The World Health Organization had a hard time deciding whether to label monkeypox a public health emergency of international concern (PHEIC) or not. That’s a rare designation, given to COVID-19 and a handful of other diseases such as swine flu in 2009, polio in 2014 and Ebola (twice). It carries binding legal commitments for member nations to act.
A majority of the WHO’s Emergency Committee, however, was unconvinced that monkeypox qualified. WHO Director-General Tedros Adhanom Ghebreyesus, who came under criticism for being slow to declare COVID-19 a pandemic and too deferential to China, cast the deciding vote. With a rising number of monkeypox cases around the world — some 16,000 have now been reported in 75 countries — the WHO chief clearly wanted to err on the side of caution.
It’s a tough call: If monkeypox fizzles, the WHO will be accused of crying wolf; if infections reach the millions, there will be questions about why intervention didn’t come earlier. Given the sluggish policy response so far, a kick in the behind is probably the right move.
The skeptics noted that the overall risk profile of monkeypox hasn’t changed in the past month, with the main burden falling on Europe and North America. They also noted that disease severity is very low (with no deaths reported in Europe or North America). A PHEIC, it was worried, could sow panic, increase demand for vaccines among those who don’t need them, or lead to stigmatization of gay and bisexual men, who seem to be most at risk.
All of those are valid concerns. But if the higher profile means more public surveillance, better testing and a proper information campaign, that would be a good thing. Monkeypox may not be the killer that COVID was before vaccines, but the often-painful virus — marked by fever, swollen lymph nodes and a rash that causes lesions — is spreading and needs a more robust response.
Nearly 99% of reported monkeypox infections in the U.S., U.K., Canada and Spain have occurred in males who have sex with other men and largely among those who have multiple partners. Cue a furious debate over Twitter and elsewhere about whether monkeypox should be classified, or at least spoken of, as a sexually transmitted infection. It’s a loaded label and one that is problematic on a couple of levels — it can undermine public health messaging by stigmatizing those at risk, and it may mean we focus surveillance efforts too narrowly.
Monkeypox also behaves differently from other infections contracted primarily through sexual contact, notes Francois Balloux, director of the Genetics Institute at University College London. Sexually transmitted diseases generally cause long-term infections with the patient remaining infectious to others for decades. Monkeypox only appears to be infectious within a window of two to four weeks. From what we’ve seen so far, monkeypox has recently spread mainly through having multiple sexual partners in a short period of time, which Balloux notes is not the norm.
Of course, there are other ways it can be transmitted — through skin-to-skin contact, or contact with a towel or surface holding the virus — and we may see more cases over time across different populations. After two-plus years of a pandemic, we should not need the WHO to tell us that “access to reliable, affordable and accurate diagnostic tests for illnesses compatible with monkeypox” is an urgent necessity. Testing has been belatedly increasing, but we need far better diagnostics as existing testing protocols may detect the virus too late or pick up “legacy” virus that is no longer active. We may also not be picking up cases outside of at-risk communities.
Better public information is crucial now too. Misinformation and fear could create more demand for vaccines, making it harder to get a still limited supply to those who are most at risk. The go-to vaccine against monkeypox is the smallpox vaccine Imvanex, produced by Bavarian Nordic A/S, which has just received an approval by the European Commission to market as a monkeypox vaccine. Older smallpox vaccines can also work, but they carry serious side effects and are not recommended for those who are immunocompromised.
Vaccine supplies are being ramped up, which should help. And the WHO’s recommendations also have the longer-term in mind. Since smallpox — also an orthopoxvirus — was eradicated in the 1970s (the WHO declared it vanquished in the 1980s), countries have stopped vaccinating against it and so our immunity to these kinds of viruses has declined. “Irrespective of what happens with this outbreak, monkeypox is something we might have to deal with in the future,” Balloux says.
That the WHO decided to ring the alarm bell now smacks of a certain hypocrisy, given that Africa has struggled with monkeypox for decades, with hundreds of suspected deaths in the Democratic Republic of Congo and a mortality rate of about 10% in Central Africa, which has had a more virulent strain. The WHO said it lacked the tools; smallpox vaccines were not licensed for monkeypox and the side effects of legacy smallpox vaccines meant they were not sent to African nations to deal with monkeypox.
The spread to Europe and North America has prompted the WHO emergency declaration this time, but the hope must be that it will lead to helping African nations respond through better surveillance and vaccinations.
What can we expect ahead? As a DNA virus, monkeypox doesn’t mutate as fast as RNA viruses such as SARS-CoV-2 and infection protects the host for life. “All else being equal, there is no selective pressure for the virus to become nastier,” Balloux notes. And yet, there is much about monkeypox we still need to understand better, including its transmission dynamics. While the emergency declaration isn’t reason for panic, if we’ve learned anything over the past two years, it should be that it’s better to act early.
