Sentinel minutes for week #32/2024

Status: greenish. Monkeypox poses an increased risk to humanity with the news that the virus has spread to four new countries in Africa.

Biological Risks

Monkeypox

A cousin of the monkeypox virus that spread around the world in 2022-2023 has now spread from the DRC to four neighboring countries in Africa and poses a pandemic risk.

Monkeypox (mpox) is endemic in the Democratic Republic of Congo (DRC), but the size, geographic spread and modes of transmission of the current outbreak are unusual. Cases have now been seen in Burundi, Kenya, Rwanda and Uganda. The WHO will hold an Emergency Committee meeting on Wednesday, August 14 to advise the Director-General of the WHO about whether the ongoing monkeypox outbreak that started in the DRC should be declared a Public Health Emergency of International Concern (PHEIC).

While cases caused by the strains involved in the outbreak originating in the DRC have not been seen outside Africa, it is possible that a PHEIC will be declared following Wednesday’s meeting; our forecasting team thinks it is likely (~60%) that the current outbreak will be declared a PHEIC at some point within the coming 12 months. The Africa CDC is expected to declare the outbreak a Public Health Emergency of Continental Security (PHECS) next week.

The current outbreak originating in the DRC is complex. This complexity is being missed in most media discussions of the outbreak, but it is critical to understand a few important details to gain insight into how the outbreak might develop in the future.

The most important thing to know is that the current outbreak is being caused by two separate genetic groups of the monkeypox virus. The monkeypox virus that spread around the world in 2022-2023 was a clade IIb virus; clade II viruses are endemic in West Africa. In contrast, clade I monkeypox viruses are endemic in the DRC, and the current outbreak originating in the DRC is caused by clade I viruses. But in the current outbreak, cases are being caused by both clade Ia and clade Ib monkeypox viruses.

It matters that the current outbreak is caused by viruses in two different genetic groups because this means that the outbreak is really two separate outbreaks. These two outbreaks are affecting two separate but overlapping populations and have separate but overlapping modes of transmission.

Most clade Ia cases are zoonotic, i.e., caught directly from animals. The geographic range of clade Ia monkeypox viruses has expanded greatly over the past year and a half, and this is probably the most important factor driving an increase in clade Ia cases. In the DRC, about 60% of cases have been in children, and probably the most important reason why is this increase in zoonotic clade Ia infections over an expanded geographical area.

At the same time, we are also seeing more human-to-human transmission of clade Ib viruses. For the first time, transmission via sexual contact is being seen as a major cause of monkeypox virus transmission in the DRC, as was also seen in the emergence of the global clade II monekypox outbreak in 2022-2023. Transmission via sexual contact also appears to be playing a role in the spread of clade Ib cases to neighboring countries. However, infections with clade Ib viruses are also being spread by direct contact that is not sexual contact, as transmission is known to occur within households and from contact with corpses. Transmission of clade Ib viruses by non-sexual direct contact is also probably a significant driver of monkeypox cases in children.

Clade I monkeypox viruses tend to cause more severe disease than do clade II monkeypox viruses. They also tend to cause more extensive pox distribution over the body than do clade II viruses and hence could be more contagious by direct contact than clade II viruses, all else equal.

Medical professionals in the DRC and neighboring countries are doing spectacular work to understand the current outbreak and treat affected patients. However, resources are limited, so the available data are limited. It remains difficult to disentangle clade Ia from clade Ib cases and transmission.

But one thing is clear: It is clade Ib viruses that we need to worry about most. Clade Ia monkeypox viruses almost certainly pose a much lower pandemic risk at the moment than do clade Ib viruses, because most clade Ia virus transmission appears to be zoonotic or at most via short chains of human-to-human transmission. And just as we saw in the global emergence of clade IIb monkeypox virus cases in 2022-2023, transmission via sexual contact is a driving force in clade Ib transmission, although a substantial portion of clade Ib cases appear to be spread by non-sexual contact as well.

Overall, the case fatality rate (CFR) in the current outbreak has been approximately 3% – 5.5%, except in South Africa, where it has been about 10%, most likely due to that country’s large HIV burden. Before 2022, the clade II CFR in West Africa was approximately 3.6%; in contrast, the clade II CFR has been 0.2% in the global outbreak that started in 2022. If the current clade Ib monkeypox virus were to spread globally, it would be reasonable to expect a similar reduction in the global CFR.

On August 7, the US CDC stated that, “Due to the limited number of travelers and lack of direct commercial flights from DRC or its neighboring countries to the United States, the risk of clade I mpox importation to the United States is considered to be very low.” The current clade Ib outbreak could potentially be contained with a large, multinational effort, just as ebola was contained in West Africa almost a decade ago. However, it is hard to see how clade Ib monkeypox viruses will be contained in the long term, and our forecasters think that clade Ib monkeypox viruses pose a large pandemic risk over the coming year.

Effective monkeypox vaccines exist. The WHO has invited “#mpox vaccine manufacturers to submit dossiers for emergency evaluation.” If the current outbreak continues to grow, it could be stopped with ring vaccination, just as this vaccination strategy was used in smallpox eradication. More broadly, a concerted international public health effort, like that seen for the ebola outbreak of 2014-2016, could be mobilized to stop the outbreak if it starts to spiral out of control.

But if the spread of clade Ib monkeypox viruses does not slow or is not stopped, then clade Ib monkeypox virus could become the new smallpox, albeit very likely with a far lower case fatality rate than smallpox strains, perhaps around 1-5 times that of seasonal flu. It would likely spread much as smallpox did, with the difference that sexual contact would likely be one prominent mode of transmission of clade Ib monkeypox viruses, whereas sexual contact has not been reported as a significant mode of transmission of smallpox viruses. Based on currently available information about the current outbreak, our team thinks that spread of clade Ib monkeypox virus would probably not be largely restricted to the community of men who have sex with men (MSM), as is seen with clade II monkeypox virus cases in the outbreak that started in 2022-2023.

The international community is on alert to spot clade I monkeypox cases. In the US, the CDC states that, in addition to aiding clinical laboratories with testing, “CDC is helping communities monitor the presence of both clades of MPXV in wastewater samples, including from select airports.” Other communities around the world may be monitoring wastewater for the presence of both clades of MPXV as well, in addition to being on the lookout for cases.

Previously, we mentioned the rise of monkeypox in weeks #28 and #31 of this year, as clade I monkeypox virus case numbers rose in the DRC. The current rise in clade Ib cases, in particular, and the human-to-human transmission that is being seen and is causing the virus to spread to nearby countries, are cause for concern. Over the coming weeks, our team will be looking to see whether the WHO Emergency Committee advises that a PHEIC be declared, how case numbers change in each country in which monkeypox clade I cases have been seen, and whether cases are seen in new countries both within and outside Africa. The situation is not yet near a tipping point but could reach such a point in the coming weeks or months.

More biological risks

Influenza A(H5N1) continues to spread to more dairy herds in the US, and the US CDC just slightly increased its assessment of the pandemic risk posed by the virus. The CDC places the pandemic risk posed by the H5N1 virus in the lower end of the moderate range, below those of some other flu viruses in recent years.

An antibiotic-resistant bug is spreading and has been detected in 16 countries, including the UK, reports the Daily Mail, a British sensationalist yet often informative outlet. “In a briefing, representatives from the World Health Organization (WHO) warned about the potentially deadly impact of a little-known bacteria called Klebsiella pneumoniae. The pathogen has been seen in the UK and US, as well as Algeria, Argentina, Australia, Canada, Cambodia, China, India, Iran, Japan, Oman, Papua New Guinea, Philippines, Switzerland and Thailand. Of these countries, 12 – including the UK – reported a specific strain of concern that has become a superbug, resistant to all antibiotics used to treat it.”

Hospital stays are being implicated in community transmission of methicillin-resistant Staphylococcus aureus infection (MRSA).

A goat plague (peste des petits ruminants) outbreak in Greece has spread to Romania.

In good news, Ethiopia has vaccinated over 10 mln people against cholera, in an effort to contain an outbreak that began two years ago, in August 2022.

In the US, deaths in CT from the “elephant tranquilizer” carfentanil are rising. Nine people are known to have died.

Geopolitics

Middle East

Israel continues to brace for attacks from Iran and Hezbollah, in retaliation for Israel’s killing of a Hezbollah leader in Lebanon and the political leader of Hamas, Ismail Haniyeh, in Iran. An Israeli strike also killed a senior Hamas figure in southern Lebanon. Airlines are avoiding Iranian and Lebanese airspace. The US told Israel that escalations in the Middle East serve no one. Hamas has appointed a new hardline leader, Yahya Sinwar, and Israel has vowed to assassinate him as well. Israeli warplanes flew at low altitude over Beirut ahead of a speech by Hezbollah’s Nasrallah.

Iran plans to carry out its leader’s order to ‘harshly punish’ Israel, the IRG deputy chief says, but Iran’s new reformist President is reportedly urging the Ayatollah and the Iranian Revolutionary Guard Corps to avoid attacking Israel, or at least its cities. Instead, the new Iranian president suggests targeting Mossad bases. Team members still think it is very likely that Iran will attack Israel by the end of the year and fairly likely that Israel will conduct a land invasion of Lebanon by the end of 2024.

In Gaza, Israeli military action has killed a World Central Kitchen worker in Deir al-Balah. Also, UNRWA staff will be fired for their suspected role in Hamas’ attacks on Israel. “An Israeli airstrike on a Gaza school compound housing displaced families killed around 100 people, the Hamas-run Gaza government said on Saturday, while the Israeli military said it targeted Hamas militants there and cast doubt on the death toll.” Meanwhile, “Israel’s Finance Minister Bezalel Smotrich sparked controversy by suggesting that starving the entire Gaza Strip could be justified as a means to pressure for the return of Israeli hostages. The U.N. reported a significant increase in child malnutrition in Gaza due to Israel’s attacks and blockade.”

The US has released $3.5 billion for Israel to buy American weapons.

The US plans to lift a ban on weapons sales to Saudi Arabia. This move could be part of a deal reportedly requested by Saudi Arabia in exchange for Saudi Arabia being willing to recognize Israel in the future. According to Reuters, “The Biden administration has decided to lift a ban on U.S. sales of offensive weapons to Saudi Arabia, the State Department said on Friday, reversing a three-year-old policy to pressure the kingdom to wind down the Yemen war. Since March 2022 — when the Saudis and Houthis entered into a U.N.-led truce — there have not been any Saudi airstrikes in Yemen and cross-border fire from Yemen into the kingdom has largely stopped, the administration official said. Yemen’s war is seen as one of several proxy battles between Iran and Saudi Arabia. The Houthis ousted a Saudi-backed government from Sanaa in late 2014 and have been at war against a Saudi-led military alliance since 2015, a conflict that has killed hundreds of thousands of people and left 80% of Yemen’s population dependent on humanitarian aid.”

Russian war on Ukraine

Ukraine’s excursion into the Kursk region of Russia demonstrates Ukraine’s military strength and may also be aimed towards improving its bargaining position if the country decides to negotiate with Russia. Apart from Argentina’s invasion of the Falklands in 1982, this is one of the only times that the soil of a nuclear-armed nation has been invaded by a non-nuclear country. Russia has called the incursion a “provocation” rather than an invasion; it is in Putin’s interest not to make a big deal of this military action as it could highlight the Russian military’s brittleness, much as the Wagner rebellion did last year.

The IAEA is monitoring the situation around Russia’s Kursk nuclear plant. July was the deadliest month for Ukraine’s civilians since 2022, according to the UN. A new US military aid package for Ukraine will include Stinger missiles and ammunition. And Ukraine is finally deploying US-made F-16s.

UK

Rioting in the UK around attacks against Muslims and migrants have roiled the UK, but have died down. “British police remained on alert on Thursday after a heavy security presence, rapid arrests and displays of unity by people across Britain on Wednesday prevented a repeat of widespread rioting involving racist attacks targeting Muslims and migrants.” The riots have died down in the UK, likely due in part to a large police presence, quick arrests, charges and prison sentencing, as well as naming and shaming; over 480 people have been arrested. King Charles has called for unity and understanding.

The UK is considering changes to the Online Safety Act, which is designed to regulate social media companies, following the riots. Many online commentators have noticed that the UK has much weaker free speech protection than the US, with vague laws that can be broadly interpreted.

The UK government will repeal the minimum service levels strike law. “Britain’s new government said on Tuesday it planned to repeal legislation brought in by the previous administration allowing employers in key public sectors to require workers to maintain minimum levels of service during strike action.”

Elon Musk is feuding with the UK government and Keir Starmer over the police response to the UK riots.

US

The Justice Department has charged a man from Pakistan with Iranian ties with plotting to carry out assassinations of US politicians and officials on US soil.

Trump said that presidents should have a say over the Federal Reserve Bank’s decisions. “I feel the president should have at least (a) say in there,” the former president told reporters at his Mar-a-Lago residence in Florida. “I think that in my case, I made a lot of money, I was very successful, and I think I have a better instinct than in many cases, people that would be on the Federal Reserve or the chairman.”

Eastern Europe

The Slovakian government is ceasing to pursue corruption cases and investigations.

The Caucasus

The EU condemned Russia’s military presence in occupied regions of Abkhazia and South Ossetia, and US Secretary of State Blinken called on Russia to recall its recognition of the independence of Abkhazia and South Ossetia.

Bangladesh

Bangladesh is in turmoil following the collapse of the government on the heels of a crisis over hiring quotas for government jobs. For a bit, it seemed that things could get even uglier as Sheikh Hasina’s son alleged that she did not resign before fleeing to Delhi. In any case, the government collapsed after the army refused to suppress protests and fire on protestors.

Bangladesh President Mohammed Shahabuddin dissolved Parliament and appointed Nobel laureate Mohammad Yunus as the head of an interim government after Prime Minister Sheikh Hasina abruptly resigned and fled the country amid violent protests. Yunnus has arrived in Bangladesh.

In the midst of the turmoil, minorities, including Hindus, are being targeted with violence in Bangladesh. “The violence has led to the destruction of Hindu temples and businesses, assaults on women, and targeted killings of Hindu leaders affiliated with Hasina’s party.”

Venezuela

Maduro continues to hold onto power in Venezuela, amid a crackdown on X and WhatsApp.

China, Taiwan and the South China Sea

The Philippine military condemned dangerous actions by the Chinese air force in the South China Sea.

“Canada & Australia signal more military cooperation.”

The US plans to increase force projection from Australia.

Southeast Asia

In Myanmar, resistance against the ruling military continues. “Myanmar’s army chief Senior General Min Aung Hlaing acknowledged pressure on his troops after anti-coup fighters claimed control of a key military base in Lashio. The Myanmar National Democratic Alliance Army (MNDAA) stated they had overrun the headquarters of the army’s Northeastern Command.” Violence against the Rohingya is ongoing in the country, as well.

“Thailand’s Constitutional Court ordered the dissolution of the popular anti-establishment opposition party, Move Forward, over its campaign to amend a law that protects the powerful monarchy from criticism.” This is less important than it sounds, since most members of parliament from the party except a few designated leaders can reform under a new party, and have done so in the past.

Africa

Tensions are escalating between the Democratic Republic of the Congo (DRC), Rwanda, and Uganda, potentially leading to a full-blown war. The conflict is primarily about control of the DRC’s valuable mineral resources, with the DRC accusing Rwanda of supporting rebel groups.”

Sudanese officials met with US mediators in Saudi Arabia to discuss conditions for holding ceasefire negotiations in Geneva. “The talks, co-hosted by Saudi Arabia and the US with observers from the African Union, Egypt, the UAE, and the UN, aim to end a 15-month-old war between the Sudanese army and the Rapid Support Forces paramilitary, following accusations of war crimes and dire humanitarian crisis.”

Air strikes hit a famine-struck displacement camp in Sudan’s Darfur region.

Risk-averse investors shun Kenyan local debt, deepening fiscal woes.

Artificial Intelligence

John Schulman, who co-founded OpenAI, has left the company for Anthropic, citing a desire to spend more time focusing on AI alignment.

The UK has initiated an antitrust probe into Amazon’s partnership with Anthropic.

AI companies are fighting to stop California from pursuing an AI bill that would regulate the riskiest AI model development. Among the companies fighting the bill is Anthropic, which is nominally focused on AI safety.

US VP candidate Tim Walz favors regulating the use of AI. “In May 2023, Tim Walz signed into law one of the first state regulations on deepfakes and elections.”

Elon Musk is suing OpenAI again, alleging ‘deceit of Shakespearean proportions.’

FLI’s Anthony Aguirre argues in The Washington Post that there’s no way for humanity to win an AI arms race.

Gary Marcus discussed Sam Altman becoming one of the most powerful people in the world. He says we should be very afraid of “the danger in AI – and in Altman himself.”

ByteDance launched an AI video app.

Computers and Cyberattacks

A leaked GitHub Python token could have caused a disaster – but didn’t. According to Bruce Schneier, “inserting malicious code that would eventually end up in Python’s distributables could mean spreading your backdoor to tens of millions of machines worldwide!”

The US Cyber Safety Review Board could do better, according to Bruce Schneier and Tarah Wheeler.

Critical vulnerabilities in six services under Amazon Web Services (AWS) could have enabled account takeover, remote code execution, AI data manipulation, sensitive information disclosure and more, researchers from Aqua Security disclosed at Black Hat USA on Wednesday.

Natural Disasters and Climate Risks

The Japan Meteorological Agency issued its first-ever warning that the risk of a mega-earthquake is larger than usual. Reuters reports that, “Japan Meteorological Agency’s Nankai Trough quake advisory panel said the chance of a bigger earthquake striking after a magnitude 7 tremor was once in a few hundred cases, relatively higher than regular times.” The meteorological agency said that before a recent quake, there was a 70-80% chance of a megaquake – an earthquake with a magnitude of at least 8 on the Richter scale – in the next 30 years, implying a 4-5% chance per year. This latest quake might be a harbinger of a megaquake; a 7.2 quake also preceded the earthquake that triggered the Fukushima disaster. However, earthquakes tend to be signals of larger quakes only about 5% of the time, so the risk of a mega-earthquake might be elevated to perhaps a 5-6% chance over the coming 12 months.

Hurricane Debbie has caused devastating flooding along the East Coast of the US and continues to pose a risk in the Northeast. In addition to individuals and communities, one group that is suffering is small businesses: “As the climate crisis causes heavier and more frequent floods across the US, one in four small businesses are one disaster away from shutting down. … Small businesses employ nearly half of US workers and represent 43.5% of America’s GDP. … First Street, a firm that models climate risk, projects the US commercial sector stands to lose $16.9bn in damages over the next 30 years due to flooding. Experts say small businesses struggle to afford insurance that might help them weather future storms – especially as rates increase and insurers exit the market in certain states due to climate risk. … According to the Federal Emergency Management Agency (Fema), as of April, only a fraction of the country’s small businesses – about 120,000 – carried insurance through Fema’s National Flood Insurance Program (NFIP), the country’s largest insurance provider for small businesses.”

Extreme rainfall and severe flooding in China led to a near doubling in economic losses from natural disasters in July from a year earlier, the government said. China suffered 76.9 billion yuan ($10.1 billion) in economic losses from natural disasters last month, with 88% of those losses caused by heavy rains, floods or their effects, according to the Ministry of Emergency Management. It was the biggest amount of losses for the month of July since 2021, ministry data showed.

A series of essays in the NY Times have profiled the coming threat to food production due to climate change. The first in the series, by David Wallace-Wells, discusses how global food production will likely change over the coming decades thanks to both pressures from climate change and innovation. He notes that by one estimate, “the effects of climate change have reduced the growth of overall global agricultural productivity by between 30 and 35 percent. The climate threats to come loom even larger. … In a much hotter world, those will indeed become likelier, particularly if agricultural innovation fails to keep pace with climate change; over a 30-year time horizon, the insurer Lloyd’s recently estimated a 50 percent chance of what it called a “major” global food shock.” Another essay in the series examines the looming groundwater shortage in the US and asks whether California agriculture will require water to be pumped in from the Great Lakes.

Terrorism

The UN is concerned about risks posed by terrorist groups in Afghanistan.

An ISIS plot for a terrorist attack at a Taylor Swift concert in Vienna, Austria was foiled. Her concerts in Austria were canceled, and a pro-ISIS news outlet celebrated the would-be attackers. One of the perpetrators who were arrested was a 19-year old man with North Macedonian roots, who “swore allegiance to the IS group’s leader on the internet and had chemicals, machetes and technical devices at his home in the town of Ternitz in preparation for an attack.”

So overall, forecasters did not anticipate events spiraling into global catastrophes this week – but that could change.