WHO's declaration on July 23 that the current monkeypox outbreak constitutes a Public Health Emergency of International Concern (PHEIC) was unprecedented. It is the seventh such declaration, but the first made against the advice of a majority of the emergency committee (nine were against, six were for). Dr Tedros’ decision is a brave one. It needs to serve as a global wake-up call. The question is whether it will prompt the escalated efforts required to control the outbreak.
Dr Tedros gave three broad reasons for his decision. “We have an outbreak that has spread around the world rapidly, through new modes of transmission about which we understand too little, and which meets the criteria in the International Health Regulations.” The details make for a compelling case. So far this year, up to July 22, 16 016 cases have been reported from 75 countries. Where monkeypox is endemic, such as in DR Congo, large new outbreaks have been reported in diverse populations. Outside of west and central Africa, the outbreak is concentrated, for now, in men-who-have-sex-with-men (MSM). Why the disease's epidemiology has changed is still unclear, as are many other aspects of the outbreak. Recent case series from non-endemic countries have shown differences in clinical features compared with previous reports. Lethargy and fever seem to be less common, and several patients have no prodromal symptoms. Skin lesions are found predominantly in genital or perianal areas. Transmission is known to occur through skin-to-skin contact, but monkeypox DNA has been found in patients’ seminal fluid—whether it represents replication-competent virus remains unknown. The rapid worldwide spread of a disease, for reasons we are unsure of, was clearly an over-riding concern for Dr Tedros. An urgent energised research effort is now needed to understand these and other issues related to the outbreak.
Countries must strengthen public health preparedness and response. Case definitions should be updated and harmonised as new data emerge, with heightened surveillance, case detection, and contact tracing. Patients need to be supported in isolation and treatment, and targeted immunisation might be needed for people at high risk of exposure. Recent experience with COVID-19 might help countries institute these measures but many health systems are at breaking point already. There is a risk too that the public is fatigued by talk of pandemics and their control. Misinformation about monkeypox has already begun to circulate. The public need to be engaged and targeted risk-communication strategies developed. Monkeypox is not COVID-19. The R0 is around 1, and transmission mechanisms are entirely different. The clade of monkeypox that seems to be responsible for the outbreak largely causes mild self-limiting illness, although patients have been admitted to hospital, mainly for pain. Ensuring wide understanding of these points is key for managing public anxiety.
Engagement among many MSM has been high since the outbreak started, and this population is—as ever—keen to take care of its health (and do their part to protect others). Countries that criminalise homosexuality and marginalise LGBTI+ communities risk both patients’ wellbeing and chances of controlling transmission. Stigma and discrimination need to be fought. It would be wrong to categorise monkeypox as a disease of MSM.
The expedited pathways for research, development, regulatory approval, and manufacturing of medical countermeasures developed for COVID-19 should be repurposed for monkeypox. A lack of diagnostic tests is hampering case identification in some countries. Tecovirimat, originally produced to treat smallpox, has been licenced by European regulators for monkeypox, but not yet by the US FDA. Other promising treatments, such as cidofovir and brincidofovir, require clinical study. A monkeypox vaccine (sold as Imvanex in Europe and Jynneos in the USA) has been approved, but supplies of both treatments and vaccines are extremely limited. WHO will have to take a much more muscular approach to ensure global access and avoid the inequities of the COVID-19 response.
Whether or not you agree with WHO's decision, there has undoubtedly been a missed opportunity. Monkeypox is not new. It has been causing illness and death in large numbers for decades. Specialists have long called for affordable countermeasures, strengthened surveillance, and more study. But like Ebola and Zika, monkeypox only commands global attention when it hits high-income countries with predominantly White populations. As a result, the window of opportunity to prevent monkeypox becoming established in communities worldwide is closing. Now is a key moment. It warrants the strongest medical, scientific, and political global effort.
For more on WHO's declaration on monkeypox see https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox
For more on monkeypox case series in non-endemic countries see Articles Lancet Infect Dis 2022; published online July 1. https://doi.org/10.1016/S1473-3099(22)00411-X and N Engl J Med 2022; published online July 21. https://www.nejm.org/doi/full/10.1056/NEJMoa2207323?query=featured_home
© 2022 Fabrice Coffrini/Pool via Reuters