For the second time in two years, the World Health Organization has taken the unusual step of declaring a global emergency. This time the cause is monkeypox, which spread in just a few weeks to dozens of countries and infected tens of thousands of people.
Dr Tedros Adhanom Ghebreyesus, director-general of the WHO, on Saturday overruled a panel of advisers who could not reach a consensus and declared a “public health emergency of international concern”, a designation the WHO currently uses to describe only two other diseases, Covid-19 and polio.
“We have an outbreak that has spread rapidly around the world through new modes of transmission that we understand very little about and that meets the criteria” for a public health emergency, Dr Tedros told reporters.
The panel’s inability to reach consensus also underscores the need for a better process for deciding which events constitute public health emergencies. It is apparently the first time the director-general has overruled his advisers to declare a public health emergency.
“This process demonstrates once again that this vital tool needs to be refined to become more effective,” Dr Tedros said, referring to the WHO’s deliberations. Member countries are considering ways to improve the process, he added.
The WHO declaration signals a public health risk that requires a coordinated international response. The designation could prompt member countries to invest significant resources in controlling the outbreak, attract more response funds and encourage nations to share vaccines, treatments and other key resources to contain the outbreak.
This is the seventh public health emergency since 2007; The Covid pandemic, of course, was the most recent. Some global health experts have criticized the WHO’s criteria for declaring such emergencies as opaque and inconsistent.
At a meeting in June, WHO advisers concluded that while monkeypox is a growing threat, it is not yet an international emergency. The panel was unable to reach a decision on Thursday, Dr Tedros said.
Many experts sharply criticized the process as short-sighted and overly cautious.
There are more than 16,000 cases of monkeypox outside Africa, roughly five times the number when advisers met in June. Almost all infections have occurred among men who have sex with men.
The WHO statement is “better late than never,” said Dr. Boghuma Titanji, an infectious disease physician at Emory University in Atlanta.
What you need to know about the monkeypox virus
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What is monkeypox? Monkeypox is a virus endemic to parts of Central and West Africa. It is similar to smallpox, but milder. It was discovered in 1958 after an outbreak in monkeys kept for research, according to the Centers for Disease Control and Prevention.
What are the symptoms? Monkeypox produces a rash that starts as flat red spots that become raised and filled with pus. Infected people may also have fever and body aches. Symptoms usually appear after six to 13 days, but may take up to three weeks after exposure to appear and may last two to four weeks. Health officials say smallpox vaccines and other treatments can be used to control an outbreak.
How contagious is it? The virus is spread mainly through bodily fluids, skin contact and respiratory droplets, although some experts suggest it can sometimes be airborne. It doesn’t usually lead to large outbreaks, although this year it spread in unusual ways and among populations that weren’t vulnerable in the past.
What is the situation in the United States? Experts say the rapid spread of monkeypox in the country and the government’s sluggish response raise questions about the nation’s preparedness for pandemic threats. Tests won’t be readily available until later this month, and vaccines will be in short supply for months. The official number of cases, now in the hundreds, is likely a vast underestimate.
But with the delay, “it could be argued that the global response continues to suffer from a lack of coordination with individual countries working at very different paces to tackle the problem.”
“There’s almost a capitulation that we can’t stop the monkeypox virus from establishing itself in a more permanent way,” she added.
Dr. James Lawler, co-director of the University of Nebraska’s Center for Global Health Security, estimated it could take a year or more to bring the outbreak under control. By then, the virus will likely have infected hundreds of thousands of people and may have become permanently established in some countries.
“Now, unfortunately, we’ve really missed the boat on being able to put a lid on the epidemic earlier,” Dr Lawler said. “Now it’s going to be a real struggle to be able to contain and control the spread.”
The longer an outbreak continues, the greater the chance that the virus will move from infected humans to animal populations, where it can persist and sporadically cause new infections in humans. This is one way for a disease to become endemic in a region.
As of Saturday, the United States had recorded nearly 3,000 cases, including two children, but the real number is believed to be much higher as testing is only now ramping up. Britain and Spain have about the same number of cases, and the rest are spread across about 70 countries.
Many of those infected in these countries did not report a known source of infection, indicating undetected community spread.
WHO advisers said in late June that they did not recommend an emergency declaration in part because the disease has not moved beyond the main risk group, men who have sex with men, to affect pregnant women, children or the elderly, who are more exposed. high risk of severe illness if infected.
In interviews, some experts said they disagreed with the rationale.
“Do you want to declare a state of emergency when it’s really bad, or do you want to do it in advance?” said Dr. Isabella Eckerle, a clinical virologist at the University of Geneva.
“Now we don’t have that problem. We don’t see the virus in children, we don’t see it in pregnant women,” she added. “But we know that if we let this go and don’t do enough, it will happen at some point.”
A similar WHO committee, which met in early 2020 to assess the coronavirus outbreak, also met twice, deciding only at its second meeting, on January 30, that the spread of the virus constituted a public health emergency .
Committee members suggested at the time that WHO consider creating an “intermediate alert level” for outbreaks of moderate concern. The organization may need such a system as outbreaks become more frequent.
Deforestation, globalization and climate change create more opportunities for pathogens to jump from animals to humans. Now, an emerging virus can quickly cross national borders and become a global threat.
But most public health authorities remain equipped only to deal with chronic diseases or small outbreaks.
The devastation of the Covid pandemic and the monkeypox surge should serve as a warning to governments to prepare for new outbreaks without warning, said Tom Inglesby, director of the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health.
“As much as the world is tired of infectious disease crises, they are part of a new normal that will require a lot of constant attention and resources,” he said. “We need global vaccine and therapeutic manufacturing and warehousing approaches that don’t yet exist.”
Monkeypox has periodically broken out in some African countries for decades. Experts have been sounding the alarm about its potential as a global threat for years, but their warnings have gone largely unheeded.
Vaccines and drugs are available largely because of fears of a bioterrorist attack with smallpox, a close relative of the monkeypox virus.
But access to a drug called tecoxiramit is hampered by time-consuming red tape and government controls on supplies, delaying treatment by days or even weeks for some patients.
Doses of Jynneos, the newer and safer of the two available vaccines, have been severely limited — even in the United States, which helped develop the vaccine.
As of Friday, New York had 839 cases of monkeypox, almost all of them in men who have sex with men, according to the city’s Department of Health. In late June, the city began offering the monkeypox vaccine, but ran out of about 1,000 doses available.
Since then, supplies have slowly increased to about 20,000 doses. The city offered another 17,000 hours for the first dose on Friday night, but those, too, were taken quickly.
“Vaccine supplies remain low,” the city’s health department website said Saturday.
Containing the virus can be even more challenging in countries with limited or no supplies of vaccines and treatments. Without the framework of a global emergency, each country must find its own way to provide tests, vaccines and treatments, exacerbating inequalities between nations.
Failure to coordinate the response also squandered opportunities to collect data in large multinational studies, especially when disease surveillance is patchy.
“This inability to characterize the epidemiological situation in this region poses a significant challenge to the development of interventions to control this historically neglected disease,” Dr Tedros said of the West and Central African countries in a statement on Thursday.
For example, cases of monkeypox in Nigeria and the Democratic Republic of the Congo, where the virus is endemic, suggest that a painful rash all over the body can develop one to two weeks after exposure.
But many patients in the current outbreak developed lesions only in the genital area. Some – especially those who develop sores in the throat, urethra or rectum – have suffered excruciating pain.
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