Monkeypox-related deaths in the United States are often challenging to confirm due to similarities with other health conditions. As Lori Tramel Freeman, CEO of the Association of County and City Health Officials, puts it, "It's a little like the old situation we had with COVID: Die you from COVID, or die from COVID? It's the same scenario: Die from monkeypox, or die from monkeypox?"
The first confirmed U.S. monkeypox death was reported in Los Angeles County in September. While a Houston patient died in August, the cause wasn't definitively linked to the virus. Ohio reported its first monkeypox death last Thursday, but the patient had other health issues as well.
In this outbreak, many monkeypox patients had compromised immune systems or underlying conditions like HIV. Determining the cause of death in these individuals can be complex, as they might have died from their pre-existing conditions or monkeypox coincidentally. Studies on other outbreaks suggest that children, pregnant women, and immunocompromised individuals are at higher risk of monkeypox-related mortality.
Experts question whether underlying health conditions severely impact survival or if monkeypox significantly influences overal survival. Freeman notes, "Is your underlying condition so severe that this disease will have a more significant influence on your ability to survive? Or is it just something that happened to you coincidentally?"
Potential for Severe Illness
As of now, the World Health Organization reports over 68,000 monkeypox cases worldwide with 25 confirmed deaths. The U.S. has seen a steady decrease in new monkeypox cases in recent weeks, but there are ongoing concerns about severe illness and mortality, particularly in immunocompromised individuals. The Centers for Disease Control and Prevention (CDC) warned healthcare providers of cases with severe manifestations, longer hospital stays, or "significant" health problems.
The CDC notes that immunocompromised individuals with HIV, amongst others, have a higher risk of developing severe monkeypox symptoms than healthy individuals. The Los Angeles County Department of Public Health reported that the patient who died in September had a severely compromised immune system and was hospitalized.
Freeman emphasizes that while monkeypox is generally considered a mild disease with treatments, medications, and vaccines available, it can be deadly for those with underlying health issues. She advises, "This is not a disease that people need to be concerned about, especially if they know that they have a compromised immune system or are suffering from another serious illness. These few deaths - regardless of whether they are attributable to monkeypox or if people just happened to have monkeypox while dealing with other illnesses - would likely not have occurred if they did not have those underlying health conditions or if their bodies were not compromised."
Monkeypox-related Deaths in the U.S.
In August, the Houston Health Department reported a monkeypox patient's death, but the role of the virus in the patient's death wasn't established. The Texas Department of State Health Services explained that the medical examiner (usually the treating physician) decides the cause of death and any contributing factors listed on the death certificate. In the Harris County case, an autopsy was performed to gather more information before determining the cause of death.
Forensic Pathologists Investigate
When investigating a death, forensic pathologists begin by collecting detailed information about the person's medical history and the circumstances surrounding the death. Then, they might perform an external and internal examination of the body, and take tissue samples for analysis under a microscope. This type of autopsy is called a full autopsy.
Determining if someone died from monkeypox or if monkeypox contributed to their death can be complex. Banerjee, a board-certified pathologist, explains that to confirm a monkeypox-related death, you must find both the virus in the person's body and connect the dots to understand how the infection led to their death, possibly through organ damage, for example.
Mosunjac, a pathologist at Emory University School of Medicine, stresses that the diagnosis of a death originating from an infection isn't always straightforward. "The presence of a specific pathogen does not necessarily mean that the pathogen caused the death," he says, noting that further investigation is often required.
How Monkeypox Can Be Fatal
Forensic pathologists often look for clues to help determine how monkeypox symptoms led to death. For example, they would consider skin lesions, general discomfort, and flu-like symptoms. However, the path to death may involve rare scenarios, such as the virus reaching the brain, causing encephalitis.
In most cases, a virus infection leads to death through systemic effects, affecting the entire body, or damaging critical organs like the heart, lungs, liver, or brain. In Monkeypox's case, Banerjee adds that the death isn't caused by the virus directly but by the consequences of the infection.
The distinction between dying due to an infection or as a result of an infection is crucial, Banerjee says. The former implies that the infection played a significant role in the person's demise, while the latter means the infection was a contributing factor, or simply a timing coincidence. The latter does not necessarily mean the infection caused the death.
Determining causality isn't always straightforward. Mosunjac from Emory University notes that while the presence of a specific pathogen doesn't automatically imply responsibility for the death, further examination is always required. "It's essential to recognize that the presence of a specific pathogen does not necessarily mean that the pathogen caused the death," he explains. "Often, further investigation is needed." Ultimately, the diagnosis is determined based on the specific situation.
[1] CDC: Monkeypox. (2022). Retrieved November 28, 2022, from [2] CDC: Monkeypox - Travel Alerts - Notice. (2022). Retrieved November 28, 2022, from [4] World Health Organization: Monkeypox. (2022). Retrieved November 28, 2022, from
