The campaign to rename monkeypox gets complicated

Since the earliest days of the current global monkeypox outbreak, scientists and public health authorities have been calling for the disease to be renamed, arguing that it has racist overtones and carries a stigma that will hinder efforts to stop its spread.

In mid-June, World Health Organization Director-General Tedros Adhanom Ghebreyesus said his agency agreed, and would be working with partners to rename the virus itself, the disease it causes, and the two clades or strains of the virus, each named after the parts of Africa where they are found.

Nearly seven weeks later, none of that has happened yet. It’s very likely some of it may not happen at all.

It turns out renaming viruses and the diseases they cause is not an easy thing to do. It raises concerns about the continuity of the scientific literature. It can be difficult to find an alternative that doesn’t offend. And something that works in one language or culture may not work in another.

Furthermore, responsibility for naming or renaming viruses, clades of viruses, and the disease those viruses cause rests in different sectors of the scientific stratosphere.

What follows is an exploration of why the process of renaming has been so complex in this case and why it may take longer than anyone would have hoped, if the changes are made at all.

Monkeypox the virus

The virus — actually the species of virus — is going to get a new name by next June. But that new name will almost certainly still contain the word monkeypox.

The naming of virus species is the responsibility of the International Committee on Taxonomy of Viruses. Coincidentally, the ICTV is in the process of giving virus names in general a major overhaul, to pull them into compliance with the way other life forms are officially named.

Most other species have binomial names. Humans are Homo sapiens. Bacteria have binomial names too — think Escherichia coli (often written as E. coli) or Staphylococcus aureus.

Monkeypox is monkeypox. But that’s going to change.

A subcommittee of the ICTV that is responsible for revising the names of the various poxvirus species is in the process of finalizing a proposal for new binomial names for all the poxviruses. Within the next month or two the proposed names will be circulated to the poxvirus research community for feedback before being finalized by next June, the ICTV’s deadline for this work.

When that process is completed, monkeypox is very likely going to become Orthopoxvirus monkeypox.

“That’s certainly the majority proposal at this stage,” Colin McInnes, chair of the poxvirus subcommittee, told STAT in an interview. McInnes is deputy director of Scotland’s Moredun Research Institute, which studies viruses that affect farmed animals.

The subcommittee is aware of the mounting discontent over the name monkeypox. It is sympathetic to the concerns about stigma, McInnes said, and it is not unmoved by the complaint that monkeypox is a misnomer. Monkeys aren’t the natural host — the reservoir — of the virus, they are just the first animal that was seen to be suffering from the disease.

But the true reservoir host isn’t known. And there are a number of species of viruses that are named in the way monkeypox virus is, after the first animal species seen to have been preyed upon by the virus in question.

Moreover, the committee is concerned that dropping the monkeypox name could disconnect future scientific papers about the virus and the disease from the more than 50 years of science already in the literature.

“By no means have we come to a final decision yet, but certainly I would say the majority of the committee was in favor of retaining the name monkeypox, just in terms of the danger of losing out on all the early scientific, epidemiological research that is out there. And obviously that’s quite a lot,” McInnes said.

Monkeypox the disease

Responsibility for naming diseases fits squarely within the purview of the WHO. Of all the pledges Tedros made, this is the only one the global health agency can actually take care of on its own.

The WHO has a protocol for naming new diseases that it adopted in 2015. The guidance contains a sizeable list of don’ts: Don’t name a new disease after a person. Don’t name a new disease after a place. Don’t name a new disease after an animal. (There’s more. You can read it here.)

This guidance relates to naming new diseases. It turns out that renaming known diseases — like monkeypox — is an even more challenging process.

“Changing a name overnight doesn’t happen,” Rosamund Lewis, WHO’s technical lead for monkeypox, said in a recent interview.

Lewis noted there have been objections to the name MERS, a Covid cousin, since it was first recognized in 2012 that a camel coronavirus was infecting people on the Arabian Peninsula. MERS (the name of the virus and the disease) is short for Middle East respiratory syndrome and violates the convention, now enshrined in the WHO guidance, that naming a disease after a place is a no-no.

And yet.

“MERS is still MERS, even though it says Middle East and people don’t like it,” Lewis said. “And monkeypox kind of falls in the same category.”

Once a disease name is established, it becomes part of the disease Bible, the International Classification of Diseases. Each disease is assigned a code.

Countries the world over use these codes for medical billing and to collect data on things such as how many people are diagnosed with melanoma, by specific body site, or how many people develop pneumonia due to respiratory syncytial virus infection, unspecified bacterial pneumonia or pneumonia caused by or secondary to flu. Use of the ICD codes is how researchers can compare rates of gestational diabetes across borders and across time.

Changes to the ICD are not made lightly. There’s a process. It’s not quick. It starts with applications to an ICD review panel, the Medical and Scientific Advisory Committee. “And they determine whether this new term is being used, if it’s appropriately being used on the basis of the medicine and the science,” said Lewis.

That could be a hurdle. Monkeypox doesn’t have an alternate name that is in use. And thus far, the WHO has received no proposals for new names for monkeypox, Chief Scientist Soumya Swaminathan said last week.

If a proposal were to make it past the Medical and Scientific Advisory Committee, it would then be reviewed by a group called the Classification and Standards Advisory Committee. The upshot is the proposed new name could be added to the ICD as an alternative name or a preferred name.

“It can be done. It’s been done before. But the precedents are not many,” said Lewis, pointing to Down’s syndrome. The condition, which occurs when someone is born with a third copy of chromosome 21, used to be called Mongolism — a name that is no longer used. Over time, it became Down’s syndrome but now the ICD lists Trisomy 21 as the preferred name.

“So basically, we need proposals. If we’re going to change the name, we need proposals,” she said.

As Lewis’ comment suggests, The WHO is open to proposals for new names for the disease; they can be submitted here.  A proposed name would have to be something that can be pronounced, and that doesn’t offend when translated into other languages. There was some discussion of the name monopox, she said, but mono in Spanish means monkey.

The process, in short, will take time.

Monkeypox clade names

The path to changing the names of the clades or strains of monkeypox is the easiest and the most likely to happen in the near term. But even here, there are some challenges.

The existing clades are known as the Congo Basin and West African clades. The former has historically been associated with more severe disease, with a fatality rate of about 10%. The latter, which is responsible for the current multi-national outbreak, causes milder disease and has an estimated fatality rate of between 1% and 3% in the African countries where it is endemic. (The current outbreak has drawn that estimate into question. Out of more than 21,000 cases, only three deaths have been reported to date outside of Central and Western Africa.)

In early June, a group of scientists, led by several from Africa, called for the renaming of the clades, saying that linking the disease to Africa was stigmatizing and discriminatory. Their commentary, posted on the website virological.org, argued that the clades should be given neutral names; they suggested clade 1 for Congo Basin viruses and clade 2 for those from West Africa.

They also proposed a third clade, for viruses from the current international outbreak and from imported cases detected in the United States, the United Kingdom, Israel, and Singapore in recent years. The group then went further, suggesting that changes in the genetic makeup of the outbreak viruses and in transmission patterns argue for naming this an entirely new virus. They proposed the name hMPXV — short for human monkeypox virus — as an interim moniker.

STAT reached out to the co-lead authors of the article, Christian Happi, director of the African Center of Excellence for Genomics of Infectious Diseases at Redeemer’s University in Ede, Nigeria, and Tulio de Oliveira, director of the Center for Epidemic Response and Innovation at Stellenbosch University in South Africa. Neither responded to interview requests for this article.

Richard Neher, an associate professor of viral evolution at the University of Basel in Switzerland, was a signatory to the article. He said the group’s main motivation was to get rid of the geographic linkages in the clade names, but agreed that “monkeypox is a very unfortunate name.”

At least part of their proposal could be relatively easily adopted, WHO’s Lewis said. That’s because neither the global health agency nor the ICTV controls the naming of the clades. That’s the purview of the scientific community.

Effectively, if researchers submitting scientific papers start using clade 1 and clade 2, those names over time will ease the geographic names out of new additions to the literature. (There will likely be a transitional period with notations such as “clade 1, formerly known as the Congo Basin clade.”)

The more people who adopt this naming approach, the faster it will become the norm. Lewis said the WHO will watch what happens to the scientific literature, but “I get the sense that numbering of the clades may not be an issue.” In fact, WHO has begun to use the terms occasionally, she said.

That said, the idea that the outbreak strain is sufficiently different to merit its own clade — or that it is its own virus — is not universally accepted at this point. And the objections are coming from within the community of pox virologists.

The Centers for Disease Control and Prevention, which is one of two WHO reference laboratories for poxviruses, is not of the view that the outbreak viruses have evolved to the degree that they merit being classified as a third clade, or a different virus for that matter.

“If you look at the outbreak strain … [it] sits within a recognized clade,” said Matthew Mauldin, a health scientist in the CDC’s Center for Preparedness and Response who worked for several years on poxvirus phylogenetics and ecology.

“There are some very clear distinctions that we’re seeing here … but there’s 40 to 50 or so shared mutations that you might see that are making this variant that’s circulating identifiable compared to other monkeypox virus genomes. But that’s not on the same level as what you’re seeing between clades 1 and 2, or Congo Basin and West African,” Mauldin said.

McInnes, chair of the ICTV’s poxvirus subcommittee, said there are strict criteria for when poxviruses can be considered distinct enough to merit being designated as a new species — a new virus — and the outbreak viruses do not hurdle that bar.

“To do so would require the criteria to be re-written and this is not something there would be any great support from the poxvirus community for,” he said. “It would introduce many more problems than it would solve.”

In science when views diverge, the debate plays out in the scientific literature. That’s where this question of whether there is a third clade — that should be designated as a separate virus — will be debated and eventually answered. In the meantime, use of clade 1 and clade 2 will likely become entrenched.

“We’ve already seen people use this new nomenclature. And I’d consider that a success,” Neher said.