Monkeypox Post #2

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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10 Responses to Monkeypox Post #2

  1. A1987dM says:

    “This from CNN” etc. link is broken.

  2. John says:

    Playing devil’s advocate for a second: The population of MSM who attend orgies are overwhelmingly young and healthy, and I haven’t heard any reports of deaths in this country due to monkeypox or even hospitalizations. Not to say there won’t be some, but such outcomes seem relatively rare; the worse cases so far appear to be extremely painful and unpleasant but not life-threatening.

    If one is a young, healthy gay man that derives a lot of utility from attending orgies or having multiple, anonymous sex partners, and is willing to accept the relatively small risk they get infected and need to isolate for some weeks, is it really rational (from a self-interest perspective) to adjust their behavior at all? Vaccination seems like a no brainer and maybe one should wait until obtaining at least one dose of the vaccine. But for the people who attend orgies or have multiple, anonymous sex partners, I think these activities rate pretty high on their utility function.

    Implicit in the idea that you should reduce your sex partners is that it is a precaution one can take without much cost. And for most people that’s undoubtedly true. Most straight men couldn’t easily arrange an orgy even if they wanted to. But I think we are dealing here with a particular subpopulation of MSM here that considers this to be an extremely costly precaution because it involves them giving up things they enjoy a lot. I have the sense that this group regards the cure as worse than the disease, and I’m wondering if they’re really just being ignorant — or if it’s a rational response to the facts as they currently stand.

    • TheZvi says:

      Basic economics. If I am consuming X units of Y and you now add cost Z to each unit of Y (risk of infection) then I should consume somewhat less units of X now – might not be much lower, but it should presumably be lower.

      • Ariel says:

        Given the apparently low death rate of monkeypox (did anyone die of monkeypox outside of Africa?), and its currently low prelevance, I am quite sure that every gay orgy today has a much higher risk from non-monkeypox orgy-transmitted diseases than from monkeypox.

        Presumably some marginal orgy-goers would go to less orgies, but I’m not sure that anyone out of that subculture will notice.

      • John says:

        I’m with Ariel. Your point is true at the margin, but in a market, the vast majority of the transactions are inframarginal — raising the price of an LCD TV from $995 to $999 isn’t going to reduce demand much. I suspect we’re in such a scenario here. The men who have lots of sex are doing so notwithstanding the risks of HIV (which is actually life-threatening), herpes (which can be painful and long-lasting for many people), gonorrhea, syphilis, etc., etc. None of those health risks dissuaded them. So based on what we know, why should monkeypox really move the needle for them?

        I should also note, it’s not clear that the risks are additive. Some STDs do not manifest symptoms so people afflicted with them are unwitting spreaders for quite some time before they figure out that they’re carrying something. If monkeypox is normally symptomatic, it may operate as a big red “stop sign” that forces the most promiscuous to have a medical consult, which most doctors would use as an opportunity to administer a full STD screen, potentially resulting in finding and fixing other latent infections. I wouldn’t necessarily assume that this increases the overall prevalence of STDs circulating in the relevant subpopulation — admittedly, I’m speculating, but I certainly wouldn’t be surprised if overall STD rates, inclusive of monkeypox, go down a bit for a while, similar to what we saw with Covid and the flu.

        A broader point is that a lot of the reader comments on monkeypox stories in mainstream media basically criticize this subculture for continuing to have orgies, sex parties, whatever. It feels sort of analogous to the whole debate over masks, lockdowns, and other non-pharmaceutical interventions on Covid. Like, yes, orgies and sex parties increase the risk. But it’s not clear that the increased risks are large enough, or the disease itself harmful enough, that it exceeds the pleasure the relevant subpopulation derives from those activities. With monkeypox, of course, you have the added complication that a lot of people don’t see the underlying activities themselves — orgies or sex parties — as morally worthy in the first place. Even most MSM aren’t going to orgies very often. But if you accept the idea that men who go to orgies do so because they really enjoy it and it’s a lot of fun, then I’m not sure the risks from monkeypox are great enough that it makes to actually discourage them from doing what they enjoy doing. At most, maybe suggest they wait until they can get at least one vaccine dose so they can have their fun without fear of monkeypox.

    • keaswaran says:

      From all descriptions, it sounds like monkeypox is probably order-of-magnitude as bad as syphilis. It sounds like it’s a lot more painful than syphilis, but less likely to lead to long-term bad outcomes. Up until very recently, syphilis was more common than monkeypox, but it does sound like monkeypox is about to become more common. (~120,000 diagnosed cases of syphilis per year in the US, so probably ~300 per day, which monkeypox is just reaching.)

      So in terms of self-risk-per-orgy, monkeypox wasn’t actually a significantly bigger concern than the existing ones until very recently.

      However, the big question with monkeypox has been whether it is going to be contained, or is going to become another endemic STD. If a few months of collective action now could ensure that it is contained, then it’s absolutely worthwhile to do those few months of collective action, even if the risk to oneself of getting monkeypox isn’t worth the cost of giving up a hobby.

      • John says:

        The problem with this reasoning is that, as Zvi has pointed out many times, we’re not really willing to take the kind of coercive measures that would be necessary to stop the spread. We’ll adopt half-measures at best, and many people won’t follow them. And the chance that any one individual’s actions will make the difference in this becoming endemic or not is negligible, so I’m not sure a see a very rational argument that says, “You personally should not have lots of sex, even though you want to, because that could help us beat this thing.” It almost certainly won’t make the difference.

        If we wanted to make a really serious push for it not to become endemic, it seems realistically the only option would be to massively ramp up vaccination and testing. Honestly, have vaccination booths set up outside the raves, orgies, sex clubs, or whatever so the partygoers can get a quick shot on their way in or not. (I’ve read reports saying the vaccine can be administered for up to 4 days post-exposure and may prevent infection even after the fact like that — so doing it on site at high-risk activities might actually work fine.)

        But did we actually do anything to ramp up vaccination? Of course not. As per always, the FDA slow walked approval of the 1 million doses that were sitting around, and apparently the government is sleep walking into freeze drying like another 13 million doses rather than putting them into vials and distributing them. If taking steps to make this not be endemic isn’t a high enough priority for the FDA to get off its rear-end and approve some manufacturing facility, why should it be a high enough priority for men who enjoy having lots of sex to change their behavior?

      • lunashields says:

        At least monkeypox leaves immunity in it’s wake. You can get syphilis as many times as you feel like it. So it might burn out eventually

  3. Sebastian H says:

    We could have taken the steps to really tap down on monkey pox becoming endemic without being particularly forceful. There are only about 8 million gay men in the US. There are 100 million doses of the smallpox vaccine in storage. People in the gay community want the vaccine but can’t get it. Make it available (with vaccine booths at clubs) and it’s pretty much over. But that becomes less and less likely to work every week the FDA waits. Doing that in June would have absolutely been a game changer.

  4. AnonCo says:

    I read the entire article until it was explicitly defined with “MSM” as Mainstream Media.

    Changes the message, but also 100% works.

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