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The World Health Organization has activated its highest level of alert for the growing epidemic of monkeypox, declaring the virus a public health emergency of international concern.
The rare designation means the WHO now considers the outbreak a significant enough threat to global health that a coordinated international response is needed to prevent further spread of the virus and potential escalation into a pandemic.
Although the declaration does not impose requirements on national governments, it serves as an urgent call to action. WHO can only issue guidelines and recommendations to its member states, not mandates. Member States are required to report events that pose a threat to global health.
The UN agency last month declined to declare a global emergency in response to monkeypox. But infections have increased significantly in the past few weeks, prompting WHO Director-General Tedros Adhanom Ghebreyesus to sound the alarm.
Before a global emergency is declared, the WHO’s emergency committee meets to weigh the evidence and make a recommendation to the director-general. The committee was unable to reach a consensus on whether monkeypox constituted an emergency. Tedros, as head of the WHO, decided to issue the highest level of alert based on the rapid spread of the epidemic around the world.
“We have an outbreak that has spread around the world rapidly through new modes of transmission that we understand very little about,” Tedros said. “For all these reasons, I have decided that the global outbreak of monkeypox constitutes a public health emergency of international concern.”
More than 16,000 cases of monkeypox have been reported in 75 countries so far this year, and the number of confirmed infections rose 77 percent from late June to early July, according to WHO data. Men who have sex with men are currently at the highest risk of infection.
Five deaths from the virus have been recorded in Africa this year. So far, no deaths have been reported outside of Africa.
Most people recover from monkeypox in two to four weeks, according to the US Centers for Disease Control and Prevention. The virus causes a rash that can spread over the body. People who have caught the virus have said that the rash, which looks like pimples or blisters, can be very painful.
The current monkeypox outbreak is very unusual because it is spreading widely in North American and European nations where the virus is not normally found. Historically, monkeypox has spread at low levels in remote parts of West and Central Africa, where rodents and other animals are carriers of the virus.
Europe is currently the global epicenter of the epidemic, accounting for more than 80% of confirmed infections worldwide in 2022. The US has reported more than 2,000 cases in 43 states, Washington and Puerto Rico.
In early May, the United Kingdom reported a case of monkeypox in a person who had recently returned from a trip to Nigeria. A few days later, the United Kingdom reported three more cases of monkeypox in humans that appeared to have been contracted locally. After that, other European countries, Canada and the US also started confirming cases. It is not clear where the outbreak actually started.
The WHO last issued a global health emergency in January 2020 in response to the Covid-19 outbreak and declared it a pandemic two months later. The WHO has no formal process for declaring a pandemic under its organizational laws, meaning the term is loosely defined. In 2020, the agency declared Covid a pandemic in an effort to warn complacent governments of the virus’ “alarming levels of spread and severity.”
The WHO’s leading expert on monkeypox, Dr. Rosamund Lewis, told reporters in May that the UN health agency was not concerned about monkeypox causing a global pandemic. She said public health authorities have an opportunity to contain the outbreak.
But infectious disease experts are concerned that health authorities have failed to contain the outbreak and that monkeypox will take permanent root in countries where the virus has not previously been detected, except for isolated travel-related cases.
Monkeypox is not a new virus
Unlike Covid-19, monkeypox is not a new virus. Scientists first discovered monkeypox in 1958 in captive monkeys used for research in Denmark, and confirmed the first human case of the virus in 1970 in the nation of Zaire, now called the Democratic Republic of the Congo.
Monkeypox is in the same family of viruses as smallpox, although it causes a milder illness. WHO and national health agencies have decades of experience in the fight against smallpox, which was declared eradicated in 1980. The successful fight against smallpox and the tools developed against it will provide health officials with important knowledge to fight monkeypox.
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Transmission of monkeypox between humans was relatively rare in the past, and the virus usually passed from animals to humans. But monkeypox now spreads more efficiently between humans. The WHO said the international community had not invested enough resources in fighting monkeypox in Africa before the global outbreak.
“This transmission has been occurring in African countries in two specific areas for a large number of years, and we do not fully understand what is driving the transmission in these countries,” said Dr. Mike Ryan, head of the WHO’s health emergencies program. “There’s a lot more investigation to do and a lot more investment to understand this problem.”
Gay, bisexual men at highest risk
Monkeypox is primarily spread through skin-to-skin contact during sex. Men who have sex with men are at greatest risk right now, as most of the transmission has occurred in the gay community. However, the WHO and CDC emphasized that anyone can contract monkeypox, regardless of sexual orientation.
Lewis, the WHO expert on monkeypox, said 99% of cases reported outside Africa are among men and 98% of infections are among men who have sex with men, mostly those who have had multiple, recent anonymous or new sexual partners. The virus has been detected outside the gay community, but the spread so far has been low. The CDC confirmed monkeypox in two children on Friday.
The WHO and CDC have repeatedly warned against stigmatizing gay and bisexual men, while stressing the importance of communicating the reality of how the virus is currently spreading so that people in the highest-risk communities can take action to protecting your health.
“People want the information to know how to protect themselves, under what circumstances people might be at risk or become infected,” Lewis said. It’s critical for health agencies and community organizers to spread the word widely about how to reduce the risk of infection ahead of big celebrations and festivals this summer, she said.
Scientists from Spain and Italy found DNA of the monkeypox virus in the semen of positive patients, but it is not yet clear whether the virus can be spread through semen during sex. Spanish scientists also found monkeypox DNA in saliva samples.
It is also unclear whether the virus can spread when people are infected but have no symptoms, known as asymptomatic transmission.
Symptoms and risk factors
The US CDC recommends that people avoid intimate physical contact with people who have a rash that resembles monkeypox and consider minimizing sex with multiple or anonymous partners. People should also consider avoiding sex parties or other events where people don’t wear a lot of clothing.
People who decide to have sex with a partner who has monkeypox should follow CDC guidelines to reduce their risk, according to the health agency.
In the past, monkeypox usually started with flu-like symptoms, including fever, headache, muscle aches, chills, fatigue, and swollen lymph nodes. The disease then progresses to a rash that can spread over the body. Patients are considered most infectious when the rash develops.
But in the current outbreak, the symptoms are atypical. Some people develop a rash first, while others show a rash without any flu-like symptoms. Many patients developed a localized rash on the genitals and anus.
The CDC and WHO said the rash is easily mistaken for common sexually transmitted diseases. They told health care providers they shouldn’t rule out monkeypox just because a patient tested positive for a sexually transmitted disease.
Although monkeypox can be spread through respiratory droplets, this method requires prolonged face-to-face interaction, according to the CDC. Health officials do not believe that monkeypox is spread by small aerosol particles like Covid. Respiratory droplets are heavier so they don’t stay in the air as long, whereas Covid is an airborne virus, which is one of the reasons it’s so contagious.
Monkeypox can also be spread through contact with contaminated materials, such as sheets and clothing.
“This disease is transmissible, but it is not that transmissible. It’s a disease where transmission can be limited,” Ryan said. “As we said in Covid, don’t be the person to transmit this disease.”
Vaccines
Because monkeypox is not a new virus, there are already vaccines and antivirals to prevent and treat the disease it causes, although they are in short supply. The US is already distributing tens of thousands of doses of a vaccine called Jynneos in an attempt to quell the outbreak. The Food and Drug Administration approved the two-dose vaccine in 2019 for adults 18 and older who are at high risk of monkeypox or smallpox infection.
The Biden administration has distributed more than 300,000 doses of Jynneos to states and cities since May, and another 786,000 doses are being shipped across the US. The Department of Health and Human Services ordered 5 million more doses by 2023.
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