It has been more than 10 days since the World Health Organization’s (WHO) Director-General, Dr. Tedros Adhanom Ghebreyesus, declared the multi-country global outbreak of the monkeypox epidemic a Public Health Emergency of International Concern (PHEIC) on July 23, 2022.
The overruling of the emergency committee’s majority opinion against such a declaration was unprecedented. However, the response to the monkeypox pandemic on the part of countries hardest hit has been characterized by continued inaction and paralysis, mirroring the crisis in the international health agency.
In the three months since the global outbreak commenced, almost 23,008 cases have been confirmed. The global seven-day moving average of monkeypox infections is approaching 1,000 per day, according to the detailed tracker by Antonio Caramia, an Italian data scientist who has provided this writer permission to use his work.
Currently, the US is the largest epicenter in the monkeypox pandemic with close to 5,200 confirmed cases. Canada has seen 818 monkeypox cases. Brazil (1,377) and Peru (307) are leading in Latin America. In Europe, Spain (4,300), Germany (2,677), the UK (2,359) and France (1,955) make up the lion’s share of cases. On a per capita basis, Spain’s rate of monkeypox cases is six times higher than in the US and the highest in the world. Some 87 countries and territories have documented monkeypox within their borders.
At the WHO press brief July 27, 2022, Director-General Ghebreyesus said during his opening remarks, words reminiscent of the early days of the COVID-19 pandemic, “This is an outbreak that can be stopped if countries and communities and individuals inform themselves, take the risk seriously, and take the steps needed to stop the transmission and protect vulnerable groups.”
Deep frustration and fatigue punctuated his warnings and call to action, with many powerful national governments refusing to act on the WHO’s warnings. Specifically, in the US, the White House has failed to declare a national emergency and has used the corporate media to tamp down public concerns about the WHO action by claiming to have increased testing and placed orders for more vaccines.
Despite this posturing, however, there is a repeated refrain from states that there are insufficient quantities of vaccines to administer, and testing is being conducted predominately within clinics for sexually transmitted infections (STI).
Meanwhile, the White House is pushing back against these complaints, with Health and Human Services Secretary Xavier Becerra stating at a Thursday press brief that state and local governments “ultimately are the ones that determine how health care is administered in their jurisdictions.”
More concerning, there continues to be a severe lack of awareness on the part of health care workers and physicians on the signs and symptoms of monkeypox, which means that community transmission is occurring undetected.
Professor Jay Varma of Weill Cornell Medicine in New York, an expert on population health sciences, told Bloomberg, “It’s likely that we will see an increasing number of cases transmitted in other social networks and settings. No social network is self-contained. They all bridge to other networks.”
Congress has yet to hold any hearings or give any thought to the growing crisis. Local health officials and LGBTQ community leaders in major cities such as New York City, San Francisco, the District of Columbia, New Orleans and Miami have indicated they have run out of vaccines, prompting the city of San Francisco and the states of New York and Illinois to declare a state of emergency to encourage federal officials to respond to their concerns. Only Montana, Wyoming and Vermont have yet to report a monkeypox case.
Dr. Ghebreyesus added, “Although 98 percent of cases are among men who have sex with men, anyone exposed can get monkeypox, which is why WHO recommends countries take action to reduce the risk of transmission to other vulnerable groups including children, pregnant women, and those who are immunosuppressed. In addition to transmissions through sexual contacts, monkeypox can be spread in the household through close contact between people such as hugging and kissing and on contaminated towels or bedding.”
Health officials are targeting the available vaccines against monkeypox to those with known exposure to someone with a monkeypox infection and a high risk of exposure, including health care workers and those with multiple sexual partners.
Currently, the Jynneos (MVA-BN) vaccine manufactured by Bavarian Nordic is the only vaccine approved for use in the US, Canada and the European Union. It requires two doses scheduled four weeks apart, with the immune response taking several weeks to be generated.
Two other vaccines developed against smallpox—LC16 and ACAM2000—are being considered but are known to have considerable side effects. The director-general added that the effectiveness of these vaccines and the number of doses required for the world remain to be determined.
Vaccine inequity has been in play for many years and continues during the current pandemic. Only Denmark, Japan and the US are producing vaccines; though there are 16.4 million vaccines in bulk globally, vials for injections remain to be filled. And while the US has already distributed more than 191,000 doses of Jynneos, added 131,000 to its stockpile, and with 786,000 more expected soon, the devastating poverty of Africa, where monkeypox is endemic in several countries, means that more than 1.2 billion people will have to fend for themselves.
One can add the need to increase the national testing capacities by several orders of magnitude, since confirmation requires complex PCR diagnostics. Currently, there is no approved rapid antigen test for monkeypox.
In post-exposure treatment, vaccines will not provide instant protection against infection and disease, possibly only dampening the symptoms of infection and potentially avoiding any fatal turns. Such individuals must isolate appropriately under the guidance of knowledgeable health officials and infectious disease experts.
Presently, about 10 percent of all confirmed cases require hospitalization to treat severe pain associated with their lesions. An unnamed man in Louisiana told the local news station, “The pain that you receive from that [infection] is just indescribable. I could sleep maybe one to two hours before getting woken up. The pain wakes you up. [And] the mental hell that you go through in your head too. I mean, not knowing and when is it going to end? And how am I going to get help? This pain isn’t stopping…”
Though the current focus is on reducing transmission among men who have sex with men, the United Nations indicated last week that more than 81 children have already been documented with monkeypox infection, which means this layer of the population is rapidly becoming a growing concern, especially as the return to school after the summer break is fast approaching.
Varma said, “It is inevitable that some kids will become infected and attend school while infected. What we don’t know is how likely it is that kids will transmit to other kids while in school, and, if transmission occurs, whether it will be limited to a few cases or cause a large outbreak.” Jynneos is still not approved for those under 18 and would require approval from health regulators.
Also, last week the Centers for Disease Control and Prevention (CDC) informed the media that a pregnant woman infected with monkeypox had given birth. Her infant received intravenous vaccinia immuno-globulins that act as antibodies. Mother and baby are doing well, but the event underscores the dangers posed to vulnerable people.
Monkeypox can be transmitted to the fetus during pregnancy, leading to spontaneous pregnancy loss, stillbirth and preterm delivery. The antiviral tecovirimat, approved in the treatment of smallpox in adults and children, has been given expanded authorization by the Food and Drug Administration for this indication.
Since the current outbreak of monkeypox began to sweep across previously non-endemic regions of the globe, a total of 10 deaths have been confirmed due to complications of infections. Spain has seen two, while India and Brazil each have documented one. However, Nigeria has noted five deaths and Ghana recently reported one. The case in Brazil occurred in a patient who had lymphoma and was immunocompromised.
Since last week, when the European Union approved Nordic Bavarian’s Jynneos vaccine, demand for the Danish companies has soared, prompting the company to operate 24 hours a day, seven days a week to meet the demand. It had received funding from the US government to develop the vaccine as a defense against any accidental reintroduction of smallpox.
The vaccine maker can only produce 30 million doses each year. However, Nordic Bavarian’s head of investor relations Rolf Sass Sørensen told Bloomberg, rather than sourcing out the manufacturing to increase production, “[That would] take a lot of time and would be expensive, so we’re trying to avoid that.”
He then added, “The product is not something that easily can be copied, so it’s highly unlikely that anyone but us would be able to quickly ramp up production of the vaccine. It’s not a standard type of product that can be copied; you need a lot of expertise to get the vaccine to work. I would say it’s an art form.”
The Danish company’s stock value had risen 150 percent to 342.6 kroner since the beginning of May when the outbreak began.