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David R. Kotok

We thank readers for their emails about monkeypox. We have, of course, been keeping an eye on its spread, its characteristics, and its potential for causing disruption. Monkeypox will not be a Covid-style pandemic, if it becomes a pandemic. For starters, Covid spreads by respiratory transmission, while monkeypox transmission is very different. But monkey is now circulating in most of the US, and you can get it. What follows is a whirlwind tour, with links, to what we know.
The WHO has declared monkeypox a public health emergency, out of concern over its rapid spread and changing characteristics.
“WHO declares rapidly spreading monkeypox outbreak a global health emergency,”
Surveillance, though far from adequate, indicates rapidly rising case numbers: “Globally, data sources indicate there are about 17,350 MPXV patients in over eighty countries, led by Spain and the USA, with 2,891. And in New York City, 839 people have been infected between late May and July 22, 2022.”
“Monkeypox Outbreak Declared Health Emergency of International Concern,”
The epidemiological curve, courtesy of Our World in Data, looks like this:


As of this writing, only three US states — Montana, Wyoming, and Vermont — have yet to report cases. That state of affairs may have changed by the time of publication. New York has seen the largest outbreak, followed by California and Florida. Here’s where to find the confirmed case count for every state:
“2022 U.S. Map & Case Count,”
See also, “Florida has nearly 10% of all monkeypox cases [in the US],”
It’s worth noting that, because of insufficient testing, the US lacks a clear picture of the scope of monkeypox’s spread. That limitation of our decentralized healthcare system is, by now, a familiar theme.
“Monkeypox Testing Shows the U.S. Learned Little from the COVID-19 Pandemic,”
This article for clinicians details monkeypox history, pathology, symptoms, diagnosis, and strategies for prevention and symptomatic treatment. It is also quite accessible for general readers.
“Monkeypox in 2022—What Clinicians Need to Know,”
The symptoms of monkeypox and the progression of the illness have been changing. Here’s a rundown on symptoms to watch for:
“CDC issues new guidance on monkeypox symptoms as U.S. cases balloon,”
The new guidance can be found here:
The CDC warns against transmission via fomites, noting: “Close contact, sustained skin-to-skin contact including sexual contact, with a person with monkeypox or contact with contaminated fomites (e.g., shared linens) are the most significant risk factors associated with human-to-human transmission of Monkeypox virus.”
There is, in fact, nothing that says that the virus is limited to spreading among men who have sex with men. That’s the community where it has become established and one where behaviors readily facilitate its spread, but the virus is capable of transmitting in other communities, too, and through less intimate contact.
“Monkeypox could spread well beyond communities of gay and bisexual men, WHO says,
In keeping with that point, the US has already begun to see pediatric cases. Kids are the last people we want to see infected with monkeypox because they are most vulnerable to serious illness.
“Two children diagnosed with monkeypox in U.S., officials say,”
Means of transmission are multiple. High viral loads of monkeypox have been detected in saliva, skin lesions, semen, feces, and urine.
“Frequent detection of monkeypox virus DNA in saliva, semen, and other clinical samples from 12 patients, Barcelona, Spain, May to June,” 2022,
The illness lasts 2–4 weeks. Needless to say, that’s not a short time frame for an infected person to have to isolate (and miss school or work). The fact that most monkeypox infections are “mild” doesn’t mean that the illness is not an intensely miserable experience for many. How miserable? The reports should give anyone pause.
In a Twitter thread, Dr. Lisa Iannattone, Assistant Professor of Dermatology at the University of Montreal Medical School, discusses the pain levels that monkeypox patients are experiencing, citing a 28-year-old’s description of what it felt like when the rash developed into boils.

A large, peer-reviewed study of more than 500 people infected with monkeypox in 22 countries found a median incubation period of seven days. Initial symptoms included fever, fatigue, muscle pain, and headache. Fully 13% of these confirmed cases were hospitalized for pain, superinfections, eye lesions (which can lead to blindness), myocarditis, or infection control. No one in this study died.
“Monkeypox Virus Infection in Humans across 16 Countries — April–June 2022,”
Those of us who are old enough remember our smallpox vaccinations and the sore that resulted. We still sport our faded scars. Those old smallpox vaccinations still offer a measure of protection against monkeypox because it is a virus closely related to smallpox. Besides the old smallpox vaccine, there’s a safer attenuated vaccine now called Jynneos. Katelyn Jetelina offers us a monkeypox vaccine primer:
“Monkeypox Vaccine 101,”
The challenge, of course, is ramping up vaccine supply and deploying strategically what we have, to vaccinate men who have sex with men and others who may be vulnerable, along with those who have been exposed to monkeypox (a strategy called ring vaccination).
“Monkeypox epidemic control hinging on scarce vaccines,”
“Ring Vaccination Beat Smallpox. Could It Work for Monkeypox?”
A person who is exposed to monkeypox has a four-day window to get vaccinated and thereby possibly prevent infection. Vaccination that falls a few days outside that window may still help to reduce the severity of a case.
“How to Get Vaccinated, Tested and Treated for Monkeypox,”
Will the spread of monkeypox in the general population be as rapid as the spread of monkeypox in the MSM community? Possibly not. The virus has found its way into sexually active networks that facilitate its spread through intimate contact.
“Why the monkeypox outbreak is mostly affecting men who have sex with men,” (Here’s the study referenced in the article: “Heavy-tailed sexual contact networks and the epidemiology of monkeypox outbreak in non-endemic regions, May 2022,”
Monkeypox was a hazard that the world ignored as long as the virus was endemic only in Africa. It is long past the ideal time to deal with this disease threat. We might do well to note that there is a strain of monkeypox in Central Africa that has a case fatality rate of 10%. Complacency is not in order.
“Monkeypox in Africa: the science the world ignored,”
“Monkeypox emergency could last months, with window closing to stop spread, experts say,”
In the US, Covid-19 Response Coordinator Dr. Ashish Jha outlined at a July 26 press conference, the Biden administration’s plan for addressing monkeypox, naming “four pillars” that define the strategy: (1) scaling up vaccines, (2) expanding testing, (3) expanding access to treatments, and (4) outreach to affected communities. At the time this is written, the White House is also considering whether to declare a public health emergency.
“Press Briefing by Press Secretary Karine Jean-Pierre and Covid-19 Response Coordinator Dr. Ashish Jha” (July 25, 2022),
“Biden administration considering a public health emergency for monkeypox as cases swell,”
As the US vows to fight monkeypox, it is no comfort that monkeypox is being found in sewerage where testing is being done. This comes as no surprise, of course. So far, however, it is just bits of viral DNA that are being detected, not whole, infectious virus. This is a key distinction since rats live in sewers and rodents are carriers of monkeypox in Africa. We do not want the virus to spill over into animal populations.
“Monkeypox is spreading in the Bay Area. Stanford wastewater data shows the region's hot spots,”
“What You Need to Know About Monkeypox,”
For its part, China is asking travelers who have been exposed to monkeypox to declare their exposure to customs and is stepping up sanitation measures for goods and means of transport that enter China in hopes of keeping monkeypox out of the country.
“China steps up monkeypox procedures, calling on travellers to announce contact with cases,”
In Europe, EU Health Commissioner Stella Kyriakides is urging European countries to step up efforts to identify and report cases and prevent the spread of monkeypox. The European Commission is purchasing 160,000 doses of vaccines and planning to purchase more, plus an antiviral.
“EU Health Commissioner Urges Reinforced Monkeypox Action,”
We’ll close with a resource that can keep us all current, whether today or months from now. The Monkeypox Resource Center maintained by the Center for Infectious Disease Research and Policy (CIDRAP) offers both basic and in-depth information about monkeypox, including current news, at
How disruptive a problem will monkeypox become? That’s hard to say. We have something of a choice in the matter, depending on how seriously we take the virus now and what we do as a country. We don’t want to see monkeypox-driven disruptions in workplaces or schools. We don’t want to have to hole up for 2–4 weeks with a painful case of monkeypox, either. Though the risk to the general public remains low for the moment, now is precisely the time for action.
In the July 28 edition of Your Local Epidemiologist, Katelyn Jetelina outlines on how the monkeypox situation differs from Covid and how it is similar. See “COVID-19 and Monkeypox: Similarities and differences,” She concludes,
We cannot give up; we have to do all we can to contain this before it establishes itself as another health risk.
Are we tired of this revolving door of panic and neglect yet?

David R. Kotok
Chairman & Chief Investment Officer
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