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
It seems to be another instance of failure of expertise, but maybe it’s wrong to classify him as an expert. His LinkedIn says he’s a program director and his skills are relationship management, change management, oversight, etc.
The real talk we need to have, regarding all current and future pandemics, is that none of them would be able to go from local problems to global ones were it not for the unprecedented speed that we are able to move around the planet. I'm not saying that we should stop flying completely, but it does need to be discussed openly and frankly. Those of us who don't travel all that much are often the ones who pay for these negative externalities, both financially and in terms of the adaptations we are forced to make to accommodate people who don't strictly need to be taking trips. No disease can become a hard to manage pandemic without assistance from cars, trains, ships and planes.
Now for a constructive solution. What we need is the ability to respond quickly and efficiently to the anticipated financial burden of local spread. We've heard a lot about wastewater surveillance. I suggest that we need big re-insurers (like Lloyd's and Swiss Re) to start offering parametric insurance policies to whoever wants them, based on wastewater surveillance. Obviously it will take careful work by actuaries, epidemiologists, etc - but it would clearly be the best way to get back to a normal-ish steady state.
Gorgias: Monkeypox is already endemic among the youth, just search for "second chickenpox" on Twitter!
Euthydemus: Oh, come now, Gorgias- a disease which sometimes requires opiods to manage the pain and has a non-negligible CFR is somehow in full stealth mode, and endemic throughout the nation's youth? Kids go to the pediatrician constantly. Surely one case would have been traced through contacts back to a daycare by now.
G: Ok, maybe not yet, but diseases closely related to monkeypox are most commonly an issue for children, that's likely to end up the vulnerable group here. All of the reported monkeypox fatalities in Africa from the 1970s to the 1990s were in children under 10 years old.
E: Different time, different variants. We have to respond to current conditions. In current conditions, looking across all the States, the mode of infections is literally one case. The median is still only a two digit number. Randomly distributing scarce tests throughout the country would be pouring them down the drain.
G: There were similar arguments for COVID tests...
E: Which is not to say those were wrong until we added more testing capacity. Res ipsa, more capacity gives you more options.
G: Fair, so long as we're increasing capacity. Focusing testing on MSM is still looking under the lamppost, and it would be good to move away from that sooner rather than later. Not completely, but we should prepare to shift to a mixed strategy as soon as possible. We need many more tests so we can randomly toss some small part into the wind. It's the only way to look for surprises.
G: Note though that testing will also be less critical for diseases with a visible clinical presentation. Monkeypox and chickenpox lesions don't look identical, and one is itchy and the other is tortuously painful. This isn't the covid problem of asymptomatic transmission.
G: A preprint. Three of 224 men receiving tests for something else were suddenly visited by researchers asking about monkeypox. They were probably nervous, and claimed they didn't know anything relevant about symptoms or close contacts. This doesn't tell us much? What's even the error rate for tests in this odd situation?
E: Well, ok, but from case testimonies it sounds like there's about a week of incubation. We know the lesions are the primary infectious route but don't fully understand spread through respiratory secretions. Asymptomatic spread isn't confirmed, but it's hard to believe there's much transmission from people poking other people's oozing painful lesions then licking their hands.
G: Ok, I will steel man this as "asymptomatic transmission is really just a stand-in for unwitting transmission, which encompasses transmission through mild cases, or transmission just at the beginning of symptom onset. This is really about how much natural behavioral adjustments are likely to impact transmission." On the optimistic side, if monkeypox hits a certain threshold, maybe people will at least postpone some of the riskiest behavior and this might be self-limiting.
E: Like it's never been in Africa? I am jealous of your optimism. When I look at Africa, I look at the variants. The Central Africa strains have a CFR around 10%! We really don't want this making it to zoonosis, even if it never posts numbers quite like covid. And we have done far more based on far less! Notably in 1947...
1947 and 1976 both saw a handful of deadly infectious cases in New York/New Jersey for influenza/smallpox. In 1947 they immediately vaccinated over 6 million people. In 1976 they hit a tenth of that using equal funding. Cost disease in everything? Are we really getting this much worse at public health responses over time?
Bonus -- Why do people in the background of this photo of Typhoid Mary look like they were drawn by AI?
I’m curious if you read the account of this man, who says his work focuses on sexual and reproductive health, who was aware of monkey pox, but nonetheless continued engaging in risky behavior and contracted monkey pox: https://www.theguardian.com/world/2022/jul/23/i-literally-screamed-out-loud-in-pain-my-two-weeks-of-monkeypox-hell
It seems to be another instance of failure of expertise, but maybe it’s wrong to classify him as an expert. His LinkedIn says he’s a program director and his skills are relationship management, change management, oversight, etc.
The real talk we need to have, regarding all current and future pandemics, is that none of them would be able to go from local problems to global ones were it not for the unprecedented speed that we are able to move around the planet. I'm not saying that we should stop flying completely, but it does need to be discussed openly and frankly. Those of us who don't travel all that much are often the ones who pay for these negative externalities, both financially and in terms of the adaptations we are forced to make to accommodate people who don't strictly need to be taking trips. No disease can become a hard to manage pandemic without assistance from cars, trains, ships and planes.
Now for a constructive solution. What we need is the ability to respond quickly and efficiently to the anticipated financial burden of local spread. We've heard a lot about wastewater surveillance. I suggest that we need big re-insurers (like Lloyd's and Swiss Re) to start offering parametric insurance policies to whoever wants them, based on wastewater surveillance. Obviously it will take careful work by actuaries, epidemiologists, etc - but it would clearly be the best way to get back to a normal-ish steady state.
As an Old, I also want someone to really research whether my smallpox vaccinations provide any protection or if they've completely worn off.
Gorgias: Monkeypox is already endemic among the youth, just search for "second chickenpox" on Twitter!
Euthydemus: Oh, come now, Gorgias- a disease which sometimes requires opiods to manage the pain and has a non-negligible CFR is somehow in full stealth mode, and endemic throughout the nation's youth? Kids go to the pediatrician constantly. Surely one case would have been traced through contacts back to a daycare by now.
G: Ok, maybe not yet, but diseases closely related to monkeypox are most commonly an issue for children, that's likely to end up the vulnerable group here. All of the reported monkeypox fatalities in Africa from the 1970s to the 1990s were in children under 10 years old.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8870502/
E: Different time, different variants. We have to respond to current conditions. In current conditions, looking across all the States, the mode of infections is literally one case. The median is still only a two digit number. Randomly distributing scarce tests throughout the country would be pouring them down the drain.
G: There were similar arguments for COVID tests...
E: Which is not to say those were wrong until we added more testing capacity. Res ipsa, more capacity gives you more options.
G: Fair, so long as we're increasing capacity. Focusing testing on MSM is still looking under the lamppost, and it would be good to move away from that sooner rather than later. Not completely, but we should prepare to shift to a mixed strategy as soon as possible. We need many more tests so we can randomly toss some small part into the wind. It's the only way to look for surprises.
G: Note though that testing will also be less critical for diseases with a visible clinical presentation. Monkeypox and chickenpox lesions don't look identical, and one is itchy and the other is tortuously painful. This isn't the covid problem of asymptomatic transmission.
E: Well, there is this preprint...
https://www.medrxiv.org/content/10.1101/2022.07.04.22277226v1
G: A preprint. Three of 224 men receiving tests for something else were suddenly visited by researchers asking about monkeypox. They were probably nervous, and claimed they didn't know anything relevant about symptoms or close contacts. This doesn't tell us much? What's even the error rate for tests in this odd situation?
E: Well, ok, but from case testimonies it sounds like there's about a week of incubation. We know the lesions are the primary infectious route but don't fully understand spread through respiratory secretions. Asymptomatic spread isn't confirmed, but it's hard to believe there's much transmission from people poking other people's oozing painful lesions then licking their hands.
G: Ok, I will steel man this as "asymptomatic transmission is really just a stand-in for unwitting transmission, which encompasses transmission through mild cases, or transmission just at the beginning of symptom onset. This is really about how much natural behavioral adjustments are likely to impact transmission." On the optimistic side, if monkeypox hits a certain threshold, maybe people will at least postpone some of the riskiest behavior and this might be self-limiting.
E: Like it's never been in Africa? I am jealous of your optimism. When I look at Africa, I look at the variants. The Central Africa strains have a CFR around 10%! We really don't want this making it to zoonosis, even if it never posts numbers quite like covid. And we have done far more based on far less! Notably in 1947...
https://link.springer.com/article/10.1007/s10900-015-0020-6
* * * *
Ok, goofy dialogues aside, I absolutely recommend that last link about state capacity and epidemics.
https://link.springer.com/article/10.1007/s10900-015-0020-6
1947 and 1976 both saw a handful of deadly infectious cases in New York/New Jersey for influenza/smallpox. In 1947 they immediately vaccinated over 6 million people. In 1976 they hit a tenth of that using equal funding. Cost disease in everything? Are we really getting this much worse at public health responses over time?
Bonus -- Why do people in the background of this photo of Typhoid Mary look like they were drawn by AI?
https://en.wikipedia.org/wiki/Mary_Mallon#/media/File:Mary_Mallon_in_hospital.jpg