Why the WHO finally declared monkeypox a global public health emergency

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On Saturday, July 23, World Health Organization Director General Tedros Adhanom Ghebreyesus declared the spread of monkeypox to be a public health emergency of international concern (PHEIC), the organization’s loudest alarm bell signifying an emerging outbreak.

Since early May, more than 16,000 cases of monkeypox have been identified across more than 60 countries. Disease caused by the monkeypox virus typically involves a few days of fever and lymph node swelling followed by a rash, which can leave scars. Most cases in the current outbreak have resolved without hospitalization or the need for medication. As of July 20, there have been five deaths, all of them in Africa.

The WHO first convened a committee in late June to determine whether monkeypox was a PHEIC. As cases have continued to rise worldwide, the committee reconvened on July 21 — and this time, the outcome was different.

“We have an outbreak that has spread around the world rapidly through new modes of transmission, about which we understand too little, and which meets the criteria in international health regulations,” Tedros said when announcing the emergency.

Tedros made the declaration despite the WHO’s emergency committee for monkeypox, which did not come to an unanimous consensus on whether to declare an emergency. “There are uncertainties on all sides,” said Michael Ryan, executive director of the WHO’s health emergencies program, explaining Tedros’s reasoning in deciding to declare a PHEIC. “He sees a window of opportunity to to bring this disease under control,” said Ryan. The committee offers a recommendation, but ultimately it was the director general’s decision.

The last time the WHO declared an international emergency was in early 2020, for Covid-19. While the disease caused by the currently spreading monkeypox virus is much less severe than Covid-19 and spreads far less easily, there are good reasons for the WHO to declare an emergency.

For starters, said Ana B. Amaya, an expert in global health governance at Pace University in New York, this monkeypox outbreak is just very different from past outbreaks of the disease. The vast majority of the latest cases have been identified among gay and bisexual men, and sexual contact with multiple sexual partners has emerged as an important risk factor. Scientists are now trying to determine if the virus spreads through sexual fluids like semen and vaginal fluid in addition to the ways it’s already known to spread: via skin-to-skin contact and, to a lesser degree, by respiratory transmission.

Prior to the current outbreak, monkeypox often spread throughout households via close contact and, possibly, shared items like utensils and linens. In the past few weeks, isolated reports of infections in children, who are thought to be at higher risk for severe outcomes of monkeypox infection, reinforce the worry that without containment, outbreaks often spread beyond the populations where they start.

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The prospect that the virus might be spreading in ways not seen before raises the concern that it will surprise us in other ways — for example, by causing severe disease if it reaches certain populations it has not yet reached, like large groups of immunocompromised people, said Amaya. “All of that is really alarming. And that’s why it’s very important for us to have a coordinated response that starts from the WHO level,” she said in a late-June interview, before the WHO’s first meeting to discuss issuing an emergency declaration.

But beyond that, this kind of declaration encourages countries to coordinate to stop the virus’s spread in a few different ways. Here’s how that works.

A public health emergency is not the same thing as a pandemic

To be resoundingly clear: The WHO did not declare monkeypox to be a new pandemic. There’s a difference between a pandemic and a PHEIC.

A pandemic is squishily defined as “an epidemic occurring over a very wide area, crossing international boundaries, and usually affecting a large number of people,” according to A Dictionary of Epidemiology. Public health experts use the phrase “pandemic” to emphasize the global reach of an outbreak. They seem to agree that calling something a pandemic means it demands a coordinated international response — and potentially, that it’s too big to contain.

On the other hand, a PHEIC is a more carefully defined term. It describes a situation that has not necessarily grown out of control, but has the potential to do so.

According to the WHO’s International Health Regulations, an outbreak qualifies as a PHEIC if 1) it’s unusual or unexpected, 2) has potential for international spread, and 3) requires an immediate international response.

The WHO has previously only declared six PHEICs before monkeypox, including Ebola, Zika, and Covid-19.

The monkeypox outbreak easily meets the first two criteria for an emergency: the virus’s spread outside West and Central Africa and among sexual networks are both unusual patterns, and the virus has already spread internationally, with cases now present in about 60 countries. And given that spread, containing monkeypox will clearly require an international response.

Why did the WHO wait to declare an emergency?

Some experts think this outbreak easily met the PHEIC criteria when the WHO first addressed the question about a month ago. Why didn’t it declare an emergency then?

“It’s possible the panel decided to take a cautious approach to avoid causing alarm,” said Amaya, who told me that in her view, the emergency threshold had already been met in June. Arguably, it was a missed opportunity: Declaring the emergency earlier could have facilitated more containment efforts early on.

Andrew Pekosz, a Johns Hopkins virologist specializing in emerging pathogens, said that when public health authorities make emergency declarations, they sometimes prioritize disease severity over case numbers. With monkeypox causing so few deaths, declaring the outbreak a global emergency in June may have felt a little over-the-top, even if thousands of people had already been infected. He thinks that’s a mistake.

“The more we allow a virus to replicate,” Pekosz said, “the more likely that these viruses are going to become better at infecting us,” much as they have with Covid-19. (Although monkeypox virus is less prone to mutation than SARS-CoV-2, it nevertheless can and does accumulate mutations over time.) An earlier declaration might have unlocked more resources — including vaccines — for the low-income countries that need them most, while the global case count was a third as high as it is right now, he said.

Declaring an emergency signals an outbreak’s seriousness and the WHO’s intention to disseminate expert knowledge

In the US, declaring a state of emergency mobilizes funds to support states’ responses to a disaster like a hurricane, or a public health crisis. That’s not the case with WHO PHEIC declarations, which do not unlock access to funding, explained David Heymann, an epidemiologist at the London School of Hygiene and Tropical Medicine who previously headed WHO’s emergencies department, in a late-June interview.

Instead, these declarations act as a signal. They inform health departments worldwide that responding to the outbreak is urgent, and this can mobilize resources to help lower-resource countries fund their response.

In some cases, declarations can include recommendations for travel restrictions, as during the 2003 SARS outbreak that largely affected countries in East Asia. Although the WHO explicitly did not recommend travel restrictions early in the Covid-19 pandemic, many countries chose to independently institute such restrictions, with varying effects. In declaring the monkeypox emergency, Tedros said, “the risk of interference with international traffic remains low for the moment.”

Amaya said declaring an outbreak an emergency also signals that the WHO plans to be a source of clinical and scientific guidelines aimed at helping public health workers worldwide achieve disease control. That guidance isn’t always perfect — the organization faced vociferous criticism for its sluggishness at acknowledging SARS-CoV-2 is transmitted by aerosol particles that can remain suspended in the air for hours — but it is nevertheless authoritative on a global scale.

Ideally, that effort draws on the deep knowledge about monkeypox that resides in the nations that have been contending with the virus for decades, she said. “It is an endemic disease in several African countries, and so part of this is we should be learning from our partners in those African countries,” said Amaya.

The emergency ought to get countries to share vaccines. But it’s not guaranteed.

Vaccination plays a key role in controlling monkeypox transmission during an outbreak, and crucially, these vaccines already exist.

The Covid-19 pandemic taught the world some painful lessons about the importance of global coordination to ensuring fast and equitable vaccine distribution. The PHEIC alarm bell hopefully will spur action so the same mistakes are not repeated.

A major reason global health experts have been anxious over the timeliness of a WHO emergency declaration for monkeypox is the declaration’s potential to get vaccines to the most vulnerable groups quickly.

Vaccines do exist to prevent monkeypox, and while many countries have a quantity of these vaccines on hand as part of their national stockpiles, US demand has greatly outpaced supply, and the global supply of vaccines is relatively small.

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Countries have been scrambling to order more vaccines, and while the producer of the most popular monkeypox vaccine has not disclosed which countries have put down orders, the nations that have announced vaccine purchases have generally been higher-income ones, like Germany, Britain, and Canada.

That portends a pattern of vaccine inequity that unfolded to tragic effect during the Covid-19 vaccine rollout, with poorer countries struggling to acquire vaccines and cut off from vaccine production efforts. In his announcement of the WHO’s emergency committee’s plan to convene in June, WHO Europe director Hans Kluge said following a more equitable blueprint for monkeypox vaccine distribution would be a key step in controlling the outbreak.

“A ‘me first’ approach could lead to damaging consequences down the road if we do not employ a genuinely collaborative and far-thinking approach,” Kluge said. “I beseech governments to tackle monkeypox without repeating the mistakes of the pandemic — and keeping equity at the heart of all we do.”

When the WHO declares an emergency, it also makes recommendations to affected countries, which often relate to vaccination strategies. This spurs countries to coordinate vaccine strategies to increase vaccine supply in less wealthy countries. It can also spur donors to fund vaccination efforts that prioritize equitable access to vaccines. However, the WHO’s recommendations in the face of an emergency are ultimately just recommendations.

“There’s no way to enforce that globally,” Heymann said.

The ACT Accelerator, a collaboration to raise funds to distribute Covid-19 tests, therapies, and vaccines to low-resource countries, was an attempt at an equitable solution in the pandemic. However, in the eyes of many, it did not succeed. Public health experts are hopeful earlier action on monkeypox could avoid some of the ACT Accelerator’s pitfalls.

In the announcement today, WHO representatives said they were encouraging countries with large vaccine stockpiles to share and donate vaccines to other countries who do not currently have access to vaccines.

Countries face stricter requirements for case finding and reporting, making disease spread easier to track

Although many countries are already reporting cases, the emergency declaration should intensify and formalize countries’ reporting requirement. “Countries should be reporting already, but this means a much more rigorous response and more surveillance,” Amaya said.

More surveillance means new crops of cases would get detected more quickly, allowing public health authorities to intervene earlier to control chains of transmission.

The WHO has faced criticism for being both too slow and too fast to declare public health emergencies in the past, and for favoring political over technical criteria in making these assessments. Prior to the emergency declaration, global health experts expressed hope that this time, WHO would get their timing just right.

Lawrence Gostin, who authored a 2020 article calling on the organization to reform its process for identifying and announcing such threats, tweeted on June 21 that it was time for the WHO to declare monkeypox an emergency. “It’s far better to act rapidly & decisively now rather than wait until monkeypox is no longer containable,” he wrote.

On Wednesday, July 20, almost exactly one month later, he tweeted, “The window for containment is rapidly closing & may well already have closed.”

Today, Ryan, the director of the WHO’s health emergencies program, said he hoped the global coordination that would follow the declaration would prevent monkeypox from becoming endemic, and also prevent it from spreading beyond the community of gay and bisexual men who currently comprise the vast majority of cases.

“We don’t wish to see this version of the disease establish itself along with other diseases that have become established,” he said. Immunocompromised people, including those with untreated or advanced HIV disease and people taking chemotherapy, are at increased risk for severe outcomes or death due to monkeypox infection.

The WHO has indicated its decision to act. Whether that will be enough to curb this outbreak before it spreads into new, increasingly vulnerable populations, we won’t know for some time.

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