On July 23, World Health Organization (WHO) director-general Tedros Adhanom Ghebreyesus declared that monkeypox is a public health emergency of international concern (PHEIC)—the highest level of alert— reflecting steeply rising cases in countries where the virus has not previously been reported.
“[W]e 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,” Tedros said at a media briefing.
As of July 25, the Centers for Disease Control and Prevention (CDC) has identified 3,487 monkeypox cases, and the United States will soon exceed all other countires. Worldwide, there are now more than 18,000 cases.
Almost all cases so far have been among gay, bisexual and other men who have sex with men, and most transmission has been associated with sexual activity. But experts fear that if the outbreak is not contained, the virus could spread beyond this group and may become endemic in more countries. The CDC has reported eight cases among cisgender women in the United States, and last Friday, CDC director Rochelle Walensky, MD, MPH, announced the first two cases in children in the U.S., both attributed to household contact.
The monkeypox virus is transmitted through close physical contact, including skin-to-skin contact, kissing and respiratory droplets at close range, but it does not spread through the air over longer distances. Monkeypox can potentially spread via clothes, bedding or surfaces, but this appears to be much less common. It is not yet known whether monkeypox is directly sexually transmitted through semen or vaginal fluid, but it does spread via contact with sores during sex.
The WHO previously considered whether to declare a PHEIC a month ago, when some 3,000 monkeypox cases had been identified. At that time, an advisory committee voted unanimously that the outbreak did not yet meet the criteria set forth in the WHO’s International Health Regulations, which include rapid spread in new countries.
But this time, the decision was more contentious. Although the WHO’s advisory committee voted 6 to 9 against a PHEIC designation after a day-long meeting, Tedros overrode advisors for the first time ever and made the declaration. Those in favor of the designation cited the rapidly growing number of monkeypox cases and affected countries. Some argued that without stronger action, the virus could become permanently established in the global population.
Those opposing the declaration noted that monkeypox is not spreading within the general population at this time and has led to just five deaths, all of them in endemic countries in Africa. Some cited preliminary evidence that the outbreak may be stabilizing. What’s more, some feared a PHEIC designation could further stigmatize men who have sex with men—a particular concern in countries where homosexuality is criminalized. On the other hand, some LGBT advocates argued that it would raise awareness and marshal resources for this group. Kai Kupferschmidt, reporting for Science, noted that those voting in favor of a PHEIC had expertise in monkeypox and LGBT health while those arguing against were more generalist global health experts.
“Although I am declaring a public health emergency of international concern, for the moment this is an outbreak that is concentrated among men who have sex with men, especially those with multiple sexual partners,” Tedros said. “That means that this is an outbreak that can be stopped with the right strategies in the right groups.”
“It’s therefore essential that all countries work closely with communities of men who have sex with men to design and deliver effective information and services and to adopt measures that protect the health, human rights and dignity of affected communities. Stigma and discrimination can be as dangerous as any virus,” he added. He called on civil society organizations, including those with experience working with people living with HIV, to collaborate with WHO on fighting stigma and discrimination.
A PHEIC enables a more coordinated global response to a health threat. Since the designation was created in 2005, there have been five such emergencies: H1N1 influenza outbreaks, polio, Zika virus, two Ebola outbreaks and the ongoing COVID-19 pandemic.
Tedros offered a list of recommendations that include engaging and protecting affected communities; intensifying surveillance and public health measures; strengthening clinical management and infection prevention and control in hospitals and clinics; accelerating research on vaccines, therapeutics and other tools; and international travel recommendations.
While the PHEIC designation will likely have little effect in the United States, the Biden administration is considering whether to declare monkeypox a public health emergency and plans to appoint a White House monkeypox coordinator, the Washington Post reports. This could lead to increased funding, give the CDC more authority to collect data from states and improve access to vaccines (including for children) and the antiviral drug tecovirimat (TPOXX).
Public health organizations applauded the PHEIC designation. The emergency declaration, “can serve to galvanize the international community to more quickly and effectively respond to and combat this virus,” the CDC said in a statement.
“This outbreak can be stopped if governments, healthcare providers, communities and pharmaceutical companies act with urgency,” UNAIDS deputy executive director Matthew Kavanagh, PhD, said in a statement. “Drawing on the hard-learnt lessons of the response to the AIDS pandemic, effective public health actions must be guided by the principles of solidarity, equality, nondiscrimination and inclusion.”
“Stigma and discrimination undermine epidemic response, sending people with symptoms underground and failing to address the underlying barriers that people face in attempting to protect their own health and that of their community. It can also cause public health authorities to act with insufficient urgency,” he continued. “UNAIDS is urging countries to partner and engage affected communities in the development, implementation and monitoring of all stages of the response.”
UNAIDS expressed concerned that low- and middle-income countries are struggling to get access to vaccines as they are snapped up by the U.S. and other high-income, mirroring the situation with COVID vaccines. “Repeating vaccine nationalism and inequality will prolong the outbreak and unjustly deepen suffering from this virus,” Kavanaugh said. “We call on governments and vaccine manufacturers to work together to ensure that all those in need can access and benefit from vaccines, including people affected in endemic countries.”
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