Since May 2022 there have been a spate of outbreaks reported in the US, UK, Australia, mainland Europe and Canada. On July 23, with more than 16,000 reported cases (and five deaths, all in Africa) in 75 countries and territories, the World Health Organization declared the outbreak a public health emergency of international concern, its highest alert for a disease, raising the status of the outbreak to a global health emergency — even though the WHO’s advisory panel opposed the declaration nine-to-six. The last time the WHO declared a public health emergency of international concern was in February 2020 for Covid, so people naturally drew parallels.

Such comparisons are completely unfounded. And yet, as the outbreak continues to make headlines around the globe, panic is once again setting in. A recent poll revealed that one in five Americans fears they’ll get monkeypox. This is especially true for young people, many of whom now claim they are more scared of monkeypox than Covid. “I had finally gotten to the point with Covid where I was starting to relax,” Lisa, a 30-year-old mother from Chicago, told Slate. “But when I heard about monkeypox, it was like a huge pit in my stomach. I open Twitter and see people telling me you need a full PPE suit to go outside. I can’t take living in fear for another two years, and I want to let my child live a normal life.”

Meanwhile, three US states, including California, have declared states of emergency over the monkeypox outbreak, just as they did for Covid-19, potentially allowing them to enact mask mandates, lockdown orders, and other restrictions. And two weeks ago, a south London school sent reception classes home until the end of term after a child came into contact with a monkeypox case, sparking fears of an outbreak. The school said it was acting on advice of the UK Health Security Agency (UKHSA) and were “obliged to follow these precautionary guidelines”. Authorities also advised parents to avoid hugging their child.

It is simply baffling that anyone would willing to go down this road again — shutting down schools; denying children physical contact — with everything that we now know about the devastating effects of such measures on children’s mental and physical well-being throughout the Covid pandemic. But that doesn’t seem to register. Today, we are seeing the first stirrings of yet another bout of mass hysteria, with politicians, the media and public health officials (including the WHO) all repeating the same mistakes they made with Covid-19: spreading misinformation about the nature of the disease, and sowing unnecessary panic and fear among those who risk little or nothing from it, while denying those who actually are at risk the kind of targeted messaging and protection they deserve.

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Will you catch monkeypox?

By Swift Centre Superforecasters

With Covid, it was known right from the start that the disease was highly selective — the overwhelming majority of people, especially children, never faced any significant risk of getting seriously ill or dying from it. And yet public health officials systematically framed Covid as a lethal, indiscriminate threat to all human beings. The consequences were devastating: on the one hand, it stoked terror and panic in the population; on the other, it abandoned those who truly needed protection from the virus  — first and foremost care home residents, who make up a staggering 40% of all Covid deaths in Western countries.

The same imprecise messaging is being delivered with regard to monkeypox. The media, for example, has given ample coverage to the fact that monkeypox has been detected in some children across the United States, making the disease a growing concern for parents, who are now worried about how safe it is to go back to school. Others are uneasy that a large-scale paediatric outbreak could ignite a full-blown pandemic or could result in staffing shortages.

Such concerns were exacerbated by the WHO’s director-general Tedros Adhanom Ghebreyesus, who stated: “I am concerned about sustained transmission because it would suggest that the virus is establishing itself and it could move into high-risk groups including children, the immunocompromised and pregnant women. We are starting to see this with several children already infected.” More recently, Rosamund Lewis, the WHO’s technical lead on monkeypox — in yet another claim that received much social media attention — went on to say that children in particular “are at higher risk of severe disease”, and that “every child that contracts a monkeypox virus infection will develop severe disease”.

The danger of monkeypox for pregnant women has also been receiving a lot of media attention. The WHO has warned that monkeypox during pregnancy could result in the foetus being infected with the virus or, worst of all, a stillbirth. Jennifer McQuiston, who is heading up the CDC’s monkeypox response, said that there are “a lot of concerns” about monkeypox and pregnancy, and that pregnant women should take extra precautions to protect themselves. Overall, the message is the same as with Covid: anyone can catch it, including children, so everyone should be concerned, especially parents and pregnant women.

It is highly misleading — and all the worse for coming from the world’s leading public health organisations. While it is technically true that anyone can catch monkeypox — most people can catch most diseases — the reality is that, according to the WHO data, 97.5% of cases are among gay or bisexual men, almost all of whom (91.5%) have contracted the disease through a sexual encounter. The median age is 37.

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As the WHO writes: “the ongoing outbreak of monkeypox continues to primarily affect men who have sex with men (MSM) who have reported recent sex with one or multiple partners. At present there is no signal suggesting sustained transmission beyond these networks.” So far, there has been a relatively small number of cases outside of this group: health officials have reported around 100 monkeypox cases among women worldwide — about 1% of the global total — while cases among children are even rarer.

These facts are confirmed by the UK Health Security Agency, in the most comprehensive study to date on the 2022 monkeypox outbreak, published in the New England Journal of Medicine (NJEM), and by a British Medical Journal (BMJ) study based on 197 cases in British men. Moreover, despite widespread speculation to the contrary, monkeypox predominantly occurring among gay men isn’t driven by sampling bias. According to the UKHSA, we can see the positivity rate among men is considerably high compared with women and children. It’s not entirely clear why monkeypox is much more prevalent among gay men, and why we aren’t seeing a greater number of sexually transmitted cases among heterosexuals, though it is likely that the number and overlap of sex partners plays a big role.

Despite this, health authorities and media outlets have been wary of labelling monkeypox a sexually transmitted disease (STD), in part because researchers weren’t sure whether the disease is transmitted through semen or vaginal fluids. A new Lancet study, however, concludes that monkeypox could indeed be an STD, as the data already suggests.

Fortunately, the data also shows that those most at risk of contracting monkeypox — adult men — tend to present non-life-threatening (though certainly painful and distressing) symptoms. Moreover, the vaccines developed for smallpox are said to be highly effective against monkeypox. And while it is true that previous monkeypox outbreaks have proven to be especially dangerous for children and pregnant women, the strain involved in the current outbreak seems to be less of a threat to these groups: the first two paediatric cases in the US reported by the CDC are said to have been relatively mild — with more or less the same symptoms as for adults — while the infant recently born to the first monkeypox-positive mother in the US also seems to be doing well so far.

The data also indicates that while it is technically true that monkeypox can be spread through close (skin-to-skin) contact with an infected person, and even through exposure to items and surfaces that have touched an infectious person’s rash, such as clothing or bedding, non-sexual transmission is very low — though it is likely to increase through prolonged close contact. There is no evidence of airborne transmission.

So overall, there seems to be little justification for the mounting monkeypox hysteria. A responsible public health approach would make sure high-risk people — gay men — were made aware of the risks and offered sensible recommendations (such as practising safe sex) and access to vaccines, while reassuring everyone else that there’s no reason to panic, at least based on current data. Instead, a confused and imprecise messaging is once again sowing unnecessary panic among the general population, while potentially failing to protect those at risk.

One of the reasons for this is the assumption that emphasising monkeypox’s disproportionate effect on gay men might lead to ostracisation and stigma against gays, as during the HIV/Aids pandemic. As bestselling author Xiran Jay Zhao wrote in a tweet which has been liked almost 60,000 times: “I am SO TIRED of the monkeypox misinformation — it is NOT limited to gay men. It is NOT an STD. ANYONE CAN GET IT AND THE VIRUS CAN LIVE ON A SURFACE FOR DAYS!!”

One can be sympathetic with the reasoning behind such claims, but still believe it is unacceptable for public health bodies to bow down to such logic. The public deserves to know the truth about the health risks posed by diseases. Placing politics and ideology above the truth — and, even more shamefully, in the name of “The Science” — has already caused massive damage throughout the Covid pandemic, and to those most at risk from the virus. We are now doing the same with monkeypox.

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As Owen Jones has claimed, it’s not stating that it’s gay men who are overwhelmingly at risk from monkeypox that puts gay men at risk, but rather denying this fact: “the problem with the HIV/Aids response wasn’t that it was targeted, it’s that it was stigmatised. We need targeted, non-stigmatised messaging: but it’s not homophobia to speak the truth about this. The real homophobia is not acting properly because it’s overwhelmingly gay and bi men at risk!” Indeed, when gay activists characterised the US authorities’ decision to give gay men prioritised access to the monkeypox vaccine as homophobic, Jones accused them of “hav[ing] completely lost the plot”. If anything, he added, what gay people should really be angry about is that “governments are failing to take swift action to protect this minority” — as evidenced by reports of vaccine shortages in the UK, US and elsewhere.

As for the homophobic discourse on social media related to monkeypox, this is arguably also a consequence of the authorities’ attempts to downplay who is most at risk. The Covid pandemic has sown massive distrust in public health authorities, and millions of people who refused to take the vaccine are still angry at misleadingly being accused of being reckless spreaders. Seeing those same authorities today go out of their way to avoid highlighting that a specific minority group is — for real in this case — much more likely to catch and transmit the virus is unlikely to make them positively disposed towards the latter, especially if this denialism contributes to the virus’s spread.

If we want to get out of this mess, and avoid a repeat of the past two years, there’s only one way forward: putting the truth back at the centre of public health. Monkeypox hysteria, just like the Covid hysteria that came before it, won’t save lives. It will only put them in danger.

However, the spread of monkeypox has been very different to the spread of Covid. While Covid is spread through the air, by droplets on patients’ breath, monkeypox is mainly spread by skin-to-skin contact. And because the initial outbreak arose among gay and bisexual men — many of the initial cases can be traced back to a Pride event in the Canary Islands, a sauna in Madrid, and other venues — the large majority of cases have, so far, been among men who have sex with men (MSM).

That said, the disease is not specific to gay men, or sexually transmitted in the strict sense of the word, and could reach the wider community. Even if it doesn’t, it’s important to get a sense of how far monkeypox could spread among MSM, and to try to minimise its damage and understand the scale of the public health problem. With that in mind, we gathered ten forecasters for a discussion of the likely outcomes of the monkeypox outbreak — to try to predict both the likely size of the outbreak, and how it will look: will it break out of the MSM community in large numbers?

A note on forecasting methods:

The classic “superforecasting” model requires forecasters to give a percentage probability for a certain outcome, such as “Britain will vote to remain in the EU, 66%”. Forecasting skill is graded on how well-calibrated those forecasts are — do your 66% forecasts come in 66% of the time? — and also how confident they are: getting a 90%-confident forecast right is rewarded more highly than getting a 55%-confident forecast right. (On the other hand, getting a 90%-confident forecast wrong is punished more severely than getting a 55%-confident forecast wrong.)

In this case, we do something similar, but, in a way, reversed. The forecasters gave a range of values that they thought was 80% likely to contain the true outcome. So, for instance, if one thought that it was 90% likely that the number of monkeypox cases in the UK before the end of 2022 would be higher than 500, and 90% likely that it would be lower than 10,000, their 80% range is 500 to 10,000.

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They also each gave a 50% value, which you can most easily think of as their central, most likely estimate. The forecasters will be graded on whether their 80% forecasts come true 80% of the time, as usual, but instead of being rewarded for making higher-confidence predictions, they’ll be rewarded for giving narrower ranges. For each question, we also gave a median of the forecasters’ 10%, 50% and 90% predictions — that is, if you took all 11 predictions and put them in a row from smallest to largest, we’d take the one in the middle.

The questions:

How many cases of monkeypox will there have been worldwide by the end of 2022?

• Median 10% estimate: 13,500
• Median 50% estimate: 45,000
• Median 90% estimate: 525,000

As of 17 June, there have been 2,103 laboratory-confirmed cases of monkeypox reported to the WHO. The forecasters think that even in a realistic best-case scenario, that number will only be a fraction of the eventual total: the median 10% (that is, low-end) estimate is six times higher. On the other hand, the median upper-end estimate, while a large number — more than half a million — is still negligible compared to the spread of Covid: by the end of 2020, there had been more than 80 million confirmed cases of Covid-19, and many times that number of undetected ones.

Yet it’s important to note that the forecasters’ predictions varied widely. Three of them pointed out that while the virus spreads through skin contact now and has a relatively low R number, it is mutating, and could easily become transmissible. One said: “Multiple somewhat distinct strains have already evolved, which leads me to be concerned that there is a fairly high amount of genetic drift occurring, which could lead to the situation turning into a more detrimental pandemic.”

Another said, citing this paper, that the virus seems to have a very high R within MSM communities, but an R below 1 outside it. (The R value is the number of people the average infected person goes on to infect.) But, they said, “as it spreads more the chance that it mutates to gain a transmissibility advantage increases, quite possibly via the airways”: as a result, that forecaster gave a 90th-percentile forecast of 30 million infections, the highest in the group by a factor of four.

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Other forecasters were more optimistic. One thought that the total would be no higher than 80,000; another, 200,000. Another with a relatively low estimate (median 40,000, 90th percentile 400,000) pointed out that “there has been limited transmission beyond networks of close contacts, so far”. Another, who had a very wide range (from 12,000 to 5 million) said: “R is clearly lower than for Covid, so there clearly is a plausible future where once governments get serious about mitigation it ceases to spread quickly. On the other hand, well, they might not.”

It’s worth noting that these estimates are of the total cases, not just the confirmed ones. (One forecaster said they “expect much of the world is vastly undercounting”.) This means it will be impossible to accurately grade who has got this question right.

How many cases of monkeypox will there have been in the UK by the end of 2022?

• Median 10% estimate: 6,000
• Median 50% estimate: 22,000
• Median 90% estimate: 85,000

As with the worldwide estimates, there was considerable spread. One — the same person who gave a high-end estimate of 30 million in the first question — used the same reasoning to say numbers could get as high as one million in the UK.

On the whole, though, the feeling among the forecasters was that the UK is better placed to control spread than most countries are. “UK monitoring is on the better end,” said one, “and there are initial attempts to vaccinate.”

But there were concerns. “It’s failed to be controlled particularly well so far, despite good monitoring,” one wrote. “It’s on the worse end of what experts would have hoped for a month ago, perhaps because of long incubation periods. There’s still a lot of opportunity for superspreader events, especially given Pride, and relatively little cautiousness so far. But awareness within LGBT communities should slow it down.”

As with the “worldwide” question, the forecasters were talking about the true number of cases, not confirmed cases. However, the monitoring in the UK is likely to be pretty comprehensive, so the two numbers should be comparable.

What percentage of 2022’s worldwide cases will be in men?

• Median 10% estimate: 50
• Median 50% estimate: 94
• Median 90% estimate: 99

At the moment, more than 99% of recorded monkeypox cases worldwide have been among men, suggesting that the spread has been almost exclusively among MSM. The forecasters, on the whole, expected that to remain the same, although they felt that there was a distinct chance, above 10%, that it could spread so rapidly among the general population that it could wash out the male head start altogether. One pointed out that once a disease gets outside the subpopulation in which it started, it can behave very differently depending on the context: “The US currently has a 5:1 male/female ratio of HIV,” wrote one, “while Sub-Saharan Africa has more women with AIDS than men. The modes of transmission do not keep the straight community safe. There are far more straight people than gay people, so once it starts to increase in that community, the potential population is much greater.”

Another forecaster thought that this is essentially the same question as the case-numbers question, somewhat repackaged. If it starts to spread very rapidly, by some other method than skin-to-skin contact, then it will spread outside MSM communities: “I think this is essentially the same as asking the chances it mutates to become more transmissible and spread outside of the networks it’s currently spreading through. It’s very hard for me to estimate this risk, but I think it increases as the case numbers increase.”

All 11 forecasters thought there was at least a 10% chance that cases among women would reach close to 50% of the total, but most thought that that was unlikely: only one put their central estimate at below 90% male, and four had it at 95% or higher.

What percentage of 2022’s UK cases will be in men?

• Median 10% estimate: 55
• Median 50% estimate: 98
• Median 90% estimate: 99

The forecasters felt the story was likely to be largely similar in the UK to worldwide, with some caveats. First, they felt the disease was likely to be better controlled here and to spread more slowly, so the chance of it spreading widely outside MSM communities was smaller, hence the higher median 10% estimate. Second, one noted that the UK’s HIV population has a higher male-to-female ratio than the global average, and used that to extrapolate to monkeypox.

Overall, the forecasters’ attitude can be summed up in this comment: “I think community spread is definitely possible, but founder effects and (reasonably) slow spread will mean the MSM community will still dominate the numbers by the end of the year.” One added that the UK government’s current strategy, of vaccinating high-risk MSM, is very good, and “may solve the problem on its own”. However, they added that public messaging at the moment is not especially useful, since it doesn’t warn at-risk communities, tending to emphasise the risk to wider society rather than to MSM groups. Changing that would, they said, be worthwhile.

Conclusions:

The forecaster group, on the whole, felt that monkeypox will continue spreading, both in the UK and worldwide. However, unless it mutates significantly to become capable of spreading in ways other than through skin contact, they felt that its numbers were likely to remain comparatively low, and that it was most likely to stay chiefly in the MSM community.

Yet they also felt there was a significant tail risk of a much wider impact. They noted that a novel disease which appears to be mutating relatively rapidly has a non-negligible chance of achieving new means of spreading — and that there was a greater than 10% chance of widespread transmission among the wider population, with hundreds of thousands or even millions of cases not unlikely.

***

A version of this research first appeared on the Swift Centre.