The two most important questions concerning the ongoing international monkeypox outbreak.
According to international data, since early May about 1000 confirmed and suspected cases of monkeypox have been reported in several Western countries. There is still significant uncertainty about the full extent of the current outbreak as the incubation period of monkeypox (time from infection until first symptoms) can be up to three weeks.
So far, the ongoing monkeypox outbreak has affected almost only homosexual men, and many of the recent infections could be traced back to two large gay festivals: the Gran Canaria pride festival – held from May 5 to May 15 and attended by about 80,000 people – and the Belgian Darklands Festival. Subsequent infections occurred in a gay sauna in Madrid and similar locations.
There are two main hypotheses to explain this peculiar pattern. Either there was a natural outbreak at one or more of these gay festivals, likely caused by one or more participants from west Africa (where monkeypox is endemic); or one or more of these gay festivals were targeted by an engineered, covert bioterrorism attack.
In the second scenario, the attack might later be blamed on a supposed terrorist group that “hates homosexuals and the Western lifestyle”, such as an Islamist terrorist group (possibly linked to Iran) or a Christian fundamentalist terrorist group (possibly linked to Orthodox Russia, such as the suspect “Russian Imperial Movement”), or on conservative Western “domestic terrorists”.
In fact, such a state-sponsored monkeypox bioterrorist attack was simulated just one year ago, in March 2021, by the NATO-linked Munich Security Conference and the US-based Nuclear Threat Initiative (see report). This 2021 US/NATO exercise assumed a monkeypox outbreak in May 2022 that would develop into a full-blown pandemic and that would be revealed only one year later, in May 2023, as a terrorist operation using genetically modified monkeypox virus.
Pandemic strategist Bill Gates has repeatedly warned of a potential smallpox bioterrorist attack, most recently during a talk in November 2021. Back in October 2019, shortly before – or in parallel to – the outbreak of the coronavirus pandemic, the Gates Foundation and Johns Hopkins University had already simulated a SARS-like coronavirus pandemic. And just last week, a G7 meeting in Germany ran a simulation of a smallpox-like pandemic that had been planned “several months ago”. However, it is true that the pandemic potential of monkeypox has been known for decades.
To evaluate the current real-world monkeypox outbreak, two questions are of paramount importance:
- First, what is the exact nature of the around 50 nucleotide mutations that have caused about 25 amino acid substitutions in the current monkeypox strain (compared to the last known ancestor)? Expert virologists have already acknowledged that the number of mutations is “far more than one would expect considering the estimated substitution rate for orthopoxviruses.”
- Second, what are the primary modes of transmission of this virus strain?
Concerning the first question, it is already known that the current monkeypox strain is closest to a 2018 strain isolated either in Israel or in the UK; both of these strains go back to a 2017 monkeypox outbreak in Nigeria. Do the additional mutations increase transmission in any way? Are these mutations natural or artificial?
In the case of SARS-CoV-2, a very small and most likely lab-engineered genetic insertion dramatically increased transmission and enabled the recent coronavirus pandemic. Both the United States and China have been performing such high-risk coronavirus genetic insertions.
Concerning the second question, the key issue is whether there is any significant human-to-human aerosol transmission. If not, then the current outbreak may remain limited to the original homosexual clusters and may be stopped through contact tracing and quarantining. But if there is widespread human-to-human aerosol transmission, then all bets are off.
Importantly, neither monkeypox nor smallpox have ever been shown to be sexually transmitted diseases. Yet close contact during sexual intercourse can greatly increase the risk of transmission, especially if there are ulcers or skin lesions. There is preliminary evidence that homosexual men affected by the current outbreak show primarily genital and oral ulcers, which would indicate such a quasi-sexual mode of transmission by skin-to-skin contact (see photo).
However, contrary to claims by most health authorities, the historic evidence strongly suggests that the main mode of transmission of smallpox was neither “droplets” nor direct or indirect skin-to-skin contact, but close-range respiratory aerosols. Furthermore, the fact that monkeypox has not yet achieved efficient human-to-human transmission (unlike smallpox) is almost certainly due to the fact that monkeypox has not yet achieved efficient aerosol transmission in humans.
If natural or artificial genetic mutations increase human-to-human aerosol transmission, this could greatly enhance the epidemic and pandemic potential of monkeypox. While it is true that there are several non-classified studies that mention “aerosolized monkeypox virus”, these studies refer to artificial aerosol lab experiments, not to genetic virus engineering to achieve aerosolization.
Both the United Kingdom and the United Arab Emirates recently appear to have detected individual monkeypox cases in travelers from Nigeria without any link to the European gay festivals. This might indicate that there is an ongoing, still unreported monkeypox outbreak in west Africa that may have served as the source of the current multi-country outbreak (as it did in 2017/2018).
On the positive side, it is believed that smallpox and monkeypox are transmitted only by symptomatic individuals (unlike influenza and covid); on the negative side, infectiousness of smallpox/monkeypox patients can last several weeks. If the monkeypox virus should spill back to rodents in Europe or North America, the situation would become even more complex.
In terms of fatality rates, many media outlets have shared greatly exaggerated figures of up to 10% based on a single outdated and incomplete survey from the Congo. Yet if immuno-compromised individuals are excluded, the actual infection fatality rate in central and western Africa is about 1%, and it is likely to be a fraction of 1% in Western countries.
For instance, during the well-known 2003 outbreak in the US – without human-to-human transmission – about 50 people were infected but nobody died. Nevertheless, monkeypox is certainly not a trivial disease, and novel mutations may increase or decrease disease severity. In smallpox, death typically occurred through viral immune suppression and cytopathic effects.
Concerning vaccine protection, there are claims that prior smallpox vaccination, which in most Western countries was performed until the early or late 1970s, offers about 80% protection against monkeypox infection. Yet this figure is again based on a single outdated study from the Congo. A study of the 2003 US outbreak found no significant vaccine protection, and novel mutations could further reduce vaccine protection (as was the case in the above-mentioned NATO exercise).
Concerning a potential engineered bioterrorism event, the best known precedent are the 2001 US anthrax letter attacks, which were closely linked, in multiple ways, to the September 11 operation. The US media and the US government initially tried to blame the anthrax letters on “Al Qaeda” and Iraq (based on various false claims), but they were caught off-guard when a leading private lab, using recently developed genomic sequencing technology, could show that the anthrax strain originated from a US military lab or from one of its military-intelligence contractors.
More recently, genetic analysis showed that both the 2009 swine flu strain and the SARS-2 coronavirus were almost certainly lab-engineered. The 2003 SARS-1 outbreak likely had a natural origin (and didn’t cause a pandemic), but the SARS-1 virus later leaked from multiple biolabs in Asia. The 1977 flu pandemic is known to have emerged from Soviet vaccine research. In 1978, there was a smallpox lab leak in the UK that caused one death.
In conclusion, preliminary evidence indicates that the ongoing monkeypox outbreak may be either a natural or an engineered event, and it may remain limited to existing homosexual clusters or spill over into the general population. To further evaluate the outbreak, the role of the 50 nucleotide mutations and potential human-to-human aerosol transmission must be determined.
Outbreak: By mid-July, there were already more than 10,000 confirmed monkeypox cases outside of Africa. In most countries, the outbreak is still growing, although in some European countries the growth rate is slowing down, while other countries are seeing new outbreaks. In Madrid alone, there are already more than 1,000 confirmed monkeypox cases.
Homosexual men: Homosexual men continue to account for 99% of confirmed monkeypox cases, but there are also some confirmed cases in other close contacts and even in children. It is possible that cases in non-homosexuals are being missed due to current testing guidelines.
Mutations: Portuguese researchers have confirmed that the current monkeypox strain has about 50 new mutations compared to the 2017/18 strains, which is about ten times more than expected, and that some of these mutations seem to increase transmissibility. The researchers believe that the new mutations, which follow a very specific genetic pattern, could be due to the adaptation of the virus to the human host, driven by the so-called APOBEC host enzyme.
Mutations II: The APOBEC-driven mutation pattern was first observed in some Nigerian monkeypox cases in 2017. It is possible that such mutations emerged in patients that were being treated with HIV drugs, or during HIV hypermutation drug trials. A monkeypox virus strain closely related to the current strain was already detected in November 2021 in Maryland (USA) in someone who had returned from Nigeria, but there were no known secondary infections at the time.
Sexual and asymptomatic transmission: Italian researchers found infectious monkeypox virus in semen, even after acute monkeypox symptoms had already disappeared. Furthermore, Belgian researchers found evidence of asymptomatic anorectal monkeypox infection. This makes true sexual transmission and asymptomatic transmission rather likely. Studies describing monkeypox cases in Israel and Singapore in 2018/2019 already mentioned lesions on the patients’ penis.
Transmission via surfaces: German researchers found infectious monkeypox virus on surfaces in hospital rooms and especially in bathrooms used by monkeypox patients. This could indicate, but does not yet prove, the possibility of indirect transmission via surfaces.
Aerosol transmission: In June, the WHO mentioned the possibility of “short-range aerosol transmission”, but the importance of aerosol transmission remains uncertain. Overall, most of the transmission seems to occur not via aerosols, but via direct and sexual contact. Otherwise, infections would already have spread to the general population.
Lethality: So far, no monkeypox deaths outside of Africa have been reported, which indicates a very low fatality rate in the general population. However, it is possible that monkeypox may be more severe in children or in the elderly (depending on smallpox vaccine protection).
China: In early July, China introduced monkeypox PCR screening of all inbound travelers. In contrast, the WHO said European (gay) summer festivals should go ahead without restrictions, despite the fact that the current global outbreak can be traced back to two large European gay festivals in early May.
Natural outbreak or bioterrorism event? The earlier Maryland case in November 2021, which occurred in a traveler from Nigeria, may indicate a natural outbreak linked to West Africa. Nevertheless, the high mutation rate and the high transmission rate remain unexplained and could be linked to (HIV) drug treatment or research activity. In the case of the March 2021 monkeypox pandemic exercise described above, the bioterrorism context was revealed only one year after the original (fictitious) outbreak in May 2022.
Outlook: The current global monkeypox outbreak is unprecedented. It appears to be driven by highly mobile and sexually very active homosexual men, based primarily on sexual and close contact transmission. Concerning future developments, there are several possible scenarios:
1) The outbreak can be contained; 2) the outbreak cannot be contained, but remains mostly limited to homosexual men; 3) the outbreak can be contained in some countries, but not in others; 4) the outbreak cannot be contained and spills over into the general population; 5) the virus further increases its transmissibility, especially via aerosols.
However, even if the current global outbreak could be contained, a renewed outbreak in Western Africa seems rather likely and indeed only a matter of time.
Re-emergence of monkeypox in Nigeria in 2017 and sexual transmission
A paper published in November 2020 in the journal Viruses describes how monkeypox, after 39 years, re-emerged in Nigeria in 2017.
In a July 2022 interview with US media outlet NPR, Nigerian doctor Dimie Ogoina confirms that monkeypox suddenly re-appeared in Nigeria in 2017. Ogoina notes that unlike the old monkeypox, which affected mostly children in rural villages, the 2017 monkeypox affected mostly young men in large cities, and blisters occurred mostly around their genitals, indicating sexual transmission. Ogoina says he tried to inform health officials and researchers about the change in the mode of transmission, but they were not interested.
It was this strain of sexually transmissible monkeypox that spread to Europe and the rest of the world in the spring of 2022, apparently driven by several large gay festivals (see above).
The reemergence of a mutated and sexually transmissible monkeypox in Nigeria in 2017 may have been a natural evolutionary event, or it may have been linked to drug trials (e.g. HIV drug trials, see above). In late May 2022, the chief of the Russian Radiation, Chemical, and Biological Defense Troops, Igor Kirillov, suggested US-funded biolabs in Nigeria as a possible source.
In addition to the APOBEC mutation pattern described above, French geneticist Jean-Clause Perez in June 2022 highlighted a “peculiar 30-T base long sequence right in the middle of the virus genome”, the role of which “is still to be determined”.
In terms of outbreaks dynamics, most European countries are currently seeing a constant rate of weekly infections (i.e. a linear increase in total infections), whereas the United States and countries like Brazil are seeing an increasing rate of weekly infections (i.e. an accelerating outbreak). A few countries, such as Germany, appear to be seeing a decreasing rate of weekly infections.
99% of confirmed infections continue to be in mostly gay or bisexual men, strongly suggesting sexual transmission as the main mode of transmission (see above). By early August, there were over 20,000 confirmed cases and 5 deaths outside of African countries.
- What was the primary mode of smallpox transmission? (2012)
- MSC/NTI monkeypox pandemic exercise report (2021)
- Monkeypox outbreak global dashboard (Caramia)
- Monkeypox genomic epidemiology (NextStrain)
- Monkeypox mutations overview (GenSpectrum)
Monkeypox nucleotide and amino acid substitutions (2022 UK strain vs. 2018 UK strain).
“Human-to-Human Transmission”, ft. Dr. Anthony Fauci (2 min; source: Function Gain)