The World Health Organization has activated its highest alert level for the growing outbreak of monkeypox, declaring the virus a public health emergency of international concern.
This rare designation means that the WHO now views the outbreak as a threat large enough to global health that a coordinated international response is required to prevent the virus from spreading further and potentially escalating into a pandemic.
Although the declaration does not impose requirements on national governments, it is an urgent call to action. The WHO can only issue guidance and recommendations to member states, not states. Member states are required to report events that pose a threat to global health.
Last month, the UN agency refrained from declaring a global emergency in response to monkeypox. But infections have increased dramatically over the past several weeks, prompting WHO chief Tedros Adhanom Ghebreyesus to issue the highest alert.
More than 16,000 cases of monkeypox have been reported in 75 countries so far this year, and the number of confirmed infections rose 77% from late June through early July, according to World Health Organization data. Men who have sex with men are currently more likely to get infections.
Five deaths from the virus have been reported in Africa this year. No deaths have been reported outside Africa so far.
Most people recover from monkeypox within two to four weeks, according to the US Centers for Disease Control and Prevention. The virus causes a rash that can spread throughout the body. People who have contracted the virus said the rash, which looks like a blister or pimple, can be very painful.
The current outbreak of monkeypox is highly unusual because it is widespread in North American and European countries where the virus is not usually present. Historically, monkeypox spread at low levels in remote parts of West and Central Africa where rodents and other animals carried the virus.
Europe is currently the global epicenter of the outbreak, reporting more than 80% of confirmed infections worldwide in 2022. The United States has reported more than 2,000 cases in 43 states, Washington DC and Puerto Rico.
In early May, the UK reported a case of monkeypox in a person who had recently returned from travel to Nigeria. Several days later, the UK reported three more cases of monkeypox in people who appeared to have been infected locally. Then other European countries, Canada and the United States, began confirming cases. It is unclear where the outbreak actually began.
The World Health Organization issued the last global health emergency in January 2020 in response to the Covid-19 outbreak and two months later declared it a pandemic. The World Health Organization does not have a formal process for declaring a pandemic under its regulatory laws, which means that the term is loosely defined. In 2020, the agency declared Covid a pandemic in an effort to warn dismissive governments of the “alarming levels of spread and severity” of the virus.
The WHO’s lead expert on monkeypox, Dr. Rosamund Lewis, told reporters in May that the UN health agency was not concerned that monkeypox was causing a global pandemic. She said public health authorities had a chance to contain the outbreak.
But infectious disease experts worry that health authorities have failed to contain the outbreak, and that monkeypox will take root permanently in countries where the virus was previously undetected except for isolated travel-related cases.
Monkeypox is not a new virus
Unlike Covid-19, monkeypox is not a new virus. Scientists first discovered monkeypox in 1958 in captive monkeys used for research in Denmark, and confirmed the first case of a human infected with the virus in 1970 in Zaire, now the Democratic Republic of the Congo.
Monkeypox belongs to the same family of viruses as smallpox, although it causes milder disease. The World Health Organization and national health agencies have decades of experience fighting smallpox, which was declared eradicated in 1980. The successful fight against smallpox, and the tools developed to combat it, will provide health officials with important knowledge to combat monkeypox.
In the past, transmission of monkeypox between humans was relatively rare, and the virus was usually transmitted from animals to humans. But monkeypox is now spreading more efficiently among people. The World Health Organization said the international community had not invested enough resources in fighting monkeypox in Africa before the global outbreak.
“This transmission has occurred in African countries in two specific regions over a large number of years, and we don’t fully understand what is driving transmission in those countries,” said Dr Mike Ryan, head of the WHO’s Health Emergencies Programme. “There is a lot of investigation that needs to be done and a lot of investment to be made to understand this problem.”
Gay and bisexual men are at greater risk
Monkeypox is spread primarily through skin-to-skin contact during sex. Men who have sex with men are currently most at risk, as the majority of transmission of the disease has occurred in the gay community. However, the World Health Organization and the CDC have emphasized that anyone can get monkeypox regardless of sexual orientation.
Lewis, a monkeypox expert at the World Health Organization, said 99% of reported cases outside Africa are among men and 98% of infections are among men who have sex with men, especially those with multiple, unknown or new sexual partners. The virus has been detected outside the gay community, but transmission has so far been low. The CDC confirmed monkeypox in two children on Friday.
The World Health Organization and the CDC have repeatedly warned against stigmatizing gay and bisexual men, while at the same time stressing the importance of communicating the reality of how the virus is currently spreading so that people in the communities most at risk can take action to protect their health.
“People want the information to know how to protect themselves, and in what circumstances people might be endangered or injured,” Lewis said. She said it was critical for health agencies and community organizers to disseminate information widely on how to reduce infection risks ahead of major celebrations and festivals this summer.
Scientists in Spain and Italy have discovered monkeypox virus DNA in the semen of infected patients, although it remains unclear whether the virus can be spread through semen during sex. Spanish scientists also discovered monkeypox DNA in saliva samples.
It is also unclear whether the virus can spread when people are infected but do not have symptoms, known as asymptomatic transmission.
Symptoms and risk factors
The Centers for Disease Control and Prevention in the United States recommends avoiding intimate physical contact with individuals with a rash resembling monkeypox, and considering minimizing sex with multiple or anonymous partners. People should also consider avoiding sex parties or other events where people don’t wear a lot of clothes.
Individuals who decide to have sex with a partner who has monkeypox should follow CDC guidelines to lower their risk, according to the health agency.
In the past, monkeypox usually started with flu-like symptoms, including fever, headache, muscle aches, chills, fatigue, and swollen lymph nodes. Then the disease developed into a rash that can spread throughout the body. Patients are considered more contagious when a rash develops.
But in the current outbreak the symptoms were atypical. Some people develop a rash first, while others develop a rash without any flu-like symptoms at all. Many patients developed a localized rash on their genitals and anus.
The Centers for Disease Control and Prevention and the World Health Organization have said that the rash can be confused with a common sexually transmitted disease. They tell health care providers that they should not rule out monkeypox just because a patient tests positive for a sexually transmitted disease.
Although monkeypox can spread through respiratory droplets, this method requires a lengthy, face-to-face interaction, according to the CDC. Health officials do not believe monkeypox is spread through small aerosol particles like Covid. Respiratory droplets are heavier, so they do not remain airborne for long, while Covid is an airborne virus, which is one of the causes of severe infection.
Monkeypox can also be spread through contact with contaminated materials, such as bed sheets and clothing.
“This disease is transmissible, but it is not transmissible,” Ryan said. “It is a disease whose transmission can be contained.” “As we said on Covid, don’t be the one transmitting this disease.”
Because monkeypox is not a new virus, there are already vaccines and antivirals to prevent and treat the disease it causes, although they are in short supply. The United States is already distributing tens of thousands of doses of a vaccine called Jynneos in an effort to stem the outbreak. The Food and Drug Administration approved the two-dose vaccine in 2019 for adults 18 years of age or older who are at increased risk of monkeypox or smallpox infection.
The Biden administration has distributed more than 300,000 Genu doses to states and cities since May, another 786,000 doses are being delivered to the United States, and the Department of Health and Human Services has ordered another 5 million doses through 2023.
The director of the CDC, Dr. Rochelle Walinsky, said the demand for monkeypox vaccines is outstripping the supply available in the United States, which has led to long queues in places like New York City – the epicenter of the outbreak.
Jynneos is manufactured by Bavarian Nordic, a biotechnology company based in Denmark. A company spokesperson said Northern Bavarian now has up to 5 million doses available to the rest of the world except for the United States. But the spokesman for the state of Northern Bavaria has the capacity to fill 40 million frozen liquids and 8 million dried doses annually.
The United States also has more than 100 million doses of an older generation smallpox vaccine called ACAM2000, manufactured by Emergent BioSolutions, and potentially effective in preventing monkeypox. But ACAM2000 can have serious side effects and is not recommended for people with weakened immune systems, including HIV patients, people with certain skin conditions, and pregnant women.
ACAM2000 uses a mild viral strain in the same family as monkeypox and smallpox to confer immunity. But the mild strain the vaccine uses can multiply, which means people receiving ACAM2000 have to take precautions to make sure they don’t give the virus to others or spread a rash from the injection site to other parts of the body. The Jynneos vaccine does not have this risk because it does not use a replicating viral strain.
There is no data yet on the effectiveness of vaccines against monkeypox in the current outbreak, according to the CDC.
The World Health Organization does not recommend universal vaccination at this time, and the United States currently maintains vaccines in its stockpile for people who have confirmed or assumed exposure to monkeypox. Unlike Covid, vaccines against smallpox and monkeypox can be given after exposure due to the virus’s long incubation period. But the vaccines should be given within four days of exposure to have the best chance of preventing the onset of illness, according to the CDC.