The number of monkeypox cases reported in the US has tripled in the past 3 weeks and globally, the growth is almost exponential. Researchers say we’re doing too little to contain it and the World Health Organization has now declared monkeypox a “public health emergency of international concern (PHEIC)” — a move meant to ignite international cooperation to contain the disease. But many fear that containment is no longer an option.
For most people, monkeypox was a virtually unknown virus until two months ago. The virus, endemic to West and Central Africa, seemed to come out of nowhere. Europe and the Americas quickly moved from zero cases of monkeypox per year to hundreds, and now thousands of cases — and probably, plenty more undetected.
As many were quick to point out, this isn’t another COVID-19. The disease is different, it’s less contagious, and it’s not new. We already have a vaccine for monkeypox, that, in a worst-case scenario, could be deployed to help the most vulnerable while production and distribution are scaled up.
The disease is also less dangerous than COVID-19. The case fatality rate is currently less than one death for every 1,000 adult cases. While this may change if more vulnerable segments of the population become infected, it’s still significantly less severe.
But this doesn’t mean it’s not a problem.
The growth and spread of the disease has been relentless. In the first stage, the disease seemed to spread more to LGBT+ community. But as the US reported its first cases in children and there’s already community transmission in several states, this no longer seems to be the case. A large part of the problem is people assuming monkepox is a sexually transmitted virus. It is not. The virus isn’t airborne, fortunately, but it is transmitted by close contact with the lesions of an infected person. So, while sexual contact contributes greatly to spread, it’s not a requirement for infection.
Initially, the WHO did not want to declare monkeypox a global emergency. Even now, the votes were split, with nine members against and six in favor of the declaration, prompting WHO Director-General Tedros Adhanom Ghebreyesus to break the deadlock. Tedros emphasized that the disease is still spreading predominantly among members of one community, but by declaring it an emergency, he emphasizes the importance of immediate action.
“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 told a media briefing in Geneva. “Stigma and discrimination can be as dangerous as any virus,” he added.
Lawrence Gostin, a professor at Georgetown Law in Washington, D.C., told Reuters the decision is “politically brave” and that not issuing the declaration would have been a historic mistake. His feelings were echoed by experts including Josie Golding, head of epidemics and epidemiology at the Wellcome Trust, who said we can’t “afford to wait” for this.
While most cases are mild, monkeypox is nothing to ignore. It can cause painful, pus-filled blisters and lesions on the skin, as well as fever, swollen lymph nodes, and flu-like symptoms. The virus isn’t airborne, but it’s not transmitted exclusively through sex — it can be transmitted by close contact, especially skin-to-skin contact.
There are currently only three Public Health Emergencies of International Concern: COVID-19, polio, and monkeypox. Since 2009, only four other emergencies have been declared: 2009 H1N1 (or swine flu) pandemic, the 2013–2016 outbreak of Ebola in Western Africa, the 2015–16 Zika virus epidemic, and the 2018–20 Kivu Ebola epidemic. This puts monkeypox in a very “select” club.
The PHEIC can be regarded as an “alarm system” or a “call to action”, but also as a “last resort” measure. It’s the last call before things get really out of control.
Experts have mixed opinions on whether the outbreak can be contained or not -- the latter would mean the disease may become endemic and may reach epidemic level, or even worse.
Researchers are also worried that the disease may become stigmatized, somewhat akin to how HIV became stigmatized. This is a disease that can threaten everyone, and with such low levels of testing, it's hard to even know how the disease is spreading.
Ironically, it's our success against another disease related to monkeypox that made us vulnerable. Vaccination eradicated smallpox, and vaccination against smallpox was stopped. Researchers at the Pasteur Institute have found that, because the two diseases were related, smallpox vaccination also offered some protection against monkeypox.
Thankfully, we know how to stop viruses like monkeypox -- at least in theory.
"Fortunately, unlike Covid, poxviruses including monkeypox are a well-known entity. Taking lessons from the 20-year global smallpox eradication campaign we know how to stop the spread of monkeypox," explains Jason Mercer Professor of Virus Cell Biology at the University of Birmingham.
But whether or not we will actually be capable of doing so (and doing so quickly, before things get out of hand) is a different problem.
In several parts of the US, people have queued for hours to get a monkeypox vaccine, and the UK is also ordering more vaccines to keep up with demand. A global, large-scale vaccination effort is currently not even on the table, however, and it's likely only the rich countries that will have access to vaccines.
When the COVID-19 pandemic started, we had no vaccine, and a very poor understanding of the virus. Thanks to gargantuan scientific and social efforts, we've gained some level of control over it -- although new strains keep emerging, becoming more severe, more contagious, and more capable of escaping vaccines. With monkeypox, we're in a much better situation. Researchers have a decent understanding of the virus, it's less contagious, less severe, and we already have a vaccine for it. But we've seen how quickly things can degenerate if we get complacent. The monkeypox outbreak comes on top of COVID-19, Russia's invasion of Ukraine, the threat of economic recession, and all the shortages and other problems the world is currently facing (many of which can be linked to the COVID-19 pandemic).
The World Health Organization is likely right to consider monkeypox an emergency. Whether or not that will trigger action remains to be seen.
