Gene sequencing efforts suggest that two different monkeypox variants are spreading in the U.S., raising the possibility that the virus has been circulating longer than experts initially thought, CDC officials said on Friday.

Currently, there have been 20 monkeypox cases identified in 11 U.S. states, all in adults, Jennifer McQuiston, DVM, deputy director of CDC’s Division of High Consequence Pathogens and Pathology explained on a call with reporters. No deaths related to the virus have been reported to date, and all patients are in recovery or have recovered.

Most of these cases have been linked to international travel, and a majority that have been sequenced in the U.S. are linked to the variant reported in Europe, she said. However, a few genetic samples are different than the others sequenced in the U.S., in cases from people who recently traveled to West Africa and the Middle East. Both strains in the U.S. share common ancestors to variants that were present in Nigeria since 2017, McQuiston added.

McQuiston said that it is possible that some monkeypox cases in the U.S. previously went under the radar, “but not to a great degree.” She added that to better understand how long the virus has been circulating, it will require analysis of “a lot more sequences from a lot more cases.”

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