In a first, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, decided on his own to declare the global monkeypox outbreak a public health emergency of international concern.
“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 international health regulations,” Tedros said in a statement.
These are the reasons, Tedros explained, that he made the declaration himself after an emergency committee that he convened for a second time was unable to come to a unanimous decision on whether to declare an emergency.
“I believe that Tedros’ decision was professionally and politically courageous and it was clearly the right decision” Lawrence O. Gostin, JD, director of the O’Neill Institute for National & Global Health Law at Georgetown University, told Healio. “This is the first time in history that a director general has declared a global emergency against the advice of the WHO emergency committee.”
Window ‘rapidly closing’
The monkeypox outbreak has grown to include more than 16,000 reported cases and five deaths from 75 countries, including 2,891 cases in the United States as of Friday, according to the CDC.
The vast majority of cases reported thus far — 98% according to a study published last week — have occurred among men who have sex with men, but the CDC also recently reported the first U.S. cases in children.
“We have to reach the MSM community with information, testing and vaccines without stigmatizing them,” Carlos del Rio, MD, Infectious Disease News Editorial Board Member and executive associate dean at Emory University School of Medicine, told Healio.
Tedros said WHO’s assessment is that the risk for monkeypox is “moderate” globally, except in the European region, where it is “high.”
Gostin explained that all the legal criteria in the International Health Regulations were met to declare a public health emergency. The outbreak is “a highly unusual event,” with the potential for the virus to become endemic in many countries around the world, he said.
“Most importantly, it is better to err on the side of decisive action than inaction,” Gostin said, adding that WHO needs to be proactive and to ensure a well-funded and internationally coordinated response to monkeypox.
“I applaud [Tedros’] decision because the window for containing monkeypox is rapidly closing, if it is not already closed,” Gostin said.
Declaring a global public health emergency does not “unleash any specific funding and powers,” Gostin explained, but it does give WHO the constitutional authority to issue recommendations that countries need to consider.
“Most importantly, it sounds the global alert, so that governments take notice and ensure an effective emergency response to the virus,” Gostin said. “By raising the political profile of monkeypox, governments and foundations are more likely to provide substantial funding and take action.”
In a statement, Tedros outlined updated recommendations for four groups of countries — those that have not yet reported a case of monkeypox or have not reported a case for more than 21 days; those with recently imported cases of monkeypox and human-to-human transmission; those with transmission of monkeypox between animals and humans; and the those with manufacturing capacity for diagnostics, vaccines and therapeutics.
“Had we not been dealing with COVID-19, the declaration for monkeypox would have been made earlier,” Amira A. Roess, PhD, MPH, a professor of global health and epidemiology at George Mason University, told Healio.
Slow US response
Amid a steady increase in cases, experts have warned that the U.S. has been too slow to respond to the outbreak.
“Our public health infrastructure was underfunded and undersupported since before the COVID-19 pandemic and has not gotten much better,” Roess said. “Monkeypox virus will continue to spread while we try to play catch up.”
She explained that a more robust response would have included rapid contact tracing and deployment of vaccines in a timely manner.
“The U.S. performance on monkeypox has been weak and mirrors many of the same problems that occurred with COVID-19,” Gostin said. “Testing and diagnosis of monkeypox have been lax, and the number of monkeypox cases have been significantly underreported.”
Gostin said the U.S. should follow WHO’s lead by declaring a national public health emergency for monkeypox, explaining that it would open up more funding and resources.
Federal officials have made numerous efforts to bolster the response. In June, HHS began shipping orthopoxvirus tests to five commercial laboratory companies — Aegis Science, Labcorp, Mayo Clinic Laboratories, Quest Diagnostics and Sonic Healthcare — to increase monkeypox testing capacity and access. By July 18, they had all begun testing.
In addition to increased testing, the CDC issued travel alerts and expanded access to vaccines in response to the outbreak. HHS ordered an additional 2.5 million doses of Bavarian Nordic’s Jynneos vaccine to strengthen preparedness. This followed an earlier order for 2.5 million doses and will bring the federal stockpile of vaccine to treat monkeypox to nearly 7 million doses by mid-2023.
“This outbreak is a good reminder of why global health is important,” del Rio said. “We could have done studies in endemic countries to show the value of treatment and of vaccines, but we did not and now we ‘have no data.’”
Moving forward, the response should be proactive and identify as many exposed individuals as possible, prioritizing them for vaccination, Roess said. She said it is also crucial to educate people who have been exposed — including health care workers and high-risk groups — on the signs and symptoms monkeypox and the best quarantine and isolation procedures, especially because many health care workers in the U.S. and other high-income countries have never seen a case of monkeypox and are still learning.
“They need resources and support to help them respond rapidly,” Roess said, noting that many facilities are understaffed because of COVID-19.
Massachusetts General Hospital, which identified the first U.S. monkeypox case in the current outbreak, recently developed a toolkit that can help identify and respond to potential exposures among health care personnel.
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