Our letter is out in @The Lancet today. tl;dr — Don't sleep on Monkeypox. That shit can evolve. thelancet.com/journals/lance…

To provide just a bit more detail, if interventions get serious only once a large number of individuals are infected, it is the *low* R0 pathogens that pose the greatest risk of adaptive evolution.

This is because when R0 is just above one, you create very long transmission chains — during which you can get a lot of adaptive evolution — before interventions kick in.

It's easy to see why when you think about the transmission tree for low- and high-R0 pathogens. By the time you have 16 concurrent cases, you've seen much longer transmission chains for R0=1.5 than for R0=4.0.

"In general, our analysis from first principles highlights the benefits of rapid intervention even for mild emerging pathogens. In summary, just because a disease like monkeypox appears to be controllable does not mean it will stay controllable."

Interesting back story on this paper. We wrote the first draft in 2013 or thereabouts, thinking about Ebola and monkeypox. Peer review was not kind to us at the time, but it seemed too important not to dust off and polish up once the current monkeypox epidemic began.