Over the weekend, the World Health Organization (WHO) declared the global outbreak of monkeypox a “public health emergency of international concern” (PHEIC). Researchers hope the announcement – the agency’s loudest alarm – will serve as a wake-up call to countries struggling to contain the spread of the virus that causes monkeypox.
Since the first cases outside Africa were discovered in May, more than 16,500 people have been confirmed infected in nearly 80 countries that normally don’t see cases. Monkeypox has been common in parts of Africa for decades.
This is the seventh time since the start of the alert system in 2005 that the World Health Organization has declared a health emergency – a move it reserves for events that pose a risk to many countries, and that require a coordinated international response (see ‘Top Alert’). Two of these warnings, regarding COVID-19 and polio, are still in effect.
In an unprecedented move, WHO Director-General Tedros Adhanom Ghebreyesus declared a primary health emergency on July 23, after a panel of advisors failed to reach a consensus. Although the committee did not officially vote, six members were in favor of declaring a health emergency, while nine opposed it, Tedros said at a press conference announcing his decision. The committee had previously met in late June, but at the time only three members were against declaring a health emergency and 11 were against, so Tedros decided not to sound the alarm at the time.
Declaring the monkeypox outbreak a global emergency is a good decision, says Ann Remoen, an epidemiologist at the University of California, Los Angeles, who is a member of the panel that has studied monkeypox in the Democratic Republic of the Congo for more than a decade. . “It sends the right message, and we hope it will mobilize attention and resources to prevent this virus from gaining a global foothold.”
Researchers have warned that the window of opportunity to contain a global outbreak of monkeypox is rapidly closing. The virus has already been established in animal reservoirs in some parts of Africa, which makes eradicating it a difficult task. One concern is that the virus could spread from humans to animals elsewhere in the world, creating other reservoirs from which humans could be infected repeatedly.
Even with cases rising in Germany, Spain and the United States, some believe containment is still possible. Caitlin Rivers, an epidemiologist at Johns Hopkins University in Baltimore, Maryland, says the PHEIC is signaling aloud to public health officials that now is the time to act. “We cannot accept this as an endemic virus,” she says.
Countries should work to increase the number of people tested, boost contact tracing efforts and isolate people as soon as possible after symptoms are detected, Rivers adds.
PHEIC is sending countries a clear message that their participation in the global response – which may include sharing vaccines and treatments – is essential for containment. The WHO issued guidance to countries when an alert was declared, and made recommendations on testing, public health measures and messaging, travel advice, infection prevention and control, and global coordination.
Rich nations have raced to deploy smallpox vaccines, which are thought to be highly effective against monkeypox because the viruses that cause these diseases are linked together. Although some children and women have contracted monkeypox, nearly all infections in the global outbreak have so far occurred in men who have sex with men (MSM), especially those with multiple sexual partners. This has led public health officials to focus their messaging and vaccine stocks on this population. Initially, some countries, such as Canada and the United Kingdom, used a “circular vaccination” approach, which vaccinates close contacts of people with monkeypox to cut off transmission routes. They then quickly moved to offer the vaccine more widely to high-risk communities, including MSM and health care workers.
Researchers know that monkeypox spreads primarily through close contact. They are still investigating whether the virus can be sexually transmitted, but it is clear that it has spread in the MSM community. Some members of the WHO committee were reluctant to support the PHEIC declaration because they were concerned it would stigmatize this community and hamper efforts to contain the virus. “People don’t always want to reveal sexual history,” says Bogoma Titanji, MD, an infectious disease physician at Emory University in Atlanta, Georgia, especially in countries where homosexuality is criminalized.
As rich countries use monkeypox vaccines, Titanji warns that ongoing outbreaks in Africa, where there have been more than 70 suspected deaths from the virus this year, “cannot be relegated to the margins.” (So far, there have been no deaths among infected people outside Africa.) She hopes the WHO will promote equity in the global response to monkeypox by helping to expand surveillance and testing for the virus in Africa, and by allocating funds for research and vaccines there. “We got into this problem by allowing monkeypox to spread for 50 years in Africa,” she says.