Is monkeypox the new elephant in the public health room?

Over the weekend, the World Health Organisation (WHO) declared the monkeypox epidemic a global health emergency. The WHO have, however, stopped short of declaring the outbreak a pandemic.

Globally, as of July 22, there have been 16,593 confirmed infections in 68 countries that have not historically reported monkeypox, and five deaths.

The spread of the smallpox-related virus that began in May now spans every inhabited continent: figures in the last few days report 3,125 cases recorded in Spain, Germany has 2,100, the US is approaching 2,891, and the UK has reported 2,137.

Monkeypox is not new to science and has relatively low transmissibility, but there are concerns among experts about the new outbreak.

Endemic in parts of Africa, the virus’ spread to other continents is raising questions. And while the strain currently circulating appears to be the less severe West Africa clade with a fatality rate of less than 1%, the clade from the Congo basin carries a 10% fatality rate.

In a climate where COVID-19 is seeing a resurgence around the world, it’s understandable that the last thing we want to hear is news of another virus spreading. But some health experts are cautioning that, if we don’t take action, the monkeypox outbreak could develop into an extremely serious problem.

Compounding the issue is the fact that health authorities aren’t keeping the public regularly informed about the situation. The Australian government Health Department website lists the “current status” of infection numbers – but that figure is from July 19, nearly a week ago. For your information, that out-of-date number is 41 across the country.

“Is Australia ready for monkeypox?” asked Raina MacIntyre and Andrew Grulich in an editorial published in the Medical Journal of Australia on July 17. The authors are two of Australia’s leading public health and biosecurity experts, both from the Kirby Institute for Infection and Immunity in Society at the University of New South Wales.

“Australia has had enormous success with HIV control, and can draw on this infrastructure, community groups and expertise, as well as the COVID-19 infrastructure,” they wrote. “Active surveillance and containment are essential, ideally with antivirals and third-generation smallpox vaccines for close contacts for immediate use.”

MacIntyre and Grulich warn that the current burden of COVID-19 on the healthcare system “may pose a challenge if the monkeypox epidemic becomes large in Australia”.

“We have the expertise, the resources and the tools to mount a rapid and successful response,” they wrote. However, the authors also note that “COVID-19 pandemic fatigue may also mean people are less inclined to follow health advice”.

While it doesn’t appear that monkeypox is sexually transmitted, there are higher numbers of cases among gay, bisexual and other men who have sex with men. As such, MacIntyre and Grulich believe Australia’s LGBTQI+ health organisations would be central to an effective response to monkeypox.

“Monkeypox is likely to spread more widely than only among men who have sex with men,” they add. “Stigmatising people with monkeypox and people who may be perceived at high risk must be avoided, as this may lead to decreased testing and reduced engagement with health advice.”

Another editorial penned by Michael T. Osterholm and Bruce Gellin, titled “Confronting 21st-century monkeypox”, was published in Science on July 19. Osterholm is a University of Minnesota professor and director of the Centre for Infectious Disease Research and Policy, and Gellin is chief of Global Public Health Strategy for The Rockefeller Foundation’s pandemic prevention institute.

In their article, Osterholm and Gellin write: “The World Health Organisation (WHO) hasn’t called the current monkeypox outbreak a Public Health Emergency of International Concern (PHEIC), but as a worldwide epidemic, it is clearly an emerging pandemic.”

On this pandemic non-call, Professor Yaneer Bar-Yam, president of the New England Complex Systems Institute and co-founder of the World Health Network (WHN), has been rightly critical.

During an online webinar to discuss the monkeypox pandemic, he said: “The reason to declare monkeypox a pandemic is to alert everyone to take action to prevent more cases from happening. That is the essential motivation. If you [WHO] tell everyone everything is okay, then everyone will go about their usual business.”

In their editorial, Osterholm and Gellin note that the vaccination program which eradicated smallpox ended in 1980. The smallpox vaccine gave some immunity to monkeypox. That no one born since 1980 has been vaccinated for smallpox may be a factor in the new monkeypox outbreak.

“Although many tools are needed to control this unfolding pandemic, it’s clear that limiting ongoing spread will require a comprehensive international vaccination strategy and adequate supplies,” they continue.

And the vaccines to do it exist.

“The ACAM2000 vaccine is licensed by the US Food and Drug Administration for smallpox and allowed for use against monkeypox on an expanded access basis (so-called ‘compassionate use’ for an investigational drug use). It is associated with potentially serious side-effects. A newer vaccine with an improved safety profile was approved for monkeypox and smallpox in 2019. This two-dose vaccine, produced by Bavarian Nordic, is a modified vaccinia virus Ankara (MVA; Jynneos in the United States, Imvanex in the European Union, and Imamune in Canada). Its supply, however, is limited,” they write.

Above all, Osterholm and Gellin insist that the mitigation of monkeypox before it gets out of hand will require international coordination.

“The smallpox eradication program was a 12-year effort that involved 73 countries working with as many as 150,000 national staff. Because of its animal reservoir, monkeypox can’t be eradicated. Unless the world develops and executes an international plan to contain the current outbreak, it will be yet another emerging infectious disease that we will regret not containing,” they write.

When it comes to viral outbreaks, if the last two-and-a-half years have shown anything, it is that complacency from governments and medical authorities will cost lives.