The US reacts too little to Monkeypox

Yesterday, a CDC panel discussed whether smallpox vaccines should be offered more widely as a preventive measure against monkeypox. The panel has not made a decision. But getting those injections into the arms of patients — especially gay and bisexual men — is an urgent matter. As of May 13, more than 3,300 cases of monkeypox have been reported in 58 countries, including the United States, where the disease was previously not considered endemic. The CDC reports at least 172 cases. Before this outbreak, monkeypox had mostly been reported from western and central Africa, or in travelers from those regions. The new cases are occurring on all inhabited continents, mainly among men who have sex with men (MSM).

The US is not responding enough to the monkeypox outbreak. Since a vaccine is available for the infection — and could target the people most at risk — public health authorities and healthcare providers must act faster and more forcefully to change the trajectory of the outbreak.

Monkeypox is related to smallpox, the only human virus that has been eradicated worldwide. A highly effective smallpox vaccine called Jynneos is also approved in the United States for use against monkeypox. Data from Africa suggests it is at least 85 percent effective at preventing the latter condition.

On June 1, the CDC updated its recommendations to say that Jynneos is the preferred post-exposure prophylaxis for health professionals and others who have had close contact with patients with monkeypox. The US has about 36,000 doses in stock and expects an additional 300,000 doses in the coming weeks. It needs to buy many more and should offer the vaccine to all MSM at risk for exposure in the next month. Canada just signed a $56 million deal with the manufacturer of the Jynneos vaccine, and Quebec has begun offering the vaccine to all MSM. The UK is expanding its vaccination campaign from this week to offer injections to the gay and bisexual men most at risk of exposure. New York City’s health department announced yesterday the opening of a clinic in Chelsea that will offer the vaccine to MSM who have had multiple partners in the past 14 days.

As the coronavirus spread globally in early 2020, we lacked an effective vaccine, so governments had to mandate masks, distance, ventilation, testing and contact tracing to minimize transmission until the COVID-19 shots arrived. The world is not at the same disadvantage as monkey pox; we have a vaccine and our current attempts to test and connect to find our way out of this epidemic are failing. A swift, targeted vaccination campaign — one that identifies Americans at risk and persuades them to take a shot — will be much more likely to stop the monkeypox outbreak.

Different diseases require different responses. The coronavirus is becoming endemic because it spreads quickly and easily, and even high-quality vaccines that protect against serious diseases do not prevent initial infection or reinfection. Smallpox, one of the deadliest pathogens in history, could be eliminated because of four distinguishing features most human pathogens lack: The symptoms — particularly the rash it causes — are highly distinctive, allowing doctors to easily identify patients who had it; the infectious period was short; new infections could be prevented by a highly effective vaccine; and the virus had no animal reservoirs from which it could infect unvaccinated humans. As such, routine smallpox vaccinations for the U.S. population were discontinued in 1972. But due to the cessation of mass vaccination programs for smallpox, people have dwindling protection against monkeypox.

The name monkeypox comes from the first documented animal cases of the disease in 1958, when two outbreaks occurred in monkeys used for research. Until recently, however, the infection was most commonly spread by rodents such as rats, mice, and squirrels, and transmitted to humans through the bite of an infected animal, or by touching an infected animal’s blood, bodily fluids, or fur. A 2003 human outbreak in the US was traced to prairie dogs infected by a shipment of mammals from Ghana.

Many of the current cases are in MSM ages 30 to 55, initially linked to two major raves in Spain and Belgium. Note that sexual transmission of monkeypox has never been described before. Although monkeypox has been reported in semen, the most likely route of spread during the current outbreak is close skin-to-skin and breathing contact during sexual activity. In addition, transmission of prolonged personal contact may place household members and other close contacts of active cases at greater risk.

The spread of monkeypox among gay men has sparked calls to postpone this month’s Pride celebrations, and the CDC has been criticized for recent posts offering tips on avoiding the pathogen during sex. Still, the agencies follow the well-founded concept of harm reduction, which calls for both minimizing the impact of a health threat and recognizing the other needs of the individuals and society involved. People crave companionship and intimacy, and messages that ignore these needs and recommend complete abstinence are unlikely to succeed. Harm reduction is the foundation of the most current public health reporting on HIV risk reduction and is of major importance in the areas of addiction and substance use.

Health authorities deserve credit for trying to minimize stigma in their communications, even as they recognize that relevant communities need to be warned about how this particular outbreak is spreading. (WHO is also considering a change to the name itself) monkeypox to avoid stigma against the geographic areas originally associated with the disease and to eliminate associations with animals that appear to play a minor role in its spread.)

Stopping the monkeypox outbreak in the US is not enough. The WHO is meeting today to decide whether monkeypox will be declared a global health emergency — a step that African clinicians say should have happened long ago. Although the virus no significant threat for the general population, as was COVID-19, declaring a global health emergency will raise awareness of both this outbreak and endemic infections. As the World Health Organization has previously noted, wealthy countries have ignored endemic monkeypox in West and Central Africa for far too long, despite having effective vaccines, which should be distributed equitably among the populations at risk worldwide. The crucial point is that all these efforts must take place now. We must stop underreacting to the world’s latest infectious disease threat.

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