Countries can’t hide from monkeypox as WHO issues orders to act

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It’s time to pull your head out of the sand and face the reality of monkeypox.

That’s in effect the message from the World Health Organization to governments that have done little to prepare for the arrival of the highly infectious virus that is rapidly spreading across the world, with Europe the epicenter of the outbreak.

Over the weekend, the World Health Organization declared monkeypox a public health emergency of international concern, a designation reserved only for the most serious global disease outbreaks. It means that countries can no longer turn a blind eye to the growing number of cases, with the WHO issuing clear and direct orders on how to act now to identify, prevent, treat and contain the further spread of this virus.

That applies to countries with no registered cases of the virus — which causes an ulcer-like rash, fever and sometimes swollen lymph nodes — as well as those with thousands. Today, more than 18,000 cases have been identified in more than 70 countries. While the infection normally resolves within a few weeks, it can be serious in some people such as infants and pregnant women. There have been five deaths in Africa this year.

The declaration will “sharpen the response” in countries that are already acting and convince other countries that have been “sitting on the fence” that they need to act now, said Catherine Smallwood, the WHO’s senior emergency officer.

But there are concerns that it could be too late. That’s because rates are continuing to grow in Europe after several months of efforts to contain them.

“It’s going to be very difficult to contain these monkeypox outbreaks that are happening. And yet that has to be our goal,” Smallwood told POLITICO in an interview.

Europe needs to stop human-to-human transmission to achieve this, she said. “That’s going to be difficult to do, but that’s why we’ve declared a public health emergency of international concern, to really rally the efforts to bring people together and think about how we could achieve that,” Smallwood said. “And if that’s the goal, then we need to put all of our resources towards that.”

Behavioral change

There’s no magic bullet to contain this infection. Monkeypox, which is endemic to central and western Africa, has been spreading rapidly across Europe since early May. There are now more than 13,000 cases in the WHO Europe region. More than 80 percent of those are concentrated in Spain, Germany, the U.K., France and the Netherlands.

While vaccination will help, supplies are severely constrained and so countries must focus on changing behaviors, pointed out Smallwood. And with cases predominantly — although not exclusively — spread through intimate contact among men who have sex with men, working with these communities will be key to halting transmission, she said.

Lessons from HIV/AIDS and COVID can be drawn on for this outbreak, pointed out Hans Kluge, head of WHO Europe’s office, on Tuesday.

Health care providers must remove any barriers to testing, medical care, or vaccination, he said, and provide clear information on how to access care. And medics need to get up to speed on how to identify cases, especially since people are coming in with atypical symptoms.

Those most at risk need to wise up and “get the facts,” Kluge said. “Consider limiting your sexual partners and interactions at this time. This may be a tough message but exercising caution can safeguard you and your wider community.”

Governments must allow medical leave for those having to isolate, and work with at-risk communities to develop and distribute messages around curtailing transmission. And countries need to quickly boost surveillance of the disease, he said, noting that “many cases are likely going undetected.”

Avoiding stigma

Paradoxically, fear of stigmatizing the community most at risk — men who have sex with men — has been a catalyst for slow or nonexistent responses in some countries, pointed out Smallwood.

“A lot of people haven’t acted for fear of creating stigma. And I don’t think that’s an excuse not to act,” she said.

Acting openly and publicly now to protect this community “may have some consequential effect on stigma,” said Smallwood. “But that’s a reality that we will face in the response.”

Saying nothing at all, however, will do even more harm to this community, allowing the outbreak to extend and spread unhindered. This is more likely to contribute to stigma, Smallwood argued.

Portugal is one country that has faced the challenge head on. “I was afraid at first that the disease would be associated with the gay community, but the government of Portugal has done a very good job on social media of educating people about monkeypox and explaining that anyone can get it,” said Francisco Silva, a general practitioner in Lisbon, who works in a sexual health clinic.

His team was among the first to identify cases in the country in May. He shared laboratory data with an online platform hosted by the European Centre for Disease Prevention and Control, which soon identified that these unusual cases were monkeypox. That triggered a national response from the health ministry.

“Portugal responded really early with a strong community-based campaign through their sexual health networks through their sexual health clinics,” said Smallwood.

The country ramped up communication efforts, especially among the gay and bisexual communities. Major events such as the Saints Day parties around Lisbon saw concerted campaigns to raise awareness.

Notably, Portugal’s growth in cases has started to plateau — and that’s without widespread use of a vaccine.

With vaccines in short supply, this focus on changing behaviors will be key to countries reversing the upward rates of infection seen since May. It will be especially important for countries including France, where cases have nearly doubled over the last week and stand at 1,567. Infections are also surging in Spain, which recorded 471 cases last week and 3,596 in total, and in Germany, which registered 300 cases last week and 2,410 to date.

But some European countries are already showing signs of decelerating. The U.K., for example, has registered 2,208 cases in total, with 71 last week, while Portugal has registered 588 cases, and 73 over the last week.

Scarce vaccines

Much like the coronavirus pandemic, there are hopes that a vaccine can put an end to this outbreak. But with just one vaccine authorized to prevent monkeypox, Bavarian Nordic’s Imvanex, countries are scrambling for limited supplies.

“Even when the vaccine is available, it’s going to be a matter of combining the vaccination with behavioral change, especially in the early phases of the vaccine administration,” said Smallwood. That’s because the shot takes some time to kick the immune response into gear, she pointed out.

“It’s not like PrEP for HIV where you can take a pill and it’s an antiviral, and then you can go about your business. This is really going to be a vaccine that takes a while to work,” she said.

For countries that do have access to doses, they are relying on men within the at-risk community to come forward to receive a dose. “We don’t even know actually what proportion of the people who are at particular risk of monkeypox will decide to do that,” she said.

Meanwhile, for those who are keen to get jabbed, getting their hands on a vaccine has been the hardest and most frustrating part of this outbreak. Anecdotal evidence from Berlin illustrates that doses are hard to access with no apparent system for selecting who receives them.

Meanwhile, a draft letter from European Health Commissioner Stella Kyriakides to health ministers, seen by POLITICO, has revealed delays to vaccine deliveries.

The European Commission has bought more than 163,000 doses of Bavarian Nordic’s smallpox shot, which was authorized for monkeypox in Europe this week. While the first batch of 30,000 doses has been delivered to nine countries most in need, a second batch of 70,000 doses is delayed. Kyriakides said they should be delivered by the end of the summer.

With supplies limited, the WHO is also considering adjusting its recommendation on who should get jabbed. At first it was close contacts of cases, but these have proved too difficult to identify, said Smallwood. So the advice was broadened to those most at risk, which in includes men in the gay and bisexual communities who are sexually active, as well as health workers caring for infected people.

But latest data in this latter group has shown that no cases have emerged through close contact at health clinics. So, these shots may be best directed to communities most at risk — it’s something the WHO is currently considering in its guidance, said Smallwood.

But there’s also a longer-term approach that needs to be taken, and that’s vaccinating in Central and West Africa to stem the source of the outbreak, said Smallwood. “If [monkeypox] continues to be there, then it will continue to represent potential risk of spread, and can very easily be reintroduced.”