This is a serious outbreak, but it is not Covid-19.
This is a serious outbreak, but it is not Covid-19.
O n July 23, , the World Health Organization declared that the monkeypox outbreak is a public-health emergency of international concern (PHEIC), defined as “an extraordinary event, which constitutes a public health risk to other States through international spread, and which potentially requires a coordinated international response.” WHO director-general Tedros Adhanom Ghebreyesus made the emergency declaration despite the fact that a majority of a WHO emergency advisory committee voted against doing so. The question is why?
The likely answer: Covid-19. Like a general fighting the last war, the director-general does not want to be seen as repeating the mistakes and missteps of WHO’s pandemic response.
The WHO emergency declaration is largely symbolic since it does not guarantee any new funding for containment or actions by any country. It is likely a public-relations ploy since, as the committee members who voted against declaring the PHEIC noted, the overall global risk assessment was “unchanged” from a month earlier, the severity of disease is low, and cases are concentrated in one particular demographic and in a few countries “with no indications . . . of an exponential increase in the number of cases in any of those countries, and early signs of stabilization or declining trends observed in some countries.”
WHO, no doubt, is still smarting from criticisms in a report it commissioned from an independent panel of experts to assess the Covid-19 pandemic. The experts concluded the response to Covid-19 was characterized by “delay, hesitation, and denial,” and faulted WHO for delaying the declaration of a PHEIC and for not advising countries early enough to take precautions against human-to-human transmission.
WHO also insisted that Covid could only be spread through large droplets that fall to the ground within a meter. WHO finally acknowledged after nearly two years that the virus could be transmitted through aerosol particles that can remain in the air for hours and spread over longer distances, creating a far greater transmission risk.
Simply put, the monkeypox virus and the current disease outbreak are quite different from the SARS-CoV-2 virus and the Covid-19 pandemic and pose a lower public-health risk. The monkeypox virus is usually found in animals in Africa and is related to the smallpox virus. It was first identified in humans in 1970. Monkeypox disease is generally less severe and transmissible than Covid. It spread through close contact, primarily via skin-to-skin contact and, to a lesser degree, by respiratory transmission of large droplets which do not travel more than a few feet before dropping to the ground. There is no evidence of longer-range airborne transmission, as with Covid.
Covid is particularly difficult to control because it can spread before symptoms are apparent. In contrast, monkeypox is only transmitted after symptoms — rash, fever, lethargy — occur. Young children and immunocompromised people, including those living with HIV infection, are at increased risk of severe monkeypox illness. Covid is almost never severe in young, healthy people.
What is new and of concern in this monkeypox outbreak is that nearly all the cases are in countries that have not historically reported monkeypox. This is the first time that cases and sustained chains of transmission have been reported in countries without direct or immediate epidemiological links to areas of West or Central Africa, where monkeypox is endemic. Indeed, prior to May 2022, human monkeypox infection was seldom reported outside of Africa.
To date, WHO reports there have been about 19,000 confirmed cases and five deaths in 78 countries. But 88 percent of cases are concentrated in just ten countries led by Spain (3,738 cases), the U.S. (3,478), Germany (2,459), and the United Kingdom (2,432). Outside of Africa, the outbreak almost exclusively affects men who reported recent sex with one or more male partners. It is suspected that in nearly all cases, transmission occurred through sexual activity. WHO says that “there is no signal suggesting sustained transmission beyond these networks.”
The CDC reports a higher number of U.S. cases (5,189) than does WHO. Over a quarter of the cases (1,345) are in New York, with the balance mostly concentrated in a few other states. Twenty-seven states and Puerto Rico report 28 or fewer cases in each (18 states have ten or fewer), and three states have no cases.
Unlike Covid-19, for now, monkeypox appears to be confined to a particular demographic and is concentrated in certain geographic areas. And unlike the situation during the first ten months of the Covid-19 pandemic, there are approved vaccines for monkeypox. As the WHO committee dissenters noted, this creates “the opportunity to stop ongoing transmission with interventions targeted to this segment of the population.”
Since monkeypox only spreads via close contact and after symptom onset, and has a long incubation period of five to 21 days, there is an opportunity to intervene with vaccination and contact tracing after exposures to known cases to prevent transmission. If vaccines and medical resources can be directed to the people and areas that are clearly at risk in a timely way, the outbreak can be contained.
Unfortunately, that has not been the case here. The first U.S. monkeypox case was in mid-May. Yet, despite owning 372,000 Danish vaccines that are effective against monkeypox and smallpox, Biden administration officials reportedly took a dilatory, piecemeal approach, ordering small shipments of vaccines and leaving most of the supply in Denmark. And when the vaccines arrived, federal officials were slow to distribute them. Finally, containment efforts have been hampered by limited testing capacity.
The bottom line is that neither WHO nor U.S. health officials should panic. Monkeypox is a serious outbreak, but it is not Covid-19 and we have the tools to contain it. All we need is the will and competence to do so.