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The growing monkeypox outbreak may appear alarming to people — potentially triggering bad memories of the rapid spread of COVID over the globe — but it does not contain the same threat level as a pandemic, experts tell Axios.

The big picture: How monkeypox is spreading around the world — with nine U.S. cases confirmed so far — is "new and certainly concerning" but the virus isn't behaving completely unexpectedly, says the CDC's poxvirus epidemiology team lead, Andrea McCollum.

"This is definitely not like COVID. ... We are still in a framework where this is controllable," McCollum tells Axios.

"People are seeing these cases every day pop up on multiple continents, and this feels very much like the early days of COVID," says Jennifer Nuzzo, director of the Pandemic Center at Brown University's School of Public Health. 

But, "what made COVID so incredibly challenging is the fact that people could be infected and have no knowledge of it and then go on to spread it to others — there's much less of a chance it will happen with this virus," Nuzzo says.

Confirmed new monkeypox cases outside of Africa

Note: Monkeypox is more common and locally transmitted in west and central Africa; Data: WHO, Axios reporting; Map: Axios Visuals

What's happening: Monkeypox patients typically develop flu-like symptoms and a blistering rash. 

But, initial reports about how this strain is affecting the body are slightly unusual — and that's always a bit of a concern, says David Freedman, president-elect of the American Society of Tropical Medicine and Hygiene. People are reporting not feeling as ill at the start of an infection as is normal and the blistering rash may not be spreading on the body as much.

"That's what's a bit mysterious about this and why they are doing all this genetic sequencing to see if there's something unique about this particular strain of the virus," Freedman adds. More definitive genetic insights will take at least several weeks, he adds. 

Another unusual aspect is that a majority of these recent cases have been linked to sexual contact during mass gatherings or festivals, with more reports of genital lesions than seen in prior outbreaks, Nuzzo says.

Between the lines: Some symptoms may be unusual but the way the virus is spreading between people is "very consistent with what we know about monkeypox," McCollum says. It is being transmitted through close, prolonged contact with an infected individual. "I don't know if we'd say that it's spreading more effectively [than normal] in terms of viral transmission."

Lesions tend to be the biggest concern, McCollum says, as they "are chock-full of the virus," remaining infectious through all of their stages including once a scab falls off. A closely related virus, smallpox, has shown scabs can contain live virus for 13 years or more under certain conditions.

The "larger risk to the overall community is extraordinarily low" and respiratory transmission is not seen as its primary method of transmission, but McCollum says "COVID precautions make a lot of sense for a lot of things," such as wearing a mask and not sharing clothing or bedding.

Be smart: Scientific knowledge of monkeypox is relatively small. "The number of cases documented in the literature since 1970 are like a few thousand," Freedman says.

And, the COVID pandemic has taught us all that viruses can quickly change.

"I’m in Team Cautious,” Virginia Tech aerosol expert Linsey Marr recently told The Atlantic. “We can’t use what happened with previous monkeypox outbreaks to make sweeping statements. If we’ve learned anything from COVID, it’s to have humility.”

What's next: It's unknown when the spread will become contained and case numbers can be expected to drop, even though awareness among doctors has been raised. 

McCollum says the U.S. plans to work with other countries to gather fine-scale data that will allow forecasting models to "get a better sense of what we should be expecting moving forward and when we'll start seeing declining numbers instead of increasing numbers."

Patients are expected to stay in isolation for three weeks, and efforts should be made for contact-tracing and to possibly give smallpox vaccinations to those directly exposed and at highest risk.

The CDC plans to start tracking and updating cases in the U.S. on a daily basis on their website soon, McCollum says.

What we know about the new monkeypox outbreak

Biden: "Everybody should be concerned" about monkeypox spread

WHO concerned monkeypox could accelerate during summer

Monkeypox is not another COVID

The rapid global spread may be triggering bad memories of the early days of COVID — but monkeypox does not contain the same threat level.

Collage of a photo of the monkeypox virus on the left side and SARS-CoV-2 on the right side.

The monkeypox virus, on left, and SARS-CoV-2. CDC Images: Alissa Eckert, Dan Higgins and Cynthia S. Goldsmith

Monkeypox

Public health

A look at the scientific breakthroughs changing the world, explorations in space and in worlds beyond our own and the threats posed to us by our own planet, both out of our control and of our own making.

Science

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

Deaths per 100,000 children, by cause

Firearms were the leading cause of death for kids one and older for the first time in 2020, the most recent year for which CDC data is available.

Why it matters: The firearm death rate among children is steadily rising, as more kids are involved in gun-related homicides like Tuesday's mass shooting in Uvalde, Texas, as well as suicides and accidents.

By the numbers: Nearly two-thirds of the 4,368 U.S. children up to age 19 who were killed by guns in 2020 were homicide victims, per the CDC. Motor vehicle crashes, formerly the leading cause of death for kids one and older, killed nearly 4,000 children.

Another 30% of firearm-related child fatalities were suicides, 3% were accidental and 2% were of undetermined intent.

Male youths were significantly more likely to be killed by guns, while vehicle crashes claimed more females.

There were also stark racial disparities. The firearm death rate for Black children was more than four times that of white children, and white children were still more likely to be killed by motor vehicles than guns.

D.C. had the highest firearm death rate, followed by Louisiana, Alaska and Mississippi. 

States with highest firearm deaths per 100,000 children in 2020

Data: CDC; Note: States with unreported or unstable data not included; Includes unintentional, violence-related and undetermined firearm deaths; Chart: Thomas Oide/Axios

Of note: Among children younger than 1, congenital anomalies — or birth defects — were the leading cause of death in 2020, resulting in 4,043 fatalities, per the CDC.

What they're saying: "As the progress made in reducing deaths from motor vehicle crashes shows, we don’t have to accept the high rate of firearm-related deaths among U.S. children and adolescents," researchers recently wrote in a New England Journal of Medicine article that highlighted the trend.

The study noted that while the National Highway Safety Administration could take the lead addressing road-traffic fatalities, firearms are one of the few products whose safety isn't regulated by a designated federal agency.

It has taken 20 years to build a database of firearm-related deaths that includes data from all 50 states, the researchers wrote. 

The bottom line: School shootings have become tragically common in the U.S., but constitute only a small fraction of gun deaths among children.

Guns have become the leading cause of death for American kids

In 2020, more kids were killed by guns than motor vehicle crashes. for the first time in recent history

Gun violence

Politics & Policy

Public health officials in Washington announced Monday they’re investigating the state’s first presumptively positive case of monkeypox.

Details: The case involves an adult man who recently traveled to an undisclosed country where other monkeypox cases have been reported, state and local health officials said.

Driving the news: Washington now joins a handful of other states to report confirmed and possible cases, including Massachusetts, New York and Florida.

Several countries also have reported confirmed or presumptive monkeypox cases, including  Australia, Canada, Belgium, Italy, the United Kingdom, Portugal, Sweden, Spain, Netherlands, Germany and France, per the World Health Organization.

What they’re saying: Dr. Jeff Duchin, health officer for public health for Seattle and King County, said in a statement Monday that the public and health care providers “should be aware of the growing international monkeypox outbreak.”

The person believed to be infected with monkeypox is isolating and poses no risk at this time, Duchin said.

"At this time, we have no evidence that monkeypox is spreading locally, but if there are unrecognized cases, that is a possibility,” he added.

Why it matters: Health experts have said the current international outbreak is not likely to cause a global pandemic as COVID did, but some officials are increasingly voicing concern and raising public awareness about the virus.

President Biden, in his first public remarks about the monkeypox outbreak, said Sunday said the recent international outbreak is "something that everybody should be concerned about."

WHO concerned monkeypox could accelerate during summer months

Seattle

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Health officials investigating possible monkeypox case in Washington

The case involves an adult man who recently traveled to an undisclosed country where other monkeypox cases have been reported.

Dr.Jeff Duchin, Health Officer for Public Health -- Seattle & King County, announced the first presumptive case of monkeypox in Washington state.

Dr. Jeff Duchin, health officer for public health for Seattle and King County. Photo: Jason Redmond/AFP via Getty Images

Washington State

Pedestrian deaths reached a 40-year high last year, according to preliminary data from the Governors Highway Safety Association.

By the numbers: Drivers struck and killed more than 7,400 people in 2021, and the percentage of children killed by speeding drivers more than doubled since 2018.

Pedestrian traffic fatalities, 2000–2021

Data: Governors Highway Safety Association; Chart: Jacque Schrag/Axios

State of play: Impaired driving and increased speeding contributed to the rise in pedestrian deaths, said Russ Martin, GHSA’s Senior Director of Policy and Government Relations.

"You also have this thought that well, I could be on a ventilator by the end of the week, I should take advantage of the time that I have. I think everyone's out there trying live their best life with an increased sense of urgency," he said. 

"So when it comes to the roadway, maybe that has contributed to more of a me first kind of attitude." 

Martin also pointed to larger vehicles on the road and crumbling infrastructure. Separating cars from pedestrians is one of the most effective engineering interventions, he said.  

The big picture: Data out this week from the Department of Transportation also revealed that an estimated 42,915 people died in motor vehicle traffic crashes in the U.S. in 2021, the highest number of traffic fatalities since 2005.

That's a 10.5% increase from 2020, when 38,824 deaths were reported.

Pedestrian deaths hit 40-year high

Pedestrian deaths reached their highest levels in four decades in 2021.

A graphic of a car moving into a crosswalk.

Deaths

People walk down a street in Philadelphia, Pennsylvania.

Share of counties that are maternity care deserts, by state

Data: March of Dimes; Map: Jacque Schrag/Axios

The red states poised to ban or severely limit abortion already tend to have limited access to health care, poor health outcomes and fewer safety net programs in place for mothers and children.

Why it matters: If the U.S. Supreme Court overturns Roe v. Wade, as it's expected to, the ensuing increase in births will likely leave families in tough circumstances and strain systems that are already hanging by a thread.

"What we're facing as a country is hundreds of thousands of births, probably disproportionately located in the states that have been most limited in what they do for pregnant women, infants and children. So this is the great paradox that we are dealing with," said Sara Rosenbaum, a health law and policy professor at George Washington University. 

"We have not ever designed these programs for a world without Roe," she added. "You need a child welfare system, the likes of which we've never seen.”

Where it stands: Experts say there's already a growing shortage of obstetricians.

In 2020, more than 2 million women of childbearing age lived in counties that had no hospital offering obstetric care, no birth center and no obstetric provider, according to a report by March of Dimes. 

Millions more lived in areas with limited access to care.

Red states in the middle of the country — many of which will automatically ban abortion if Roe is overturned — are particularly likely to have a high number of maternity care deserts.

States with more abortion restrictions also tend to have higher maternal mortality rates and worse health care outcomes generally. 

A recent AP analysis found that states with the strictest abortion laws are also some of the most difficult places to have and raise healthy children.

Many of the states with abortion bans have also refused to expand Medicaid, meaning low-income women in those states have limited access to health care and thus may be in poor health before becoming pregnant.

By the numbers: In 2019, there were more than 600,000 abortions in the U.S., according to the CDC. About 3.75 million babies were born in the same year.

Between the lines: Experts say abortion bans would also likely put more pressure on U.S. foster and adoption systems. 

More than 600,000 children were served by the foster care system at some point in the 2020 fiscal year, according to HHS. 

As of September 2020, more than 100,000 of them were waiting to be adopted, and nearly 60,000 were adopted through a public agency that year. 

An increase in births that would have otherwise not occurred "almost certainly means more foster children," said Richard Shannon, chief quality officer for Duke Health. And while the foster care system is "a vital social service, it is in desperate need of further improvement and will only be stressed by an increase in pregnancies and live births among moms who can't take care of their kids."

What we're watching: The statistics around children who live in traumatic or volatile circumstances are grim.

"We know from focus on health outcomes that kids born into poverty, kids born into unstable social circumstances, tend to have higher incidence of early onset chronic diseases," Shannon said. "We also know that when those children are raised in unstable circumstances and have to be cared for in foster care, the outcomes there are really sobering."

Red states aren't prepared for a post-Roe baby boom

Millions more lived in areas with limited access to maternity care.

Abortion

A monkeypox outbreak in several European countries and one U.S. state may become the largest outbreak of the virus outside of Africa, but it's not likely to cause a global pandemic like COVID, an infectious disease expert tells Axios.

Why it matters: The CDC has confirmed at least  nine cases in the United States. The current outbreak is small so far and scientists continue gathering data, but there may be community transmission of the virus.

"I'm sure that ultimately this will be the largest outbreak of monkeypox that we've had outside of the endemic areas in Africa," says Daniel Bausch, infectious disease expert and president of the American Society of Tropical Medicine & Hygiene.

"I don't think there's a reason for panic. I don't think we're going to have tens of thousands of cases," he tells Axios.

What's happening: Various countries are reporting confirmed and possible cases, including Australia, Canada, Belgium, Italy, the United Kingdom, Portugal, Sweden, Spain, Netherlands, Germany and France, per the World Health Organization.

Argentina on Friday reported its first case of monkepox and announced another suspected case of the disease, according to Reuters.

Related to smallpox, monkeypox has two main types: the West African clade with a fatality rate of around 1% and the Congo Basin (Central African) clade, with a fatality rate of around 10%.

The current circulating strain appears to be the milder West African type that often starts with flu-like symptoms and swelling lymph node, progressing to a blistering rash. 

The smallpox vaccine is believed to be effective against monkeypox.

Details: Monkeypox, which can be transmitted by droplets and by close contact with infected skin lesions or contaminated materials, usually incubates in people for 6 to 13 days before symptoms appear.

Transmission can come from animals or human-to-human but "it is generally documented among very close contacts. So family members, people taking care of ill patients. Or health care providers," Andrea McCollum, the poxvirus epidemiology team lead at the CDC, told STAT News. 

Children are at higher risk, and monkeypox can cause pregnancy complications or stillbirth, per the WHO.

In the U.S., there have been reports of individuals infected with monkeypox before, particularly in international travelers from Nigeria, including a case in Texas and one in Maryland last year. 

Per the CDC, monkeypox re-emerged in Nigeria in 2017 after more than 40 years with no reported cases. 

Between the lines: The improvement in the global infectious diseases surveillance system is paying off with not only COVID but disease like monkeypox, Bausch adds.

What's next: WHO is scheduled to meet next week to discuss pox viruses, per STAT. 

Go deeper: First U.S. monkeypox case confirmed in Massachusetts

Editor's note: This post was updated to include countries that announced new confirmed cases of monkeypox.

This could become the largest outbreak of monkeypox in countries outside of Africa — but there's no need to panic, an infectious disease expert says.

If abortion were illegal and you had an unwanted or unplanned pregnancy, what would you do?

Data: Generation Lab; Chart: Simran Parwani/Axios

Over half of young women aged 18-29 say they would get an abortion if they had an unwanted or unplanned pregnancy — even if it were illegal, according to a new Generation Lab flash poll first provided to Axios.

Why it matters: Last week's news that the Supreme Court is prepared to overturn Roe v. Wade has raised questions on what access would look like without a federal right to an abortion. Even in states where they remain legal, abortions could be harder to access because those clinics could be flooded with patients from states that have cracked down.

Women in their 20s accounted for the majority of abortions between 2010 and 2019. 

By the numbers: 56% of respondents who identified as women said they would seek out an abortion provider even if it was illegal and they had an unwanted or unplanned pregnancy.

34% said they would have the baby in the event abortion was illegal, while 10% said they'd attempt to end the pregnancy at home.

45% of respondents who identified as men said they would take additional precautions like using physical contraceptives more often if abortion were illegal, while 43% said they would not change anything and 11% said they would be more likely to get a vasectomy.

49% of all respondents said abortion should be legal in all cases, 27% said it should be legal in most cases, 16% said it should be illegal in most cases and 8% said it should be illegal in all cases.

46% of respondents said they have a "mostly unfavorable" opinion of the Supreme Court, while 22% said their opinion was "very unfavorable." 28% said it was "mostly favorable," and only 4% said they had a "very favorable" opinion.

The big picture: Approximately six in 10 U.S. adults believe abortion should be legal in "all or most cases," according to a recent Pew Research Center survey.

Abortion clinics are already preparing to shift people and resources away from red states, while blue states are taking steps to plan for a potential influx in patients if Roe falls.

Methodology: This poll surveyed 813 people ranging from ages 18 to 29 between May 5 and 8. 460 people self-identified as women and 353 self-identified as men. 

Go deeper: The state of abortion in America

Poll: Over half of young women say they would get an abortion even if it were illegal

Women in their 20s accounted for the majority of abortions between 2010 and 2019.

Data: Guttmacher Institute; Map: Thomas Oide and Erin Davis/Axios

The number of U.S. women who get abortions has decreased dramatically in recent decades, with typical patients now tending to be in their 20s and living in blue states. 

Why it matters: Abortion access is likely to be drastically curtailed in red states should a leaked draft of a U.S. Supreme Court decision hold, gutting the federal right to an abortion. But the profile of abortion patients has trended older since that right was established, and the vast majority of procedures tend to be early in pregnancies.

State of play: In 2019, nearly 630,000 abortions were reported to the CDC, reflecting a rate of about 11.4 abortions per 1,000 women aged 15–44 years. 

Around 18% of all pregnancies in the U.S. end in abortion, according to the CDC. 

Women in their 20s accounted for the majority of abortions between 2010 and 2019 

That year, more than three-quarters of abortions were performed by nine weeks of a pregnancy, and rates were higher among Black and Hispanic women than among white women.

Factors influencing the abortion rate include access to health care services and contraception; the availability of abortion providers; state regulations, such as mandatory waiting periods; parental involvement laws and legal restrictions on providers, the CDC writes. The state of the economy and resulting impact on family planning decisions and contraceptive use also play a role. 

Abortion rate by age group, 1973-2017

Data: Guttmacher Institute; Chart: Erin Davis/Axios Visuals

The big picture: Abortion rates have been declining for years, particularly among adolescents. The overall birth rate has also declined since 1973, according to the Guttmacher Institute.

Many of the states in the South and Midwest most immediately poised to act to eliminate access should the high court rule against a federal abortion right already have lower-than-average abortion rates. 

Zoom in: These national trends are largely encapsulated in Texas, one of the states that would automatically ban abortion if SCOTUS overturns its earlier ruling. 

In 2020, 58% of women who received an abortion were in their 20s and were disproportionately Black, according to a report released by the Texas Health and Human Services Commission.

84% were unmarried, 63% were receiving their first abortion and 39% were among women who hadn't given birth before. Nearly a quarter had given birth once before, 21% had had two previous live births and 16% had three or more. 

The state of abortion in America

Recently, the majority of abortions are received by women in their 20s.

Axios Explains: Abortion

A cure for multiple sclerosis remains elusive, but a decade of technological and scientific advances is starting to shed light on possible causes, better diagnostics and potential treatments for the disease.

Why it matters: MS — a central nervous system disease affecting almost 3 million people globally — has baffled doctors since it was discovered over a century and a half ago.

The disease can advance silently for years, but then attack myelin, the protective coating around nerve cells, and produce lesions that can cause vision problems, muscle weakness and more. It is unknown why the disease can progress in unpredictable and different ways.

MS is difficult to study, as many people are asymptomatic for the first several years and don't see a doctor until the disease has progressed, says Daniel S. Reich, neuroradiologist and senior investigator for NIH's National Institute of Neurological Disorders and Stroke.

FDA-approved treatments are designed to slow the progress of the disease or try to reverse myelin damage, but often have serious side effects, including possible liver damage, an elevated risk of certain cancers and rendering COVID-19 vaccines less effective. 

The latest: Researchers on Wednesday published a study that found four new autoantigens, or disease-driving immune cells, that could be targeted in both diagnostics and drugs.

Autoantigens "may lie at the core of MS" and could help researchers understand what aspects of the immune system MS is targeting, says study co-author Mattias Bronge, a Ph.D. student at Karolinska Institutet.

While this hasn't been tested yet, it might be possible to increase the immune system's tolerance for some antigens so the disease's effects are reduced, similarly to what is done in allergy treatments, Bronge says, and those four new identified proteins may help advance this idea.

Yes, but: Scientists must first better understand how "the immune system orchestrates damage to brain cells and what is required for the brain to repair itself better," Reich says.

Between the lines: MS is believed to be caused by a mix of genetic susceptibility, faulty immune systems, and environmental factors. A crucial discovery is the probable link of MS with the Epstein-Barr virus, a common herpes virus that infects almost all people by adulthood and is more well-known as a cause of mononucleosis.

A long-term study of more than 10 million young adults in the military found the risk of developing MS increased 32-fold after infection with EBV but not after infection with other viruses.

This bolsters the belief that MS may be a rare complication of EBV — but also also leads to questions on why such a small percentage of EBV-exposed people wind up having MS.

There are about 15 EBV vaccines in development, most in very early phases, as well as trials to transplant immune cells. But, determining whether or not these will help prevent MS will take years with large trials, Reich points out.

Meanwhile, diagnostics and assessments via high resolution MRIs, spinal fluid analysis techniques or genomics continue to rapidly improve, says Reich, whose lab uses MRI imaging in its MS research.

Some researchers are looking at imaging of the retina or central vein sign to improve early diagnostics.

"We need to develop MRI technologies that can get us down to the resolution of a few cells. We're not quite there yet, but we're a lot closer than we were five or 10 years ago," Reich says.

What's next: Taken together, these incremental advances will likely begin to answer some fundamental questions in the next few years about why some people get MS and how it might be treated, Reich says.

"The MS research field is moving forward with great speed at the moment," Bronge says. "I’m absolutely optimistic, and I think we have a very exciting decade ahead of us."

Tackling the century-long mystery of multiple sclerosis

While there's no cure in sight yet, recent advances are bringing some optimism.

Illustration of a person with a cane near a hole shaped like a red cross symbol.

Multiple sclerosis

Pfizer and BioNTech asked the Food and Drug Administration (FDA) on Tuesday to authorize a COVID vaccine booster dose for children ages 5 through 11.

Why it matters: If approved, it would be the first booster accessible to children of this age group, who have been hit hard in recent months. Infections rose most sharply among children and adolescents during the Omicron surge, according to the Centers for Disease Control and Prevention.

Details: Data from a clinical trial showed that children ages 5 through 11 who received a booster about six months after their second Pfizer shot developed a "strong immune response," according to the company.

Boosters are currently only authorized for people who are 12 and older in the U.S.

The FDA authorized Pfizer's two-shot vaccine for kids ages 5 through 11 in October.

Worth noting: Pfizer said it plans to also submit the data to the European Medicines Agency and other global regulatory agencies for authorization in the coming weeks.

The big picture: The FDA said Monday it had expanded approval of the COVID-19 treatment Veklury, also known as remdesivir, for children 28 days and older in an effort to boost protections for young kids.

A majority of Americans, including three in four children, have had COVID-19 as a result of the Omicron surge this past winter.

Pfizer asks FDA to authorize COVID booster for children 5 to 11

If approved, it would be the first booster accessible to children of this age group, who were hit hard by Omicron.

Photo of a child in red with their sleeve rolled up as a nurse injects a COVID shot into their left arm

A child receives a dose of the Pfizer-BioNTech COVID-19 vaccine at an elementary school vaccination site for children ages 5 to 11 in Miami on Nov. 22, 2021. Photo: Eva Marie Uzcategui/Bloomberg via Getty Images

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