Madison Muller, Riley Griffin and Deirdre Hipwell
The COVID-19 outbreak forced governments around the world to revamp their pandemic response programs, invest in drugs and vaccines and establish viral surveillance systems. Now monkeypox is putting those upgrades to the test — and they’re falling short.
Getting out in front of the global flare-up of the monkeypox virus, which has spread to about 16,000 people in more than 70 countries in just a few months, is an achievable goal, according to infectious disease experts. Yet the lack of urgency and coordination in testing and treatment in many parts of the world has prompted the World Health Organization to sound the alarm.
On Saturday, WHO Director-General Tedros Adhanom Ghebreyesus declared the outbreak a public health emergency of international concern, or PHEIC. Tedros acted even though a majority of expert advisers suggested such a move wasn’t necessary.
“This is an outbreak that can be stopped with the right strategies in the right groups,” Tedros said, referring to the fact that the outbreak is thus far concentrated among men who have sex with men and among those who have multiple partners.
At the same time, Tedros warned: “We have an outbreak that has spread around the world rapidly, through new modes of transmission, about which we understand too little,” suggesting that scientists should focus on the basic detective work of decoding the virus to help public health officials understand why it has spread so quickly.
Monkeypox has been around for decades. It was first reported in humans in West Africa in 1970 and has largely been contained to two countries in Africa ever since. Public health officials were able to contain a 2003 outbreak in the US that was traced to imported rodents.
The current version is spread through direct contact with a rash or the bodily fluids of an infected person. But monkeypox has the ability to mutate, which could alter how it affects people if the virus continues to circulate. The current version, according to early research, has amassed almost 50 mutations in the past few years.
Already there are reports of cases in children, illustrating how the outbreak could intensify. While monkeypox is rarely deadly, it can be more dangerous for children and people with weakened immune systems.
As with most infectious-disease outbreaks, speed matters. The longer monkeypox spreads around the world, the greater the chances that the virus becomes an endemic disease and long-term health threat. Though it’s not anywhere near as harmful as SARS-CoV-2, the virus that causes COVID, public health experts are racing to contain the infection rate of the monkeypox pathogen before it circulates widely in human populations. So far, the global response has been uneven.
“You would have thought that we would have learned the lessons from COVID with monkeypox, but it’s the exact opposite,” said Lawrence Gostin, director of the WHO’s Center on Global Health Law and a public health professor at Johns Hopkins University in Baltimore.
Public health departments have been grappling with limited testing, insufficient vaccine doses, inadequate access to antiviral treatments and data gaps that are making it hard to understand the full picture of the monkeypox outbreak.
The WHO is recommending governments in countries without cases to step up surveillance, train health workers on detection and raise awareness about transmission. In countries where the virus has already been detected, the health agency recommends governments create response plans with the “goal of stopping human-to-human transmission” with a focus on high-risk groups.
“It is to be hoped that the increased attention to this disease leads to more focus on control within Africa, the natural home of this virus, where the number of cases has been increasing for the past 20 years,” said Jimmy Whitworth, professor at the London School of Hygiene and Tropical Medicine.
Testing for monkeypox has long been a problem. It’s likely the true number of cases in this current outbreak is higher than what’s been estimated because of a lack of testing or mis-diagnosis. Monkeypox surveillance has been “very poor” over the last few decades, Mike Ryan, WHO emergencies program director, said at a media briefing earlier this month.
“What we’re actually seeing at the moment is a little bit like the drunk man looking for his keys under the lamppost,” he said. “We’re looking where the light is, but we’re not looking in the dark.”
A lack of resources at sexual health clinics, the front line of the current outbreak, has been another weakness in the current international response, particularly because symptoms differ from those seen in previous outbreaks and because monkeypox can potentially be mistaken for other infections like herpes or syphilis.
“Naming this a PHEIC adds political weight and urgency to the situation, to ensure that this outbreak can be prioritized when there are multiple competing priorities for governmental attention and funds,” said Hugh Adler, from the Liverpool School of Tropical Medicine. “The WHO believes, as I do, that this outbreak is controllable with public health measures including a concerted vaccination campaign, but that this window of opportunity is closing fast.”
The WHO’s emergency declaration came one day after U.S. health officials said they were weighing a similar move, which could free up funding to support a robust public health response, and two days after the White House released research priorities aimed at improving the government’s knowledge of the virus and how to prevent its spread.
The U.S. outbreak, which has spread to more than 2,800 people, has raised concerns, including from Republican Sen. Richard Burr, a fierce critic of the nation’s COVID-19 response who says health agencies are now failing to show leadership during monkeypox’s spread.
Back in May, with the monkeypox outbreak newly underway, U.S. health officials sought to reassure the public that the country was well prepared based on decades of research into the virus’s more lethal cousin, smallpox.
Yet it quickly became apparent that wasn’t enough. Insufficient testing and a shaky vaccine rollout were unsettling reminders of problems that persisted throughout the COVID pandemic. Data collection has been yet another problem: CDC Director Rochelle Walensky said the agency is struggling to get states to share demographic information about monkeypox cases, despite the fact that this information is reported for COVID. Currently there are no data on who has been vaccinated against monkeypox either.
Other issues have emerged more recently. Clinicians have reported they’re unable to get antivirals to patients due to a regulatory process that requires dozens of pages of paperwork. And while other countries have started clinical trials for Tpoxx, an antiviral being used to treat monkeypox, the U.S. is not running similar studies as of yet.
U.S. health officials have stressed they’re working round-the-clock to fix problems that have emerged, deploying $140 million to support research to improve modeling, forecasting and surveillance of monkeypox cases, among other efforts to prevent spread and treat infections. HHS has ordered millions of doses of Bavarian Nordic A/S’ Jynneos vaccine, though most of them won’t be available until later this year.
Scientists at the White House are looking into strategies that could help stretch the existing supply of the vaccine. The U.S. should have 750,000 additional doses of vaccine by the end of the month, Anthony Fauci, chief medical adviser to President Joe Biden, said on MSNBC’s “The Sunday Show.” HHS has ramped up testing with the help of large commercial labs and on Friday, the CDC announced efforts to make prescribing Tpoxx easier for clinicians.
“There is real, true human suffering right now,” said Andrew Hebbeler, who leads the health and life sciences efforts in the White House Office of Science and Technology Policy, noting that the government is trying to secure additional funding to advance its research and containment efforts. “We need to do everything we can to accelerate not only the generation of data that will plug the gaps in our knowledge, but the application of that knowledge.”
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