tag:theconversation.com,2011:/us/topics/smallpox-19144/articlesSmallpox – The Conversation2024-02-21T13:17:46Ztag:theconversation.com,2011:article/2234702024-02-21T13:17:46Z2024-02-21T13:17:46ZWhat is Alaskapox? A microbiologist explains the recently discovered virus that just claimed its first fatality<figure><img src="https://images.theconversation.com/files/575275/original/file-20240211-16-m5e8r4.jpg?ixlib=rb-1.1.0&rect=29%2C32%2C993%2C617&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Red-backed voles may be harboring Alaskapox.</span> <span class="attribution"><a class="source" href="https://ecuador.inaturalist.org/">iNaturalist Ecuador</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p><em>Alaskapox, a virus in the same family as smallpox, cowpox and mpox, <a href="https://abcnews.go.com/Health/wireStory/alaskapox-recent-death-brings-attention-virus-small-animals-107207953">claimed its first fatality</a> in January 2024 when an elderly Alaskan man died of the illness.</em></p>
<p><em>The virus, which was discovered in 2015, had previously resulted in only relatively mild illnesses in the six other people infected by it. So why did the Alaskan man die?</em></p>
<p><em>Raúl Rivas González, a microbiologist at the University of Salamanca in Spain, explains what we know about Alaskapox, what happened to the man in Alaska, and the threat posed by the thousands of similar viruses out there.</em></p>
<h2>What’s the origin of Alaskapox?</h2>
<p>Alaskapox is an orthopox virus <a href="https://doi.org/10.1093%2Fcid%2Fcix219">discovered in 2015</a> in the Fairbanks area of Alaska. </p>
<p>Until the most recent case, there were only six known human infections, which all involved mild illnesses consisting of a localized rash and the swelling of lymph nodes. </p>
<h2>How did the man in Alaska die?</h2>
<p>In mid-September 2023, the man was living on the Kenai Peninsula, south of the city of Anchorage, Alaska, and <a href="https://abcnews.go.com/Health/wireStory/alaskapox-recent-death-brings-attention-virus-small-animals-107207953">undergoing drug treatment for cancer</a>, and so had a suppressed immune system. He noticed a tender red papule – a type of skin lesion – in his right armpit.</p>
<p>Understandably, he was scared and decided to go to the doctor immediately. Over the next six weeks, he made several visits to the primary care center and the local emergency department for clinical evaluation of the lesion.</p>
<p>The case was confusing and the possible infection difficult to identify. He did not respond to antibiotic treatment. A needle biopsy revealed no evidence of malignancy or bacterial infection. The health care providers were puzzled. </p>
<p>After the situation worsened, the man was hospitalized in Anchorage. Eventually, doctors performed an extensive battery of tests and sent a sample to the Centers for Disease Control and Prevention, which determined he had <a href="http://www.doi.org/10.3390/v11080708">Alaskapox</a>.</p>
<p>He was immediately given treatment for the virus, but it was too late and he died at the end of January. Officials <a href="https://epi.alaska.gov/bulletins/docs/b2024_02.pdf">confirmed the cause of death</a> was Alaskapox in February.</p>
<h2>Where do viruses like Alaskapox come from?</h2>
<p>Currently, more than <a href="https://doi.org/10.1128%2Fjcm.00337-22">10,000 species of viruses</a> have been recognized by the International Committee on Taxonomy of Viruses. We know that about 270 of them can infect people. </p>
<p>Some of these viruses have been known for centuries, such as polio and smallpox, while others like Alaskapox have only recently emerged. In fact, viruses constitute about <a href="https://doi.org/10.1098%2Frstb.2011.0354">two-thirds of all new human pathogens</a>. These new viruses differ widely in their risk to human health, ranging from the rare and mild illness caused by the Menangle virus to the <a href="https://covid.cdc.gov/covid-data-tracker/#datatracker-home">devastating public health impact</a> of the virus that causes COVID-19. </p>
<p>Of the viruses known to infect humans, about 80% are naturally occurring in nonhuman hosts, primarily <a href="https://doi.org/10.1016%2Fj.scitotenv.2020.142372">in mammals and birds</a> and, to a lesser extent, in arthropods and other wildlife. </p>
<p>Infectious agents transmitted from animals to humans are estimated to constitute about 60% of known human pathogens and up to <a href="https://doi.org/10.1073/pnas.1919176117">75% of emerging human pathogens</a>. Unfortunately, there is insufficient knowledge about wild animals that may harbor thousands of unknown virus species that could be human pathogens. </p>
<p>The evidence so far indicates that the Alaskapox virus is present in several species of <a href="https://doi.org/10.1093%2Fcid%2Fcix219">small mammals</a>, most notably shrews and the red-backed vole. In other words, Alaskapox is a new example of an infectious disease that can make the leap from animals to humans, a process known as zoonosis. Although available data suggests that the public health impact of Alaskapox virus is limited, it is likely widespread in small mammal populations in Alaska, and other infections in people may not have been diagnosed. </p>
<p>At present, no person-to-person transmission of Alaskapox has been documented. However, because some types of orthopoxviruses can be transmitted by direct contact with skin lesions, it is recommended that people with wounds that are suspected to be caused by Alaskapox keep the affected area covered with a bandage.</p>
<h2>What other orthopoxviruses pose a risk?</h2>
<p>In addition to Alaskapox virus, some other orthopoxviruses have recently been recognized, such as Akhmeta virus and/or Abatino virus, that highlight the possibility of unknown members of this genus with <a href="https://doi.org/10.1056%2FNEJMoa1407647">zoonotic potential</a>. </p>
<p>Other orthopoxviruses with zoonotic potential, such as mpox virus and cowpox virus, are increasingly being reported as a cause of human disease. In fact, the ongoing mpox outbreak that started in May 2022 has resulted in more than <a href="https://www.cdc.gov/poxvirus/mpox/response/2022/index.html">93,000 cases and 177 deaths</a>. This situation may have been facilitated by the discontinuation of routine vaccination against the eradicated human smallpox, as this vaccine gave rise to <a href="https://doi.org/10.1038/s41392-023-01574-6">some degree of population immunity</a> against other orthopoxviruses.</p>
<p>In addition to the above, there are many other orthopoxviruses that infect mammals. Examples are the ectromelia virus that causes mousepox, camelpox, raccoonpox, gerbilpox and skunkpox or some sublineages of vaccinia virus such as rabbitpox and buffalopox. </p>
<p>Poxviruses infect a broad spectrum of hosts, including insects, birds, reptiles and mammals. The wide host range, the wide geographical distribution and the constant global emergence of zoonotic viruses, including new orthopoxviruses, pose a global health threat that requires close monitoring and appropriate preventive measures. </p>
<p>In this situation, I believe the most prudent course of action is to urgently adopt a <a href="https://www.cdc.gov/onehealth/basics/index.html">One Health approach</a> that recognizes that the health of humans, animals, plants and the wider environment are interconnected, and accept that we cannot address human health without also addressing animal and environmental health.</p><img src="https://counter.theconversation.com/content/223470/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Raúl Rivas González does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Alaskapox was discovered in 2015 and has generally only caused mild illness – until now.Raúl Rivas González, Catedrático de Microbiología. Miembro de la Sociedad Española de Microbiología., Universidad de SalamancaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2186712023-12-18T16:17:17Z2023-12-18T16:17:17ZVictorian Britain had its own anti-vaxxers – and they helped bring down a government<figure><img src="https://images.theconversation.com/files/565425/original/file-20231213-31-19s6sa.jpg?ixlib=rb-1.1.0&rect=11%2C5%2C3663%2C2886&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://wellcomecollection.org/works/tr7x4acf/images?id=chsz86gd">E.E. Hillemacher/Wellcome Collection</a></span></figcaption></figure><p>As the 1906 UK general election results <a href="https://www.theguardian.com/politics/1906/jan/15/electionspast.past">rolled in</a>, it became clear that the Conservative party, after 11 years in power, had suffered one of the most disastrous defeats in its history. Of 402 Conservative MPs, 251 lost their seats, including <a href="https://www.gov.uk/government/history/past-prime-ministers/arthur-james-balfour">their candidate for prime minister</a>, defeated on a 22.5% swing against him in the constituency he had held for two decades. </p>
<p>Rising food prices, unpopular taxes and an opposition that promised to spend heavily on an expanded welfare state all contributed to the <a href="https://liberalhistory.org.uk/history/1906-election/">Tory downfall that year</a>. But something else had tipped the opposition Liberal landslide over the edge – compulsory vaccination. </p>
<p>Anti-vaccination campaigner <a href="https://www.bmj.com/content/1/2374/1566.1">Arnold Lupton</a> had taken Sleaford in Lincolnshire for the Liberals on a 12% swing and immediately started his parliamentary campaign to abolish compulsory vaccination against smallpox, a public health policy that had been in place in England and Wales since 1853 (with Scottish and Irish legislation following suit in later years). </p>
<p>Hardly a single Conservative MP was an anti-vaccinator, but 174 of the 397 Liberal MPs in the new parliament signed Lupton’s petition. </p>
<p>Their attempt at changing the law was unsuccessful, but this flexing of parliamentary muscle by the anti-vaccinators persuaded the new Liberal government that the most expedient option was to reach a compromise with its backbench rebels.</p>
<p>In 1907, the law was changed to permit quick and easy opt-out by parents. Vaccination of all babies against smallpox remained theoretically compulsory until 1946, but in practice, it was now optional. A five-decade-long campaign, in the streets, the courts and finally parliament, had resulted in victory for the opponents of vaccination.</p>
<p>This is a sobering story for those of us who are researchers, medical professionals or public health activists campaigning against the spread of vaccine hesitancy in the modern world. </p>
<p>The success of vaccination in saving millions of lives, not just from <a href="https://theconversation.com/eradicating-smallpox-the-global-vaccination-push-that-brought-the-world-arm-to-arm-162091">smallpox</a> but a host of other diseases, seems so obvious that the case scarcely needs to be made. And yet it does, as just a cursory glance at social, <a href="https://www.theguardian.com/media/2023/may/09/gb-news-censured-after-naomi-wolf-compared-covid-jab-to-mass-murder">even at times mainstream</a>, media will reveal. </p>
<p>In response to this tide of dangerous disinformation, vaccine advocacy work often focuses on issues such as the lack of <a href="https://www.cidrap.umn.edu/lack-high-school-education-predicts-vaccine-hesitancy">public comprehension of scientific concepts</a> of “relative risk” and “efficacy”, and the connections of the anti-vaccine activists to more general conspiracy theories and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9111101/">extreme religious</a> or <a href="https://researchonline.lshtm.ac.uk/id/eprint/4670453/1/Alarcon-etal-2023-The-far-right-and-anti.pdf">political movements</a>. </p>
<p>The conclusion of many vaccine advocacy pieces is often that we must simply educate the public better while simultaneously cutting the flow of disinformation, yet this has often proved to be an uphill struggle. Why? Can vaccine advocates learn anything from the historic defeat of 1906?</p>
<h2>Social media of the Victorian era</h2>
<p>A recently published resource of Victorian anti-vaccination <a href="https://academic.oup.com/dsh/advance-article/doi/10.1093/llc/fqad075/7330453">“street literature”</a> seeks to contribute to this effort by providing free access to 3.5 million words from 133 documents, ranging from short pamphlets to longer publications over the period 1854-1906.</p>
<p>What the 133 sources have in common is that they were all produced for public consumption, designed to strengthen or maintain the beliefs of the converted while reaching out for new converts. Existing outside the conventional publishing industry, this street literature was the social media of the Victorian era.</p>
<figure class="align-center ">
<img alt="Etching of children being vaccinated in East London in a crowded, chaotic room." src="https://images.theconversation.com/files/565150/original/file-20231212-25-cw1fnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565150/original/file-20231212-25-cw1fnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=466&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565150/original/file-20231212-25-cw1fnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=466&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565150/original/file-20231212-25-cw1fnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=466&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565150/original/file-20231212-25-cw1fnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=586&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565150/original/file-20231212-25-cw1fnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=586&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565150/original/file-20231212-25-cw1fnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=586&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children being vaccinated in East London.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/fmrb5a8p/images?id=dnmduxyq">Wellcome Collection</a></span>
</figcaption>
</figure>
<p>Computational analysis of these texts reveals anti-vaccination themes that are very similar to those of today. For instance, doubts about the effectiveness of vaccines, what they’re made of and their safety, feature prominently. </p>
<p>Other common themes include complaints that civil liberties are infringed by compulsory vaccination, alongside conspiracy theories of government cover-ups, general distrust of the medical profession, and an orientation towards alternative medicine. </p>
<p>What changes is the detail. For instance, fear of the inadvertent introduction of syphilis, tuberculosis and skin diseases, as very occasionally happened in Victorian times, may be compared to the <a href="https://theconversation.com/under-40s-can-ask-their-gp-for-an-astrazeneca-shot-whats-changed-what-are-the-risks-are-there-benefits-163571">blood clots</a> issue with the COVID vaccine. </p>
<p>Other more spurious scare stories, such as an association between vaccination and tooth decay or mental illness have their parallels in the <a href="https://theconversation.com/autism-and-vaccines-more-than-half-of-people-in-britain-france-italy-still-think-there-may-be-a-link-101930">discredited autism claims</a> of the present day. Likewise, modern conspiracy theories about big pharma have their Victorian parallel in allegations of medical profiteering from vaccination fees.</p>
<p>This study of the Victorian anti-vaxxers shows us that there are indeed recurrent fears more than two centuries old. But it also teaches us that some of the motivations of vaccine hesitancy stem from social, political and religious beliefs that are equally deep in time and often deeply held. </p>
<figure class="align-center ">
<img alt="A calf being used to make vaccines." src="https://images.theconversation.com/files/565148/original/file-20231212-21-thvmg9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565148/original/file-20231212-21-thvmg9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565148/original/file-20231212-21-thvmg9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565148/original/file-20231212-21-thvmg9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565148/original/file-20231212-21-thvmg9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565148/original/file-20231212-21-thvmg9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565148/original/file-20231212-21-thvmg9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The use of cattle to produce vaccines was one of the first biotechnology industries but drew fire from anti-vaccination activists on grounds of animal cruelty.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/ju78dfph">Wellcome Collection</a></span>
</figcaption>
</figure>
<p>For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9728709/pdf/homoeopathphys132846-0032.pdf">William Tebb</a>, one of the most prominent anti-vaxxers of Victorian times campaigned with equal energy on a whole raft of causes, from women’s suffrage to the abolition of slavery via vegetarianism, animal rights and mystical religion. </p>
<p>For Tebb and many of his followers, these were intimately connected causes. To reach the root of the problem, we need to untangle these connections in sensitive ways that go beyond conventional public engagement.</p><img src="https://counter.theconversation.com/content/218671/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The project described in this article is funded by the UK Economic & Social Research Council.</span></em></p><p class="fine-print"><em><span>Chris Sanderson received funding from the UK Economic & Social Research Council for this project. </span></em></p><p class="fine-print"><em><span>Alice Deignan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Victorian anti-vaccine literature shows that the fears and concerns remain largely the same today.Derek Gatherer, Lecturer, Biomedical and Life Sciences, Lancaster UniversityAlice Deignan, Professor of Applied Linguistics, University of LeedsChris Sanderson, PhD Candidate, ESRC Centre for Corpus Approaches to Social Science, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2078792023-07-05T21:06:31Z2023-07-05T21:06:31ZFresh air has long been seen as important for our health, even if we haven’t always understood why<figure><img src="https://images.theconversation.com/files/535667/original/file-20230704-24289-i8a98e.jpg?ixlib=rb-1.1.0&rect=23%2C419%2C5152%2C3026&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Getting some fresh air has long been viewed as an important part of staying in good health. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The New Brunswick legislature recently passed a motion to improve indoor air quality in the province’s public buildings “<a href="https://www.cbc.ca/news/canada/new-brunswick/new-brunswick-clean-air-quality-public-buildings-covid-19-liberal-motion-passed-1.6870983">to reduce the spread of airborne illnesses, such as COVID-19</a>.”</p>
<p>There are many ways to improve the air we breathe indoors, including <a href="https://aghealth.ucdavis.edu/news/corsi-rosenthal-box-diy-box-fan-air-filter-covid-19-and-wildfire-smoke">filtration</a> and ventilation: bring fresh air in, send <a href="https://www.canada.ca/en/health-canada/services/publications/healthy-living/carbon-dioxide-home.html">exhaled air and contaminants</a> out. And we have <a href="https://www.scientificamerican.com/article/we-need-to-improve-indoor-air-quality-here-rsquo-s-how-and-why/">good reasons</a> for looking at indoor air quality. </p>
<p>From <a href="https://www.canada.ca/en/environment-climate-change/services/air-quality-health-index/wildfire-smoke.html">wildfire smoke</a>, to industrial <a href="https://apnews.com/article/business-india-smog-new-delhi-gun-politics-2798027680d388b3aa49acb2193f6750">pollution</a>, many of us have felt the impacts of poor air quality and turned to air filters and respirators to cope. </p>
<p>The White House held a summit last year on <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2022/10/12/readout-of-the-white-house-summit-on-improving-indoor-air-quality/">improving indoor air quality</a> to reduce the transmission of COVID-19. This September, there will be a <a href="https://site.genevahealthforum.com/index.php?option=com_content&view=article&id=30">similar meeting in Europe</a> organized by the World Health Organization. </p>
<p>How new is all this? Well, it is and it isn’t. Eighteenth-century physicians were big advocates for ventilation as a way of reducing the transmission of contagious diseases, though not entirely for sound reasons.</p>
<h2>Ventilation and eighteenth-century medicine</h2>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An engraving showing old ventilators." src="https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=811&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=811&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=811&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1020&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1020&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535625/original/file-20230704-21-9g7ccz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1020&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An 1817 engraving showing ventilators by W. Lowry.</span>
<span class="attribution"><span class="source">(Wellcome Collection)</span></span>
</figcaption>
</figure>
<p>I teach about eighteenth-century <a href="https://doi.org/10.1017/9781108632218.005">literature and medical writing in the British Isles</a>. In the 1700s, British physicians took advantage of new scientific approaches but had little technology to see what was going on. </p>
<p>They believed that most contagious illnesses spread through smelly decaying matter, or miasma, from rotting food, sick bodies and so on. This is called “<a href="https://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/miasma-theory">miasma theory</a>,” and it was eventually replaced by <a href="https://www.britannica.com/science/germ-theory">germ theory</a>. </p>
<p>Miasma theory meant that physicians associated bad smells with disease. But they also had the evidence of their eyes. Eighteenth-century physicians saw diseases spreading easily in crowded, poorly ventilated structures, from ships and jails to the homes of the poor. Ventilation made sense as a way to make people safer: blow out the bad air. It also seemed to make a difference when they used it.</p>
<p>So <a href="https://doi.org/10.1080/03605310490500509">they acted</a>. In 1756, the British Navy ordered the installation of <a href="https://www.joehistorian.com/blog/2021/8/19/dr-hales-ventilator-and-the-seven-years-war">recently invented ventilators on ships</a>. A naval hospital required “<a href="https://wellcomecollection.org/works/yhkner4g/items?canvas=43">doors and windows to be opened for the purposes of ventilation</a>.” In 1802, the British parliament passed legislation requiring factories to have enough “<a href="https://oem.bmj.com/content/oemed/30/2/118.full.pdf">Windows and Openings…to insure a proper Supply of Fresh Air</a>.”</p>
<h2>Outbreaks in the Navy</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An old engraving on a man in an 18th century outfit." src="https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=780&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=780&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=780&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=981&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=981&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535624/original/file-20230704-9037-kx5ryw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=981&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A 1796 engraving of Thomas Trotter by English artist Daniel Orme.</span>
<span class="attribution"><span class="source">(Wikimedia)</span></span>
</figcaption>
</figure>
<p>In his 1797 book on naval medicine, physician and poet Thomas Trotter drew on his extensive experience at sea. He questioned both <a href="https://wellcomecollection.org/works/yhkner4g/items?canvas=199">miasma</a> and <a href="https://wellcomecollection.org/works/yhkner4g/items?canvas=194">germ theory</a>.</p>
<p>However, Trotter partly agreed with miasma theory. He was convinced that many contagious diseases, including smallpox, were spread by “<a href="https://wellcomecollection.org/works/yhkner4g/items?canvas=189">the exhalations of the sick</a>.” </p>
<p>We now know that smallpox was <a href="https://www.canada.ca/en/public-health/services/laboratory-biosafety-biosecurity/pathogen-safety-data-sheets-risk-assessment/variola-virus.html">spread via respiratory droplets or fine-particle aerosol</a>. Trotter was basically right about the pathway for smallpox transmission — and a few other diseases — even though he was very wrong about how.</p>
<p>Eighteenth-century physicians had successes with the partial information they had. Trotter explains how they ended an outbreak of a “malignant fever” on a navy ship in 1791. They quarantined the sick, fumigated the vessel and “<a href="https://wellcomecollection.org/works/yhkner4g/items?canvas=449">the ventilators worked unremittingly day and night</a>.” </p>
<h2>Ventilation spreads</h2>
<p>These ideas spread widely beyond medical circles through literature and kept spreading after germ theory. Writers paid a lot of attention to “exhalations.” In his 1744 poem on health, John Armstrong wrote, “<a href="https://quod.lib.umich.edu/e/evans/N04464.0001.001/1:2?rgn=div1;view=fulltext">It is not air / That from a thousand lungs reeks back to thine</a>.” Dozens of poets repeated phrases such as “infectious breath,” from <a href="https://xtf.lib.virginia.edu/xtf/view?docId=chadwyck_ep/uvaGenText/tei/chep_1.1872.xml;chunk.id=d35;toc.depth=1;toc.id=d3;brand=default">Thomas Carew</a> to <a href="https://www.gutenberg.org/files/29222/29222-h/29222-h.htm">Thomas Godfrey</a> and <a href="https://xtf.lib.virginia.edu/xtf/view?docId=chadwyck_ep/uvaGenText/tei/chep_3.0930.xml;chunk.id=d456;toc.depth=1;toc.id=d383;brand=default;query=neglected%20child#1">more</a>. </p>
<p>Like eighteenth-century doctors, nineteenth-century writers promoted ventilation and fresh air. In fiction, Jane Austen had her characters “<a href="https://www.gutenberg.org/files/121/121-h/121-h.htm">breathing fresh air</a>,” while Lady Morgan complained about “<a href="https://broadviewpress.com/product/the-obriens-and-the-oflahertys/#tab-description">thickly populated and ill ventilated</a>” streets helping to spread disease.</p>
<p>Some famous poets wrote about air so much that American literary critic M.H. Abrams remarked, “<a href="https://www.jstor.org/stable/4333734">That the poetry of Coleridge, Wordsworth, Shelley, [and] Byron should be so thoroughly ventilated is itself noteworthy</a>.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&rect=14%2C298%2C9475%2C6018&q=45&auto=format&w=1000&fit=clip"><img alt="A ventilation duct on a ceiling." src="https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&rect=14%2C298%2C9475%2C6018&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535627/original/file-20230704-24289-cwk6cv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">From wildfire smoke to pollution, many of us have felt the impacts of poor air quality and turned to air filters and ventilation to cope.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Ventilation comes back</h2>
<p>By the 1840s, the public health debate was turning to <a href="https://victorianweb.org/periodicals/punch/publichealth/7.html">cleaner water</a>, as germ theory began to take hold. But advances in germ theory couldn’t erase the benefits of breathing fresh air from the public consciousness. Around 1850, journalist Henry Mayhew interviewed one Londoner who <a href="https://www.gutenberg.org/cache/epub/55998/pg55998-images.html">said the following</a> about the city’s cheap housing: </p>
<blockquote>
<p>“Nothing can be worse to the health than these places, without ventilation, cleanliness, or decency, and with forty people’s breaths perhaps mingling together in one foul choking steam of stench.”</p>
</blockquote>
<p>In 1859, Florence Nightingale helped revive ventilation in healthcare. In her book <em>Notes on Nursing</em>, she emphasized, “<a href="https://digital.library.upenn.edu/women/nightingale/nursing/nursing.html">The air within as pure as the air without</a>.” </p>
<p>Fresh air was seen as critical during the 1918-1920 influenza pandemic as well. People were encouraged to <a href="https://www.bloomberg.com/news/articles/2020-08-05/the-curious-history-of-steam-heat-and-pandemics">keep windows open</a> and move events outdoors, <a href="https://www.influenzaarchive.org/cities/city-sanfrancisco.html">including court proceedings</a>.</p>
<p>Now, <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/main-modes-transmission.html">another pandemic</a> has got us talking about the importance of fresh air. The difference is this time we have better tools to measure and improve indoor air quality, and a much better understanding of why fresh air is good for us.</p><img src="https://counter.theconversation.com/content/207879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julia M. Wright receives funding from the Social Sciences and Humanities Research Council of Canada. </span></em></p>Eighteenth-century writers worried about “infectious air,” so they opened windows and built ventilation systems to bring fresh air indoors.Julia M. Wright, George Munro Chair in Literature and Rhetoric, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1880942022-08-11T15:25:00Z2022-08-11T15:25:00ZMonkeypox vaccines: what’s available and why they aren’t a silver bullet<figure><img src="https://images.theconversation.com/files/477187/original/file-20220802-19-wlgzm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A dose of Imvanex vaccine used to protect against Monkeypox virus.</span> <span class="attribution"><span class="source">Lex van Lieshout/ANP/AFP via Getty Images</span></span></figcaption></figure><p><em>In July 2022 the World Health Organization <a href="https://theconversation.com/monkeypox-world-health-organization-declares-it-a-global-health-emergency-heres-what-that-means-186518">declared the recent current monkeypox outbreak</a> a global health emergency. Since the start of the year thousands of cases have been reported from over 80 countries. The <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">current outbreak</a> is unlike any previous ones. Infections are happening in non-endemic countries outside of Africa. And the pattern is of sustained person-to-person transmission. But there has also been an increase in the number of cases in countries in west and central Africa where the disease is endemic. The current outbreak monkeypox virus strain has a relatively low mortality <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395797/">compared to other strains</a>. If other strains escape Africa the problem is going to be far more challenging. The Conversation Africa spoke to virologist Anna-Lise Williamson about monkeypox vaccines and best way forward for African countries.</em> </p>
<hr>
<h2>Are there vaccines against Monkeypox? How effective are they?</h2>
<p>The monkeypox virus is related to variola virus which caused smallpox and so the smallpox vaccines also protected from monkeypox. But these early smallpox vaccines are no longer commercially available because the disease was certified as eradicated in 1980 and so <a href="https://www.who.int/health-topics/smallpox#tab=tab_1">vaccination stopped</a>. </p>
<p>For a long time monkeypox was rare because of the cross-protection provided by the smallpox vaccine.</p>
<p>There are now two types of vaccine available. </p>
<p>The first is based on a replicating vaccinia virus and formed the basis of the smallpox virus <a href="https://www.who.int/news-room/feature-stories/detail/the-smallpox-eradication-programme---sep-(1966-1980)">eradication campaigns</a>. This required one immunisation and gave protection for life. </p>
<p>These vaccines are not regarded as very safe because they can have serious side effects. In some cases 1 to 2 people per million vaccinated died of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069029/">vaccine complications</a>. </p>
<p>This was acceptable in the days of smallpox because about <a href="https://www.who.int/teams/health-product-and-policy-standards/standards-and-specifications/vaccine-standardization/smallpox#:%7E:text=Two%20forms%20of%20the%20disease,most%20prominent%20on%20the%20face.">30% of people</a> who got the disease died from it. </p>
<p>The vaccine faces additional challenges in the era of HIV. People with certain immunodeficiency diseases, <a href="https://www.nejm.org/doi/10.1056/NEJM198703123161106?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">including HIV</a>, can’t receive this type of vaccine.</p>
<p>The second vaccine is based on an attenuated form of vaccinia virus called modified vaccinia Ankara (MVA) which cannot complete its replication cycle in humans. This is a very safe vaccine. But protection does not last as long as the conventional vaccines based on replicating vaccinia virus. </p>
<p>It is marketed in the US as <a href="https://www.fda.gov/vaccines-blood-biologics/jynneos">Jynneos</a> and in Europe as <a href="https://www.ema.europa.eu/en/medicines/human/EPAR/imvanex">Imvanex</a>. It requires two immunisations. Both are made by Bavarian Nordic.</p>
<p>As far as I am aware it is uncertain how long people remain protected from infection. </p>
<h2>How widely available are the vaccines?</h2>
<p>The MVA based vaccine – which is the safest vaccine – appears to be in very <a href="https://www.science.org/content/article/there-s-shortage-monkeypox-vaccine-could-one-dose-instead-two-suffice">short supply</a>. According to <a href="https://healthpolicy-watch.news/exclusive-china-monkeypox-bavarian-nordics/">newspaper articles</a> Bavarian Nordic are not able to produce the vaccines at present. </p>
<p>There are stockpiles of the vaccinia virus replicating vaccines. But they can’t be rolled out in countries with a high prevalence of HIV without extensive management ensuring HIV-positve people do not get it. South Africa is an example.</p>
<h2>Vaccines are key to controlling a number of diseases. Is this true for monkeypox too?</h2>
<p>Vaccines are the only way to control monkeypox once you have outbreak as we’re <a href="https://theconversation.com/monkeypox-this-is-an-entirely-new-spread-of-the-disease-184085">currently seeing</a> in the US and several European countries. </p>
<p>The problem is the cost. Countries have to weigh up the cost of vaccinating everybody versus the cost of treating the disease.</p>
<p>The cost/benefit analysis is different for each country. The scenarios will look very different depending on whether you’re sitting in London or in Lagos. Vaccinating high risk populations is a possible strategy to stop the spread of the disease.</p>
<p>Nigeria has been managing monkeypox outbreaks for some time. But the strategy has not relied on vaccines because, from their viewpoint, it wouldn’t be cost effective. You’d have to vaccinate a lot of people for it to be effective. It obviously makes sense to make sure there’s good disease surveillance. </p>
<p>There is also an antiviral drug, tecovirimat <a href="https://www.cdc.gov/poxvirus/monkeypox/treatment.html">(TPOXX)</a> that has been developed for smallpox and works for treating monkeypox. However this is not available in Africa and so Africa needs to manufacture drugs for the continent. </p>
<p>For developed countries, it makes sense to do contact tracing and to identify high risk communities. And then to vaccinate at-risk populations. This is true particularly if you can’t change people’s behaviour.</p>
<h2>What’s the longer term solution for African countries?</h2>
<p>African countries must start making the vaccines that they need. For example there’s a vaccine – a recombinant vaccine based on MVA – in final trials that addresses both monkeypox and respiratory syncytial virus (RSV). RSV kills <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30251-5/fulltext">millions of children</a> in Africa every year. If you could vaccinate against both at the same time that may be cost effective.</p>
<p>I belong to <a href="https://africacdc.org/download/partnerships-for-african-vaccine-manufacturing-pavm-framework-for-action/">Partnerships for African Manufacturing</a>, an initiative that’s pushing for local production capacity.</p>
<p>But it’s hard. We have virtually no expertise. And it requires a great deal of work to set up manufacturing capability. </p>
<p>And it’s going to cost money. Those who have money to invest need to do that.</p>
<p>After the <a href="https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html">flu pandemic in 2010</a> everyone said African countries should manufacture flu vaccines. Africa didn’t get any vaccines until the pandemic had ended – a forerunner to the COVID situation.</p>
<p>The danger is that the issue just disappears again and nothing gets done. We must try and keep some momentum in place so we can look after ourselves for next pandemic.</p><img src="https://counter.theconversation.com/content/188094/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna-Lise Williamson receives funding from TIA, SAMRC and NRF.</span></em></p>Countries have to weigh up the cost of vaccinating everybody versus the cost of treating the disease.Anna-Lise Williamson, Professor in Vaccinology, Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1883992022-08-11T10:28:56Z2022-08-11T10:28:56ZMonkeypox: demand for vaccines is outstripping supply – this is what’s causing the shortages<figure><img src="https://images.theconversation.com/files/478708/original/file-20220811-5117-k495hz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3594%2C2392&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The smallpox vaccine is currently being used to protect against monkeypox.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-researcher-scientist-hand-blue-glove-1396494821">PhotobyTawat/ Shutterstock</a></span></figcaption></figure><p>Over <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">30,000 cases</a> of monkeypox have been reported in more than 80 countries worldwide in 2022. Most are in countries that have never previously reported monkeypox. While monkeypox is not as <a href="https://www.gov.uk/guidance/monkeypox">transmissible</a> as many respiratory infections (such as COVID-19), it’s still important to curb the spread.</p>
<p>One way to control spread is by <a href="https://www.gov.uk/government/publications/monkeypox-vaccination-resources/protecting-you-from-monkeypox-information-on-the-smallpox-vaccination">vaccinating vulnerable people</a>. Fortunately, we already have vaccines which are <a href="https://www.gov.uk/government/publications/smallpox-and-vaccinia-the-green-book-chapter-29">very effective</a> at preventing monkeypox. But as case numbers continue to rise, reports are emerging that <a href="https://www.science.org/content/article/there-s-shortage-monkeypox-vaccine-could-one-dose-instead-two-suffice">demand for vaccines</a> is <a href="https://www.ft.com/content/1d9f678b-33d0-480d-b5d7-f5cbc9c41141">outstripping supply</a> in many parts of the world currently seeing an outbreak, including <a href="https://www.nytimes.com/2022/08/05/health/monkeypox-vaccine-hiv.html">the US</a>, <a href="https://www.theguardian.com/world/2022/aug/10/uk-will-run-out-of-monkeypox-vaccine-in-10-to-20-days">UK</a> and <a href="https://www.reuters.com/world/europe/europe-consider-dose-sparing-increase-monkeypox-vaccine-who-seeks-trials-2022-08-10/">Europe</a>.</p>
<h2>Vaccine supply</h2>
<p>There are a number of reasons why we are seeing shortages of the vaccine used to protect against monkeypox. Broadly, it’s due to chronic weaknesses in our global vaccine manufacturing and distribution systems, which make it especially difficult to supply the vaccines needed to protect against new infections and outbreaks.</p>
<p>The vaccine currently being used to protect against monkeypox is the smallpox vaccine, which works because the monkeypox virus is so closely related to smallpox.</p>
<p>Until now, the smallpox vaccine has been a niche product because it’s not been needed since smallpox was <a href="https://www.who.int/health-topics/smallpox">eradicated</a> in 1980. Pharmaceutical companies can’t afford to manufacture vast numbers of doses just in case, and few governments can justify buying a vaccine that isn’t used. This means the vaccines currently being administered are from <a href="https://www.phe.gov/about/sns/Pages/products.aspx">emergency stockpiles</a> that were created to respond to an accidental (or deliberate) release of smallpox.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-qanda-how-do-you-catch-it-and-what-are-the-risks-an-expert-explains-183606">Monkeypox Q&A: how do you catch it and what are the risks? An expert explains</a>
</strong>
</em>
</p>
<hr>
<p>As such, there are limited stocks and production capacity globally, so demand is rapidly outstripping supply. Even the US, with one of the largest smallpox vaccine stockpiles, recently ordered <a href="https://www.hhs.gov/about/news/2022/07/01/hhs-orders-2-point-5-million-more-doses-jynneos-vaccine-for-monkeypox-preparedness.html">2.5 million additional doses</a> in response to the monkeypox outbreak. But there are reports that the factory in Denmark which makes the world’s only smallpox vaccine approved for monkeypox is <a href="https://healthpolicy-watch.news/exclusive-china-monkeypox-bavarian-nordics/">temporarily closed</a>, which may further impact the world’s ability to source more vaccine doses. And unfortunately, transferring production to other facilities is not straightforward. </p>
<p>One particular problem for vaccine manufacturers is that it’s hard to predict when or where big outbreaks of infections may happen. Of course, there are some infections that we know consistently require a regular supply of vaccines – such as the influenza virus. But while <a>1 billion influenza vaccines</a> are produced globally each year, it still takes <a href="https://www.cdc.gov/flu/prevent/vaccine-selection.htm">approximately six months</a> from picking the most important new strains to manufacturing and rolling out jabs.</p>
<p>So even with vaccines in high demand, it isn’t simple to manufacture more doses. This is why we are <a href="https://100days.cepi.net/">still striving</a> to innovate ways to rapidly produce new vaccines affordably and at a very large scale.</p>
<p>Vaccines are inherently complicated to make. Because they are made from relatively fragile and complex biological materials (such as a virus), the product has to be exactly right every time. If the formula changes even slightly, it might not work as well – or even increase the risk of side-effects. </p>
<p>Adding to this challenge is the fact that different vaccine products may be manufactured by different methods. For example, the equipment needed to produce a viral vaccine (such as the smallpox vaccine used against monkeypox) will be very different to that used to make COVID-19 RNA vaccines. It’s also slow and expensive to test any necessary modifications or improvements that may be needed to make a vaccine safer and more effective. </p>
<figure class="align-center ">
<img alt="Glass vials arranged in a row move through a conveyer belt, where they are filled with the vaccine." src="https://images.theconversation.com/files/478711/original/file-20220811-15-y3tft6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478711/original/file-20220811-15-y3tft6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478711/original/file-20220811-15-y3tft6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478711/original/file-20220811-15-y3tft6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478711/original/file-20220811-15-y3tft6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478711/original/file-20220811-15-y3tft6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478711/original/file-20220811-15-y3tft6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It isn’t just as easy as making more vaccines to meet demand.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-render-pharmaceutical-manufacture-background-glass-2115129506">wacomka/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Surprisingly, even some simple processes common to all vaccines and other medicines – such as filling doses into vials for distribution to patients – still have a mismatch of capacity. Vaccines are usually manufactured in different locations to <a href="https://www.thechemicalengineer.com/news/volunteers-publish-guide-to-help-public-understand-fill-and-finish-and-drug-product-release/">packaging facilities</a>, raising logistical hurdles (such as strictly controlled refrigeration requirements) that can further delay distribution. These facilities are used for many different medicines and are usually fully booked years in advance; schedules that are still recovering from COVID-19 disruptions may now be experiencing urgent changes to package the smallpox vaccine from stockpiles. </p>
<p>It also isn’t just a case of developing new monkeypox vaccines that are easier to manufacture. Even with major recent scientific progress, it would take many months to develop a safe and effective new vaccine. For monkeypox, it’s far quicker and simpler to use the existing smallpox vaccine.</p>
<h2>What can be done?</h2>
<p>Smallpox vaccine production is likely to be increased to meet demand. But until this happens, many countries will have to make best use of what supplies they can access, and rely on other strategies to help curb the virus’s spread.</p>
<p>The most effective way to prevent monkeypox causing further harm is by using an integrated, locally led public health response – vaccines are just one part of this. Testing and contact tracing is vital. If enough infected people in a region can be identified and supported to isolate while they’re infectious, transmission can be blocked.</p>
<p>Given the vaccine shortages, we expect that people don’t need two vaccine doses to be protected against monkeypox. This is why vaccinating the most at-risk groups with <a href="https://www.gov.uk/government/publications/monkeypox-vaccination-resources/monkeypox-waiting-for-your-vaccination">one dose now</a>, paired with other public health measures, is the most effective strategy for curbing the spread of monkeypox – especially while vaccine supplies are limited. Second doses can be administered to maximise immunity when supplies do become available.</p>
<p>The current monkeypox outbreak is yet another reminder of the importance of investing in global health, and ensuring there’s more equal access to vaccines and other medical interventions that can help prevent the spread of harmful diseases.</p><img src="https://counter.theconversation.com/content/188399/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexander Edwards does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Chronic weaknesses in our global vaccine manufacturing and distribution systems may broadly be to blame.Alexander Edwards, Associate Professor in Biomedical Technology, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1882142022-08-04T20:44:37Z2022-08-04T20:44:37ZMonkeypox vaccines: A virologist answers 6 questions about how they work, who can get them and how well they prevent infection<figure><img src="https://images.theconversation.com/files/477723/original/file-20220804-20-4y65ta.jpg?ixlib=rb-1.1.0&rect=86%2C113%2C3683%2C2351&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Jynneos monkeypox vaccine provides strong protection against infection but is in short supply.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vial-of-the-jynneos-monkeypox-vaccine-sits-on-a-table-at-a-news-photo/1412754952?adppopup=true">Mario Tama/Getty Images</a></span></figcaption></figure><p><em>Monkeypox isn’t going to be the next COVID-19. But with the outbreak having bloomed to <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html">thousands of infections, with cases in nearly every state</a>, on Aug. 4, 2022, the <a href="https://www.msn.com/en-us/news/us/as-monkeypox-spreads-u-s-declares-a-health-emergency/ar-AA10j7ha?cvid=d63b6a053efb410ca447e51c2fcde7cc">U.S. declared monkeypox a national public health emergency</a>. One reason health experts did not expect monkeypox to become so widespread is that the U.S. had previously approved two vaccines for the virus. <a href="https://scholar.google.com/citations?user=Dxbq8hkAAAAJ&hl=en&oi=ao">Maureen Ferran</a>, a virologist at Rochester Institute of Technology, has been keeping tabs on the two vaccines that can protect against monkeypox.</em></p>
<h2>1. What are the available monkeypox vaccines?</h2>
<p>Two vaccines are currently approved in the U.S. that can provide protection against monkeypox, the <a href="https://www.fda.gov/vaccines-blood-biologics/jynneos">Jynneos vaccine</a> – known as Imvamune/Imvanex in Europe – and <a href="https://www.fda.gov/media/75800/download">ACAM2000</a>, an older smallpox vaccine.</p>
<p>The Jynneos vaccine is produced by <a href="https://www.bavarian-nordic.com/">Bavarian Nordic</a>, a small company in Denmark. The vaccine is for the prevention of smallpox and monkeypox disease in adults ages 18 and older who are at high risk for infection with either virus. It was approved in Europe in 2013 and by the U.S. <a href="https://www.fda.gov/media/131079/download">Food and Drug Administration in 2019</a>. </p>
<p>The Jynneos vaccine is given in two doses four weeks apart and <a href="https://www.webmd.com/a-to-z-guides/monkeypox-vaccination#">contains a live vaccinia virus</a>. Vaccinia normally infects cattle and is a type of poxvirus, a family of viruses that includes smallpox and monkeypox. The virus in this vaccine has been crippled – or attenuated – so that it is no longer able to replicate in cells. </p>
<p>This vaccine is good at protecting those who are at high risk for monkeypox from getting infected before exposure and can also lessen the severity of disease post-infection. It is effective against smallpox as well as monkeypox. Until the recent monkeypox outbreak, this vaccine was primarily given to health care workers or people who have had confirmed or suspected monkeypox exposure.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A circular mass of squiggly lines." src="https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=580&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=580&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477726/original/file-20220804-14-ckx2sj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=580&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Both the Jynneos and ACAM2000 vaccines use the vaccinia virus, shown here, to produce immunity to smallpox and monkeypox.</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/details.aspx?pid=2143">CDC/ Cynthia Goldsmith</a></span>
</figcaption>
</figure>
<p>The <a href="https://www.fda.gov/vaccines-blood-biologics/vaccines/acam2000-smallpox-vaccine-questions-and-answers">ACAM2000 vaccine</a> was <a href="https://www.fda.gov/media/75792/download">approved by the FDA in 2007</a> for protection against smallpox disease. This vaccine is also based on vaccinia virus, however the version of the vaccinia virus in the ACAM2000 vaccine is able to replicate in a person’s cells. Because of this, the ACAM2000 vaccine can be <a href="https://www.fda.gov/vaccines-blood-biologics/vaccines/acam2000-smallpox-vaccine-questions-and-answers#">associated with serious side effects</a>. These can include severe skin infections as well as <a href="https://www.cdc.gov/smallpox/vaccine-basics/vaccination-effects.html">potentially life-threatening heart problems in vulnerable people</a>. Another potential issue with the ACAM2000 vaccine is that it is more <a href="https://www.vox.com/2022/7/29/23281407/monkeypox-vaccine-acam2000-jynneos-smallpox">complicated to administer compared to a normal shot</a>.</p>
<p>The U.S. government has over <a href="https://www.fda.gov/vaccines-blood-biologics/vaccines/acam2000-smallpox-vaccine-questions-and-answers">200 million doses of ACAM2000 stockpiled</a> in case of a biological weapon attack of smallpox. But despite the adequate supply of the vaccine, ACAM2000 is not being used to vaccinate against monkeypox because of the risk of serious adverse side effects. For now, only designated U.S. military personnel and laboratory researchers who work with certain poxviruses may receive this vaccine. </p>
<h2>2. How effective are these vaccines?</h2>
<p>According to the U.S. Centers for Disease Control, there is not <a href="https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html">yet any data available</a> on the effectiveness of either vaccine in the current outbreak of monkeypox. But there is older data available from animal studies, clinical trials and studies in Africa.</p>
<p>A number of clinical trials done during the approval process for the Jynneos vaccine show that when given to a person, it <a href="https://www.precisionvaccinations.com/vaccines/jynneos-smallpox-monkeypox-vaccine">triggers a strong antibody response</a> on par with the ACAM2000 vaccine. An additional study done in nonhuman primates showed that vaccinated animals that were infected with monkeypox survived <a href="https://www.fda.gov/media/131078/download">80% to 100% of the time, compared with zero to 40% survival</a> in unvaccinated animals.</p>
<p>Another use of the Jynneos vaccine is as a <a href="https://www.nmhealth.org/publication/view/policy/7661/">post-exposure prophylaxis, or PEP</a>, meaning the vaccine can be effective even when given after exposure to the virus. Because the monkeypox virus incubates in a person’s body for six to 14 days, the body of someone who <a href="https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html">gets the Jynneos vaccine shortly after being exposed</a> will produce antibodies that can help fight off infection and protect against a serious monkeypox case.</p>
<p>The ACAM2000 data is older and less precise but shows strong protection. Researchers tested the vaccine during an outbreak of monkeypox in central Africa in the 1980s. Although the study was small and didn’t directly test vaccine efficacy, the authors concluded that unvaccinated people faced an <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html">85% higher risk of being infected than vaccinated people</a>. </p>
<h2>3. Does a smallpox vaccine protect against monkeypox?</h2>
<p><a href="https://www.charlotteobserver.com/news/state/north-carolina/article264045516.html">According to the CDC</a>, a previous smallpox vaccination does provide some protection against monkeypox, though that <a href="https://www.charlotteobserver.com/news/state/north-carolina/article264045516.html#storylink=cpy">protection wanes over time</a>. Experts advise that anyone who had the <a href="https://www.npr.org/2022/07/24/1113197119/monkeypox-symptoms-prevention-vaccines-what-to-know">smallpox vaccine more than three years ago</a> and is at increased risk for monkeypox get the monkeypox vaccine.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People lining up for monkeypox vaccines." src="https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477725/original/file-20220804-23-gdsh7v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In California and New York City, demand for vaccines has been high among at-risk communities.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/MonkeypoxVaccineCalifornia/acac850b3b834fe6aa41d421eb737748/photo?Query=monkeypox%20vaccine&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=59&currentItemNo=13">AP Photo/Marcio Jose Sanchez</a></span>
</figcaption>
</figure>
<h2>4. Who should get vaccinated?</h2>
<p>At the national level, anyone who has had close contact with an infected person, who has a weakened immune system or who had dermatitis or eczema is <a href="https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html">eligible for a Jynneos vaccine</a>.</p>
<p>Some state and local governments are also making vaccines available to people in communities at higher risk for monkeypox. For example, New York City is allowing men who have sex with men and who have had multiple sexual partners in the past 14 days <a href="https://www.nytimes.com/article/monkeypox-vaccine-nyc.html?action=click&pgtype=Article&state=default&module=styln-monkeypox&region=MAIN_CONTENT_1&block=storyline_levelup_swipe_recirc">to get vaccinated</a>. </p>
<h2>5. What is the supply like for the Jynneos vaccine?</h2>
<p>As of July 29, 2022, a little over <a href="https://aspr.hhs.gov/SNS/Pages/JYNNEOS-Distribution.aspx">300,000 doses have been shipped to points of care or administered</a>, with another 700,000 already allocated to states across the U.S. However, demand is far outpacing supply. Public health officials acknowledge that <a href="https://www.forbes.com/sites/roberthart/2022/07/18/struggling-to-find-a-monkeypox-shot-severe-shortages-and-technical-mishaps-are-slowing-down-rollouts/?sh=2a3b4ed9e018">vaccine supply shortages have resulted in</a> long lines and clinics having to close when they run out of vaccines. The issues have been magnified by <a href="https://www.axios.com/2022/07/13/monkeypox-vaccine-new-york-website">technical problems with online booking systems</a>, particularly in New York City. </p>
<p>To help boost supply, the U.S. has ordered nearly <a href="https://www.nytimes.com/2022/07/15/health/monkeypox-vaccine-supply.html">7 million doses of the Jynneos vaccine</a>, which are expected to arrive over the coming months. </p>
<h2>6. What about just using one dose of Jynneos?</h2>
<p>Although federal health officials advise against withholding the second dose, some places – including <a href="https://www.washingtonpost.com/dc-md-va/2022/07/25/dc-monkeypox-vaccines-first-dose/">Washington, D.C.</a>, and <a href="https://www1.nyc.gov/site/doh/about/press/pr2022/monkeypox-vaccination-prioritization-first-doses.page">New York City</a> – are withholding the second dose until more become available. This strategy is being used in <a href="https://www.gov.uk/government/publications/monkeypox-vaccination-resources/protecting-you-from-monkeypox-information-on-the-smallpox-vaccination">Britain</a> and Canada as well to vaccinate as many people as possible at least one time.</p>
<p>A previous study reported that a <a href="https://doi.org/10.1073/pnas.0804985105">single shot</a> of the Jynneos vaccine <a href="https://doi.org/10.1056/NEJMoa1817307">protected monkeys infected with monkeypox</a> and that this protection lasted for at least two years. If this holds up in the real world, it would support withholding second doses in favor of immunizing more Americans. This would be key as many health experts expect the virus to continue spreading, furthering increasing demand of the vaccine.</p><img src="https://counter.theconversation.com/content/188214/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Ferran receives funding from the National Institutes of Health.</span></em></p>There are two approved monkeypox vaccines in the US. Both use a related poxvirus called vaccinia to produce an immune response that protects against smallpox and monkeypox.Maureen Ferran, Associate Professor of Biology, Rochester Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879172022-08-02T03:00:00Z2022-08-02T03:00:00ZMonkeypox in Australia: should you be worried? And who can get the vaccine?<p>On July 23, World Health Organisation Director-General Tedros Adhanom Ghebreyesus took the unprecedented step and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01419-2/fulltext">declared</a> the monkeypox outbreak a “public health emergency of international concern” – the highest global alert level for a disease outbreak. </p>
<p>Following this and with <a href="https://www.health.gov.au/health-alerts/monkeypox-mpx/about#current-status">45 cases in Australia</a>, Chief Medical Officer Paul Kelly <a href="https://www1.racgp.org.au/newsgp/clinical/monkeypox-now-a-disease-of-national-significance?feed=RACGPnewsGPArticles">declared</a> last week that monkeypox is now a “communicable disease incident of national significance”.</p>
<p>So what is monkeypox? And who’s eligible for a vaccine?</p>
<p>Most cases in the current global outbreak are occurring among men who have sex with men. How can this group and others who are at risk protect themselves?</p>
<h2>What is monkeypox?</h2>
<p>Monkeypox <a href="https://news.un.org/en/story/2022/07/1123212">is not a new disease</a>, it was found in the late 1950s in lab primates in Denmark, and was first diagnosed in humans in an infant in the 1970s in the Democratic Republic of Congo.</p>
<p>In the past, monkeypox has mainly been <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">transmitted</a> from infected animals to humans (it is a zoonotic disease), and has been endemic to West and Central Africa. Transmission can occur through contact with infected animals including rodents, mice, rats, squirrels, monkeys and other primates.</p>
<p>But in this outbreak we’re seeing human-to-human transmission.</p>
<p>There are two distinct <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">strains</a> of monkeypox. These are the Central African and the West African types, the latter of which is believed to be one linked to the current global outbreak.</p>
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<p>According to US Centers for Disease Control and Prevention (CDC) data, 23,620 cases have been <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">reported</a> since May in 80 countries, with 73 countries that had no previous reported monkeypox cases. </p>
<p>There have been at least <a href="https://www.smh.com.au/world/south-america/first-monkeypox-deaths-recorded-outside-africa-in-brazil-and-spain-20220730-p5b5vf.html">seven deaths</a>. </p>
<p>Most of the cases in Australia have been in New South Wales and Victoria, among returned travellers and men who have sex with men, and in the age group 21-40 years.</p>
<p>The <a href="https://www.abc.net.au/news/2022-07-28/monkey-pox-declared-a-disease-of-significance-australia/101277158">declaration</a> that monkeypox is now a disease of national significance means the outbreak requires national policies, interventions and public health messaging, with the deployment of more <a href="https://www.health.gov.au/news/chief-medical-officers-statement-declaring-monkeypox-a-communicable-disease-incident-of-national-significance">resources</a> to assist affected areas and groups most at risk.</p>
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<h2>Symptoms and transmission</h2>
<p>The incubation period – the time taken to develop the disease after exposure to the virus – is usually around <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">6-13 days</a>.</p>
<p>Transmission generally requires <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">close contact</a> with an infected person. It can be transmitted via respiratory droplets.</p>
<p>It can also be transmitted through direct contact with body fluids or the rash (“lesions”), often through skin-on-skin contact, or indirect contact such as through contaminated clothing or bedding.</p>
<p>Transmission <a href="https://www.bmj.com/content/bmj/378/bmj-2022-072410.full.pdf">may occur</a> from people without symptoms, or with barely-detectable symptoms.</p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">Symptoms</a> are similar to smallpox, though less severe. They can include:</p>
<ul>
<li>fever</li>
<li>headache</li>
<li>aches</li>
<li>fatigue</li>
<li>sweats and chills</li>
<li>cough and sore throat</li>
<li>a rash that can look like blisters or pimples, which can be painful. These “lesions” typically go through several stages before eventually falling off.</li>
</ul>
<p>The CDC <a href="https://www.cdc.gov/poxvirus/monkeypox/symptoms.html">says</a> most people who get the virus will develop the rash.</p>
<p>A <a href="https://www.bmj.com/content/378/bmj-2022-072410">study</a> in the British Medical Journal published last week also found 88% of 197 people with monkeypox in London had lesions on their genitals or anus. </p>
<p>Symptoms generally last between two and four weeks, and the disease usually resolves on its own. Most adults with a healthy immune system <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">won’t have severe illness</a> and won’t experience long-term harmful effects.</p>
<p>There’s no specific treatment for monkeypox yet. People with the infection should be given supportive treatment and light dressings on the rash, depending on the symptoms. Antivirals such as “tecovirimat” have been made available to patients in some countries who have or are at high risk of severe disease, such as being <a href="https://www.cdc.gov/poxvirus/monkeypox/treatment.html">immunocompromised</a>.</p>
<p>People with the infection should <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/isolation-procedures.html">isolate</a> immediately for the duration of the illness – usually two to four weeks, until the lesions heal. </p>
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<h2>Higher risk groups</h2>
<p>Monkeypox can affect anyone. But men who have sex with men are at higher risk at the moment. WHO Director-General Tedros Adhanom Ghebreyesus <a href="https://twitter.com/DrTedros/status/1552382934300200960">said</a> 98% of cases so far are among men who have sex with men. </p>
<p>It’s important we provide as much information about the virus as possible, and it’s absolutely crucial we do this in a way that is not stigmatising.</p>
<p>This outbreak is seeing cases spread via close prolonged contact from sexual activity in the LGBTIQ+ group. Many from this group want to take proactive actions to help their community.</p>
<p>Specific actions governments can take <a href="https://cdc.gov/poxvirus/monkeypox/sexualhealth/index.html">include</a>: </p>
<ul>
<li>prioritising vaccines as a matter of urgency for those most at risk</li>
<li>targeting public health messaging so the LGBTIQ+ community can make informed decisions.</li>
</ul>
<p>Actions individuals can take include:</p>
<ul>
<li>maintaining contact details of sexual partners in case of need to follow up </li>
<li>avoiding sex if you have a rash until you get tested </li>
<li>considering avoiding skin to skin contact during large gatherings</li>
<li>if diagnosed with monkeypox, <a href="https://www.cdc.giov/ngpoxvirus/monkeypox/clinicians/isolation-procedures.html">avoiding</a> close physical contact, including sexual contact, with other people for the duration of the illness.</li>
</ul>
<p>The CDC says condoms <a href="https://www.cdc.gov/poxvirus/monkeypox/sexualhealth/index.html">may help</a> lower the risk of spread if the lesions are confined to the genital and/or anal region, but they’re likely not enough to prevent transmission on their own.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-this-is-an-entirely-new-spread-of-the-disease-184085">Monkeypox: ‘This is an entirely new spread of the disease’</a>
</strong>
</em>
</p>
<hr>
<h2>Who should have the vaccine?</h2>
<p>Australia has secured small supplies of two smallpox vaccines, which provide protection against monkeypox.</p>
<p>The vaccine advisory body, the Australian Technical Advisory Group on Immunisation (ATAGI), has recommended key risk groups be administered the vaccines. They <a href="https://www1.racgp.org.au/newsgp/clinical/monkeypox-now-a-disease-of-national-significance">include</a>: </p>
<ul>
<li>those identified as a high risk monkeypox contact in the past 14 days</li>
<li>men who have sex with men who are at high risk of exposure. This includes those living with HIV, or with a recent history of a high number of sexual partners or group sex</li>
<li>sex workers, with clients in high-risk categories</li>
<li>and anyone in the risk categories planning travel to a country experiencing a significant outbreak, with vaccination recommended four to six weeks prior to leaving.</li>
</ul>
<p>ATAGI has <a href="https://www.health.gov.au/sites/default/files/documents/2022/08/atagi-clinical-guidance-on-vaccination-against-monkeypox-atagi-clinical-guidance-on-vaccination-against-monkeypox_0.pdf">stated</a> that vaccination within four days of exposure to someone who’s infectious with monkeypox will provide the highest chance of preventing disease.</p>
<p>Avoiding close contact with people who have the infection can help prevent transmission. Monkeypox doesn’t spread as easily as the coronavirus and can be kept under control if we are cautious.</p>
<h2>The need for vaccine equity and global health leadership</h2>
<p>We can’t repeat the “vaccine nationalism” we’ve seen during COVID with rich countries hoarding vaccine doses, as this will unjustly prolong the outbreak.</p>
<p>Currently, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01419-2/fulltext">according</a> to The Lancet medical journal, a smallpox vaccine sold as “Jynneos” in the US costs around US$100 a dose. The WHO has <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">called on</a> countries and manufacturers to ensure the vaccines, as well as diagnostics and therapeutics, are made available “at reasonable cost” where most needed.</p>
<p>Thus we have major political and policy challenges ahead and will need strong global health leadership going forward.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-vaccine-nationalism-could-doom-plan-for-global-access-to-a-covid-19-vaccine-145056">Why 'vaccine nationalism' could doom plan for global access to a COVID-19 vaccine</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/187917/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaya Dantas is Professor of International Health in the Curtin School of Population Health where she teaches a core unit in the Masters in Public Health and Master of Sexology course and leads a program of research in refugee and migrant health. She is currently lead CI on grants funded by Healthway and CI on a DISER grant. Jaya is the International Health SIG Convenor of the Public Health Association of Australia, has been appointed to the Global Gender Equality in Health Leadership Committee of Women in Global Health, Australia and is on the Editorial Advisory Group of the Medical Journal of Australia. She has lived experience of infectious diseases in India and Africa.</span></em></p>Most cases in the current global outbreak are occurring among men who have sex with men. So how can this group and others who are at risk protect themselves?Jaya Dantas, Deputy Chair, Academic Board; Dean International, Faculty of Health Sciences and Professor of International Health, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1845782022-06-21T12:13:06Z2022-06-21T12:13:06ZHow monkeypox epidemic is likely to play out – in four graphs<figure><img src="https://images.theconversation.com/files/469759/original/file-20220620-19-zr7atp.jpg?ixlib=rb-1.1.0&rect=4%2C4%2C3022%2C1997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smallpox vaccines are effective against monkeypox.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=367791">James Gathany/CDC</a></span></figcaption></figure><p>The first case of monkeypox in a human was reported <a href="https://www.nationalgeographic.com/science/article/monkeypox-cases-are-risingheres-what-we-know-so-far">in 1970 in the Democratic Republic of the Congo</a>. Since then, there have been many monkeypox outbreaks, but they have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131633/">self-limiting</a>, with chains of human transmission ending without establishing epidemics. The current outbreak, however, is different. There is more human-to-human transmission, and it is over a much broader geographical area.</p>
<p>In mere weeks, monkeypox has spread to <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">37 non-endemic countries</a>, with <a href="https://ourworldindata.org/monkeypox">over 2,600 cases</a>. So, what is likely to happen to monkeypox in the following weeks and months?</p>
<p>There are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131633/">huge gaps</a> in what we know about monkeypox, but combining what we do know with a history of other infectious diseases makes it possible to analyse likely future scenarios.</p>
<p>The four scenarios below are based on the following knowledge: the average number of people an infected person is likely to infect (assuming they have not been vaccinated against the virus or have had the disease before) is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463189/">2.13</a>. This is called the basic reproduction number, or R. Herd immunity – the point at which enough people have immunity such that disease transmission can’t be sustained – is 53% (<a href="https://theconversation.com/herd-immunity-why-the-figure-is-always-a-bit-vague-141839">corresponding to this value of R</a>). And the <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">incubation period</a>, the time from catching the virus to the appearance of symptoms, is between five and 21 days. </p>
<h2>Scenario 1: Self-limiting outbreak</h2>
<p>The 2022 epidemic appears to have started as a <a href="https://theconversation.com/is-the-k-number-the-new-r-number-what-you-need-to-know-140286">super-spreader event</a> involving a <a href="https://www.medrxiv.org/content/10.1101/2022.06.13.22276353v1">network</a> of predominantly men who have sex with men. </p>
<p>But until the current outbreak it was assumed that the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491159/">relatively low</a> human-to-human transmissibility of the virus <a href="https://www.medrxiv.org/content/10.1101/2022.05.28.22275721v2.full-text">makes it unlikely</a> for the virus to spread outside the initial community.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/469974/original/file-20220621-16-35c970.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469974/original/file-20220621-16-35c970.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=500&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469974/original/file-20220621-16-35c970.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=500&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469974/original/file-20220621-16-35c970.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=500&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469974/original/file-20220621-16-35c970.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=628&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469974/original/file-20220621-16-35c970.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=628&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469974/original/file-20220621-16-35c970.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=628&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Plot illustrating the daily number of cases under scenario 1. The size and duration of the outbreak here and in the graphs below are for illustration purposes only and do not constitute a detailed prediction of what might happen in the future. More details available at https://statisticallyinsignificant.blog/monkeypox-scenario-modelling/</span>
<span class="attribution"><span class="source">Adam Kleczkowski</span></span>
</figcaption>
</figure>
<p>In this scenario, the outbreak ends quickly once the population at risk becomes immune and herd immunity is reached locally. In the past, many people had some immunity (called “cross-immunity”) from the smallpox mass vaccination programmes of the late 20th century. So the effective reproduction number, R, can be close to or even lower than one, and the transmission will soon stop. </p>
<p>Behavioural changes can reduce the number R even more. For example, the <a href="https://www.health.harvard.edu/blog/ring-vaccination-might-help-curtail-monkeypox-202206062757">ring vaccination</a> can form a “firebreak”, further reducing the susceptible population. Similar previous epidemics include the <a href="https://en.wikipedia.org/wiki/2002%E2%80%932004_SARS_outbreak">Sars outbreak</a> in 2002-04, when a quick intervention stopped the disease from spreading. </p>
<h2>Scenario 2: All population</h2>
<p>The <a href="https://www.gov.uk/government/publications/monkeypox-outbreak-technical-briefings/investigation-into-monkeypox-outbreak-in-england-technical-briefing-1">continuing spread</a> of monkeypox in May and June 2022 suggests that the virus is moving beyond the original network. </p>
<p>The size of the outbreak is already well beyond the most prominent 2017-19 outbreak in the Democratic Republic of Congo (760). It is possible that <a href="https://apnews.com/article/monkeypox-explained-health-72a9efaaf5b55ace396398b839847505">large gatherings</a>, including raves and festivals, have created new transmission clusters. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/469975/original/file-20220621-13-bk7tlm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469975/original/file-20220621-13-bk7tlm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=500&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469975/original/file-20220621-13-bk7tlm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=500&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469975/original/file-20220621-13-bk7tlm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=500&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469975/original/file-20220621-13-bk7tlm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=628&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469975/original/file-20220621-13-bk7tlm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=628&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469975/original/file-20220621-13-bk7tlm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=628&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A plot illustrating the daily number of cases under Scenario 2.</span>
<span class="attribution"><span class="source">Adam Kleczkowski</span></span>
</figcaption>
</figure>
<p>Scenario 2 assumes that everybody below the age of 50 is susceptible to the infection, reflecting <a href="https://www.ncbi.nlm.nih.gov/books/NBK545998/">the end of compulsory smallpox vaccination</a> in the 1970-80s. The virus will continue spreading, effectively searching for pockets of high-risk and non-immune communities. </p>
<p>Unless a combination of contact tracing and ring vaccination stops the spread, the monkeypox will continue spreading. But, given the low transmissibility of monkeypox, the epidemic may fizzle out before reaching the herd immunity threshold of 50% of the population. </p>
<h2>Scenario 3: Becoming endemic</h2>
<p>Complete eradication is impossible because monkeypox exists in a wide range of animal hosts. The low transmissibility also means it can survive at low levels in the population. In addition, the long incubation period and variable symptoms allow it to avoid detection. Therefore, monkeypox may have already been <a href="https://www.statnews.com/2022/05/25/viruses-that-were-on-hiatus-during-covid-are-back-and-behaving-in-unexpected-ways/">spreading</a> for a long time. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/469976/original/file-20220621-7895-eny4r6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469976/original/file-20220621-7895-eny4r6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=500&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469976/original/file-20220621-7895-eny4r6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=500&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469976/original/file-20220621-7895-eny4r6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=500&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469976/original/file-20220621-7895-eny4r6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=628&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469976/original/file-20220621-7895-eny4r6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=628&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469976/original/file-20220621-7895-eny4r6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=628&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A plot illustrating the daily number of cases under Scenario 3. Details available at https://statisticallyinsignificant.blog/monkeypox-scenario-modelling/</span>
<span class="attribution"><span class="source">Adam Kleczkowski</span></span>
</figcaption>
</figure>
<p>In scenario 3, following the large outbreak, the disease will settle on a long-term, relatively constant level. Similar to the pre-vaccination <a href="https://www.cdc.gov/smallpox/">smallpox</a> or <a href="https://www.cdc.gov/chickenpox/">chickenpox</a>. </p>
<p>The influx of susceptible people through birth or migration will keep the virus in the population. <a href="https://ourworldindata.org/smallpox-is-the-only-human-disease-to-be-eradicated-heres-how-the-world-achieved-it">Mass vaccination programmes</a> might be needed to eradicate the disease. But relatively low monkeypox transmissibility means such programmes are likely to be highly effective.</p>
<h2>Scenario 4: Recurrent large epidemics</h2>
<p>The current epidemic might be the first instance of a series of outbreaks. In the long term (scenario 4), we should expect a return of monkeypox caused by future “zoonotic events” where the disease jumps from animal hosts to humans. As the cross-immunity from smallpox vaccines wanes, the epidemics can become even more substantial. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/469977/original/file-20220621-26-gw4wp3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469977/original/file-20220621-26-gw4wp3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=500&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469977/original/file-20220621-26-gw4wp3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=500&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469977/original/file-20220621-26-gw4wp3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=500&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469977/original/file-20220621-26-gw4wp3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=628&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469977/original/file-20220621-26-gw4wp3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=628&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469977/original/file-20220621-26-gw4wp3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=628&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A plot illustrating the daily number of cases under Scenario 4. Details available at https://statisticallyinsignificant.blog/monkeypox-scenario-modelling/</span>
<span class="attribution"><span class="source">Adam Kleczkowski</span></span>
</figcaption>
</figure>
<p>Little is known about the potential of monkeypox to mutate. Still, there is <a href="https://twitter.com/RothenburgLab/status/1528108562894901249">potential</a> for it to evolve into a more rapidly spreading variant.</p>
<p><a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html">Effective vaccines</a> for monkeypox exist and are about 85% effective. Although there are currently not enough doses to vaccinate everyone, there is no need for a mass-vaccination programme given monkeypox’s low transmissibility. Instead, vaccines should be offered to those most at risk, including communities in Africa most in contact with the wild animals that carry the virus.</p><img src="https://counter.theconversation.com/content/184578/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Kleczkowski receives funding from the UK Research and Innovation and the Scottish Government.</span></em></p>Possible outcomes of the current monkeypox epidemic under four different scenarios.Adam Kleczkowski, Professor of Mathematics and Statistics, University of Strathclyde Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1853072022-06-20T14:27:55Z2022-06-20T14:27:55ZWhat’s in a name? Why giving monkeypox a new one is a good idea<figure><img src="https://images.theconversation.com/files/469761/original/file-20220620-16-ctd4wc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lab technician in Spain picks up a reactive to test suspected monkeypox samples.
</span> <span class="attribution"><span class="source">Pablo Blazquez Dominguez/Getty Images</span></span></figcaption></figure><p>In its <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON393">latest update</a> on monkey pox in mid-June, the World Health Organization (WHO) said that cases had been reported from 42 member states across five of its regions – the Americas, Africa, Europe, Eastern Mediterranean, and Western Pacific. A total of 2,103 laboratory cases had been reported, including one death.</p>
<p>The outbreak mostly affected men who had sex with men or who had reported recent sex with new or multiple partners. The WHO pointed out that the unexpected appearance of monkeypox in several regions that hadn’t previously reported cases suggested that there may have been undetected transmission for some time. It said it considered the risk at the global level as moderate.</p>
<p>The debate that dominated the headlines, however, has been around the WHO <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-covid-19-media-briefing--14-june-2022">announcing</a> that it’s “working with partners and experts from around the world on changing the name of monkeypox virus, its clades and the disease it causes”.</p>
<p>Just prior to the WHO’s statement a group of 29 scientists <a href="https://virological.org/t/urgent-need-for-a-non-discriminatory-and-non-stigmatizing-nomenclature-for-monkeypox-virus/853">advocated</a> for a non-discriminatory and non-stigmatising nomenclature for monkeypox virus. </p>
<p>They called for a nomenclature or name that is neutral and more acceptable to the global health community. They suggested a naming system similar to the <a href="https://cov-lineages.org/">Pango nomenclature</a> used by researchers and public health expert globally to track the transmission and spread of SARS-CoV-2, including variants of concern.</p>
<p>As an African scientist I agree with this call. The new name for monkeypox must be aligned with best practices in naming of infectious diseases to avoid the uninformed negative narrative that associate diseases with regions. There are no wild non-human primates in <a href="https://www.atlasobscura.com/articles/last-monkeys-in-europe">Europe</a>. There are many monkeys and apes in Africa, Asia, and in Central and South America. Monkeys are usually associated with the global south, especially Africa. </p>
<p>In addition, there is a long dark history of black people being compared <a href="https://theconversation.com/comparing-black-people-to-monkeys-has-a-long-dark-simian-history-55102">to monkeys</a>. No disease nomenclature should provide a trigger for this. </p>
<h2>The history</h2>
<p><a href="https://www.who.int/emergencies/situations/monkeypox-oubreak-2022">Monkeypox</a> is a disease caused by the monkeypox virus, a member of the same family of viruses (<em>Poxviridae</em>) as smallpox. The virus was first identified in laboratory monkeys in the 1950s – hence the name. However, rodents, squirrels and non-human primates are believed to be the reservoir hosts.</p>
<p>The first human monkeypox case was confirmed in 1970 in the Democratic Republic of Congo. Since then, there have been periodic outbreaks in western and central Africa, where it is endemic in <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">11 countries</a>. We don’t know the real prevalence of the disease. </p>
<p>Nearly all monkeypox outbreaks in Africa prior to 2022 emanated from spillover from animals to humans. Only rarely have there been reports of sustained human-to-human transmission. This has not been so with the cases <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON393">reported</a> since May 2022. The cases presented at healthcare facilities involved people who had travelled to countries outside of Africa. </p>
<p>The main symptom of monkeypox is a rash that looks like chickenpox. Monkeypox can spread through close contact with an infected person’s body fluids, respiratory droplets and contaminated materials. </p>
<p>Monkeypox is rarely a public health emergency. The infections are usually mild, compared to smallpox or chickenpox.</p>
<h2>Naming conventions</h2>
<p>WHO <a href="https://apps.who.int/iris/bitstream/handle/10665/163636/WHO_HSE_FOS_15.1_eng.pdf">guidelines recommend</a> avoiding animal names or geographic regions for viruses and diseases. </p>
<p>The <a href="https://virological.org/t/urgent-need-for-a-non-discriminatory-and-non-stigmatizing-nomenclature-for-monkeypox-virus/853">current classification</a> of monkeypox virus’ genetic diversity recognises two clades of the virus referred to as the “West African” clade and the “Central African” or “Congo Basin” clade. </p>
<p>Some genome sequences on the <a href="https://www.ncbi.nlm.nih.gov/nuccore/NC_063383">NCBI Genbank database</a> use “West African” for the field “strain” or “genotype”. </p>
<p>Lessons learnt from objections to calling the B.1.1.529 variant (omicron) of SARS-CoV-2 as the ‘South African variant’ informed the use of the <a href="https://cov-lineages.org/">Pango nomenclature for SARS-CoV-2</a>. </p>
<p>To name infectious diseases based on locations of first detection is misleading because of limited diagnostic or priorities in different regions. It could also delay reporting of new variants of infections discovered in Africa. </p>
<p>As leadership in infectious diseases research in Africa is <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00977-1/fulltext">gaining recognition</a>, African scientists are also working to ensure the gains are not overshadowed by historical prejudices. It is good to know that people are listening.</p><img src="https://counter.theconversation.com/content/185307/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Moses John Bockarie works for EDCTP which is funded by the European Commission. In addition to his adjunct professorship at Njala University, Sierra Leone, he is honorary Chief Specialist Scientist at the South African Medical Research Council, and also a honorary professor in the Department of Medicine, University of Cape Town, South Africa. He previously received funding from the UK Department for International Development</span></em></p>The new name for monkeypox must be aligned with best practices in naming of infectious diseases to avoid the uninformed negative narrative that associates diseases with regions.Moses John Bockarie, Adjunct Professor, Njala UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1843092022-06-05T12:22:39Z2022-06-05T12:22:39ZMonkeypox FAQ: How is it transmitted? Where did it come from? What are the symptoms? Does smallpox vaccine prevent it?<figure><img src="https://images.theconversation.com/files/467005/original/file-20220603-14-1gthd.jpg?ixlib=rb-1.1.0&rect=0%2C59%2C2096%2C1420&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Magnified and colourized monkeypox virus particles. Since early May, over 550 confirmed cases of human infection with monkeypox virus have been reported in 30 countries. </span> <span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>With cases reported in a number of countries, human monkeypox infection is generating global interest and concern as an emerging infectious disease threat even in the midst of a slowly relenting COVID-19 pandemic. </p>
<h2>What is monkeypox virus?</h2>
<p>Monkeypox is a member of a closely related group of viruses in the Orthopoxvirus genus that includes smallpox, cowpox and camelpox. Monkeypox virus was <a href="https://doi.org/10.1111/j.1699-0463.1959.tb00328.x">first discovered in the summer of 1958</a> as a non-lethal, smallpox-like, skin disease of captive monkeys at a research institute in Denmark. </p>
<p>The name monkeypox is a misnomer since <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491157/pdf/bullwho00071-0068.pdf">terrestrial African rodents (rats and squirrels</a>) serve as the natural reservoir of the virus, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2631782/pdf/11384521.pdf">while monkeys and other primates are believed to be accidental hosts</a>.</p>
<h2>When was monkeypox first reported in humans?</h2>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2480792/pdf/bullwho00192-0028.pdf/?tool=EBI">first-known case of human monkeypox infection</a> was reported from Democratic Republic of Congo in 1970, in a nine-month-old boy with a non-fatal smallpox-like illness. </p>
<p>Since then, <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385">sporadic human cases have occurred in many Central and West African countries</a>, with infections being <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON381">more common in children</a> and young adults. In countries where monkeypox is endemic (where it is typically found), recent increases in cases are believed to be related to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857192/pdf/mm6710a5.pdf">climate change, deforestation</a>, <a href="https://doi.org/10.1016/j.ijid.2018.11.008">warfare, increased population mobility</a> and <a href="https://doi.org/10.1016/j.vaccine.2020.04.062">waning herd immunity from smallpox vaccination</a>.</p>
<h2>How is monkeypox transmitted?</h2>
<p><a href="https://doi.org/10.1016/j.ijid.2018.11.008">Transmission occurs</a> through close physical contact with <a href="https://doi.org/10.3390%2Fv12111257">animals</a> or <a href="https://doi.org/10.1371/journal.pntd.0010141">humans</a>, their body fluids, contaminated droplet particles from respiratory secretions or infected skin lesions and indirectly by way of “<a href="https://doi.org/10.3201/eid2604.191164">fomites</a>” (inanimate objects such as bed linens, towels and hard surfaces that may be laden with infectious virus particles). </p>
<p>Animal bites and consumption of <a href="https://doi.org/10.3390%2Fv12111257">animal meat</a> are common <a href="https://doi.org/10.1053/j.spid.2004.09.001">modes of transmission</a> in endemic areas. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395797/pdf/bullwho00425-0002.pdf">Secondary infections among unvaccinated close contacts</a> occur in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491157/pdf/bullwho00071-0068.pdf">about 12.3 per cent household contacts and 3.3 per cent</a> of others.</p>
<h2>When was monkeypox first reported in non-African countries?</h2>
<figure class="align-center ">
<img alt="A prairie dog" src="https://images.theconversation.com/files/467015/original/file-20220603-12-8ivjid.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467015/original/file-20220603-12-8ivjid.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467015/original/file-20220603-12-8ivjid.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467015/original/file-20220603-12-8ivjid.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467015/original/file-20220603-12-8ivjid.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467015/original/file-20220603-12-8ivjid.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467015/original/file-20220603-12-8ivjid.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The first outbreak of monkeypox in the United States occurred in 2003 when several people became infected after contact with pet prairie dogs that had the virus.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>The first cluster of human monkeypox infections outside of Africa <a href="https://www.science.org/doi/epdf/10.1126/science.300.5626.1639a">occurred in the United States in 2003</a>. A multi-state outbreak involving 87 children and young adults was attributed to close contact with infected prairie dogs acquired as pets from an animal distributor. The ultimate source of infection was found to be <a href="https://www.cdc.gov/mmwr//preview/mmwrhtml/mm5224a1.htm">imported Gambian rats that transmitted the infection to the prairie dogs</a>. There were no human deaths, although three children experienced severe illness.</p>
<p>Prior to 2022, several <a href="https://doi.org/10.1016/j.vaccine.2020.04.062">travel-associated cases</a> had been reported in the United Kingdom, Israel, Singapore and the U.S. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8989376/pdf/mm7114a1.pdf">among individuals who had visited Nigeria</a>.</p>
<h2>What do we know about the global monkeypox outbreak in non-endemic countries?</h2>
<p>On May 7, 2022, public health authorities in the U.K. were informed of <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385">a case of imported human monkeypox infection</a> in a traveller returning from Nigeria. Since then, over 550 confirmed cases of human infection <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON381">have been reported in the U.K. and 29 other countries</a>. Cases have been exceedingly higher <a href="https://news.un.org/en/story/2022/06/1119472">among men who have sex with men</a>, although the virus is not known to be sexually transmitted.</p>
<h2>What are the symptoms of monkeypox?</h2>
<p>The <a href="https://doi.org/10.1053/j.spid.2004.09.001">clinical manifestations</a> of <a href="http://dx.doi.org/10.3390/v12111257">human monkeypox infection</a> mimic <a href="http://dx.doi.org/10.3390/v9120380">those of smallpox</a>, but are typically much milder. Unlike monkeypox, smallpox is an eradicated disease, has no animal reservoir and does not usually affect the lymph nodes.</p>
<p>The incubation period of <a href="https://doi.org/10.3201/eid2604.191164">monkeypox in humans</a> ranges from four to 21 days and is followed by a one- to five-day phase of fevers, chills, sweats, fatigue and enlarged, tender lymph nodes in the neck and groin. </p>
<p>The next phase involves a <a href="https://doi.org/10.1016/j.ijid.2018.11.008">multi-stage rash</a> that progresses from small skin patches to papules (small bumps on the skin), followed by vesicles (small bumps filled with clear fluid) and then pustules (small bumps filled with pus). These are most prominent on the face, palms and soles of the feet. The pustules resolve by scarring or crusting over in the ensuing two to four weeks. </p>
<p>Exposed people may also develop a sore throat, cough and/or a rash on the mucous membranes of the mouth.</p>
<h2>How severe is monkeypox infection?</h2>
<p>The disease is usually mild, although severe illness and death can occur. There are two common genetic variants of monkeypox virus: the Central African variant and the West African variant. <a href="https://doi.org/10.1371/journal.pntd.0010141">Mortality rates</a> of 3.6 per cent for the West African variant and 10.6 per cent for the Central African variant have been reported in endemic regions. </p>
<p>However, <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385">no deaths have occurred to date</a> in any of the cases reported <a href="https://www.cdc.gov/mmwr//preview/mmwrhtml/mm5224a1.htm">outside of Africa</a>. All confirmed cases from the 2022 outbreak in the 30 non-endemic countries have been due to the <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON381">West African variant</a>.</p>
<h2>Are there any other public health recommendations for monkeypox?</h2>
<figure class="align-right ">
<img alt="Green rectangles with rounded corners against a beige background" src="https://images.theconversation.com/files/467017/original/file-20220603-24-vj11au.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/467017/original/file-20220603-24-vj11au.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=549&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467017/original/file-20220603-24-vj11au.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=549&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467017/original/file-20220603-24-vj11au.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=549&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467017/original/file-20220603-24-vj11au.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=690&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467017/original/file-20220603-24-vj11au.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=690&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467017/original/file-20220603-24-vj11au.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=690&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Colourized and magnified monkeypox virus particles.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p><a href="https://doi.org/10.1371/journal.pntd.0010141">People who are infected with monkeypox</a> should wear surgical masks, and skin lesions should be covered until they have healed. Personal use items such as towels and sheets should not be shared. Frequently touched surfaces should be regularly disinfected, contaminated clothing should be laundered and contact with household and non-household members should be avoided until the illness has resolved. </p>
<p><a href="https://www.canada.ca/en/public-health/services/diseases/monkeypox/health-professionals/interim-guidance-infection-prevention-control-healthcare-settings.html">Health-care workers</a> should use gloves, gowns and respiratory protection with N95 masks and face shields, and maintain excellent hand hygiene while caring for patients with monkeypox. Hospitalized patients with confirmed or suspected monkeypox should be isolated with precautions for airborne, droplet and contact transmission until they are no longer contagious.</p>
<h2>Does smallpox vaccine protect against monkeypox?</h2>
<p><a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html">Smallpox vaccine</a> — administered either before or after <a href="https://doi.org/10.1086/595552">exposure to monkeypox</a> — may prevent or reduce the effects of <a href="https://doi.org/10.1093/ije/17.3.643">human monkeypox</a> infection. However, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069029/pdf/ClinMedRes0102-0087.pdf">rare but serious adverse events</a> have been reported from older generation smallpox vaccines. A newer generation, non-replicating, live vaccine is now available and is <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-21-smallpox-vaccine.html">deemed safe for use in all populations, including those with compromised immune systems</a>. </p>
<p>The <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7122e1.htm">U.S. Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices</a> recommends pre-exposure prophylaxis (vaccination prior to exposure to the virus) with the newer generation vaccine for laboratory workers performing monkeypox diagnostic testing, as well as for health-care workers administering smallpox vaccine or caring for patients with monkeypox. (Its <a href="https://www.cdc.gov/smallpox/clinicians/vaccines.html">trade name</a> is Jynneos in the U.S., Imvamune in Canada and Imvanex in Europe.)</p>
<p>In Canada and other developed countries, people born before 1972 were likely <a href="https://doi.org/10.1016/j.amjmed.2008.08.019">vaccinated against smallpox</a>. Although immunity following vaccination tends to wane with age, lifelong immunity appears to be the norm following smallpox vaccination in otherwise healthy individuals, and its cross-protective efficacy against monkeypox is believed to be <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html">85 per cent</a>.</p>
<h2>Is monkeypox the next viral pandemic?</h2>
<p>The emergence of infectious diseases such as monkeypox in non-endemic areas has created a great deal of anxiety in light of our experience with COVID-19. </p>
<p>Monkeypox had been a neglected tropical disease until the current outbreak in the developed world. But the trajectory of these cases, coupled with the pattern of transmission in Africa, <a href="https://doi.org/10.1371/journal.pntd.0010141">suggests that the virus will not become pandemic</a>.</p>
<p>The basic reproduction number (R0), a measure of viral contagiousness, where R0 equals the number of secondary infections transmitted from a single case in a non-immune population, is 0.6 to 1.0 for the Central African variant, <a href="https://doi.org/10.1371/journal.pntd.0010141">and much lower for the West African variant</a>.</p>
<p>In contrast, the R0 for the Omicron variant of SARS-CoV-2 is approximately 10, and the R0 for measles <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9113689/pdf/germs-12-01-7.pdf">ranges from 11 to 18</a>. The R0 for the West African variant of monkeypox virus <a href="https://doi.org/10.18683/germs.2022.1301">may be too low to sustain human-to-human transmission</a> outside of endemic areas.</p><img src="https://counter.theconversation.com/content/184309/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sameer Elsayed does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Recent outbreaks have drawn attention to monkeypox. Get answers to common questions about this relative of the smallpox virus, including transmission, symptoms and effectiveness of smallpox vaccine.Sameer Elsayed, Professor of Medicine, Pathology & Laboratory Medicine, and Epidemiology & Biostatistics, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1836862022-05-26T10:10:02Z2022-05-26T10:10:02ZMonkeypox: we have vaccines and drugs to treat it<p>Medicines are not <a href="https://www.nhs.uk/conditions/monkeypox/">normally needed</a> to treat monkeypox. The illness is <a href="https://www.gov.uk/guidance/monkeypox#treatment">usually mild</a> and most people infected will recover within a few weeks without needing treatment. But there are vaccines that can be used to control monkeypox outbreaks, which some countries are already using. And treatments do exist for those who become quite ill from the virus.</p>
<p>Monkeypox belongs to the <a href="https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/smallpox-and-other-orthopoxvirus-associated-infections"><em>Orthopoxvirus</em></a> genus of viruses, which includes smallpox. Luckily, due to something called cross-protection, smallpox vaccines also work for monkeypox.</p>
<p>Although the world was declared free of smallpox in 1980, many countries keep stocks of smallpox vaccines for emergencies. For example, the smallpox vaccine is used to protect <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/148501/Green-Book-Chapter-29-dh_063660.pdf">laboratory workers</a> who accidentally come into contact with pox viruses (such as monkeypox or <a href="https://theconversation.com/monkeypox-some-countries-are-protecting-contacts-with-the-smallpox-vaccine-which-uses-humanitys-only-domesticated-virus-183551">vaccinia</a> – a pox virus that is similar to smallpox but less harmful). They are also kept in case of a <a href="https://www.parliament.uk/globalassets/documents/post/pn166.pdf">terrorist attacks</a> that might use smallpox as a <a href="https://www.cdc.gov/smallpox/bioterrorism/public/index.html">biological weapon</a>. </p>
<p>Smallpox vaccine can be up to <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1077678/Recommendations-for-use-of-pre-and-post-exposure-vaccination-during-a-monkeypox-incident.pdf">85%</a> effective in stopping infection with the monkeypox virus if it is given before people are exposed to the virus. </p>
<p>There are two types of smallpox vaccine. Both types are based on the vaccinia virus. An older type of smallpox vaccine contains the “live” vaccinia virus. The main one in this group is <a href="https://www.fda.gov/vaccines-blood-biologics/vaccines/acam2000">ACAM2000</a>, which is approved in the US for protecting people against smallpox. </p>
<p>Although ACAM2000 cannot cause smallpox, the vaccinia virus it contains can replicate after the vaccine is given, <a href="https://www.cdc.gov/smallpox/vaccine-basics/who-gets-vaccination.html">transmitting</a> from the vaccinated person to an unvaccinated person who comes into close contact with the injection site or any leaking fluid for up to 21 days afterwards. </p>
<p>This also means that ACAM2000 can cause many <a href="https://www.cdc.gov/smallpox/vaccine-basics/vaccination-effects.html">side effects</a> and shouldn’t be given to at-risk groups, such as pregnant or breastfeeding women, and those with weakened immune systems. People with weakened immune systems, including those with <a href="https://www.bhiva.org/file/NriBJHDVKGwzZ/2015-Vaccination-Guidelines.pdf">HIV</a>, can get very ill from the vaccine. </p>
<p>The other “live” vaccinia virus is the <a href="https://www.cdc.gov/smallpox/clinicians/vaccines.html">Aventis Pasteur Smallpox Vaccine</a>. It is not formally approved, but can be made available if other supplies run out.</p>
<p>A newer type of smallpox vaccine, called Imvanex, contains a live but modified form of the vaccinia virus called vaccinia Ankara. Imvanex, made by Danish biotechnology firm Bavarian Nordic, has been <a href="https://www.ema.europa.eu/en/medicines/human/EPAR/imvanex">licensed in the European Union</a> for preventing smallpox. </p>
<p>In the US, the vaccine goes by the brand name <a href="https://www.fda.gov/vaccines-blood-biologics/jynneos">Jynneos</a> and is licensed for preventing both smallpox and monkeypox in adults at risk of these diseases. Jynneos has been used <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1077678/Recommendations-for-use-of-pre-and-post-exposure-vaccination-during-a-monkeypox-incident.pdf">in the UK</a> in previous monkeypox cases. </p>
<p>Because Bavarian Nordic vaccines are made of a modified form of the vaccinia virus, they are considered safe for people in at-risk groups.</p>
<p>It would usually take between five and 21 days for someone who comes into close contact with an infected person to <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/850059/Monkeypox_information_for_primary_care.pdf">show symptoms</a> of monkeypox (and most likely seven to 14 days) so it is hard to tell if giving the vaccine after someone has been exposed to monkeypox will fully protect them. However, the recommendation in the <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html">US</a> and the <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1077678/Recommendations-for-use-of-pre-and-post-exposure-vaccination-during-a-monkeypox-incident.pdf">UK</a> is that, after a risk assessment, people exposed to the monkeypox virus are offered a modified vaccinia Ankara vaccine dose as soon as possible, ideally within four days, but up to 14 days afterwards.</p>
<h2>Antivirals</h2>
<p>Apart from vaccines, there are <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html">some medicines</a> that could be used for treating monkeypox.</p>
<p>One such drug is <a href="https://www.sps.nhs.uk/medicines/tecovirimat/">tecovirimat</a> which stops the spread of infection by interfering with a protein found on the surface of <em>Orthopoxviruses</em>. </p>
<p>Tecovirimat is <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-indication-treatment-smallpox">approved</a> in the US for treating smallpox only. It has been <a href="https://www.cdc.gov/smallpox/prevention-treatment/index.html">tested in healthy humans</a> and shown to stop the smallpox virus in the lab. However, it has not been tested in people with smallpox or other <em>Orthopoxviruses</em>. Still, in Europe <a href="https://www.ema.europa.eu/en/medicines/human/EPAR/tecovirimat-siga">tecovitimat</a> has been authorised for treating smallpox, monkeypox and cowpox under exceptional circumstances. </p>
<p>Another antiviral that might be used is cidofovir – an injectable drug licensed in the UK to <a href="https://bnf.nice.org.uk/drug/cidofovir.html">treat a serious viral eye infection</a> in people with Aids. </p>
<p>In the body, cidofovir is converted into the antiviral ingredient cidofovir diphosphate. Because cidofovir stops smallpox in the laboratory, it could be authorised for emergency use in <a href="https://www.cdc.gov/smallpox/prevention-treatment/index.html">smallpox</a> or <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html">monkeypox</a> outbreaks. </p>
<p>However, cidofovir is quite a potent medicine and can <a href="https://www.medicines.org.uk/emc/product/11151/smpc#gref">damage</a> the kidneys, so a better alternative might be the closely related drug <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/214460s000,214461s000lbl.pdf">brincidofovir</a>, which has been <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/214460s000,214461s000lbl.pdf">approved</a> in the US for treating smallpox. </p>
<p>Brincidofovir (brand name Tembexa) is <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/214460s000,214461s000lbl.pdf">given by mouth</a> and can be prescribed to people of any age. Its special design helps get the right amount of the drug into cells to release the cidofovir component and also makes it <a href="https://www.sciencedirect.com/science/article/pii/S0166354203001104?via%3Dihub">less damaging</a> to the kidneys.</p>
<p>Brincidofovir has been <a href="https://clinicaltrials.gov/ct2/show/NCT02439957?term=brincidofovir&draw=2&rank=7">tested in humans</a> for other viral conditions. Its approval for use in smallpox in the US comes from <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/214460s000,214461s000lbl.pdf">laboratory studies</a> showing that it works against <em>Orthopoxviruses</em>. For this reason, brincidofovir is also listed as a potential drug for treating <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html">monkeypox</a>.</p>
<p>What we still lack, though, is data on how effective cidofovir, brincidofovir and tecovitimat will be in treating monkeypox infections in humans. A recent paper, published in <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00228-6/fulltext">The Lancet Infectious Diseases</a> investigated the effectiveness of brincidofovir (three patients) and tecovirimat (one patient) in monkeypox cases between 2018 to 2021 in the UK. The researchers reported poor efficacy for brincidofovir and called for more studies of tecovirimat in human monkeypox infection.</p><img src="https://counter.theconversation.com/content/183686/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Parastou Donyai does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A number of vaccines and several antivirals could be used to control the global monkeypox outbreak.Parastou Donyai, Professor of Social and Cognitive Pharmacy, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1835512022-05-24T13:58:06Z2022-05-24T13:58:06ZMonkeypox: some countries are protecting contacts with the smallpox vaccine, which uses humanity’s only domesticated virus<p>The good news about monkeypox is that it <a href="https://www.gov.uk/guidance/monkeypox#transmission">doesn’t spread that well</a> between humans. Because of this, the current monkeypox outbreak will probably be kept under control by isolating infected people and their contacts, coupled with <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/britain-offers-smallpox-shot-monkeypox-cases-spread-europe-2022-05-19/">selected vaccination</a>. </p>
<p>Fortunately, monkeypox is similar enough to smallpox that the smallpox vaccine is <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html">effective against both viruses</a>. Rather than vaccinate everyone, we will most likely use “ring vaccination”: vaccinating contacts of known infected people to keep the outbreak under control. </p>
<p>Ring vaccination works when there are limited cases that can be easily identified. This approach was used in the past for outbreaks of Ebola (<a href="https://www.who.int/news-room/questions-and-answers/item/ebola-vaccines">highly effective Ebola vaccines</a> were developed after the <a href="https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html">2014 epidemic</a> to little fanfare) as well as to <a href="https://www.cdc.gov/smallpox/history/history.html#:%7E:text=Almost%20two%20centuries%20after%20Jenner,achievement%20in%20international%20public%20health.">eradicate smallpox in the 1970s</a>. </p>
<p>Unless there is surprising new information about this strain of monkeypox, selective isolation and ring vaccination will be enough – this is not another COVID-19. But the smallpox vaccine, <em>vaccinia</em>, which has saved millions of lives already, is one of the strangest things that humanity has ever created. This is a virus that we domesticated for our own uses as a vaccine, repurposed for other vaccines and may have been accidentally released into the wild. </p>
<figure class="align-center ">
<img alt="Vaccinia virus." src="https://images.theconversation.com/files/465006/original/file-20220524-25-kfci14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465006/original/file-20220524-25-kfci14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465006/original/file-20220524-25-kfci14.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465006/original/file-20220524-25-kfci14.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465006/original/file-20220524-25-kfci14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=580&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465006/original/file-20220524-25-kfci14.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=580&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465006/original/file-20220524-25-kfci14.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=580&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vaccinia, the world’s first domesticated virus.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=1586332">CDC/Cynthia Goldsmith</a></span>
</figcaption>
</figure>
<h2><em>Vaccinia</em> - when humans domesticated a virus</h2>
<p>Many people know the story of <a href="https://www.jenner.ac.uk/about/edward-jenner">Edward Jenner</a>, the English doctor who, in the late 18th century, noticed that milkmaids who had caught cowpox were protected from smallpox. So he started vaccinating: intentionally giving people cowpox to protect them from smallpox.</p>
<p>After a while, it became easier to harvest smallpox vaccine from the vaccinated, rather than from cows. Once a human was spiked with the cowpox virus, they developed pustules a few days later, and then virus was taken by puncturing the pustule and passed it on to the next person. </p>
<p>This dirty technique obviously carried across all sorts of skin infections but also gave cowpox time to adapt and mutate to its new ecological niche, eventually becoming the <em>vaccinia</em> virus we know today. This means that <em>vaccinia</em> is a virus that has been cultivated by humans for our own benefit. So <em>vaccinia</em> is what I would call a “domesticated virus”. </p>
<p><em>Vaccinia</em>, however, is genetically distinct from cowpox. This is because it was cultured for a long time in human-to-human transmission chains. </p>
<p>As the smallpox vaccine is made with the live <em>vaccinia</em>, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5925a2.htm">it can spread</a> from recently vaccinated people to unvaccinated contacts. </p>
<h2><em>Vaccinia</em> can be used to vaccinate against other viruses</h2>
<p>The AstraZeneca vaccine against COVID was a viral vector vaccine, where a strain of adenovirus had the spike protein from the novel coronavirus (SARS-CoV-2) added in. </p>
<p><em>Vaccinia</em> was one of the first viruses to get this treatment almost <a href="https://pubmed.ncbi.nlm.nih.gov/6835382/">40 years ago</a>. In the 1980s, we knew we had a safe and effective vaccine for smallpox, which was going out of use once smallpox was eradicated. If we used DNA splicing (a brand new concept at the time) to put in genes from other viruses, we could make vaccines against them as well. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7112317/">A lot of vaccines</a> have been through clinical trials which use modified versions of <em>vaccinia</em>. Outside of a pandemic this is generally a slow process from testing to approval, but one <em>vaccinia</em>-based vaccine has been approved: <a href="https://www.ema.europa.eu/en/medicines/human/EPAR/mvabea">Mvabea</a>, which is an approved vaccine for Ebola. </p>
<h2>Accidentally released into the wild?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869513/">Bovine vaccinia</a> is a disease endemic to Brazilian milking cattle. It causes rashes and lesions on the udders that can spread to the hands of workers who milk the cattle. </p>
<p>This is an economic problem in Brazil as infected cattle can’t be milked (and sometimes need to be put down) and workers have to take time off sick. Bovine vaccinia is a reminder that viruses regularly spread from livestock to humans, and we need to handle live animals in a hygienic way. It also reminds us that viruses can travel the other way.</p>
<p>The Bovine vaccinia genome has a remarkable resemblance to <em>vaccinia</em>. This isn’t too surprising as <em>vaccinia</em> originated from European cowpox, and bovine vaccinia might be a new world variant of cowpox. However, bovine vaccinia might also be due to early vaccination efforts in South America. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/26378174/">Several</a> <a href="https://pubmed.ncbi.nlm.nih.gov/11080491/">groups</a> believe that bovine vaccinia is most likely to be an older smallpox vaccine that “escaped” from a vaccinated farm worker into the local population of cows and has adapted to its new environment. </p>
<p>Much like a domesticated pet cat that wreaks havoc in the local bird population, it looks as if our domesticated virus is wreaking havoc on Brazilian milk farming.</p><img src="https://counter.theconversation.com/content/183551/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben Krishna does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Humans have cultivated their own virus (vaccinia) that can be used in many vaccines. But there may be a price to pay.Ben Krishna, Postdoctoral Researcher, Immunology and Virology, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1836062022-05-23T12:08:49Z2022-05-23T12:08:49ZMonkeypox Q&A: how do you catch it and what are the risks? An expert explains<p>The latest outbreak of monkeypox has, at the time of writing, reached 17 countries with <a href="https://bnonews.com/monkeypox/">110 confirmed cases and a further 205 suspected cases</a>. It’s a fast-moving story, so if you need to catch up on the latest, here are answers to some of the most pressing questions. </p>
<h2>How is monkeypox spreading?</h2>
<p>The first patient in the current outbreak had returned to the UK from <a href="https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-updates">travels to Nigeria</a> where monkeypox is endemic. However, cases are now spreading among people who have not travelled to west or central Africa, suggesting local transmission is occurring.</p>
<p>Monkeypox usually spreads by close contact and respiratory droplets. However, sexual transmission (via semen and/or vaginal fluid) has been posited as an additional possible route. <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON381">The World Health Organization</a> (WHO) says: “Studies are needed to better understand this risk.”</p>
<p>Most cases in the current outbreak have been in <a href="https://www.statnews.com/2022/05/19/17-suspected-monkeypox-cases-seen-in-montreal-as-european-tally-increases/">youngish men</a>, but the virus can spread to anyone. </p>
<h2>What are the symptoms?</h2>
<p>Early symptoms are flu-like, such as a fever, headaches, aching muscles and swollen lymph nodes.</p>
<p>Once the fever breaks, a rash can develop, often beginning on the face and then spreading to other parts of the body – most commonly the palms of the hands and soles of the feet.</p>
<figure class="align-center ">
<img alt="Monkeypox lesions." src="https://images.theconversation.com/files/464758/original/file-20220523-20-uid52v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464758/original/file-20220523-20-uid52v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464758/original/file-20220523-20-uid52v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464758/original/file-20220523-20-uid52v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464758/original/file-20220523-20-uid52v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464758/original/file-20220523-20-uid52v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464758/original/file-20220523-20-uid52v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Evolution of monkeypox lesions.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=118186900">UK government/Wikimedia</a></span>
</figcaption>
</figure>
<h2>How deadly is monkeypox?</h2>
<p>Monkeypox is mostly a mild, self-limiting disease lasting two-to-three weeks. However, in some cases, it can cause death. According to the WHO, the fatality rate “in recent times” has been <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">around 3% to 6%</a>. The west African monkeypox virus is considered to be milder than the central African one. </p>
<p>Monkeypox tends to cause more serious disease in people who are immunocompromised – such as those undergoing chemotherapy – and children. There have been no deaths from monkeypox in the current worldwide outbreak, but, according to the <a href="https://www.telegraph.co.uk/news/2022/05/22/british-scientists-warned-monkeypox-would-fill-void-left-smallpox/">Daily Telegraph</a>, one child in the UK is in intensive care with the disease.</p>
<h2>Why is it called monkeypox?</h2>
<p>Monkeypox was first identified in laboratory monkeys (macaques) in <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1699-0463.1959.tb00328.x">Denmark in 1958</a>, hence the name. However, monkeys don’t seem to be the natural hosts of the virus. It is more commonly found in rats, mice and squirrels. The first case in humans was seen in the <a href="https://apps.who.int/iris/bitstream/handle/10665/67095/WHO_SE_80.153.pdf?sequence=1&isAllowed=y">1970s in the Democratic Republic of the Congo</a>.</p>
<h2>Is monkeypox related to smallpox and chickenpox?</h2>
<p>Monkeypox is related to smallpox – they are both orthopoxviruses – but it is not related to chickenpox. Despite the name, chickenpox is a herpes virus, not a poxvirus. (How “chicken” got in the name is not entirely clear. In his dictionary of 1755, Samuel Johnson surmised that it is so named because it is “<a href="https://johnsonsdictionaryonline.com/views/search.php?term=Chickenpox">of no very great danger</a>”.) Nevertheless, the vesicles (little pus-filled blisters) caused by monkeypox are similar in appearance to those of chickenpox.</p>
<h2>Are cases likely to continue rising?</h2>
<p>Cases are likely to continue <a href="https://news.sky.com/story/monkeypox-significant-rise-in-uk-cases-expected-in-next-week-says-expert-as-some-clinics-stop-walk-ins-12618092">to rise significantly</a> over the next two-to-three weeks, but this is not another pandemic in the making. Monkeypox doesn’t spread anywhere near as easily as the airborne virus SARS-CoV-2 that causes COVID-19.</p>
<h2>Has monkeypox evolved to be more virulent?</h2>
<p>RNA viruses, such as SARS-CoV-2, don’t have the ability to check their genetic code for mistakes each time they replicate, so they tend to evolve faster. Monkeypox is a DNA virus, which does have the ability to check itself for genetic mistakes each time it replicates, so it tends to mutate a lot slower. </p>
<p>The <a href="https://virological.org/t/first-draft-genome-sequence-of-monkeypox-virus-associated-with-the-suspected-multi-country-outbreak-may-2022-confirmed-case-in-portugal/799">first genome sequence</a> of the current outbreak (from a patient in Portugal) suggests that the virus is <a href="https://www.newscientist.com/article/2321407-first-monkeypox-genome-from-latest-outbreak-shows-links-to-2018-strain/">very similar</a> to the monkeypox strain that was circulating in 2018 and 2019 in the UK, Singapore and Israel. So it is unlikely that the current outbreak is the result of a mutated virus that is better at spreading.</p>
<h2>How is monkeypox diagnosed?</h2>
<p>In the UK, swab samples taken from the patient are sent to a specialist laboratory that handles rare pathogens, where a PCR test is run to confirm monkeypox. The UK Health Security Agency has only <a href="https://www.economist.com/news/2022/05/20/monkeypox-is-popping-up-in-more-countries-how-worrying-is-this">one rare and imported pathogens laboratory</a>. </p>
<h2>Is there a vaccine for it?</h2>
<p>Vaccines for smallpox, which contain the lab-made vaccinia virus, can protect against monkeypox. However, the vaccine that was used to eradicate smallpox can have severe side-effects, killing around <a href="https://www.science.org/content/article/monkeypox-outbreak-questions-intensify-cases-soar">one in a million</a> people vaccinated.</p>
<p>The only vaccine <a href="https://www.science.org/content/article/monkeypox-outbreak-questions-intensify-cases-soar">specifically approved for monkeypox</a>, Imvanex, is made by a company called Bavarian Nordic. It uses a nonreplicating form of vaccinia, which causes fewer side-effects. It was approved by the <a href="https://www.precisionvaccinations.com/vaccines/jynneos-smallpox-monkeypox-vaccine#">US Food and Drug Administration and the European Medicines Agency</a> in 2019 – but only for use in people 18 years of age or older.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-isnt-like-hiv-but-gay-and-bisexual-men-are-at-risk-of-unfair-stigma-183571">Monkeypox isn’t like HIV, but gay and bisexual men are at risk of unfair stigma</a>
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</em>
</p>
<hr>
<p>UK health secretary Sajid Javid said that the UK government will be <a href="https://www.bbc.co.uk/news/health-61520228.amp">stocking up</a> on vaccines that are effective against monkeypox. The UK currently has about <a href="https://www.thescottishsun.co.uk/health/8891841/britains-stockpiles-of-monkeypox-vaccines/">5,000 doses</a> of smallpox vaccine, which has an efficacy of around 85% against monkeypox.</p>
<h2>Are there drugs to treat it?</h2>
<p>There are no specific drugs to treat monkeypox. However, antivirals such as cidofovir and brincidofovir have been proven to be <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html#:%7E:text=Smallpox%20vaccination%20kit.-,Cidofovir%20and%20Brincidofovir%20(CMX001),in%20vitro%20and%20animal%20studies.">effective against poxviruses in animals</a> and may also be effective against monkeypox infections in humans.</p><img src="https://counter.theconversation.com/content/183606/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ed Feil does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How deadly is monkeypox? Why is it called monkeypox? Is it related to chickenpox? All your questions answered.Ed Feil, Professor of Microbial Evolution at The Milner Centre for Evolution, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1834992022-05-20T12:43:49Z2022-05-20T12:43:49ZWhat is monkeypox? A microbiologist explains what’s known about this smallpox cousin<figure><img src="https://images.theconversation.com/files/464377/original/file-20220519-12-yjgwpg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1022%2C813&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Monkeypox causes lesions that resemble pus-filled blisters, which eventually scab over.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/in-this-centers-for-disease-control-and-prevention-handout-news-photo/2067975">CDC/Getty Images</a></span></figcaption></figure><p>On May 18, 2022, <a href="https://www.wcvb.com/article/massachusetts-first-monkeypox-case-2022-confirmed-health-officials/40038782#">Massachusetts health officials</a> and the <a href="https://www.cdc.gov/media/releases/2022/s0518-monkeypox-case.html">Centers for Disease Control and Prevention</a> confirmed a single case of monkeypox in a patient who had recently traveled to Canada. Cases have also been <a href="https://www.npr.org/sections/goatsandsoda/2022/05/18/927043767/rare-monkeypox-outbreak-in-u-k-and-europe-what-is-it-and-should-we-worry">reported in the United Kingdom and Europe</a>.</p>
<p>Monkeypox isn’t a new disease. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2480792/">first confirmed human case was in 1970</a>, when the virus was isolated from a child suspected of having smallpox in the Democratic Republic of Congo (DRC). Monkeypox is unlikely to cause another pandemic, but <a href="https://www.theatlantic.com/health/archive/2022/05/monkeypox-outbreak-covid-pandemic/629920/">with COVID-19 top of mind</a>, fear of another major outbreak is understandable. Though rare and usually mild, monkeypox can still potentially cause severe illness. Health officials are concerned that more cases will arise with increased travel.</p>
<p>I’m a researcher who has worked in <a href="https://rodneyerohde.wp.txstate.edu/">public health and medical laboratories</a> for over three decades, especially in the realm of diseases with animal origins. What exactly is happening in the current outbreak, and what does history tell us about monkeypox?</p>
<h2>A cousin of smallpox</h2>
<p><a href="https://www.cdc.gov/poxvirus/monkeypox/about.html">Monkeypox</a> is caused by the monkeypox virus, which belongs to a subset of the Poxviridae family of viruses called Orthopoxvirus. This subset includes the smallpox, <a href="http://doi.org/10.3121/cmr.1.2.87">vaccinia</a> and cowpox viruses. While an <a href="https://www.ncbi.nlm.nih.gov/books/NBK574519/">animal reservoir for monkeypox virus is unknown</a>, African rodents are suspected to play a part in transmission. The monkeypox virus has only been isolated twice from an animal in nature. <a href="https://www.cdc.gov/poxvirus/monkeypox/lab-personnel/lab-procedures.html#">Diagnostic testing for monkeypox</a> is currently only available at Laboratory Response Network labs in the U.S. and globally.</p>
<p>The name “monkeypox” comes from the <a href="https://doi.org/10.1128/br.37.1.1-18.1973">first documented cases</a> of the illness in animals in 1958, when two outbreaks occurred in monkeys kept for research. However, <a href="https://www.contagionlive.com/view/virus-spillover-and-emerging-pathogens-pick-up-speed">the virus did not jump</a> from monkeys to humans, nor are monkeys major carriers of the disease.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Electron microscope view of monkeypox, showing oval-shaped, mature virus particles and spherical, immature virions" src="https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464367/original/file-20220519-13752-jfwfff.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Monkeypox belongs to the Poxviridae family of viruses, which includes smallpox.</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=22664">CDC/ Cynthia S. Goldsmith</a></span>
</figcaption>
</figure>
<h2>Epidemiology</h2>
<p>Since the first reported human case, monkeypox has been found in <a href="https://www.cdc.gov/poxvirus/monkeypox/about.html">several other central and western African countries</a>, with the majority of infections in the DRC. Cases outside of Africa have been linked to international travel or imported animals, including in the U.S. and <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox#">elsewhere</a>. </p>
<p>The <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5227a5.htm">first reported cases of monkeypox in the U.S.</a> was in 2003, from an outbreak in Texas linked to a shipment of animals from Ghana. There were also travel-associated cases in <a href="https://www.cdc.gov/poxvirus/monkeypox/outbreak/us-outbreaks.html">November and July 2021</a> in Maryland.</p>
<p>Because monkeypox is closely related to smallpox, the smallpox vaccine can <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html">provide protection</a> against infection from both viruses. Since smallpox was officially eradicated, however, <a href="https://www.cdc.gov/smallpox/vaccine-basics/index.html">routine smallpox vaccinations</a> for the U.S. general population were stopped in 1972. Because of this, monkeypox has been <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">appearing increasingly</a> in unvaccinated people.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person getting temperature tested at airport" src="https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464369/original/file-20220519-26-10sgpc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Indonesia began screening travelers after a monkeypox case was reported in Singapore in May 2019.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/health-officer-uses-a-thermal-head-to-detect-a-monkeypox-news-photo/1144024293">Jepayona Delita/Future Publishing via Getty Images</a></span>
</figcaption>
</figure>
<h2>Transmission</h2>
<p>The virus can be <a href="https://www.cdc.gov/poxvirus/monkeypox/transmission.html">transmitted</a> through contact with an infected person or animal or contaminated surfaces. Typically, the virus enters the body through broken skin, inhalation or the mucous membranes in the eyes, nose or mouth. Researchers believe that human-to-human transmission is mostly through inhalation of large respiratory droplets rather than direct contact with bodily fluids or indirect contact through clothes. Human-to-human transmission rates for monkeypox have been <a href="https://www.nj.gov/agriculture/divisions/ah/diseases/monkeypox.html">limited</a>.</p>
<p><a href="https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-updates">Health officials</a> are worried the virus may currently be spreading undetected through community transmission, possibly through a new mechanism or route. Where and how infections are occurring are still under investigation.</p>
<h2>Signs and symptoms</h2>
<p>After the virus enters the body, it starts to <a href="https://www.ncbi.nlm.nih.gov/books/NBK574519/">replicate and spread</a> through the body via the bloodstream. Symptoms usually don’t appear until one to two weeks after infection.</p>
<p>Monkeypox produces smallpox-like skin lesions, but <a href="https://www.cdc.gov/poxvirus/monkeypox/symptoms.html">symptoms</a> are usually milder than those of smallpox. Flu-like symptoms are common initially, ranging from fever and headache to shortness of breath. One to 10 days later, a rash can appear on the extremities, head or torso that eventually turns into blisters filled with pus. Overall, symptoms usually last for two to four weeks, while skin lesions usually scab over in 14 to 21 days. </p>
<p>While monkeypox is rare and usually non-fatal, <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">one version</a> of the disease kills <a href="https://doi.org/10.1099/vir.0.81215-0">around 10% of infected people</a>. The form of the virus currently circulating is thought to be milder, with a fatality rate of less than 1%. </p>
<h2>Vaccines and treatments</h2>
<p><a href="https://www.cdc.gov/poxvirus/monkeypox/treatment.html">Treatment for monkeypox</a> is primarily focused on relieving symptoms. According to the CDC, no treatments are available to cure monkeypox infection.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/yqUFy-t4MlQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Because smallpox is closely related to monkeypox, the smallpox vaccine can protect against both diseases.</span></figcaption>
</figure>
<p>Evidence suggests that the smallpox vaccine can help prevent monkeypox infections and decrease the severity of the symptoms. One vaccine known as <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html">Imvamune or Imvanex</a> is licensed in the U.S. to prevent monkeypox and smallpox.</p>
<p>Vaccination after exposure to the virus may also help decrease chances of severe illness. The CDC currently recommends smallpox vaccination only in people who have been or are likely to be exposed to monkeypox. <a href="https://www.ecdc.europa.eu/en/news-events/monkeypox-cases-reported-uk-and-portugal">Immunocompromised people</a> are at high risk.</p><img src="https://counter.theconversation.com/content/183499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rodney E. Rohde has received funding from the American Society of Clinical Pathologists (ASCP), American Society for Clinical Laboratory Science (ASCLS), U.S. Department of Labor (OSHA), and other public and private entities/foundations. Dr. Rohde is affiliated with ASCP, ASCLS, ASM, and serves on several scientific advisory boards. See <a href="https://rodneyerohde.wp.txstate.edu/service/">https://rodneyerohde.wp.txstate.edu/service/</a>.</span></em></p>Monkeypox has been spreading in humans since as early as 1970. While most monkeypox infections are mild, some can be fatal.Rodney E. Rohde, Regents' Professor of Clinical Laboratory Science, Texas State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1835262022-05-20T08:26:34Z2022-05-20T08:26:34ZMonkeypox in Australia: what is it and how can we prevent the spread?<figure><img src="https://images.theconversation.com/files/464443/original/file-20220520-19-f6x9om.png?ixlib=rb-1.1.0&rect=2%2C0%2C1851%2C1209&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Monkeypox.jpg">CDC/Wikimedia</a></span></figcaption></figure><p><a href="https://www.abc.net.au/news/2022-05-20/nsw-identifies-probable-case-of-monkeypox/101084864">Two cases</a> of monkeypox have been detected in Australia, following reported cases in <a href="https://theconversation.com/european-outbreak-of-monkeypox-what-you-need-to-know-183298">several European countries</a>. Both are in men just returned from Europe. </p>
<p>Health authorities have <a href="https://www.abc.net.au/news/2022-05-20/nsw-identifies-probable-case-of-monkeypox/101084864">said</a> the cases are not a cause for panic, but to remain vigilant for symptoms if you have just returned from overseas. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/european-outbreak-of-monkeypox-what-you-need-to-know-183298">European outbreak of monkeypox: what you need to know</a>
</strong>
</em>
</p>
<hr>
<h2>What is monkeypox?</h2>
<p>Monkeypox is caused by an orthopoxvirus that is closely related to the virus that caused smallpox, variola. Smallpox only infected humans, but monkeypox is an animal virus that occasionally infects humans after they are bitten or scratched by a monkey or other animal. </p>
<p>It is a respiratory virus and can also spread to humans without contact, <a href="https://www.nature.com/articles/nm1273">probably through aerosols</a>. However, it does not usually spread easily between humans, and typically only in close contacts. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491159/?page=3">Studies have found</a> about 3% of contacts of a monkeypox case will be infected.</p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">A week or two after exposure</a>, infection starts with fever, headache, swelling of the lymph nodes and muscle ache. Skin eruptions usually appear within one to three days of the fever commencing, and in most cases affect the face, hands and feet. </p>
<p>There are two types of the virus, one which has a <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON383">fatality rate</a> of about 1% and one with a fatality rate of about 10%. The UK outbreak outbreak appears to be the less severe type, but 1% is similar to the fatality rate for COVID, so it is still a concern. It is more severe in children. </p>
<h2>Why is it emerging now?</h2>
<p>It was first identified in humans in 1970, in the Democratic Republic of Congo (DRC). It is a re-emerging disease that’s been causing large outbreaks in Nigeria and DRC since 2017.</p>
<p>Scientists have puzzled over why a previously rare infection is now becoming more common. The vaccine against smallpox also protects against monkeypox, so in the past, mass vaccination against smallpox protected people from monkeypox too. It is 40 years since smallpox was declared eradicated, and most mass vaccination programs ceased in the 1970s, so few people aged under 50 have been vaccinated. </p>
<p>There are even fewer in Australia, where mass smallpox vaccination was never used, and an estimated <a href="https://wwwnc.cdc.gov/eid/article/24/4/17-1233_article">10% of Australians have been vaccinated</a>. The vaccine gives immunity for anything from five to 20 years or more, but may wane at a rate of about <a href="https://academic.oup.com/milmed/article/184/11-12/e668/5542515?login=false">1-2% a year</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&rect=2%2C0%2C1705%2C1127&q=45&auto=format&w=1000&fit=clip"><img alt="Man showing monkeypox rash on hands" src="https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&rect=2%2C0%2C1705%2C1127&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464422/original/file-20220520-19-26w55u.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Monkeypox rash in an infected man in the Democratic Republic of the Congo.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/ncezid/images/features/global-stories/mokeypox-drc.jpg">CDC</a></span>
</figcaption>
</figure>
<p>Our <a href="https://wwwnc.cdc.gov/eid/article/27/4/20-3569_article">research shows</a> waning of immunity from smallpox vaccination may explain the increasing outbreaks of monkeypox – it is more than 40-50 years since mass vaccination ceased.</p>
<h2>Current outbreak</h2>
<p>In September 2018, a case of monkeypox occurred at a naval base in Cornwall, UK, in a person who had travelled from Nigeria. Simultaneously, a second case occurred in Blackpool in an unrelated person returning from Nigeria, and a nurse also became infected in the hospital. </p>
<p>In the current outbreak, the first case in the UK had travelled from Nigeria, where there have been <a href="https://www.premiumtimesng.com/news/top-news/528825-monkeypox-nigeria-records-558-cases-eight-deaths-in-five-years.html">over 500 cases and 8 deaths since 2017</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-in-nigeria-why-the-disease-needs-intense-management-165022">Monkeypox in Nigeria: why the disease needs intense management</a>
</strong>
</em>
</p>
<hr>
<p>The current outbreak in the UK is the largest outside of Africa and has spread to many countries in Europe, <a href="https://www.devdiscourse.com/article/health/2043540-health-news-roundup-massachusetts-identifies-first-2022-us-case-of-monkeypox-infection-explainer-why-monkeypox-cases-are-s">North America</a> and now <a href="https://www.theguardian.com/australia-news/2022/may/20/australias-first-probable-case-of-monkeypox-virus-identified-in-nsw">Australia</a>. </p>
<p>Clusters have occurred among men who have sex with men, a pattern not seen before. The initial importation could have spread at a venue or within a community that resulted in more spread in the same group.</p>
<p>This is an unusual outbreak, with unrelated cases in different locations in the UK. This could be explained by substantial numbers of asymptomatic infection, but asymtomatic infection is uncommon and usually in people who have had the smallpox vaccine. </p>
<p>In a <a href="https://www.nature.com/articles/nm1273">well-studied outbreak in the US</a> linked to imported animals, only three in 20 cases were asymptomatic, and they had been vaccinated. The other 17 cases all had the rash. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1527512669389205504"}"></div></p>
<p>Most people infected in the current epidemic are too young to have been vaccinated, so substantial asymptomatic infection is unlikely. Further, smallpox does not transmit in asymptomatic people, so it is unlikely monkeypox will be very different. </p>
<p>Serological studies to measure asymptomatic infection are being done in the UK and should shed more light on this hypothesis. Hopefully further investigations can help us understand the epidemiologic links between cases in the UK and elsewhere. </p>
<p>This is the first time there has been travel-related spread from outside of the African continent, where the virus is endemic in animals. There have been a number of travel related importations to the UK, Singapore, Israel and other countries from Nigeria and DRC since 2017, but now the source of spread appears to be the UK, which is unprecedented. Given visits between the UK and Australia are very common, it is not surprising we now have cases here.</p>
<h2>Preventing further outbreak</h2>
<p>There are effective vaccines against monkeypox – the second and third generation smallpox vaccines, both live virus vaccines using the vaccinia virus. Vaccinia is another orthopoxvirus that confers immunity against smallpox and monkeypox, but can have serious side effects in some people, especially those with compromised immune systems.</p>
<p>Mass vaccination would not be warranted because of the side effects. The best strategy is to identify contacts and vaccinate them, rather than mass vaccination. </p>
<p>This is called “ring vaccination” and was used to <a href="https://www.tandfonline.com/doi/full/10.1080/21645515.2020.1800324">eradicate smallpox</a>. Monkeypox has a long incubation period (one to two weeks), so being vaccinated post-exposure can protect.</p>
<p>The third generation vaccines do not replicate in the body and can be used in immunocompromised people. However they are expensive and it’s unlikely Australia would have much supply. For health workers who will be at risk of exposure, the use of third generation vaccines should be considered if the epidemic grows.</p>
<p>There are also <a href="https://finance.yahoo.com/news/contract-awarded-u-department-defense-200500172.html?guccounter=1&guce_referrer=aHR0cHM6Ly9uZXdzLmdvb2dsZS5jb20v&guce_referrer_sig=AQAAAM-2VYm4lJYgozvZPJx6mcSKce3h7FPkiWEYe3yVO-EE_WoaFm3ya5QuimnNwcrzIOsCCg2oubtdqaVuS93p0y0dqcPqbKCw1Yu5xMtWVxjVSqD489MVsObf_4yQsc7ljv1-u8f1_2l35ocILmZNECgaL5edwPDNMUuhAHs3o6e0">effective antivirals</a> against monkeypox and smallpox which were not available before smallpox was eradicated.</p>
<p>Given the unusual nature of this epidemic, it would be wise to ensure we have a stockpile of antivirals and enough of both types of vaccines, together with regulatory processes to use them against monkeypox.</p>
<p>Isolation of cases and quarantine of contacts works to curtail epidemics. We would also do well to draw on the contact tracing infrastructure developed during COVID, so contacts can be rapidly identified and quarantined, and the spread of the virus curtailed.</p><img src="https://counter.theconversation.com/content/183526/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Raina MacIntyre is on the WHO SAGE Ad Hoc advisory group on smallpox and monkeypox, and has received funding for advisory boards and for a smallpox a table top exercise from smallpox vaccine manufacturers Bavarian Nordic and Emergent Biosolutions (the latter also make a smallpox antiviral); and from antiviral manufacturers SIGA Technologies and Meridien Medical. She is a recognised global expert on smallpox, an area she has done research on since 2005. In May 2022 she was part of a two-day global roundtable on smallpox and monkeypox hosted by Bavarian Nordic.</span></em></p>Two cases of monkeypox have been reported in Australia. Resurgence of this virus could be due to the ending of smallpox vaccination.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1754962022-01-27T13:28:42Z2022-01-27T13:28:42ZIs the omicron variant Mother Nature’s way of vaccinating the masses and curbing the pandemic?<figure><img src="https://images.theconversation.com/files/442657/original/file-20220126-17-75f6ee.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7592%2C3940&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Preliminary research suggests that the omicron variant may potentially induce a robust immune response.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/coronavirus-royalty-free-image/1357650209?adppopup=true">Olga Siletskaya/Moment via Getty Images</a></span></figcaption></figure><p>In the short time since the omicron variant was <a href="https://www.cnn.com/2021/12/02/world/south-africa-omicron-origins-covid-cmd-intl/index.html">identified in South Africa</a> in November 2021, <a href="https://doi.org/10.12998/wjcc.v10.i1.1">researchers have quickly learned</a> that it has three unique characteristics: It spreads efficiently and quickly, it generally causes milder disease than previous variants and it may confer strong protection against other variants such as delta. </p>
<p>This has many people wondering whether omicron could act as a vaccine of sorts, inoculating enough people to effectively bring about <a href="https://theconversation.com/what-is-herd-immunity-a-public-health-expert-and-a-medical-laboratory-scientist-explain-170520">herd immunity</a> – the threshold at which enough of the population is immune to the virus to stop its spread – and end the COVID-19 pandemic.</p>
<p>As <a href="https://sc.edu/study/colleges_schools/medicine/about_the_school/faculty-staff/nagarkatti_mitzi.php">immunology researchers</a> at the University of South Carolina who are <a href="https://pubmed.ncbi.nlm.nih.gov/?term=nagarkatti+p&sort=date&size=200&show_snippets=off">working on inflammatory and infectious diseases</a>, including COVID-19, we find the characteristics of omicron in the pandemic setting particularly intriguing. And it is these characteristics that can help answer that question. </p>
<p>Some 4.73 billion people across the globe – about 61.6% of the world’s population – have received at least <a href="https://www.nytimes.com/interactive/2021/world/covid-vaccinations-tracker.html">one dose of a COVID-19 vaccine</a>. In the United States, 63.4% of the population <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total">is fully vaccinated with two doses</a> as of late January 2022, while only 39.9% of Americans have received the booster dose. Such low levels of vaccination resulting from <a href="https://data.cdc.gov/stories/s/Vaccine-Hesitancy-for-COVID-19/cnd2-a6zw/">vaccine hesitancy</a> and the complexities of the <a href="https://dx.doi.org/10.1016%2Fj.ijpe.2021.108193">global vaccine supply chain</a> cast doubt on reaching <a href="https://theconversation.com/what-is-herd-immunity-a-public-health-expert-and-a-medical-laboratory-scientist-explain-170520">herd immunity</a> through vaccination anytime soon. </p>
<h2>How does omicron mimic a vaccine?</h2>
<p><a href="https://www.hhs.gov/immunization/basics/types/index.html">All vaccines</a> work on the principle of training the immune system to fight against an infectious agent. Each vaccine, regardless of how it is made, exposes the human or animal host to the critical molecules used by the infectious agent – in this case, the SARS-CoV-2 virus – to gain entry into the host’s cells.</p>
<p>Some vaccines expose the host only to select portions of the virus. For example, the Pfizer-BioNTech and Moderna vaccines use a <a href="https://theconversation.com/how-mrna-vaccines-from-pfizer-and-moderna-work-why-theyre-a-breakthrough-and-why-they-need-to-be-kept-so-cold-150238">molecule called messenger RNA</a>, or mRNA, to encode and produce a fragment of the “spike protein” – the knobby protrusion that is expressed on the outside of SARS-CoV-2 viruses – inside a person’s body. These spike proteins are the key way that <a href="https://theconversation.com/what-happens-when-the-covid-19-vaccines-enter-the-body-a-road-map-for-kids-and-grown-ups-164624">the coronavirus invades cells</a>, so the mRNA vaccines are designed to mimic that protein and trigger an immune response against it. </p>
<p>In contrast, some vaccines against other infections, <a href="https://theconversation.com/the-chickenpox-virus-has-a-fascinating-evolutionary-history-that-continues-to-affect-peoples-health-today-168636">such as chickenpox</a> and <a href="https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.html">measles, mumps and rubella (MMR)</a>, expose the host to a “live attenuated” form of the virus. These vaccines use small amounts of a weakened form of the live virus. They mimic a natural infection, trigger a strong immune response and afford lasting resistance to infection. </p>
<p>In some respects, omicron mimics these live attenuated vaccines because it causes milder infection and trains the body to trigger a strong immune response against the delta variant, as shown in a recent <a href="https://doi.org/10.1101/2021.12.27.21268439">study that is not yet peer-reviewed</a> from South Africa. </p>
<h2>Deliberate infection with omicron is not the answer</h2>
<p>While omicron may share certain characteristics with a vaccine, it should not be considered a viable alternative to the existing vaccines. For one, COVID-19 infection can result in <a href="https://www.nytimes.com/live/2022/01/10/world/omicron-covid-testing-vaccines">severe illness, hospitalization or death</a>, especially in <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html">vulnerable individuals with underlying conditions</a>. It can also cause long-term health effects in some people, called <a href="https://theconversation.com/deciphering-the-symptoms-of-long-covid-19-is-slow-and-painstaking-for-both-sufferers-and-their-physicians-164754">long COVID</a>. In contrast, vaccines currently available against COVID-19 have been tested for safety and efficacy. </p>
<p>The high transmission of omicron combined with ongoing vaccination efforts could help attain herd immunity soon and end the most acute phase of the pandemic. However, there is little chance of it eradicating COVID-19, since all signs point to the likelihood that the virus <a href="https://theconversation.com/is-covid-19-here-to-stay-a-team-of-biologists-explains-what-it-means-for-a-virus-to-become-endemic-168462">will become endemic</a> – meaning SARS-CoV-2 will be in circulation but will likely not be as disruptive to society.</p>
<p>Thus far, smallpox is the only infectious disease that <a href="https://www.cdc.gov/smallpox/index.html#">has been eradicated globally</a>, which shows how difficult it is to fully eliminate a disease. However, it is easier to control an infection effectively. One example is <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">polio</a>, which has been reduced or eliminated in most countries through vaccination. </p>
<h2>What happens when the body meets a virus or vaccine</h2>
<p>Both viral infections or the mimicking of a virus through vaccination activate a critical component of the immune system, called B cells, in the body. These cells produce antibodies that bind to the virus, preventing it from infecting cells. These antibodies act much like anti-ballistic missiles that shoot down an incoming virus missile. However, once a virus manages to get inside the body’s cells, antibodies are less effective. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A 3-D illustration of antibody proteins attacking a coronavirus pathogen cell." src="https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442658/original/file-20220126-13-ngm9rq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Antibodies behave similarly to anti-ballistic missiles, shooting down their target – in this case, the SARS-CoV-2 virus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/immunoglobulin-or-antibody-proteins-attack-a-corona-royalty-free-image/1299604801?adppopup=true">Christoph Burgstedt/iStock via Getty Images Plus</a></span>
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<p>That’s where another key player in the immune system, called killer T cells, come in. These cells can recognize and destroy a cell as soon as it is infected, thereby preventing the virus from multiplying and spreading further. Think of this as an anti-ballistic missile that detects and destroys the factory where missiles are manufactured. </p>
<p>Immunologists believe that antibodies against COVID-19 prevent an individual from catching the infection, while the <a href="https://www.nature.com/articles/d41586-021-00367-7">killer T cells are crucial</a> in preventing severe disease. Despite its numerous mutations, omicron can trigger a <a href="https://www.nature.com/articles/d41586-022-00063-0#">strong killer T cell response</a>. This may explain why the COVID-19 vaccines – by triggering the T cells – have provided strong enough immunity against omicron to, in most cases, <a href="https://doi.org/10.1001/jamanetworkopen.2021.42725">prevent hospitalization and death</a>.</p>
<p>But, critically, the first wave of antibodies and killer T cells produced during infection or vaccination last for only a few months. This is why recurrent infections of COVID-19 have occurred even in the vaccinated population, and it’s also <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html">why booster shots are needed</a>. In contrast, some vaccines – like the one against smallpox – have been shown to trigger immunity that lasts for several years. </p>
<h2>Memory immune response</h2>
<p>So what exactly triggers strong and lasting immunity? The lifelong immunity seen in certain infections such as smallpox can be explained by a phenomenon called “<a href="https://www.ncbi.nlm.nih.gov/books/NBK27158/">immunological memory</a>.”</p>
<p>After the B cells and killer T cells first encounter the virus, some of them get converted into what are called memory cells, which are known to <a href="https://doi.org/10.1038/nm917">live for several decades</a>. As their name suggests, when memory cells “see” a virus again after initial exposure, they recognize it, divide rapidly and mount a robust antibody and killer T cell response, thereby preventing reinfection.</p>
<p>[<em>Over 140,000 readers rely on The Conversation’s newsletters to understand the world.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140ksignup">Sign up today</a>.]</p>
<p>For this reason, memory cells are critical for establishing strong, long-lasting immunity. This is evidenced from studies with smallpox in which people that were infected or vaccinated were found to have the antibody response <a href="https://dx.doi.org/10.1016%2Fj.amjmed.2008.08.019">even after 88 years</a>! Why some infections or vaccines trigger long-lasting memory and others do not is under active investigation. Because COVID-19 is only two years old, we researchers don’t know yet how long the memory B and T cells last. Based on recurrent infections, it looks like longer-term immunity does not last very long, but that could also in part be due to the evolution of new variants. </p>
<p>All of these considerations leave room for hope that when new variants of SARS-CoV-2 inevitably arise, omicron will have left the population better equipped to fight them. So the COVID-19 vaccines combined with the omicron variant could feasibly move the world to a new stage in the pandemic – one where the virus doesn’t dominate our lives and where hospitalization and death are far less common.</p><img src="https://counter.theconversation.com/content/175496/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prakash Nagarkatti receives funding from the National Institutes of Health and the National Science Foundation.</span></em></p><p class="fine-print"><em><span>Mitzi Nagarkatti receives funding from the National Institutes of Health.</span></em></p>Some of the omicron variant’s unique properties – such as its ability to spread rapidly while causing milder COVID-19 infections – could usher in a new phase of the pandemic.Prakash Nagarkatti, Professor of Pathology, Microbiology and Immunology, University of South CarolinaMitzi Nagarkatti, Professor of Pathology, Microbiology and Immunology, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1737322022-01-11T01:36:45Z2022-01-11T01:36:45ZHow the kidnapping of a First Nations man on New Year’s Eve in 1788 may have led to a smallpox epidemic<figure><img src="https://images.theconversation.com/files/439958/original/file-20220110-25-oa7qh1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">R. Cleveley. View in Port Jackson.
Dixson Library, State Library of New South Wales</span> <span class="attribution"><a class="source" href="https://digital.sl.nsw.gov.au/delivery/DeliveryManagerServlet?dps_pid=FL634951&embedded=true&toolbar=false">Dixson Library, State Library of New South Wales</a></span></figcaption></figure><p><em>First Nations people please be advised this article speaks of racially discriminating moments in history, including the distress and death of First Nations people.</em></p>
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<p>Research continues to show that First Nations people’s burden of disease is more than double that of non-Indigenous Australians. This is despite widespread awareness of health inequalities experienced by First Nations people and successive governments’ efforts to “<a href="https://humanrights.gov.au/our-work/closing-gap-national-indigenous-health-equality-targets-2008">Close the Gap</a>.”</p>
<p>Strengthening our awareness of history can help us understand how historical trauma contributes to the poor health of First Nations people today.</p>
<p>This New Year’s Eve, Sydney once again hosted an extraordinary party with a fantastic display of light and colour. However, many Australians were probably unaware that New Year’s Eve also marks the anniversary of the British invaders’ first capture of a First Nations person in Australia in the 1700s. </p>
<p>This kidnapping preceded a smallpox epidemic that killed <a href="https://www.tandfonline.com/doi/pdf/10.1080/14443058.2013.849750?casa_token=uUqdlbvy2rAAAAAA:oedOHeGJbZO1uGDQS5EwmyO-TVzFLbulWo7pLdj81y8pZ6zsOVJArS0STrQW_p1b2mvh4YA-b25mIEY">more than 50% of the Aboriginal people</a> in the Sydney Basin, along with large numbers further inland.</p>
<p>In our new research published in the international journal <a href="https://journals.sagepub.com/doi/10.1177/0957154X211053208">History of Psychiatry</a>, we describe evidence supporting the theory that smallpox was deliberately unleashed by the British invaders. </p>
<p>We also introduce a new theory that ground zero for the smallpox epidemic of 1789 began during the kidnapping of Aboriginal man Arabanoo on New Year’s Eve in 1788.</p>
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Read more:
<a href="https://theconversation.com/friday-essay-its-time-for-a-new-museum-dedicated-to-the-fighters-of-the-frontier-wars-155299">Friday essay: it's time for a new museum dedicated to the fighters of the frontier wars</a>
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<h2>Deception leading to kidnapping and death</h2>
<p>When the British invaded in early 1788, they struggled to survive. As they were establishing their colony, British convicts stole fishing nets and canoes from local Aboriginal people of the Eora nation, causing minor altercations. </p>
<p>The colonists were concerned about future quarrels with Aboriginal people when their early expeditions indicated much <a href="https://nla.gov.au/nla.obj-472896848/view?partId=nla.obj-473155577#page/n87/mode/1up/search/numerous">higher numbers of Aboriginal people</a> inhabiting the Sydney Basin than they had anticipated.</p>
<p>As 1788 drew to a close, British food supplies were dwindling and, although land-clearing had begun at Parramatta in November, the colonists were unsure if they would be able to cultivate crops. By December, it had been several months since any Aboriginal people had come near the colonists’ camp, and Governor Arthur Phillip became anxious they might attack his fledgling colony. </p>
<p>So, on New Year’s Eve he decided to go on the offensive, sending a group of soldiers to <a href="https://journals.sagepub.com/doi/10.1177/0957154X211053208">take Aboriginal people as prisoners in order to gain information</a>.</p>
<p>Led by lieutenants Henry Ball and George Johnston, a squadron of British marines rowed to Manly Beach, where they began handing out gifts to a group of Aboriginal people gathered on the shore. Using the gifts as a distraction, the soldiers captured a young Aboriginal man named Arabanoo.</p>
<figure class="align-center ">
<img alt="Captain Arthur Phillip Fountain, Sydney." src="https://images.theconversation.com/files/437975/original/file-20211216-13-5qd2ne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/437975/original/file-20211216-13-5qd2ne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/437975/original/file-20211216-13-5qd2ne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/437975/original/file-20211216-13-5qd2ne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/437975/original/file-20211216-13-5qd2ne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/437975/original/file-20211216-13-5qd2ne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/437975/original/file-20211216-13-5qd2ne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Captain Arthur Phillip Fountain, Sydney.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/captain-arthur-phillip-fountain-sydney-australia-541720621">shutterstock</a></span>
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<p>When word spread about the deceptive kidnapping of Arabanoo, animosity towards the British increased. Then, a few weeks after receiving the gifts at Manly, fear broke out when several Aboriginal people fell ill with smallpox.</p>
<p>Referred to by the Eora as “galgalla”, smallpox was well known by the British, who used a process called <a href="https://www.jstor.org/stable/pdf/44448714.pdf?casa_token=QtkahCeRM58AAAAA:bB8RplxDMPEHqEBh0oln2Jrgg3UxH197FHZnVAL17XU3e-KYzt0MNbhnZ08QY5zhlm2tNfXoP79IoAIaCuRiPIU3OtmCD3Cvh_PSGR9wSjnADVDIw_4HaQ">variolation for immunisation</a>. The treatment involved either sniffing smallpox scabs into the nose, or inserting scabs under a small cut in a person’s skin in order to contract a mild form of the disease and trigger the immune system. </p>
<p>There was no record of anyone suffering smallpox during the voyage of the First Fleet. However, as a precautionary measure, British surgeons on the First Fleet <a href="https://setis.library.usyd.edu.au/ozlit/pdf/p00044.pdf">carried jars of smallpox flakes</a> in their medical cases. </p>
<p>When the colonists received news smallpox had broken out among the Eora, Judge Advocate David Collins took a surgeon and Arabanoo to inspect the effects of the disease around Port Jackson. <a href="https://adc.library.usyd.edu.au/data-2/colacc1.pdf">Collins described</a> Arabanoo’s reaction as an expression of agony impossible to forget.</p>
<p>The expedition looked anxiously for survivors, but found nothing besides rotting corpses of people who had fallen victim to smallpox all around the harbour. When the colonists ventured north and south of Manly over the coming months, they continued to find dead bodies. </p>
<p>It remains unclear whether the British deliberately infected the First Nations people they encountered. Historians have posited a range of <a href="https://www.news.uwa.edu.au/archive/2020061712162/covid-19/covid-19-what-can-we-learn-first-smallpox-epidemic-and-its-impact-aboriginal-/">theories</a> about what caused the outbreak.</p>
<p>Following exposure to the smallpox virus, it takes one to two weeks for symptoms to appear. Our theory is the epidemic had been spreading for several weeks before the British became aware of it, and it may have originated from the gifts handed out when Arabanoo was kidnapped about 12–13 weeks earlier.</p>
<p>This theory is supported by <a href="https://journals.sagepub.com/doi/10.1177/0957154X211053208">Aboriginal oral history</a> from the Manly area. According to other research, several British marines had also previously fought battles in North America, where they may have heard stories about spreading smallpox as a strategy <a href="https://www.jstor.org/stable/pdf/2567577.pdf?casa_token=Ij445zwD_wQAAAAA:FrjvkO8s2T4EjsS4JahrKEUm-WIZNtGadpx7ts5pP8ZBM88rb_EzliFt-CSw6bkMFEmSoiXGpqFpVbBsiwSTt1bygbBCBSI13sOVTDsRvB05jrW7pGNVYg">against</a> First Nations people there. </p>
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Read more:
<a href="https://theconversation.com/oral-testimony-of-an-aboriginal-massacre-now-supported-by-scientific-evidence-85526">Oral testimony of an Aboriginal massacre now supported by scientific evidence</a>
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<h2>The death of Arabanoo</h2>
<p>As April passed, a hut near the British tent hospital was used to accommodate two Aboriginal men and two children suffering from smallpox. The men died, but with Arabanoo’s care, a young girl named Abaroo (also known as Boorong), and little boy named Nanbaree, managed to recover. Sadly, in the process of nursing them, Arabanoo contracted smallpox himself and subsequently died on May 18.</p>
<p>It is important for us to remember that First Nations people’s earliest interactions with British health care did not occur in response to injury, accident or natural disaster. Instead, it occurred because of deception, kidnapping and disease in the context of invasion by the British. </p>
<p>First Nations people’s relationship with white health care has been haunted by this and continuing <a href="https://theconversation.com/yes-we-need-to-close-the-gap-on-health-but-many-patients-wont-tell-hospitals-theyre-indigenous-for-fear-of-poorer-care-14367">malpractices</a> ever since.</p>
<p>Remembering Arabanoo each New Year’s Eve may assist Australians to better understand our nation’s traumatic history and the intergenerational effects of colonisation. </p>
<p>Improving our understanding of history also has potential to create better communication with First Nations people. It makes us more ready to listen when Aboriginal people tell us what they need to close the gap in health care, and when they tell us how we can build better relationships through messages such as the <a href="https://ulurustatement.org/the-statement">Uluru Statement from the Heart</a>.</p><img src="https://counter.theconversation.com/content/173732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aunty Kerrie Doyle receives funding from the Commonwealth Government for her research. Aunty Kerrie is also a board member for Ngarra Mura Indigenous Corporation, CASTINaM and AIATSIS.</span></em></p><p class="fine-print"><em><span>Paul Saunders and Toby Raeburn do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New Year’s Eve is the anniversary of the British invaders’ first kidnapping of a First Nations person in Australia. This kidnapping led to a devastating smallpox outbreak.Toby Raeburn, Associate Professor in Nursing (mental health), University of Notre Dame AustraliaKerrie Doyle, Professor, Indigenous Health, School of Medicine, Western Sydney UniversityPaul Saunders, Research fellow, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1686362021-11-10T13:40:52Z2021-11-10T13:40:52ZThe chickenpox virus has a fascinating evolutionary history that continues to affect peoples’ health today<figure><img src="https://images.theconversation.com/files/429786/original/file-20211102-19-1gjsqqg.jpg?ixlib=rb-1.1.0&rect=57%2C0%2C5406%2C3489&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most children today receive the chickenpox vaccine as a routine part of childhood immunizations. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/chickenpox-royalty-free-image/1144939011?adppopup=true">Solidcolours/E+ via Getty Images</a></span></figcaption></figure><p>In July 2021, a Centers for Disease Control and Prevention presentation <a href="https://www.washingtonpost.com/context/cdc-breakthrough-infections/94390e3a-5e45-44a5-ac40-2744e4e25f2e/">obtained by the press</a> noted that the delta variant of COVID-19 “is as transmissible as chickenpox.” </p>
<p>As some researchers have pointed out, <a href="https://www.npr.org/sections/goatsandsoda/2021/08/11/1026190062/covid-delta-variant-transmission-cdc-chickenpox">the CDC’s comparison was an overstatement</a>. Based on various studies and projections, on average a person infected with the delta strain of COVID-19 can infect six or seven people, whereas someone infected with chickenpox can infect nine or 10. Nonetheless, both diseases are highly contagious, although the viruses that cause them are very different.</p>
<p>While many diseases, such as <a href="https://www.cdc.gov/vhf/ebola/about.html">Ebola</a> and <a href="https://theconversation.com/influenzas-wild-origins-in-the-animals-around-us-91058">influenza</a>, originate from viruses that made relatively recent “jumps” from animals to humans, other disease-causing pathogens have been with humans throughout evolution. The virus that causes chickenpox is one of these, coexisting with the human evolutionary line for <a href="https://doi.org/10.1128/JVI.00357-12">millions of years</a>. </p>
<p>I am a microbiologist interested in <a href="https://biology.indiana.edu/about/faculty/foster-patricia.html">pathogens and the diseases they cause</a>. Chickenpox is a childhood disease, and until a couple of decades ago, nearly <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/chickenpox">all children in the United States got it</a>. A vaccine campaign that began in the 1990s has made the disease rare in children in the U.S., but the virus lingers in the body and can reappear in unvaccinated adults years later as shingles. The virus’s ability to do this disappearing-and-reappearing trick may be the key to its <a href="https://doi.org/10.1128/JVI.00357-12">long evolutionary history</a>.</p>
<h2>Chickenpox and shingles stem from the same virus</h2>
<p>I became painfully aware of the virus that causes chickenpox a few years ago when my husband developed shingles soon after starting a stressful job. <a href="https://doi.org/10.1111/bjd.19832">Chronic stress is one trigger</a> for reactivation of the dormant virus, as it is for the closely related <a href="https://doi.org/10.3389/fmicb.2019.00016">herpes viruses</a>.</p>
<p>The virus that causes both chickenpox and shingles, varicella-zoster, is only known to <a href="https://doi.org/10.1038/nrdp.2015.16">infect humans</a>. “Varicella” means “<a href="https://www.merriam-webster.com/dictionary/varicella">little variola</a>,” or little smallpox, because both diseases cause skin blisters.</p>
<figure class="align-center ">
<img alt="Varicella zoster (chickenpox) virus, illustration." src="https://images.theconversation.com/files/427906/original/file-20211021-22-18g4m4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427906/original/file-20211021-22-18g4m4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427906/original/file-20211021-22-18g4m4p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427906/original/file-20211021-22-18g4m4p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427906/original/file-20211021-22-18g4m4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427906/original/file-20211021-22-18g4m4p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427906/original/file-20211021-22-18g4m4p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Varicella-zoster, the virus depicted in this illustration, causes both chickenpox in children and shingles in adults.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/varicella-zoster-viruses-illustration-royalty-free-illustration/1209159885?adppopup=true">Roger Harris/Science Photo Library/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<p>Shingles is known in medical terms as herpes zoster. Both “zoster” and “shingles” derive from words for belt or girdle in <a href="https://www.merriam-webster.com/dictionary/zoster">Greek</a> and <a href="https://www.merriam-webster.com/dictionary/shingles">Latin</a>, respectively, referring to the typical arrangement of blisters on the torso during shingles outbreaks. </p>
<h2>Chickenpox is primarily a childhood disease</h2>
<p>Chickenpox is spread by inhalation, and children are infectious a few days before <a href="https://www.cdc.gov/chickenpox/about/transmission.html">symptoms appear</a>. The blisters also contain live viruses that can become <a href="https://doi.org/10.1038/nrdp.2015.16">airborne and inhaled</a> or can be transmitted through direct contact. After inhalation, chickenpox viruses invade the cells of the respiratory tract, replicate in the lymph nodes and are spread by white blood cells throughout the body. Eventually, they <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html">lodge in the skin</a>, causing the itchy blisters that are characteristic of the disease.</p>
<p>In healthy children, chickenpox lasts about a week and goes away without medical intervention. But it can be more severe in adolescents, adults and people with compromised immune systems. Infection with chickenpox typically provides <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/chickenpox">lifelong immunity to reinfection</a>.</p>
<h2>Shingles mostly affects older adults</h2>
<p>Even after the chickenpox blisters are gone, the varicella-zoster virus is not. The viruses travel to nerve root clusters <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/herpes-zoster.html">located along the spinal cord</a>. There, the viruses establish a persistent, dormant state in the <a href="https://doi.org/10.1038/nrdp.2015.16">nuclei of the nerve cells</a>.</p>
<p>Over the course of a person’s life, the viruses may reactivate, but usually the immune system eliminates the active viruses before they can appear as shingles. However, as the immune system weakens with age, or as a result of illness or stress, reactivated viruses can travel back along the nerves and erupt again as painful blisters. Typically, only one nerve-root cluster is involved, and the blisters appear in the area of the skin supplied by those nerves. This leads to the classic <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/herpes-zoster.html">belt-like appearance</a>, although the blisters can localize to other areas of the skin.</p>
<p>Although even children can develop shingles, the risk of that happening and the severity of the disease increases sharply after the age of 50. The CDC estimates that 1 in 3 people in the U.S. <a href="https://www.cdc.gov/shingles/surveillance.html">will have shingles</a> at some point in their lives. In healthy adults, a shingles outbreak typically lasts from seven to 10 days; however, about 15% of shingles sufferers develop persistent, often debilitating, neurological pain, called <a href="https://doi.org/10.1038/nrdp.2015.16">postherpetic neuralgia</a>, that can last for months or even years. </p>
<h2>Varicella-zoster has a long, slow evolutionary history</h2>
<p>Unlike the COVID-19 and influenza viruses, which have genomes of <a href="https://asm.org/Articles/2020/July/COVID-19-and-the-Flu">single-stranded RNA</a>, varicella-zoster’s genome is double-stranded DNA. This makes its genome more stable and able to be copied more accurately than <a href="https://doi.org/10.1128/JVI.00694-10">single-stranded RNA genomes</a>. </p>
<p>Although experts disagree on the exact rate at which varicella-zoster accumulates genetic changes, called mutations, a reasonable estimate of its evolution rate is one new mutation every <a href="https://doi.org/10.1099/0022-1317-75-3-513">200</a> to <a href="https://doi.org/10.1371/journal.pone.0022527">400</a> years. This rate is in contrast to influenza, for example, whose RNA genome is copied so sloppily that it accumulates about 40 new mutations every year, according to my calculations based on <a href="https://doi.org/10.1128/JVI.02163-13">data published here</a>. </p>
<p>Varicella-zoster is a member of a large group of viruses, the Herpesviridae, that <a href="https://doi.org/10.1007/s00705-008-0278-4">infect mammals, birds and reptiles</a>. Although there have been some “<a href="https://doi.org/10.1093/ve/veab025">jumps” between hosts in the distant past</a>, these viruses tend to infect only specific hosts. Thus, scientists can deduce the evolutionary history of the viruses by looking at the known <a href="https://doi.org/10.1006/jmbi.1995.0152">evolutionary relationships of their hosts</a>. </p>
<p>Such analyses indicate that the viruses that eventually led to varicella-zoster and its relatives existed 200 million years ago in the <a href="https://doi.org/10.1093/ve/veab025">Triassic/Jurassic period</a> – the age of dinosaurs! The closest existing relative to varicella-zoster infects an <a href="https://doi.org/10.1006/viro.2001.0912">old-world monkey</a>. The evolutionary lines that led to humans and old-world monkeys split <a href="https://doi.org/10.1093/molbev/msg050">23 million years ago</a>; thus, our cohabitation with varicella-zoster goes back at least that far.</p>
<p>Recent DNA analysis of varicella-zoster strains currently infecting humans complicates this history somewhat. The data indicates that the virus is accumulating <a href="https://doi.org/10.1093/infdis/jiz227">mutations faster</a> than would be consistent with its evolutionary history, and that the ancestor of the current strains appeared only <a href="https://doi.org/10.1093/molbev/msu406">about 8,000 years ago</a>. Such discrepancies between short-term and long-term evolutionary rates have appeared in <a href="https://doi.org/10.1016/j.cub.2021.08.020">numerous similar studies</a>, and scientists are <a href="https://doi.org/10.1146/annurev-ecolsys-011921-023644">currently analyzing why this is so</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of Shingles vaccine with syringe in background." src="https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/429783/original/file-20211102-39236-xwqges.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The CDC recommends that all adults age 50 and older get vaccinated for shingles.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/shingles-vaccine-syringe-stock-photo-royalty-free-image/1264660305?adppopup=true">Fotolgahan/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>The ability to enter a latent state may have given varicella-zoster a survival advantage. Ancient hunter-gatherers would have lived in small groups where an outbreak of chickenpox could have infected the whole population. <a href="https://doi.org/10.1128/JVI.00357-12">A credible theory</a> proposed by Charles Grose, a pediatric infectious disease specialist at the University of Iowa, holds that, since chickenpox conveys lifelong immunity, the survivors could not be reinfected. And without new hosts, the virus would die out. However, by persisting for years in survivors in its latent state, varicella-zoster could reappear after a new generation of children was born. Since the shingles blisters are infectious, these children would get chickenpox and a new cycle would begin.</p>
<h2>Vaccines for chickenpox and shingles are effective</h2>
<p>Prior to 1995, when the chickenpox vaccine was introduced, nearly all U.S. children got infected with <a href="https://doi.org/10.1038/nrdp.2015.16">chickenpox by age 10</a>. Although usually mild, rare complications resulted in more than <a href="https://www.cdc.gov/chickenpox/vaccine-infographic.html">10,000 hospitalizations and 100 deaths per year</a>. </p>
<p>The two-dose vaccine has resulted in greater than 90% protection against infection. Currently the vaccination rate among schoolchildren <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7003a2.htm">approaches 95%</a>. By preventing the virus from spreading, this level of vaccination <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html">protects unvaccinated children</a> through <a href="https://theconversation.com/what-is-herd-immunity-a-public-health-expert-and-a-medical-laboratory-scientist-explain-170520">herd immunity</a>. </p>
<p>The chickenpox vaccine is a live, attenuated varicella-zoster strain that, like the original strain, stays in the body in a dormant state. But the vaccine strain is <a href="https://doi.org/10.1542/peds.2018-2917">weakened for activation</a>, and as of 2016 <a href="https://doi.org/10.1093/cid/ciy954">data show</a> that children vaccinated for chickenpox develop shingles less frequently than children did when chickenpox was common. Public health experts do not yet know whether the rate of vaccine-derived shingles will rise as the vaccinated population ages and becomes more susceptible to the disease.</p>
<p>Shingrix, an effective, protein-based vaccine against shingles, has been available since 2017. The CDC recommends <a href="https://www.cdc.gov/shingles/multimedia/shringrix-50-older.html">everyone over age 50 to get vaccinated</a> for shingles, whether or not they have had chickenpox, shingles or have been vaccinated with Zostavax – a former shingles vaccine that was less effective. Shingrix reduces the incidence of shingles an average of 97% and, if a case occurs, reduces the <a href="https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html#how-well-does-shingrix-work">incidence of postherpetic neuralgia by 91%</a>.</p>
<p>Vaccination requires two doses and is known, so far, to be protective for <a href="https://doi.org/10.1093/infdis/jiab387">at least 10 years</a>. As of 2018, <a href="https://www.cdc.gov/nchs/products/databriefs/db370.htm?deliveryName=USCDC_171-DM32740">34.5% of U.S. adults 60 and over</a> were vaccinated against shingles, most with Zostavax.</p>
<p>With effective vaccines against both chickenpox and shingles now available, I believe that the countries with high vaccination rates could eventually be free of both of the diseases caused by varicella-zoster – ultimately making the chickenpox-shingles duo go the way of the dinosaurs.</p>
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<p class="fine-print"><em><span>Patricia L. Foster is affiliated with the Union of Concerned Scientists and Concerned Scientists at Indiana University.</span></em></p>Chickenpox has largely disappeared from the public’s memory thanks to a highly effective vaccine. But the virus’s clever life cycle allows it to reappear in later adulthood in the form of shingles.Patricia L. Foster, Professor Emerita of Biology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1688992021-10-22T12:39:13Z2021-10-22T12:39:13ZParents were fine with sweeping school vaccination mandates five decades ago – but COVID-19 may be a different story<figure><img src="https://images.theconversation.com/files/427788/original/file-20211021-14-cn140n.jpg?ixlib=rb-1.1.0&rect=197%2C8%2C2645%2C1814&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children and parents lined up for polio vaccines outside a Syracuse, New York school in 1961.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/LinedUpForPolioVaccine1961/4da7b3b42ecd4a68a089a5985f951f32/photo?Query=school%20vaccine&mediaType=photo&sortBy=arrivaldatetime:asc&dateRange=Anytime&totalCount=1077&currentItemNo=9">AP Photo</a></span></figcaption></figure><p>The ongoing battles over COVID-19 vaccination in the U.S. are likely to get more heated when the Food and Drug Administration authorizes emergency use of a vaccine for children ages 5 to 11, expected later this fall.</p>
<p>California <a href="https://www.gov.ca.gov/2021/10/01/california-becomes-first-state-in-nation-to-announce-covid-19-vaccine-requirements-for-schools/">has announced</a> it will require the vaccine for elementary school attendance once it receives full FDA approval after emergency use authorization, and other states may follow suit. COVID-19 vaccination mandates in workplaces and colleges have sparked controversy, and the possibility that a mandate might extend to younger children is <a href="https://www.kff.org/coronavirus-covid-19/press-release/most-parents-dont-want-their-schools-to-require-covid-19-vaccination-but-most-favor-requiring-masks-for-unvaccinated-children-and-staff/">even more contentious</a>.</p>
<p>Kids are already required to get a host of other vaccines to attend school. School vaccination mandates have been around since the 19th century, and they became a fixture in all 50 states in the 1970s. Vaccine requirements are among the <a href="https://pubmed.ncbi.nlm.nih.gov/12508514/">most effective means of controlling infectious diseases</a>, but they’re currently under attack by small but vocal minorities of parents who consider them unacceptable intrusions on parental rights.</p>
<p>As a public health historian who studies the <a href="https://www.ucpress.edu/book/9780520247499/state-of-immunity">evolution of vaccination policies</a>, I see stark differences between the current debates over COVID-19 vaccination and the public response to previous mandates.</p>
<h2>Compulsory vaccination in the past</h2>
<p>The <a href="https://doi.org/10.1353/bhm.2004.0062">first legal requirements for vaccination</a> date to the early 1800s, when gruesome and deadly diseases routinely terrorized communities. A loose patchwork of local and state laws were enacted to stop epidemics of smallpox, the era’s only vaccine-preventable disease. </p>
<p>Vaccine mandates initially applied to the general population. But in the 1850s, as universal public education became more common, people recognized that schoolhouses were likely sites for the spread of disease. Some states and localities began enacting <a href="https://doi.org/10.1093/jhmas/XXXIII.3.344">laws tying school attendance to vaccination</a>. The smallpox vaccine was crude by today’s standards, and concerns about its safety led to numerous lawsuits over mandates.</p>
<p>The U.S. Supreme Court upheld compulsory vaccination in two decisions. The first, in 1905, <a href="https://supreme.justia.com/cases/federal/us/197/11/">affirmed that mandates are constitutional</a>. The second, in 1922, <a href="https://supreme.justia.com/cases/federal/us/260/174/">specifically upheld school-based requirements</a>. In spite of these rulings, many states lacked a smallpox vaccination law, and some states that did have one failed to enforce it consistently. Few states updated their laws as new vaccines became available.</p>
<p>School vaccination laws underwent a major overhaul beginning in the 1960s, when health officials grew frustrated that <a href="https://doi.org/10.1177/0033354919826558">outbreaks of measles were continuing to occur in schools</a> even though a safe and effective vaccine had recently been licensed.</p>
<p>Many parents mistakenly believed that measles was an annoying but mild disease from which most kids quickly recovered. In fact, it often caused <a href="https://www.cdc.gov/measles/symptoms/complications.html">serious complications</a>, including potentially fatal pneumonia and swelling of the brain.</p>
<p>With encouragement from the Centers for Disease Control and Prevention, all states updated old laws or enacted new ones, which generally covered all seven childhood vaccines that had been developed by that time: diphtheria, pertussis, tetanus, polio, measles, mumps and rubella. In 1968, just half the states <a href="https://www.ucpress.edu/book/9780520247499/state-of-immunity">had school vaccination requirements; by 1981, all states did</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Smiling boy rolls up his sleeve to get a shot from a nurse" src="https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sometimes, students even received vaccinations from nurses at school.</span>
<span class="attribution"><a class="source" href="http://resource.nlm.nih.gov/101447463">NIH U.S. National Library of Medicine</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Expanding requirements, mid-20th century</h2>
<p>What is most surprising about this major expansion of vaccination mandates is how little controversy it provoked.</p>
<p>The laws did draw scattered court challenges, usually over the question of exemptions – which children, if any, should be allowed to opt out. These lawsuits were often brought by chiropractors and other adherents of alternative medicine. <a href="https://pubmed.ncbi.nlm.nih.gov/15868682/">In most instances, courts turned away these challenges</a>.</p>
<p>There was scant public protest. In contrast to today’s vocal and well-networked anti-vaccination activists, organized resistance to vaccination remained on the fringes in the 1970s, the period when these school vaccine mandates were largely passed. Unlike today, when <a href="https://www.cdc.gov/vaccinesafety/concerns/index.html">fraudulent theories of vaccine-related harm</a> – such as the discredited notion that vaccines cause autism – <a href="https://theconversation.com/anti-vaccination-mothers-have-outsized-voice-on-social-media-pro-vaccination-parents-could-make-a-difference-120572">circulate endlessly on social media</a>, public discussion of the alleged or actual risks of vaccines was largely absent.</p>
<p>Through most of the 20th century, <a href="https://doi.org/10.1353/bhm.2013.0047">parents were less likely to question</a> pediatricians’ recommendations than they are today. In contrast to the empowered “patient/consumer” of today, an attitude of “doctor knows best” prevailed. All these factors contributed to overwhelmingly positive views of vaccination, with more than 90% of parents in a 1978 poll reporting that <a href="https://www.ucpress.edu/book/9780520247499/state-of-immunity">they would vaccinate their children even if</a> there were no law requiring them to do so.</p>
<p>Widespread public support for vaccination enabled the laws to be passed easily – but it took more than placing a law on the books to control disease. Vaccination rates <a href="https://doi.org/10.1177/0033354919826558">continued to lag in the 1970s</a>, not because of opposition, but because of complacency.</p>
<p>Thanks to the success of earlier vaccination programs, most parents of young children lacked firsthand experience with the suffering and death that diseases like polio or whooping cough had caused in previous eras. But public health officials recognized that those diseases were far from eradicated and would continue to threaten children unless higher rates of vaccination were reached. Vaccines were already becoming a victim of their success. The better they worked, the more people thought they were no longer needed.</p>
<p>In response to this lack of urgency, <a href="https://press.uchicago.edu/ucp/books/book/chicago/V/bo14237741.html">the CDC launched a nationwide push in 1977</a> to help states enforce the laws they had recently enacted. Around the country, health officials partnered with school districts to audit student records and provide on-site vaccination programs. When push came to shove, they would exclude unvaccinated children from school until they completed the necessary shots.</p>
<p>The lesson learned was that making a law successful requires ongoing effort and commitment – and continually reminding parents about the value of vaccines in keeping schools and entire communities healthy.</p>
<h2>Add COVID-19 to vaccine list for school?</h2>
<p>Five decades after school mandates became universal in the U.S., <a href="https://www.pewresearch.org/science/2017/02/02/vast-majority-of-americans-say-benefits-of-childhood-vaccines-outweigh-risks/">support for them remains strong overall</a>. But misinformation spread over the internet and social media has weakened the public consensus about the value of vaccination that allowed these laws to be enacted.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="adults and kids with signs protesting COVID-19 vaccines" src="https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some anti-vaccination activists are vocal opponents of vaccine mandates for kids.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/with-her-daughter-ella-baindourov-nara-varderesyan-leads-news-photo/1235967787?adppopup=true">Sarah Reingewirtz/MediaNews Group/Los Angeles Daily News via Getty Images</a></span>
</figcaption>
</figure>
<p>COVID-19 vaccination has become politicized in a way that is unprecedented, with sharp partisan divides over whether <a href="https://www.pewresearch.org/fact-tank/2020/07/22/republicans-remain-far-less-likely-than-democrats-to-view-covid-19-as-a-major-threat-to-public-health/">COVID-19 is really a threat</a>, and whether the <a href="https://news.gallup.com/poll/352397/democratic-republican-confidence-science-diverges.aspx">guidance of scientific experts can be trusted</a>. The attention focused on COVID-19 vaccines has given new opportunities for anti-vaccination conspiracy theories to reach wide audiences. </p>
<p>[<em>Over 115,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.] </p>
<p>Fierce opposition to COVID-19 vaccination, powered by <a href="https://www.npr.org/2021/10/17/1046598351/the-political-fight-over-vaccine-mandates-deepens-despite-their-effectiveness">anti-government sentiment and misguided notions of freedom</a>, could undermine support for time-tested school requirements that have protected communities for decades. Although vaccinating school-aged children will be critical to controlling COVID-19, lawmakers will need to proceed with caution.</p><img src="https://counter.theconversation.com/content/168899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Colgrove has received funding from the National Library of Medicine, the Greenwall Foundation, the Milbank Memorial Fund, and the William T. Grant Foundation. </span></em></p>Public health experts know that schools are likely sites for the spread of disease, and laws tying school attendance to vaccination go back to the 1800s.James Colgrove, Professor of Sociomedical Sciences, Mailman School of Public Health; Dean of the Postbaccalaureate Premedical Program, Columbia School of General Studies, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1699242021-10-21T12:45:18Z2021-10-21T12:45:18ZThe American founders didn’t believe your sacred freedom means you can do whatever you want – not even when it comes to vaccines and your own body<figure><img src="https://images.theconversation.com/files/427319/original/file-20211019-18-atnfa9.jpeg?ixlib=rb-1.1.0&rect=23%2C0%2C5298%2C3766&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protests against mandates and quarantines get the Founding Fathers' ideas wrong.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/small-group-of-approximately-50-people-hold-open-solvang-news-photo/1222462576?adppopup=true">George Rose/Getty Images</a></span></figcaption></figure><p>President <a href="https://www.nytimes.com/2021/09/09/us/politics/biden-mandates-vaccines.html">Joe Biden has mandated vaccines</a> for a large part of the American workforce, a requirement that has prompted <a href="https://www.bostonglobe.com/2021/10/14/metro/new-hampshire-protests-over-covid-mandates-roil-state-local-governments/">protest from those opposed to the measure</a>.</p>
<p>Meanwhile, a similar move in New York City to enforce vaccinations has resulted in more than <a href="https://nypost.com/2021/10/09/over-a-dozen-businesses-fined-for-flouting-nyc-vaccine-mandate/">a dozen businesses’ being fined for flouting the rules</a>.</p>
<p>The basic idea behind the objections: Such mandates, which also extend to requirements to wear masks and quarantine if exposed to COVID-19, are a breach of the Constitution’s <a href="https://www.law.cornell.edu/constitution/amendmentxiv">14th Amendment</a>, which states that “no state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States.” </p>
<p>The objectors ask: Aren’t mandates un-American?</p>
<p>As a scholar who has spent decades trying to unravel the hurdles that mark the beginning of this nation, I offer some facts in response to that question – a few very American facts: Vaccination mandates have <a href="https://www.governing.com/now/the-long-history-of-mandated-vaccines-in-the-united-states">existed in the past</a>, even though they have similarly <a href="https://www.nytimes.com/2021/09/09/us/politics/vaccine-mandates-history.html">sparked popular rage</a>. </p>
<p>No vaccination foe, no latter-day fan of the Gadsden Flag’s “<a href="https://theconversation.com/yellow-gadsden-flag-prominent-in-capitol-takeover-carries-a-long-and-shifting-history-145142">DONT TREAD ON ME</a>” message, would ever gain the posthumous approval of the American founders.</p>
<p>George Washington, John Adams, Thomas Jefferson, Alexander Hamilton and the rest of the group cultivated different visions about America. But they agreed on one principle: They were unrelenting on the notion that circumstances often emerge that require public officials to pass acts that abridge individual freedoms.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A print of Gen. George Washington standing among his fellow Revolutionary War generals." src="https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427287/original/file-20211019-19-2btmux.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Gen. George Washington, center, ordered smallpox inoculations for his soldiers, saying there was ‘no possible way of saving the lives of most of those who had not had it, but by introducing innoculation generally.’</span>
<span class="attribution"><a class="source" href="https://lccn.loc.gov/2006691571">Ritchie, Alexander Hay, engraver; Library of Congress Prints and Photographs Division</a></span>
</figcaption>
</figure>
<h2>Keen sense of civic duty</h2>
<p>Most of the founders, to begin with, were slave owners, not especially concerned about trampling over and <a href="https://constitution.congress.gov/constitution/amendment-1/">abridging</a> the rights of the persons they held in bondage. But even when they dealt with those they deemed to be their peers, American citizens, their attitude was rather authoritarian – at least by today’s standards.</p>
<p>In 1777, during the American Revolution, Washington had his officers and troops <a href="https://www.mountvernon.org/video/view/7O5xE5hMNkU?pid=PLr40fFkNNADFEgbM2t-CG0kGnHRDHZoje">inoculated against smallpox</a>. The procedure was <a href="https://www.monticello.org/site/research-and-collections/inoculation">risky</a>. But for Washington, the pros outweighed the cons. It was an order, an actual mandate, not an option that individuals could discuss and eventually decide. </p>
<p>“After every attempt to stop the progress of the small Pox,” Washington explained to the New York Convention, “I found, that it gained such head among the Southern Troops, that there was no possible way of saving the lives of most of those who had not had it, <a href="https://founders.archives.gov/?q=%22After%20every%20attempt%20to%20stop%20the%20progress%20of%20the%20small%20Pox%22&s=1111311111&sa=&r=1&sr=">but by introducing innoculation generally</a>.”</p>
<p>During the summer of 1793 an epidemic of yellow fever <a href="https://www.history.com/news/yellow-fever-outbreak-philadelphia">struck Philadelphia</a>, then the American capital. It shattered the city’s health and political infrastructure. Food supplies dwindled; business stopped. Government – federal, state and municipal – was suspended. Within just three months, 5,000 out of nearly 55,000 inhabitants died of the infection.</p>
<p>Public hysteria took off. Philadelphians at first pinned the outbreak on the arrival of refugees from the French colony of Saint-Domingue who were escaping that island’s <a href="https://www.britannica.com/topic/Haitian-Revolution">slave revolution</a>. </p>
<p>But there was also heroism. Black clergymen <a href="https://www.britannica.com/biography/Richard-Allen">Richard Allen</a> and <a href="https://en.wikipedia.org/wiki/Absalom_Jones">Absalom Jones</a>, for example, <a href="https://theconversation.com/how-philadelphias-black-churches-overcame-disease-depression-and-civil-strife-153374">tirelessly transported the sick, administered remedies and buried the dead</a>. </p>
<p><a href="https://www.pabook.libraries.psu.edu/literary-cultural-heritage-map-pa/feature-articles/philadelphia-under-siege-yellow-fever-1793">Urged on by Gov. Thomas Mifflin</a>, the Pennsylvania state Legislature imposed sweeping quarantines. And almost everyone complied. </p>
<p><a href="https://www.britannica.com/biography/Henry-Knox">Henry Knox, then the U.S. secretary of war</a>, didn’t object. Knox had fought during the Revolution. He had risked his life on many battles. He had developed a keen sense of what “civic duty” means: “I have yet six days quarantine to perform,” he wrote to President Washington, “which of the choice of evils <a href="https://founders.archives.gov/?q=%22I%20have%20yet%20six%20days%C2%A0quarantine%C2%A0to%20perform%22&s=1111311111&sa=&r=1&sr=">is the least</a>.”</p>
<h2>‘Without a flinch’</h2>
<p>The epidemic didn’t abate as quickly as expected. By September 1794 <a href="https://www.pbs.org/wgbh/americanexperience/features/fever-major-american-epidemics-of-yellow-fever/">the yellow fever lingered in Baltimore</a>, where it had spread from Philadelphia. In 1795 it reached New York City.</p>
<p>One John Coverdale, from Henderskelfe, Yorkshire, England, wrote President Washington a long letter. He advocated more drastic measures, including three weeks of quarantine and policemen strategically placed in every corner to hinder people from passing from zone to zone; and he wanted people “to carry with them <a href="https://founders.archives.gov/?q=%22certificates%20either%20of%20their%20coming%20from%20places%20not%20infected%22&s=1111311111&sa=&r=1&sr=">certificates</a> either of their coming from places not infected or of their passing the line by permission.”</p>
<p>In other words, a quarantine, lockdown and vaccine passports. </p>
<p>No politician we know of at the time considered such measures un-American. In May of 1796, Congress adopted, and President Washington signed, the <a href="https://archive.org/details/lawsofunitedstat03unit/page/314/mode/2up?view=theater">first federal quarantine law</a>. There wasn’t much controversy. In 1799, Congress passed a second and more restrictive <a href="https://www.loc.gov/resource/rbpe.22401000/?sp=1">quarantine law</a>. President Adams signed it without a flinch.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A head-and-shoulders portrait of Alexander Hamilton." src="https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=753&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=753&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=753&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=946&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=946&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427271/original/file-20211019-19-a5pf9z.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=946&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Founding Father Alexander Hamilton stated, ‘It shall never be said, with any color of truth, that my ambition or interest has stood in the way of the public good.’</span>
<span class="attribution"><a class="source" href="https://www.loc.gov/item/2016816335/">Library of Congress Prints and Photographs Division</a></span>
</figcaption>
</figure>
<h2>‘Ambition’ vs. public good</h2>
<p>So apparently it’s not certificates, quarantines and vaccine mandates that are un-American, <a href="https://twitter.com/Jim_Jordan/status/1434978332513292291">as some maintain today</a>. </p>
<p>The argument that individual rights trump the greater good is un-American, or at least out of step with American tradition. It’s an attitude that the founders would have put under <a href="https://yalebooks.yale.edu/book/9780300182804/ambition-history">the encompassing banner of “ambition</a>.”</p>
<p>“Ambition” comes when individuals are blinded by their little – or large – egotisms and personal interests. They lose track of higher goals: the community, the republic, the nation. In the most severe cases, ambition turns anti-social.</p>
<p>Ambitious individuals, the founders were sure, are persons stripped of their membership in a community. They choose to relegate themselves to their solitary imagination. They have become slaves to their own opinions.</p>
<p><a href="https://en.wikipedia.org/wiki/Alexander_Hamilton">Alexander Hamilton</a> was tired of being turned into the butt of endless accusations: “<a href="https://founders.archives.gov/?q=%22my%20ambition%20or%20interest%20has%20stood%20in%20the%20way%22&s=1111311111&sa=&r=2&sr=">It shall never be said</a>, with any color of truth, that my ambition or interest has stood in the way of the public good.”</p>
<p>When facing a quarantine, a mandate, or similar momentary abridgments of their liberties, many Americans today react the same way Hamilton did. Like Hamilton, they look beyond themselves, their opinions, their interests. They don’t lose sight of the public good.</p>
<p>Others remain ambitious.</p>
<p>[<em>The Conversation’s Politics + Society editors pick need-to-know stories.</em> <a href="https://theconversation.com/us/newsletters/politics-weekly-74/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=politics-need-to-know">Sign up for Politics Weekly</a>._]</p><img src="https://counter.theconversation.com/content/169924/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maurizio Valsania does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Founding Fathers were unrelenting in their commitment to the idea that circumstances can arise that require public officials to take actions abridging individual freedoms.Maurizio Valsania, Professor of American History, Università di TorinoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1690822021-10-06T12:28:20Z2021-10-06T12:28:20ZAs American independence rang, a sweeping lockdown and mass inoculations fought off a smallpox outbreak<figure><img src="https://images.theconversation.com/files/424543/original/file-20211004-15-1sh5x21.jpg?ixlib=rb-1.1.0&rect=41%2C48%2C2106%2C3266&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The first reading of the Declaration of Independence in Boston, July 18, 1776.</span> <span class="attribution"><a class="source" href="https://ark.digitalcommonwealth.org/ark:/50959/wh246s47c">Tichnor Brothers Collection, Boston Public Library via Digital Commonwealth</a></span></figcaption></figure><p>Many Americans of the founding era denounced government tyranny, celebrated the Declaration of Independence – and favored lockdowns and mass inoculations to combat a viciously contagious disease.</p>
<p>Unchecked, <a href="https://en.wikipedia.org/wiki/Smallpox">smallpox</a> kills more than one in 10 of its victims, leaving many of the rest blind, disfigured and sometimes sterile. Many <a href="https://doi.org/10.1353/jmh.2004.0012">historians</a> say the reason George Washington never had children was his near-fatal bout of smallpox in 1751.</p>
<p>The summer of 1776 was a time of crisis for the budding republic. A <a href="https://www.worldcat.org/title/pox-americana-the-great-smallpox-epidemic-of-1775-82/oclc/872598533">smallpox outbreak in the Continental Army</a> killed hundreds. And as the soldiers came home from a failed invasion of Canada, they brought the disease to Boston.</p>
<p>Yet the country badly needed healthy men: <a href="http://www.ouramericanrevolution.org/index.cfm/page/view/p0217">The British landed on Staten Island on July 2</a>, the same day <a href="https://constitutioncenter.org/blog/on-this-day-the-declaration-of-independence-is-officially-signed">Congress declared independence</a>. </p>
<p>A perfect solution beckoned: <a href="https://www.worldcat.org/title/pox-americana-the-great-smallpox-epidemic-of-1775-82/oclc/872598533">inoculation</a>, the 18th-century precursor to vaccination. As <a href="https://www.worldcat.org/title/pox-americana-the-great-smallpox-epidemic-of-1775-82/oclc/872598533">historian Elizabeth Fenn explains</a>, the physician would make small incisions in the patient’s skin, then introduce scabs or pus from a person with smallpox. The inoculee would then contract a mild form of the virus, only one-tenth as lethal as the accidentally acquired version.</p>
<p>It would be 20 years before English scientist <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696/">Edward Jenner</a> pioneered the practice of immunizing people against smallpox with the similar cowpox virus, which is harmless to humans. Since the Latin word for cow is “vacca,” that process became known as vaccination.</p>
<p>In Colonial times, people who got inoculated generally did so in groups in order to keep down the cost and logistical complications. For the several weeks that they remained contagious, they would take over a home or tavern and proclaim it a <a href="https://www.worldcat.org/title/pox-americana-the-great-smallpox-epidemic-of-1775-82/oclc/872598533">smallpox hospital</a>: off-limits to everyone but inoculees.</p>
<h2>Imposing a lockdown</h2>
<p>Boston and other towns required people undergoing inoculation to remain indoors and post <a href="https://boston1775.blogspot.com/2007/04/newspapers-on-flag-at-liberty-tree.html">red warning flags</a> around the immunization site. Sometimes, though, restless individuals would slip out, endangering neighbors who either could not afford the expensive procedure or chose not to undergo it. Even when inoculees remained indoors, townspeople so feared catching this horrific disease that they often <a href="https://www.jstor.org/stable/25652028">rioted</a> against doctors who set up inoculation sites.</p>
<p>But by early summer 1776, the majority of not-yet-inoculated Bostonians were eager for the procedure – and so were many out-of-towners. Abigail Adams, famous today for imploring the Continental Congress to “<a href="https://www.masshist.org/digitaladams/archive/doc?id=L17760331aa&bc=%2Fdigitaladams%2Farchive%2Fbrowse%2Fdate%2Fall_1776.php">Remember the Ladies</a>,” acted quickly to inoculate herself and her children. Traveling from the nearby town of Braintree to Boston for the treatment, she wrote her husband, future president John Adams, “<a href="https://www.washingtonpost.com/history/2020/12/12/abigail-adams-smallpox-coronavirus-vaccine/">Our Little ones stood the operation Manfully</a> … The Little folks are very sick then and puke every morning, but after that they are comfortable.”</p>
<p>Still, others refused, and Boston’s selectmen (city council) could not just let everyone decide for themselves. A patchwork of families, some undergoing and some refusing inoculation, would assuredly have set off an epidemic. So Massachusetts legislators made a <a href="https://babel.hathitrust.org/cgi/pt?id=umn.31951002355939u&view=1up&seq=557&skin=2021">bold decision</a>. Since most Bostonians wanted to be inoculated, they would not, per usual, have to confine themselves to smallpox hospitals. </p>
<p>Instead, they would have the run of Boston, and the anti-inoculators would be the ones who had to either <a href="https://babel.hathitrust.org/cgi/pt?id=umn.31951002355939u&view=1up&seq=557&skin=2021">lock down or get out of town</a> before inoculation began. </p>
<p>Until the city was deemed safe, guards would be posted at the sole road and several ferry landings connecting Boston to the wider world. Only those who had already had smallpox would be allowed in, and no one could leave until the selectmen deemed them smallpox-free.</p>
<p>By July 18, when Col. Thomas Crafts stepped out onto the balcony of the Massachusetts State House to read the just-received Declaration of Independence, no one in attendance needed to fear either catching smallpox or giving it to someone else.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A painting of a woman" src="https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=790&fit=crop&dpr=1 600w, https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=790&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=790&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=993&fit=crop&dpr=1 754w, https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=993&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/424545/original/file-20211004-15-79s80p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=993&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Abigail Adams remarked upon the cheering crowds in a locked-down Boston.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Abigail_Adams.jpg">Benjamin Blyth via Wikimedia Commons</a></span>
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<p>Abigail Adams was among the “<a href="https://www.masshist.org/digitaladams/archive/doc?id=L17760721aa">Multitude</a>” who attended the reading. As Crafts finished the Declaration of Independence and shouted, “God Save our American States,” Adams reported, “<a href="https://www.masshist.org/digitaladams/archive/doc?id=L17760721aa">the Bells rang … the cannon were discharged, the platoons followed and every face appeard joyfull</a>.” </p>
<p>As late as August 26, Boston leaders were still trying to stamp out vestiges of the smallpox virus, but their bold action had prevented an epidemic. <a href="https://www.washingtonpost.com/outlook/2021/07/02/we-can-repeat-bostons-1776-freedom-summer/">Nearly 5,000 people</a> had been inoculated. That was equivalent to a <a href="https://www.nar.realtor/blogs/economists-outlook/largest-cities-in-the-united-states-in-1776-and-in-2076">third of Boston’s population</a>, though about half of the inoculees were actually out-of-towners like the Adams family.</p>
<h2>Conflicting notions of freedom</h2>
<p>At the time, Boston had five newspapers, but no one used their pages to complain about the lockdown and other enforcement measures.</p>
<p>Some people took their belief in the individual’s responsibility to the community to extremes. The claim that “<a href="https://archive.csac.history.wisc.edu/Benjamin_Rush.pdf">Every man in a republic is public property</a>” came not from some crazed utopian but from Benjamin Rush, a signer of the Declaration of Independence. And Benjamin Franklin, in a Christmas 1783 letter advocating federal taxes to pay off the Revolutionary War debt, conceded that citizens have the right to retain enough property for their survival and for “the Propagation of the Species.” But he added: “<a href="https://founders.archives.gov/documents/Franklin/01-41-02-0231">all Property superfluous to such purposes is the Property of the Publick</a>.”</p>
<p>Few Americans today would go as far as Rush and Franklin, but their comments, like Boston’s July 1776 decision to turn itself into one giant immunization site, remind us of the American Revolutionaries’ provocative conviction that communities have rights, too.</p>
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<p class="fine-print"><em><span>Woody Holton received funding from the National Endowment for the Humanities Henry E. Huntington Library, and Newberry Library.</span></em></p>In the summer of 1776, Boston offered smallpox inoculation to everyone and required those who declined to leave town or stay in their homes.Woody Holton, Professor of History, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1620912021-07-23T02:59:51Z2021-07-23T02:59:51ZEradicating smallpox: the global vaccination push that brought the world ‘arm-to-arm’<figure><img src="https://images.theconversation.com/files/412353/original/file-20210721-27-wcaw1d.jpeg?ixlib=rb-1.1.0&rect=18%2C2%2C859%2C731&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Edward Jenner vaccinating his son, held by Mrs Jenner; a maid rolls up her sleeve, a man stands outside holding a cow. Coloured engraving by C. Manigaud after E Hamman. The Wellcome Collection.</span></span></figcaption></figure><p>As the roll-out of COVID vaccines proceeds, it’s worth looking back on the challenges and successes of the early global spread of smallpox vaccination.</p>
<p>Smallpox (also known by its scientific name, variola) was a horrible, highly infectious disease, with a case fatality-rate of 30%. In 1798, Edward Jenner, an English country doctor, published data on cowpox (or “vaccine”, a term derived from the Latin for cow and increasingly preferred by Jenner; modern scientific name vaccinia). His data suggested this pustular disease found on dairy cows protected people from smallpox.</p>
<p>He detailed experiments in which he inoculated children with cowpox (usually by nicking the arm and inserting cowpox pus under the skin), and presented the inoculation of cowpox as a safe and effective way to prevent smallpox.</p>
<p>Jenner’s claims were initially met with scepticism. Even in Britain, vaccination was not taken up on any scale until 1800. By this time, though, cowpox samples were being dispatched overseas and attracting great interest as a way to protect people against smallpox. By 1805, at the height of the Napoleonic Wars, people were already being vaccinated all around the world. By 1815, several million people, half of them outside Europe, had been vaccinated.</p>
<p>Sadly, however, the global eradication of smallpox was not achieved until the late 1970s.</p>
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<h2>The wonder of cowpox</h2>
<p>Smallpox was universally feared but people had learned to live with it. It was easy enough to recognise; victims became visibly ill before they became infectious. Crucially, people knew that if they survived the attack, they could be confident of lifelong immunity.</p>
<p>Learning to live with smallpox sometimes involved deliberately exposing children to the disease in the hope of a mild outcome. In Britain, it was found smallpox inoculation — that is, making a light cut in the arm and applying smallpox pus to the wound — resulted in far fewer deaths than in cases of naturally acquired smallpox. </p>
<p>It was as a practitioner of smallpox inoculation (which was also known as variolation) that Jenner found evidence people who had been casually infected with cowpox appeared to be immune to smallpox infection. </p>
<p>He put the theory to the test by inoculating a boy with cowpox lymph — taken not from the cow but from a vesicle or blister on a milkmaid’s hand — and demonstrating his resistance to smallpox by variolation.</p>
<p>Jenner’s presentation of cowpox as a safe and effective substitute for smallpox found corroboration in trials in London in 1799. It wasn’t easy to allay doubts among parents. Still, people were even more scared of smallpox, and recognised smallpox inoculation involved significant risk to the patient and the community. Cowpox was a game-changer.</p>
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<h2>More diaspora than roll-out</h2>
<p>Although hailed as a boon, the new approach got off to a shaky start. Cowpox was rare, appearing only sporadically in dairy farms. The supply of vaccine depended from the outset on its propagation on human bodies. If the vaccine “took” on the child’s arm then, nine or ten days later, the ripe pustule was pricked to provide fresh vaccine. </p>
<p>Children of the poor were immunised at no charge and, on returning to clinics for examination, were put arm-to-arm with the next batch of children. Some vaccine was dried, often on cotton threads, as a future supply. Quality control was a major problem. In 1800, a cowpox institute was set up in London to propagate and distribute vaccine and in 1803 the Royal Jenner Society was established to promote the practice.</p>
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<a href="https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/406916/original/file-20210617-27-z89ro6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Cowpox was a rare disease, appearing only sporadically in dairy farms.</span>
<span class="attribution"><span class="source">J. Pass, Public domain, via Wikimedia Commons</span></span>
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</figure>
<p>The spread of the first vaccine was more diaspora than roll-out. Samples of cowpox on cotton threads were sent in the post, in Britain and overseas, rather in the manner of plant seeds. </p>
<p>Many samples proved useless on arrival, but by sending them in some profusion, it proved relatively simple to seed the practice in Europe and North America. Improvements in packaging even made it possible to send vaccine from Vienna to Baghdad, where it was propagated for onward transmission to India in 1802. Viable vaccine was even delivered, after a 154-day voyage, to Sydney in 1804. </p>
<h2>The world arm-to-arm</h2>
<p>Another approach to conquering the tyranny of distance was to move patients under vaccination. Early in 1802, Tsar Alexander approved an expedition to establish vaccination through Russia in which children vaccinated in one province were escorted to go “arm-to-arm” with children in the next. In 1803, King Carlos of Spain launched an even grander expedition that, by vaccinating a succession of children, delivered live vaccine to Spanish America and then across the Pacific to Manila and Macao.</p>
<p>Vaccination literally brought the world arm-to-arm. The rapid global spread of the vaccine itself owed a lot to the universal dread of smallpox but also to humanitarian enthusiasm and international collaboration. </p>
<p>A range of measures were used to embed the practice. In Berlin, children were given trinkets and medals. Poor mothers in Mexico and India were bribed to have their children vaccinated. In Austria, mothers whose children died of smallpox were named and shamed. </p>
<p>Some states moved rapidly along the road to compulsion. In France, where Napoleon was a great advocate of the practice, vaccination was urged as a civic duty but not made mandatory. In Denmark, a vaccination certificate was rapidly made a requisite for schooling, public employment and even marriage.</p>
<h2>Complacency and lack of resolve</h2>
<p>Aware of vaccine’s global success, Jenner and his colleagues deplored the loss of momentum in Britain itself. In London, the practice was under challenge from a noisy anti-vaccination lobby led by old-style inoculators. </p>
<p>A smallpox epidemic in 1805, while showing the value of vaccination, disclosed some failures arising from poor early practice. In claiming vaccination was for life, Jenner had set the bar too high. To the end of his life in 1823, he was reluctant to concede the need for periodic re-vaccination.</p>
<p>The major problem in Britain and elsewhere was complacency. The early success in suppressing smallpox, and indeed eliminating it in some places, led parents to neglect vaccination. </p>
<p>Outbreaks in the 1830s were a major shock and pushed the British government to fund vaccination in 1840 and to make it mandatory in 1853. Victoria — though not New South Wales — followed this lead. Although it was controversial and fuelled anti-vaccination sentiment, compulsory vaccination, with some provision for conscientious objection, played a vital role making the practice routine. This kept smallpox at bay, prompted improvements, and helped inspire the development of new vaccines.</p>
<p>From the outset, vaccination was seen as a means of eradicating smallpox. It saved countless lives, kept communities safe for as long as vaccination was maintained, and limited the severity of outbreaks. </p>
<p>The permanent elimination of smallpox required governments to provide the infrastructure and resources, and show the political will to incentivise if not mandate vaccination. </p>
<p>Although the disease was largely brought under control in the West, millions were still dying from smallpox elsewhere in the middle of the twentieth century when the World Health Organization committed itself to the global eradication of smallpox.</p>
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<a href="https://theconversation.com/four-of-the-most-lethal-infectious-diseases-of-our-time-and-how-were-overcoming-them-78101">Four of the most lethal infectious diseases of our time and how we're overcoming them</a>
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<p class="fine-print"><em><span>Michael Bennett has received support for his work on this topic from the Australian Research Council.
He is the author of War Against Smallpox. Edward Jenner and the Global Spread of Vaccination (Cambridge University Press, 2020).
</span></em></p>The major problem in Britain and elsewhere was complacency. The early success in suppressing smallpox, and indeed eliminating it in some places, led parents to neglect vaccination.Michael Bennett, Professor in School of History and Classics, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1642562021-07-20T10:35:45Z2021-07-20T10:35:45ZLady Mary Wortley Montagu – the forgotten immunisation pioneer<figure><img src="https://images.theconversation.com/files/411091/original/file-20210713-13-owgwm3.jpeg?ixlib=rb-1.1.0&rect=0%2C3%2C794%2C659&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Visionary: Lady Mary Wortley Montagu.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Liotard_Lady_Montagu.jpg">Jean-Étienne Liotard/Wikimedia Commons</a></span></figcaption></figure><p>The remarkable progress with immunisation against COVID-19 has focused the world’s attention on the brilliance of vaccines. Many people know the story of Edward Jenner’s discovery of vaccination against smallpox in Gloucestershire nearly 250 years ago. But far fewer have heard of Lady Mary Wortley Montagu. She was the socialite whose pioneering inoculation experiments laid the groundwork for Jenner’s discovery, but whose contribution is all but forgotten. This year, the 300th anniversary of her extraordinary human experiments, provides a timely occasion to review her amazing contribution to public health.</p>
<p>Born Mary Pierrepont in 1689, she was a vivacious and headstrong woman who <a href="https://www.britannica.com/biography/Lady-Mary-Wortley-Montagu">wrote poems and letters and held progressive views</a> on women’s role in society. To avoid an arranged marriage, she eloped at the age of 23 and wedded Edward Wortley Montagu, grandson of the first Earl of Sandwich.</p>
<p>In 1716, Edward became England’s ambassador to Istanbul (or Constantinople as it was then), capital of the Turkish Ottoman Empire. From there Wortley Montagu <a href="https://www.pen-and-sword.co.uk/The-Pioneering-Life-of-Mary-Wortley-Montagu-Hardback/p/18797">wrote vivid descriptions of oriental life</a>, especially the Turkish women, whose dress, lifestyle and traditions intrigued her. Most notable among these was their method of inoculation against the dreaded smallpox. </p>
<p>It had long been recognised that people could only get this disease once. If they survived, they were immune for the rest of their lives. Rather than take their chances with a natural infection and its high fatality rate, the older Turkish women sought to induce a mild case in children by “ingrafting” as they called it. </p>
<p>Smallpox causes blisters and scabs on the skin of those afflicted by the disease. The women would take the pus from one patient’s blister and scratch it into a cut they would make on the arm of the person they wanted to protect. This would usually lead to mild symptoms, followed by lifelong protection.</p>
<p>“There is a set of old women [here],” Wortley Montagu wrote, “who make it their business to perform the operation, every autumn … thousands undergo this … [and there] is not one example of anyone that has died in it.”</p>
<p>Wortley Montagu herself had survived smallpox but was left with facial scarring. Her brother had succumbed to the illness. She was keen to protect her young son from the disease and convinced the embassy surgeon to inoculate him.</p>
<p>“The Boy was engrafted last Tuesday,” she wrote in a letter to her husband, “and is at this time singing and playing, and very impatient for his supper.”</p>
<p>Wortley Montagu was determined to “bring this useful invention into fashion in England”.</p>
<p>Within a couple of years, she had returned home. In 1721, there was a smallpox epidemic, and Wortley Montagu asked the embassy doctor, who had come to London with her, to engraft her young daughter who had not been inoculated.</p>
<p>Nervous for his reputation, the doctor asked several medical witnesses to observe the procedure. In April 1721, he inoculated young Mary Alice, the first time the procedure was performed in Britain. Although the observers were impressed, others were sceptical about this dangerous, exotic practice. Wortley Montagu and her daughter visited households affected by smallpox to demonstrate that she was protected. However, many doctors remained cautious. Wasn’t this a risky procedure? What if it caused severe or fatal disease?</p>
<h2>Death or inoculation</h2>
<p>In August 1721, an extraordinary experiment was performed at London’s Newgate Prison that helped persuade people of the benefit of smallpox inoculation. Several prisoners awaiting execution were offered the chance to have inoculation with smallpox instead – being allowed their freedom if they survived. All took the offer and lived to tell the tale. To prove the immunisation actually protected against disease, one of the female prisoners was sent to nurse a young boy with smallpox, sleeping with him every night for six weeks without becoming unwell.</p>
<p>Although inoculation remained a controversial practice, with some medical and religious opposition, this prison experiment strengthened considerably the campaign for “variolation”, as the procedure is now known. Wortley Montagu’s friend, the Princess of Wales, was convinced and had her own children inoculated. Royalty across Europe followed suit, as did the wealthy of New England, where smallpox was raging. </p>
<figure class="align-center ">
<img alt="Drawings showing smallpox and cowpox inoculation." src="https://images.theconversation.com/files/411092/original/file-20210713-13-1lanfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411092/original/file-20210713-13-1lanfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411092/original/file-20210713-13-1lanfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411092/original/file-20210713-13-1lanfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411092/original/file-20210713-13-1lanfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411092/original/file-20210713-13-1lanfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411092/original/file-20210713-13-1lanfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Drawings showing smallpox and cowpox inoculation.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/d/d1/Drawings_showing_smallpox_and_cowpox_inoculation._Wellcome_L0015944.jpg">Wellcome Library/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Even though severe disease occasionally occurred after inoculation, and was sometimes fatal, the procedure saved thousands of lives. Wortley Montagu’s contribution was celebrated by French poet Voltaire among others, and inoculation became a rallying point for the enlightenment.</p>
<p>Seventy-five years later, English physician <a href="https://jennermuseum.com">Dr Edward Jenner</a>, who had been inoculated as a child, took the process one step further. He realised those who had suffered from cowpox, a related disease of cattle that is very mild in humans, were subsequently immune to smallpox. Jenner therefore jabbed people with cowpox material and then proved this was effective against smallpox by injecting them with smallpox using Wortley Montagu’s variolation approach. </p>
<p>Vaccination, as the Jenner procedure became known after the Latin <em>vacca</em> for cow, proved to be safe and was subsequently taken up globally. Jenner received many honours and awards, and the work led to the eventual eradication of smallpox in 1976.</p>
<p>Every medical student around the world now learns about Jenner; his <a href="https://artuk.org/discover/artworks/edward-jenner-17491823-192395">portrait</a> hangs in the Royal College of Physicians of London. Even Blossom, the cow who provided the original cowpox material for Jenner’s experiment, is remembered. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)73326-2/fulltext">Her hide</a> sits in St George’s Hospital Medical School, and <a href="https://www.rcpath.org/uploads/assets/73a2a525-c5de-4de4-993cb77470582552/26-Blossom-The-Cow.pdf">her portrait</a> hangs in the Royal College of Pathologists. But Wortley Montagu, whose pioneering efforts laid the groundwork for Jenner’s experiments, is forgotten. Whether her work would be remembered had she been a gentleman physician, rather than a lady socialite, can only be guessed at. Now, 300 years later, the Royal College of Physicians of London is looking into the most appropriate way to recognise her contribution.</p><img src="https://counter.theconversation.com/content/164256/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tom Solomon receives funding from the UK MRC, NIHR and Wellcome. He is president of The Encephalitis Society </span></em></p>Wortley Montagu popularised the Turkish practice of ‘variolation’, kickstarting the global battle against smallpox.Tom Solomon, Director of the National Institute for Health Research (NIHR) Health Protection Research Unit in Emerging and Zoonotic Infections, and Professor of Neurology, University of Liverpool, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1615692021-07-01T12:15:51Z2021-07-01T12:15:51ZBenjamin Franklin’s fight against a deadly virus: Colonial America was divided over smallpox inoculation, but he championed science to skeptics<figure><img src="https://images.theconversation.com/files/409191/original/file-20210630-21-sgosjo.jpg?ixlib=rb-1.1.0&rect=0%2C551%2C4653%2C3592&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As a printer's apprentice in 1721, Franklin had a front-row seat to the controversy around a new prevention technique.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/1700s-1721-benjamin-franklin-age-15-in-his-brothers-news-photo/658540811">ClassicStock/Archive Photos via Getty Images</a></span></figcaption></figure><p>Exactly 300 years ago, in 1721, Benjamin Franklin and his fellow American colonists <a href="https://sitn.hms.harvard.edu/flash/special-edition-on-infectious-disease/2014/the-fight-over-inoculation-during-the-1721-boston-smallpox-epidemic/">faced a deadly smallpox outbreak</a>. Their varying responses constitute an eerily prescient object lesson for today’s world, similarly devastated by a virus and divided over vaccination three centuries later.</p>
<p>As <a href="https://scholar.google.com/citations?user=Xy_EasYAAAAJ&hl=en&oi=ao">a microbiologist</a> and <a href="https://scholar.google.com/citations?user=QrpiSzEAAAAJ&hl=en">a Franklin scholar</a>, we see some parallels between then and now that could help governments, journalists and the rest of us cope with the coronavirus pandemic and future threats.</p>
<h2>Smallpox strikes Boston</h2>
<p>Smallpox was nothing new in 1721. Known to have affected people for <a href="https://www.cdc.gov/smallpox/history/history.html">at least 3,000 years</a>, it ran rampant in Boston, eventually striking <a href="https://sitn.hms.harvard.edu/flash/special-edition-on-infectious-disease/2014/the-fight-over-inoculation-during-the-1721-boston-smallpox-epidemic/">more than half the city’s population</a>. The virus killed about <a href="https://doi.org/10.1056/NEJM192108251850802">1 in 13 residents</a> – but the death toll was probably more, since the lack of sophisticated epidemiology made it impossible to identify the cause of all deaths.</p>
<p>What was new, at least to Boston, was a simple procedure that could protect people from the disease. It was known as “variolation” or “inoculation,” and involved deliberately exposing someone to the smallpox “matter” from a victim’s scabs or pus, injecting the material into the skin using a needle. This approach typically caused a mild disease and induced a state of “immunity” against smallpox.</p>
<p>Even today, the exact mechanism is <a href="https://apps.who.int/iris/handle/10665/39485">poorly understood</a> and not much research on variolation has been done. Inoculation through the skin seems to activate an immune response that leads to milder symptoms and less transmission, possibly because of the route of infection and the lower dose. Since it relies on activating the immune response with live smallpox variola virus, inoculation is different from the modern vaccination that <a href="https://theconversation.com/a-massive-public-health-effort-eradicated-smallpox-but-scientists-are-still-studying-the-deadly-virus-139468">eradicated smallpox</a> using the much less harmful but related vaccinia virus.</p>
<p>The inoculation treatment, which originated in Asia and Africa, came to be known in Boston <a href="https://doi.org/10.1258/jrsm.2012.12k044">thanks to a man named Onesimus</a>. By 1721, <a href="https://www.americanantiquarian.org/proceedings/48057585.pdf">Onesimus was enslaved</a>, owned by the most influential man in all of Boston, the Rev. Cotton Mather.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="etching of an 18th century man in white wig" src="https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=770&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=770&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=770&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=968&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=968&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409192/original/file-20210630-21-ix8xvo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=968&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cotton Mather heard about variolation from an enslaved West African man in his household named Onesimus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/an-engraved-portrait-of-cotton-mather-a-boston-news-photo/517387846?adppopup=true">Bettman via Getty Images</a></span>
</figcaption>
</figure>
<p>Known primarily as a Congregational minister, <a href="https://www.britannica.com/biography/Cotton-Mather">Mather was also a scientist</a> with a special interest in biology. He paid attention when <a href="https://doi.org/10.1258/jrsm.2012.12k044">Onesimus told him</a> “he had undergone an operation, which had given him something of the smallpox and would forever preserve him from it; adding that it was often used” in West Africa, where he was from.</p>
<p>Inspired by this information from Onesimus, Mather teamed up with a Boston physician, <a href="https://www.britannica.com/biography/Zabdiel-Boylston">Zabdiel Boylston</a>, to conduct a scientific study of inoculation’s effectiveness worthy of 21st-century praise. They found that of the approximately 300 people Boylston had inoculated, <a href="http://dx.doi.org/10.1136/qshc.2003.008797">2% had died</a>, compared with almost 15% of those who contracted smallpox from nature.</p>
<p>The findings seemed clear: Inoculation could help in the fight against smallpox. Science won out in this clergyman’s mind. But others were not convinced.</p>
<h2>Stirring up controversy</h2>
<p>A local newspaper editor named James Franklin had his own affliction – namely an insatiable hunger for controversy. Franklin, who was no fan of Mather, set about attacking inoculation in his newspaper, The New-England Courant.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="frontpage of a 1721 newspaper" src="https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=863&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=863&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=863&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1085&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1085&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409174/original/file-20210630-21151-1xbbyj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1085&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">From its first edition, The New-England Courant covered inoculation.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:NewEnglandCourant_00001.jpg">Wikimedia Commons</a></span>
</figcaption>
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<p>One article from August 1721 tried to guilt readers into resisting inoculation. If someone gets inoculated and then spreads the disease to someone else, who in turn dies of it, <a href="https://nationalhumanitiescenter.org/pds/becomingamer/ideas/text7/smallpoxinoculation.pdf">the article asked</a>, “at whose hands shall their Blood be required?” The same article went on to say that “Epidemeal Distempers” such as smallpox come “as Judgments from an angry and displeased God.”</p>
<p>In contrast to Mather and Boylston’s research, the Courant’s articles were designed not to discover, but to sow doubt and distrust. The argument that inoculation might help to spread the disease posits something that was theoretically possible – at least if simple precautions were not taken – but it seems beside the point. If inoculation worked, wouldn’t it be worth this small risk, especially since widespread inoculations would dramatically decrease the likelihood that one person would infect another?</p>
<p>Franklin, the Courant’s editor, had a kid brother apprenticed to him at the time – a teenager by the name of Benjamin.</p>
<p>Historians don’t know which side the younger Franklin took in 1721 – or whether he took a side at all – but his subsequent approach to inoculation years later has lessons for the world’s current encounter with a deadly virus and a divided response to a vaccine.</p>
<h2>Independent thought</h2>
<p>You might expect that James’ little brother would have been inclined to oppose inoculation as well. After all, <a href="https://doi.org/10.1080/10463280701592070">thinking like family members and others you identify with</a> is a common human tendency.</p>
<p>That he was capable of overcoming this inclination shows <a href="https://theconversation.com/talking-politics-in-2021-lessons-on-humility-and-truth-seeking-from-benjamin-franklin-153924">Benjamin Franklin’s capacity for independent thought</a>, an asset that would serve him well throughout his life as a writer, scientist and statesman. While sticking with social expectations confers certain advantages in certain settings, being able to shake off these norms when they are dangerous is also valuable. We believe the most successful people are the ones who, like Franklin, have the intellectual flexibility to choose between adherence and independence.</p>
<h2>Truth, not victory</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="etching of Franklin standing at a table in a lab" src="https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=744&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=744&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=744&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=935&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=935&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409194/original/file-20210630-20925-1fg34y6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=935&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Franklin matured into a well-known scientist and statesman, with many successes aided by his open mind.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/an-engraving-depicting-benjamin-franklin-in-his-laboratory-news-photo/1130664685?adppopup=true">Universal History Archive/Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<p>What happened next shows that Franklin, unlike his brother – and plenty of pundits and politicians in the 21st century – was <a href="https://theconversation.com/talking-politics-in-2021-lessons-on-humility-and-truth-seeking-from-benjamin-franklin-153924">more interested in discovering the truth</a> than in <a href="https://www.psychologytoday.com/us/blog/shift-mind/201103/why-is-it-so-important-be-right">proving he was right</a>.</p>
<p>Perhaps the inoculation controversy of 1721 had helped him to understand an unfortunate phenomenon that continues to plague the U.S. in 2021: When people take sides, progress suffers. <a href="https://doi.org/10.1126/science.1197754">Tribes</a>, whether long-standing or newly formed around an issue, can devote their energies to <a href="https://blogs.cardiff.ac.uk/openfordebate/2019/05/30/what-polarization-does-to-us/">demonizing the other side</a> and rallying their own. Instead of attacking the problem, they attack each other.</p>
<p>Franklin, in fact, became convinced that inoculation was a sound approach to preventing smallpox. Years later he intended to have his son Francis inoculated after recovering from a case of diarrhea. But before inoculation took place, the 4-year-old boy contracted smallpox and died in 1736. Citing a rumor that Francis had died because of inoculation and noting that such a rumor might deter parents from exposing their children to this procedure, Franklin made a point of setting the record straight, explaining that the child had “<a href="https://founders.archives.gov/documents/Franklin/01-02-02-0025">receiv’d the Distemper in the common Way of Infection</a>.”</p>
<p>Writing his autobiography in 1771, Franklin reflected on the tragedy and used it to advocate for inoculation. He explained that he “<a href="https://www.gutenberg.org/files/20203/20203-h/20203-h.htm">regretted bitterly and still regret</a>” not inoculating the boy, adding, “This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”</p>
<h2>A scientific perspective</h2>
<p>A final lesson from 1721 has to do with the importance of a truly scientific perspective, one that embraces science, facts and objectivity.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="19th-century photo of a smallpox patient" src="https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409195/original/file-20210630-21327-fftq4q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Smallpox was characterized by fever and aches and pustules all over the body. Before eradication, the virus killed about 30% of those it infected, according to the U.S. Centers for Disease Control and Prevention.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/smallpox-1898-middle-east-news-photo/1139698133">Sepia Times/Universal Images Group via Getty Images</a></span>
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<p>Inoculation was a relatively new procedure for Bostonians in 1721, and this lifesaving method was not without deadly risks. To address this paradox, several physicians meticulously collected data and compared the number of those who died because of natural smallpox with deaths after smallpox inoculation. Boylston essentially carried out what today’s researchers would call a clinical study on the efficacy of inoculation. Knowing he needed to demonstrate the usefulness of inoculation in a diverse population, he <a href="http://resource.nlm.nih.gov/2544007R">reported in a short book</a> how he inoculated nearly 300 individuals and carefully noted their symptoms and conditions over days and weeks.</p>
<p>The recent emergency-use authorization of <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/mRNA.html">mRNA-based</a> and <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/viralvector.html">viral-vector vaccines</a> for COVID-19 has produced a vast array of <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html">hoaxes, false claims and conspiracy theories</a>, especially in various social media. Like 18th-century inoculations, these vaccines represent new scientific approaches to vaccination, but ones that are based on decades of scientific research and clinical studies. </p>
<p>We suspect that if he were alive today, Benjamin Franklin would want his example to guide modern scientists, politicians, journalists and everyone else making personal health decisions. Like Mather and Boylston, Franklin was a scientist with a respect for evidence and ultimately for truth. </p>
<p>When it comes to a deadly virus and a divided response to a preventive treatment, Franklin was clear what he would do. It doesn’t take a visionary like Franklin to accept the evidence of medical science today.</p>
<p>[<em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>.]</p><img src="https://counter.theconversation.com/content/161569/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I have written and recorded an Audible Original about Benjamin Franklin (due to be released on July 20, 2021).</span></em></p><p class="fine-print"><em><span>Christian Chauret does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When Bostonians in 1721 faced a deadly smallpox outbreak, a new procedure called inoculation was found to help fend off the disease. Not everyone was won over, and newspapers fed the controversy.Mark Canada, Executive Vice Chancellor for Academic Affairs, Indiana University KokomoChristian Chauret, Dean of School of Sciences, Professor of Microbiology, Indiana University KokomoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1557472021-04-04T20:36:05Z2021-04-04T20:36:05ZWhy are Australians so accepting of hotel quarantine? A long history of confining threats to the state<p>It’s been a year since Australia introduced its policy of mandatory hotel quarantine for returning travellers. In the past year, <a href="https://www.abc.net.au/news/2021-03-05/australia-home-quarantine-coronavirus-returned-travellers/13204474">some 211,000 travellers</a> have been confined for two weeks in hotel rooms, in conditions many have found difficult to endure. </p>
<p>The policy remains one of the main reasons the Australian community has managed to escape the worst of the COVID-19 pandemic. For the most part, it has been accepted without question by the public.</p>
<p>This isn’t to say it’s been perfectly executed. The program has been the focus of much criticism and <a href="https://www.theaustralian.com.au/nation/coronavirus-australia-victoria-resumes-hotel-quarantine-program/news-story/58cdae44ced1847bc7c4f77c14f9d62d">investigation</a> over the past year — particularly in Victoria, where it has been twice suspended when the virus “leaked” into the community. The state’s program is again about to begin accepting international arrivals, <a href="https://www.abc.net.au/news/2021-03-25/victorian-government-to-resume-international-flights-quarantine/100027186">starting on April 8</a>. </p>
<p>Experts continue to advocate for a stronger system, including moving quarantine hotels to <a href="https://www.smh.com.au/national/just-makes-logical-sense-top-adviser-joins-calls-to-move-covid-quarantine-out-of-big-cities-20201122-p56gun.html">regional locations</a> and considering some form of <a href="https://www.abc.net.au/news/2021-03-25/victorian-government-to-resume-international-flights-quarantine/100027186">home quarantine</a>.</p>
<p>But the fundamental idea of quarantine – the mandatory removal of a person’s liberties for the benefit of the whole community – remains uncontroversial. </p>
<p>The reaction in other countries has been very different. When the UK introduced an Australian-style quarantine system in February, it was <a href="https://www.independent.co.uk/travel/news-and-advice/hotel-quarantine-complain-disgusting-food-tripadvisor-reviews-b1807248.html">deeply unpopular</a> with travellers. And let’s not forget how tennis players <a href="https://www.abc.net.au/news/2021-01-31/australian-open-bosses-received-request-for-kitten-quarantine/13106906">complained bitterly</a> about Australia’s quarantine system in the lead-up to the Australian Open.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1352372290919358465"}"></div></p>
<p>So, why is the feeling so different among Australians? We argue that one reason may be Australia’s long history of incarceration of migrants, Indigenous people and anyone considered an “enemy” of the state. Since the early days of colonial settlement, different forms of confinement have been used not only to control the spread of illness, but also to respond to a wide range of perceived social and political problems. </p>
<p>These policies reinforced the imaginary idea of Australia as a clean, strong and healthy nation, a united federation in control of its borders.</p>
<p>As a result, Australians have become somewhat conditioned to accept the idea that liberty — at least the liberty of outsiders — should at times take second priority to the national interest. </p>
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Read more:
<a href="https://theconversation.com/another-day-another-hotel-quarantine-fail-so-what-can-australia-learn-from-other-countries-144804">Another day, another hotel quarantine fail. So what can Australia learn from other countries?</a>
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<h2>Australia as a quarantine nation</h2>
<p>Australia’s history of quarantine began in the 1830s, when authorities in NSW first confined all international arrivals to their ships in harbour to prevent the spread of disease. </p>
<p>Soon afterwards, these arrivals were held for an “incubation period” of 14 days (and sometimes, longer) in a system of purpose-built quarantine stations. The program began only to wind down in the 1950s after air travel became popular. </p>
<p>As such, it was the longest-running quarantine program in the modern world, lasting nearly a century after England, France, and other parts of Europe abandoned the practice for overseas arrivals. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/392995/original/file-20210331-21-1wi56av.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392995/original/file-20210331-21-1wi56av.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=434&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392995/original/file-20210331-21-1wi56av.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=434&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392995/original/file-20210331-21-1wi56av.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=434&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392995/original/file-20210331-21-1wi56av.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=545&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392995/original/file-20210331-21-1wi56av.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=545&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392995/original/file-20210331-21-1wi56av.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=545&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Passengers disembark from a Sydney ferry at a quarantine wharf in 1919.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
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<p>One explanation for the early enthusiasm for quarantine was it allowed the authorities to manage who could enter the colonies. The policy quickly took on a racialised tone and played into the <a href="https://www.sbs.com.au/gold/story.php?storyid=46">anti-Chinese sentiment</a> brewing in the goldfields.</p>
<p>Australia’s quarantine system ramped up in the 1880s after an outbreak of smallpox in Sydney. While evidence suggests the disease arrived from Britain (where smallpox was endemic), authorities used the opportunity to raid the homes of Sydney’s Chinese community and force them into quarantine. From that time, regardless of the evidence, Chinese people were regarded as the most potent vectors of disease.</p>
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Read more:
<a href="https://theconversation.com/before-coronavirus-china-was-falsely-blamed-for-spreading-smallpox-racism-played-a-role-then-too-137884">Before coronavirus, China was falsely blamed for spreading smallpox. Racism played a role then, too</a>
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<p>According to historians, the <a href="https://www.legislation.gov.au/Series/C1908A00003">Quarantine Act of 1908</a> is best understood as part of a suite of laws designed to control entry to Australia and entrench a racialised notion of “membership” in society. </p>
<p>Well into the 20th century, returning travellers had very different quarantine experiences, depending on their race and class. </p>
<p>White, first-class arrivals were serviced with good accommodation, food and entertainment, and many enjoyed their time in confinement. Lower-class and non-white passengers suffered poorer conditions, and could be detained far longer than the mandatory 14 days. </p>
<h2>Confinement of Indigenous people and refugees</h2>
<p>Quarantine was not the only form of confinement practised by colonial — and later, state and federal — governments. </p>
<p>A range of institutions were implemented to respond to perceived social and political problems, creating what we call an “institutional memory” — or template — for administrative confinement. </p>
<p>For each successive challenge over the years, Australian policymakers have reached for the same toolkit.</p>
<p>From the mid-1800s until well into the second half of the 20th century, for instance, governments established a network of protectorates, reserves and missions to confine and isolate First Nations people. </p>
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Read more:
<a href="https://theconversation.com/enforcing-assimilation-dismantling-aboriginal-families-a-history-of-police-violence-in-australia-140637">Enforcing assimilation, dismantling Aboriginal families: a history of police violence in Australia</a>
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<p>Their purpose shifted over time, from protecting Indigenous people from frontier violence to “<a href="https://indigenousx.com.au/10-questions-i-get-from-non-indigenous-students/">smoothing the dying pillow</a>” (placing First Nations people on reserves where it was believed the elderly would gradually die off and the younger generations would be assimilated into the larger population). </p>
<p>As part of this network, islands became particular sites of horror. <a href="https://www.sbs.com.au/nitv/living-black/article/2018/06/25/long-road-paradise-street-100-years-palm-island">Palm Island</a> in Queensland, for example, became known as a place for extra-judicial punishment. Nearby <a href="https://www.couriermail.com.au/news/queensland/island-site-of-historic-aboriginal-leprosy-colony-listed-by-queensland-heritage-council/news-story/c037e959ec38c979868e72895b4839b0">Fantome Island</a> was used for the compulsory isolation of Indigenous leprosy patients at a time when other countries had long abandoned this practice. </p>
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<p>Australian policymakers drew on the same confinement toolkit during the two world wars. Australia’s enemy alien internment camps were the <a href="https://www.naa.gov.au/explore-collection/immigration-and-citizenship/wartime-internment-camps-australia#:%7E:text=Internees%20were%20mostly%20'enemy%20aliens,they%20had%20done%20no%20wrong.">most extensive of all allied nations</a>. They were also used, uniquely, to detain prisoners of war on behalf of Australia’s allies.</p>
<p>We would argue that Australian policymakers also relied on this institutional memory when devising a plan to respond to the arrival by boat of 26 Cambodian asylum seekers in 1989. The government <a href="https://www.nma.gov.au/defining-moments/resources/port-hedland-detention-centre">fenced in an abandoned mining camp</a> in Port Hedland, Western Australia, and detained the refugees there while their applications for protection were processed. </p>
<p>Australia’s <a href="https://www.unhcr.org/en-au/united-nations-observations.html">punitive and damaging</a> immigration detention system was introduced soon after. Over the past three decades, refugees have been detained across the breath of the continent (including remote Christmas Island) and in Nauru, Papua New Guinea and Indonesia. </p>
<p>Hotels have recently been repurposed as “<a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Joint/Former_Committees/immigrationdetention/report/c02">alternative places of detention</a>” for some refugees and asylum seekers in Melbourne and Brisbane, as well. </p>
<p>Though many Australians have protested the mistreatment and lengthy detention of refugees in both onshore and offshore centres, the government has refused to bend to pressure to end the controversial program, despite the <a href="https://www.theguardian.com/australia-news/2020/dec/11/budget-blowouts-offshore-processing-costs-12bn-for-fewer-than-300-people">cost of over A$1 billion per year</a>.</p>
<p>For now, quarantine hotels are also here to stay. While Australians have enjoyed the freedoms and safety from COVID-19 that they provide, we should remember these hotels are the latest in a long history of administrative confinement, many of which have been sites of pain and despair.</p><img src="https://counter.theconversation.com/content/155747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Nethery is a member of the Comparative Network of Refugee Externalisation Policies (CONREP), which is co-funded by the European Union under the Erasmus+ Programme - Jean Monnet Activities (599660 EPP-1-2018-1-AU-EPPJMO-NETWORK).</span></em></p><p class="fine-print"><em><span>Umut Ozguc does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australia has a long history of incarceration of migrants, Indigenous people and those considered ‘enemies’ of the state. This has formed a ‘template’ for modern-day quarantine and detention policies.Amy Nethery, Senior Lecturer in Politics and Policy Studies, Deakin UniversityUmut Ozguc, Lecturer in International Relations, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.