Where are the next pockets of monkeypox cases likely to be?

The nation now has a second infectious disease outbreak to deal with, monkeypox. Although quite different from COVID-19 in how it is transmitted, treated and managed, people continue to be befuddled with the risks and how to protect themselves.

To date, the United States has reported nearly 12,000 cases and rapidly increasing. New York, California, Florida, Georgia and Texas round out the top five among all states, collectively representing around 60 percent of all confirmed cases. The preponderance of monkeypox infections in the United States have occurred in gay and bisexual men. Yet, there is nothing that precludes the virus from spreading into the broader population.

The current trend in the United States is not representative of cases in Africa, where women account for 40 percent of the reported cases. Therefore, the risk of penetration into the broader population is real, with widespread dissemination plausible.

Anyone is susceptible to monkeypox, with it particularly harmful to pregnant women, the immunosuppressed and young children. The condition can be excruciatingly painful and uncomfortable for anyone until the flu-like symptoms resolve and the lesions heal.

The World Health Organization declared monkeypox a global health emergency in late July, as the virus has reached into areas where it is not endemic. The Biden administration followed suit and declared monkeypox a national public health emergency.

Risk management suggests that the limited stockpile of monkeypox vaccines must be targeted for those who are most vulnerable to infection and spreading the virus right now. Gay and bisexual men are at the top of this list and will remain there to dampen the exponential growth of new cases.

So where could the next pockets of monkeypox cases occur? 

College campuses: College campuses bring together millions of young adults, mostly young adults 18 to 24 years old. The college campus environment encourages student social interactions and close physical contact. Whatever the circumstances, college students naturally gather in close physical proximity to each other. This makes the college campus environment vulnerable to pockets of monkeypox infections.

Sex economy: Illegal and unregulated prostitution is a credible vector for spreading the virus to unsuspecting patrons. In contrast, Nevada, which highly regulates the trade by limiting such activity to licensed brothels, has more safeguards in place to identify cases early and limit the spread of the virus.

Sports teams: Certain professional, college and high school sports may be a fertile environment for spreading the virus if a rogue infection enters their locker rooms or playing fields. Wrestling appears to be most at risk, while football and rugby would be next in line, given the intense physical contact involved when practicing and participating in matches.

So, what can be done to curtail outbreaks in such environments?  

As more vaccine supply becomes available, these groups fit the risk profile for vaccination. Until supply ramps up, educating everyone on the risks and appropriate precautions is critical. Colleges are taking such actions as the fall semester begins.

Given that infected persons are contagious for a two to four weeks period while they have symptoms, testing is critical to prevent further virus transmission to others. Those infected should also isolate during this period, which would be highly disruptive for students and athletes.

Some will argue that the monkeypox threat is being overblown, much like how some believe COVID-19 has been. The upward trend in new cases suggests that if left untethered, many more new monkeypox infections are waiting to erupt in the gay and bisexual men community — and possibly beyond.

The most effective strategy to suppress this growth is expanding access to testing and widespread education now, as well as securing a sufficient number of monkeypox vaccines for the highest risk population, gay and bisexual men, and looking forward, other potentially high-risk populations noted here. The current vaccine stockpile falls woefully short to meet the existing and anticipated need.

Monkeypox has been considered rare in high-income countries. This is no longer the case. If a population allows unchecked transmission, then a rare condition can become common. Like any infectious disease, the rate that infected people transmit it to others determines whether it stays contained or spreads quickly and more broadly. This is epidemiology 101.

The future trajectory of monkeypox in the United States remains unknown. No crystal ball exists that can accurately forecast where it will move and who will be affected. Evidence of this is the recent monkeypox case in a daycare worker in central Illinois, which was responded to quickly and decisive. Unfortunately, such a response is not scalable if many more such cases simultaneously erupt across the nation. Limiting further spread must be a top priority for everyone.

Just like weather forecasting, the skies may be clear even when the forecast calls for stormy weather. It is during such early times that preparation is the best defense to avoid unnecessary suffering.

Sheldon H. Jacobson, Ph.D., is a founder professor of computer science at the Carle Illinois College of Medicine at the University of Illinois Urbana-Champaign. A data scientist, he applies his expertise in data-driven risk-based decision-making to evaluate and inform public health and public policy.