As the World Health Organization Meets on the 2022 Monkeypox Outbreak, an Early Examination of U.S. Responses

By Dr. Dan Regan

The World Health Organization (WHO) has concluded that the ongoing outbreak of monkeypox, a disease endemic in parts of Africa and newly spreading in many countries in which it is extremely uncommon, is not currently a public health emergency of international concern (PHEIC). While this disease is very different from COVID-19, the dramatic effects of that ongoing pandemic show the importance of starting now to examine key aspects of the initial response.

First, a basic timeline. On May 7th the first case of monkeypox outside of the endemic regions within Africa was detected in the United Kingdom, and within ten days an additional ten cases were detected across, Australia, Canada, and seven European countries. We are just over one month since the first detected U.S. case was reported in Massachusetts on May 18th. On June 17th, the United States reached its 100th confirmed case of monkeypox. This was just a few days before the WHO held its emergency meeting to determine this monkeypox outbreak’s status as a PHEIC, which declares the outbreak’s spread poses a serious public health risk to the international community and helps to guide responses. 

Since the outbreak’s discovery in mid-May, the virus has been detected in every continent with the exception of Antarctica. 

For the United States, one major highlight of the initial response has been the rapid identification of a monkeypox outbreak in a novel geographic context. Within five days of the aforementioned patient being admitted to Massachusetts General Hospital, their physician consulted other doctors on the reports from the UK and reported the potential case of monkeypox to the state’s public health department. After moving the patient to a specialty unit with negative pressure, test results were positive for a pox virus, and Centers for Disease Control and Prevention (CDC) tests confirmed it was monkeypox the following day. 

Another major highlight of the U.S. response has been the rapid mobilization and acquisition of medical countermeasures. Following the CDC’s confirmation of monkeypox, deliveries of JYNNEOS vaccine from the Strategic National Stockpile (SNS) arrived at Mass General for vaccinating close contacts the following week. 

Soon after the delivery of the first vaccines, the Assistant Secretary of Health and Human Services for Preparedness and Response announced on June 8th that the United States would purchase 500,000 doses of the JYNNEOS vaccine arriving in late 2022 from the manufacturer, Bavarian Nordic. In the near term, the SNS is expecting 300,000 doses from Bavarian Nordic to bolster the 72,000 on-hand of the two-dose JYNNEOS vaccine. 

The rapid availability of the vaccine, along with two antiviral therapeutics, is due to prior funding and technical support from the Biomedical Advanced Research and Development Authority (BARDA). Dating back to 2007 under Project BioShield, BARDA granted over a half-billion dollars to Bavarian Nordic for the development and procurement of the smallpox vaccine, which also has strong efficacy for monkeypox. This is one of 63 medical countermeasures approved by the Food and Drug Administration that BARDA has fueled to date.

However, the rapid response has not been the case across the board. While the first reported case occurred on the 7th of May in the UK, a potential case may have been in Montreal weeks earlier on the 29th of April. The symptoms brought on by infection are incredibly similar to those of some sexually transmitted infections, making the virus more difficult to diagnose without prior knowledge that would lead medical workers to test for it. It was not until May 26th that the WHO urged countries to intensify surveillance for monkeypox. Genetic sequencing analysis conducted by the CDC on May 29th revealed two distinct outbreaks of monkeypox spreading simultaneously. Based on this data, experts believe that the virus may have been spreading globally well before the May 7th case. Experts are also warning that the current testing protocols and rates are insufficient in the United States, similar to a trend that has continued throughout the COVID-19 pandemic. 

These findings continue to highlight the importance of investing in global pathogen early warning and increased biosurveillance efforts within the United States and globally.

The ongoing monkeypox outbreak highlights the importance of two critical components of a strong biodefense strategy: strategic investments in the rapid development and production of medical countermeasures and a robust early warning network. BARDA’s past investments are already taking on a major role in the U.S. response to monkeypox. This echoes the game-changing nature of investments by the Defense Advanced Research Program Agency that drove the development of mRNA vaccines later used to combat COVID-19. 

Yet medical countermeasures can’t be fully effective without knowledge of how to use them.  The fact that two separate and simultaneous outbreaks of monkeypox have evaded detection while spreading highlights the need to significantly strengthen global pathogen early warning systems.
Years of preparation for the threat of a deliberate attack from smallpox (a related virus) and a situationally-aware medical staff have given the United States a decent footing in the initial response to monkeypox. However, even after three years of practice from COVID-19, an even less transmissible monkeypox virus for which detection has not been optimal shows that further improvements can be made to our early warning networks.

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