Testing squeeze keeps the scope of monkeypox a mystery

• The onus is on primary care providers, including sexual health clinics, to track an unfamiliar disease that manifests itself in different ways.

By the numbers: The CDC says 556 samples have been sent to labs for testing for monkeypox as of June 13, and as of last week, 2% of national lab capacity is being devoted to the outbreak, per the Association of Public Health Laboratories.

• "We must increase testing for those with a characteristic, pimple-like or blister-like rash so we can make swift diagnoses," CDC director Rochelle Walensky said on Friday.
• Experts say the true number of U.S. cases is significantly higher than the 49 confirmed so far and question why the federal government isn't doing more.
• "The sheer geographic spread of cases means this is a bigger outbreak than we are capturing right now," David Harvey, executive director of the National Coalition for STD Directors, told Axios. "So we are very worried about this; we're worried about a lack of an effective federal response, and we think we need to kick into high gear to deal with this."

How it works: The 69 public health laboratories in the Laboratory Response Network in the United States have the capacity to test 6,000 to 8,000 specimens per week for orthopoxvirus, the family of viruses to which monkeypox belongs.

• But under a two-step process, specimens must be sent to one of those laboratories for confirmatory testing before being sent on to the CDC, STAT reports.
• This process takes time and can delay the response at the local level, where contact tracing is used to find high-risk contacts and offer them vaccines in some cases.
• Some companies are already racing to develop PCR testing for monkeypox, though there is not yet a need for hundreds of thousands of tests, which was the case when COVID emerged, Reuters reports.

Yes, but: Some believe that a wave of testing demand is headed our way, pointing to the experience in England, where more than 300 cases have been confirmed and contact tracing has already become a challenge.

• "We are still learning a lot about monkeypox; we've never seen anything like this with this particular virus in the United States," Sarah Turbett, infectious disease physician and microbiologist at Massachusetts General Hospital, told Axios.
• Monkeypox is presenting differently than it typically does in parts of Africa where it is endemic, with a rash that is limited to certain areas of the body and mild symptoms in those infected so far.
• In Africa, monkeypox can be deadly, but the current outbreak has to date not resulted in any deaths.

Between the lines: Because the disease is spread through intimate contact, finding new cases is falling to front-line clinicians, as well as patients who report telltale rashes.

• The San Francisco Health Department started to get inquiries about the virus and testing last week, and local health officials anticipate that demand to increase in the coming weeks.

• "We need to ramp up and help sexual health clinics in the U.S. prepare for what we think will be an onslaught of patients seeking testing," Harvey, with the National Coalition of STD Directors, said.
• While the public health labs can handle the current amount of testing for monkeypox currently, the CDC is working with the FDA and CMS to explore how commercial labs might help expand testing capacity.

Go deeper: The virus has a longer incubation period than the virus that causes COVID-19, giving public health officials up to three weeks to ask people to isolate and identify close contacts.

• So far, the majority of people who have tested positive identify as men who have sex with men, but the virus is not unique to that group — anyone can test positive if they come in close contact with someone who has it.

Threat level: The majority of confirmed cases have been traced to international travel or direct contact with a person who has a confirmed case. But a few cases have no connection to a confirmed case, implying there is some community spread.

• "We don't have one area where we feel like there's community transmission happening," Jennifer McQuiston, CDC deputy director of pathology, told reporters Friday.

What we're watching: While local health departments say they're prepared to respond, the outbreak could grow beyond their capacity, Lori Tremmel Freeman, CEO of the National Association of City and County Health Officials, said.

"If you have a larger type of outbreak, then it becomes less manageable," Freeman said. "Although health departments know how to source it, whether or not they have the funding and money to do that and can do it quickly, is another question."

Editor's note: This story has been updated to reflect new testing numbers the CDC provided to Axios after deadline.