new year celebrations, that was a different NYC health commissioner. The more things things change.)

The goal remains eradication. There isn’t zero chance we can turn this around, but I am definitely skeptical.

WHO finally willing to say it, recommends MSMs reduce their number of sex partners and get contact info (find out WHO!) from them. Which go hand in hand. If you want to have fewer partners you will want their contact information.

Caitlin Rivers proposes three metrics to measure our progress: Number of individuals tested, proportion of cases coming from known contacts (or, at least, where we can point to a known contact, since you can never know for sure), and days from symptom onset to isolation.

That third one seems like it should be pretty close to zero already. Either you have pox on your skin or you don’t. If you do, you should presumably isolate, modulo getting tested. If it’s not that close to zero, then sure, let’s track it.

How many people we test is a benefit but also a cost. Whether it is good or bad to test more people depends on the limiting factor and how you are deciding whether to test. I’m not sure how I would use this to decide if things were going well, although I would expect to find the number useful. Cases from known contacts does seem like a decent proxy for ‘how often are we catching this’ but also could be a proxy for whether some networks of infection are off the radar entirely.

In terms of your own personal risk, a gentle reminder.

Recent data from New York City shows that about 98% of reported monkeypox cases are among men and 2% among transgender, gender nonconforming and nonbinary individuals. Almost all are men who have sex with men (MSM).

That doesn’t mean there are actual zero other cases, but there are a lot of dangers in life. Unless you are coming into a lot of contact with the particular group at risk, you should adjust your life decisions exactly zero.

Zeynep Tufekci is similarly frustrated.

I strongly agree that the ‘don’t panic’ messaging isn’t helping. Anyone who responds to an official ‘don’t panic’ by reducing their propensity to panic is not doing a good job updating on information. There are less such people every day.

I still don’t see how decisive early action is good enough. Could we have slowed things down? Sure, absolutely. Stop it entirely? I don’t see how.

Kai Kupferschmidt is also understandably frustrated.

The core problem seems to be that public health officials believe (correctly or otherwise) that you can either send the message that this is an STD impacting the MSM community or you can say it is something everyone can get, but you cannot do both – the public simply cannot handle, in the minds of those in charge of official communication, the idea that this mostly spreads one way but can also spread in another, and also there’s worry about stigmatization.

I would be surprised if this was mostly anything other than a fake problem. People can totally understand all of this, and also people mostly do understand most of this. And I am guessing they are mostly doing reasonable things in response, except for a few who are needlessly freaking out the same way they are constantly needlessly freaking out. Can’t be helped.

Chise information thread on the monkeypox vaccine.

Final Note: If you’re quick there may be some value at Manifold Markets. First come, first serve.

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Caitlin Rivers proposes three metrics to measure our progress: Number of individuals tested, proportion of cases coming from known contacts (or, at least, where we can point to a known contact, since you can never know for sure), and days from symptom onset to isolation.

That third one seems like it should be pretty close to zero already. Either you have pox on your skin or you don’t.

I think it's a littlemore complicated than that. MPX lesions in this outbreak are sometimes solitary, and in hard-to-see places like the inside of the mouth or bottom of the penis. This is what they might look like:

They are reputedly painful prior to scabbing, then itchy until the scabs fall off.

It therefore seems possible in this outbreak that the average time between a person becoming infectious and realizing they have symptoms of MPX is significant. Perhaps this isn't quite asymptomatic spread, but it would be sufficiently "low-symptomatic" spread to have a similar effect. I'd emphasize that this just a hypothesis, based on extrapolating from some reports from previous outbreaks of asymptomatic spread and current reports of having just one lesion in the mouth or on the genitals.

People can totally understand all of this, and also people mostly do understand most of this

On the other hand, the very fact that we say Monkeypox is spreading within the community of Men having Sex with Men is symbolic of the problem, to me. Being MSM and being in this monkeypox-spreading community is very correlated sure, but not synonymous, the cluster we're talking about is more specific: It's the cluster of people participating in orgies, have sex with other strangers several times a week, etc.

Seeing how we're still conflating the two in discussions I've seen, I can understand the worries that this will reflect on the non-straight community, though I do agree that this messaging makes little sense.


people mostly do understand most of this

I know four people who went to a sex-positive/kind of orgy event recently, this did not seem to be a concern to them (neither to the event itself, its safety consideration only included COVID). I also know someone who still had hookups two-three weeks ago.

It seems like the warning against monkeypox may be failing in the very community we're talking about.


Also, I wouldn’t ban orgies, that won’t work

I'm not sure on that point anymore. Monkeypox' spread seems so slow, and the fact that only men gets infected while the proportions of women who have sex with men having sex with men is not that narrow. I wonder if the spread of Monkeypox is not mostly driven by orgies/big events at the moment, and if it's not the best moment to do this. Though it might be a bit too late now, I think it'd have worked two-four weeks ago)