4 COVID-19 Ds to remember when approaching Monkeypox

To the Editor

The WHO declared Monkeypox as a Public Health Emergency of International Concern (PHEIC) on the 23rd of July 2022 [1]. At the time of writing this letter, there are 25,000 globally confirmed Monkeypox cases [2]. Considering the steep and constant rise in cases over the last weeks, the authors believe that lessons from the ongoing COVID-19 pandemic need to be harnessed for framing a comprehensive public health response. The 4Ds from COVID-19 are four domains which policy-makers, the healthcare community and the general public need to heed when devising a response to Monkeypox. These are 1) Disinformation 2) Development 3) Distribution and 4) Diplomacy.

The primary concern which governed the response to COVID-19 was the crisis around Disinformation, a challenge which predated the COVID-19 pandemic but reached an unprecedented extent during the past two years. Disinformation about COVID-19 ranged from therapeutics, vaccination and disease severity to political and financial conspiracy [3]. The compounding effect of misleading information contributed to large - scale COVID-19 vaccine hesitancy and subsequent morbidity, disability and mortality. The erosion of trust in healthcare authorities and even healthcare workers is expected to plague humanity for years after the expected end of the pandemic. Therefore, any response around the Monkeypox outbreak needs to take into account the causes, channels and forms of disinformation about COVID-19 and ensure that the flow of reliable information can overcome these challenges. Given the limited trust that the general public can have in healthcare authorities, risk and preventive measures communication needs to be compassionate, factual, to curb misinterpretations and encourage adherence. Restoring vaccine confidence should be a priority with either providing selected population groups with small-pox vaccination or developing a Monkeypox vaccine.

The development of vaccines and immunotherapeutics against Monkeypox should also be prioritized. The COVID-19 pandemic demonstrated that a unified approach to sharing knowledge, resources and galvanizing the scientific and pharmaceutical sectors into action is central to a cohesive, global health response. Currently, effective vaccines against Monkeypox exist, such as the JYNNEOS and ACAM2000 vaccines [4]. The development of vaccines should, however, be equitable in a manner that allows for broad coverage and vaccination campaigns in low-income countries. The broad coverage approach should emphasize on easing of Intellectual Property laws within the context of vaccine development to allow countries with greater manufacturing ability to develop these vaccines independently. Balancing and coupling efforts for vaccine development with research in novel immunotherapeutics can further reassure the public, which tended to consider singular emphasis on vaccines suspicious during the COVID-19 pandemic.

Distribution of vaccines and healthcare support such as medical equipment and pharmaceuticals should follow an equitable approach, prioritizing under-resourced countries and communities across the globe [5]. Vaccine inequality is a major public health concern [6]. Low and middle income countries (LMICs) in Africa and Asia have lower rates of vaccinations against COVID-19, and this must not be repeated within the context of monkeypox. A truly comprehensive public health policy response should take into account the importance of equitable vaccine distribution, but particular emphasis must be directed towards the implementation of this policy. The gap between policy and its implementation should be narrowed as much as possible.

The final lesson from COVID-19 is Diplomacy. During the pandemic, it was demonstrable that vaccines and other healthcare support was used as a geopolitical tool for alliances in the pursuit of diplomacy [7]. The approach of using healthcare as an instrument of diplomacy does not take into account healthcare outcomes, or objective data, but is governed only on the principle that vaccines and healthcare itself can be used in the same way as weapons or energy exports. The COVID-19 pandemic has shown that equating vaccines with other instruments of diplomacy is neither ethical nor benefits health and recovery from the pandemic at large. Over the last two years of the pandemic, we have also witnessed that countries with lower diplomatic power, or those in conflict, are often faced with increased isolation or are neglected, with patients and the general public bearing the brunt of the disasters that follow. Countries with greater diplomatic capital should not be allowed to use this diplomatic capital to hoard, redirect, or reward and punish when it comes to the health of the public.

In a globalized world, the spread of epidemics knows no borders and makes no distinction between wealthy and developing countries and territories. COVID-19 has set a harsh reminder of this reality. The same applies to Monkeypox considering its onset as an endemic disease in Africa in the 1970s and its rapid spread in the western world today. Learning from the past offers a safer way through the future.