It’s time to get your head out of the sand and face the reality of monkey pox.
That is, 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 spreading rapidly around 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 for only the most serious global disease outbreaks. It means 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 spread of this virus.
This applies to countries with no recorded cases of the virus, which causes an ulcer-like rash, fever and sometimes swollen lymph nodes, as well as those with thousands. Currently, more than 18,000 cases have been identified in more than 70 countries. Although the infection usually 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 statement will “sharpen the response” in countries that are already acting and convince other countries that have been “sitting on the fence” that they must act now, said Catherine Smallwood, the WHO’s senior emergencies officer.
But there is concern that it may be too late. That’s because rates continue to rise 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 must stop human-to-human transmission to achieve this, he said. “It’s going to be hard to do, but that’s why we’ve declared a public health emergency of international concern, to really bring together the efforts to bring people together and think about how we can achieve this,” Smallwood said. “And if that’s the goal, we need to devote all our resources to that.”
Behavior change
There is no magic bullet to contain this infection. Monkeypox, which is endemic to central and western Africa, has spread rapidly across Europe since early May. There are now more than 13,000 cases in the WHO Europe region. More than 80 percent of these are concentrated in Spain, Germany, the United Kingdom, France and the Netherlands.
While vaccination will help, supplies are very limited, so countries must focus on changing behaviors, Smallwood noted. And with cases predominantly, though not exclusively, spread through intimate contact between men who have sex with men, working with those communities will be key to stopping transmission, he said.
Lessons can be drawn from HIV/AIDS and COVID for this outbreak, Hans Kluge, head of the WHO European office, noted on Tuesday.
Health care providers must remove any barriers to testing, medical care or vaccination, he said, and provide clear information about how to access care. And doctors need to be up-to-date on how to identify cases, especially since people come in with atypical symptoms.
Those most at risk need to be aware and “get the facts,” Kluge said. “Please consider limiting your interactions and sexual partners at this time. It may be a harsh message, but exercising caution can protect you and your community at large.”
Governments must allow medical leave for those who must self-isolate and work with at-risk communities to develop and distribute messages to reduce transmission. And countries must quickly boost disease surveillance, he said, noting that “many cases are likely to go undetected.”
Avoid stigma
Paradoxically, the fear of stigmatizing the most at-risk community — men who have sex with men — has been a catalyst for slow or non-existent responses in some countries, Smallwood noted.
“Many people have not acted for fear of creating stigma. And I don’t think it’s an excuse not to act,” he said.
Acting openly and publicly now to protect this community “may have some consequential effect on stigma,” Smallwood said. “But that’s a reality we’re going to face in the response.”
Saying nothing, however, will hurt this community even more, allowing the outbreak to spread and spread unhindered. That’s more likely to contribute to stigma, Smallwood argued.
Portugal is a country that has faced the challenge head on. “At first I was afraid that the disease would be associated with the gay community, but the Portuguese government has done a very good job on social media to educate people about monkey pox and explain that anyone can get it” , said Francisco Silva, a general practitioner in Lisbon who works at 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 Center for Disease Prevention and Control, which soon identified these unusual cases as monkeypox. This prompted a national response from the health ministry.
“Portugal responded very early with a strong community-based campaign through its sexual health networks through its sexual health clinics,” Smallwood said.
The country stepped up communication efforts, especially among the gay and bisexual communities. Major events such as All Saints’ Day festivities around Lisbon saw concerted awareness campaigns.
Notably, Portugal’s case growth has begun to level off, and that’s without the widespread use of a vaccine.
With vaccines in short supply, this focus on changing behaviors will be key for countries to reverse the rising infection rates seen since May. It will be especially important for countries like France, where cases have almost doubled in the past week to 1,567. Infections are also rising in Spain, which reported 471 cases last week and 3,596 in total, and Germany, which reported 300 cases last week and 2,410 so far.
But some European countries are already showing signs of slowing down. The UK, for example, has recorded 2,208 cases in total, with 71 in the past week, while Portugal has recorded 588 cases and 73 in the past week.
Scarce vaccines
Like the coronavirus pandemic, there is hope that a vaccine could end this outbreak. But with only one vaccine licensed to prevent monkeypox, Bavarian Nordic’s Imvanex, countries are scrambling for limited supplies.
“Even when the vaccine is available, it will be about combining vaccination with behavior change, especially in the early phases of vaccine administration,” Smallwood said. That’s because the shot takes a while to kick in the immune response, he noted.
“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’s going to take a while to work,” he said.
For countries that have access to doses, they rely on men in the at-risk community to come forward for a dose. “We actually don’t even know what proportion of people who are at particular risk of monkeypox will decide to do it,” he said.
Meanwhile, for those willing to get the shot, getting their hands on a vaccine has been the most difficult and frustrating part of this outbreak. Anecdotal evidence from Berlin illustrates that doses are difficult to access without an 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 in vaccine deliveries.
The European Commission has bought more than 163,000 doses of the Nordic Bavarian smallpox vaccine, which was authorized for smallpox in Europe this week. While the first batch of 30,000 doses has been delivered to the 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 be jabbed. At first it was close contacts of cases, but those have proven too difficult to identify, Smallwood said. Thus, the advice was extended to those most at risk, which include men in the gay and bisexual communities who are sexually active, as well as healthcare workers who care for infected people.
But the latest data from the latter group have shown that no cases have occurred through close contact in health clinics. So these traits can be better targeted at communities at highest risk, something the WHO is currently considering in its guidelines, Smallwood said.
But a long-term approach must also be taken, and that is to vaccinate in central and western Africa to stem the source of the outbreak, Smallwood said. “Yes [monkeypox] continues to be there, then it will continue to pose a potential risk of spread and can be reintroduced very easily.”