Monkeypox virus has long been endemic — meaning there is a continuous baseline level of infection — in West and Central Africa. But nine weeks ago, the virus left the continent and began spreading in Europe and now the U.S. There are now at least 13,000 cases across 60 countries and three reported deaths. In the U.S. alone there are almost 2,300 cases and unfortunately, it seems that the public health infrastructure and the Centers for Disease Control and Prevention (CDC) are demonstrating some the same pitfalls of the early days of COVID. Experts say that the window to contain the disease is closing.
The monkeypox virus presents itself with fever, body aches, chills, and fatigue, and if it is a more severe infection, rashes, and lesions. It spreads person-to-person through direct contact with the rash, respiratory droplets, and through touching contaminated clothing or linens. It has a long infectious period of roughly 2-4 weeks. Though the symptoms can resolve themselves, it can be highly uncomfortable and is a greater threat to immunocompromised people, children, and pregnant women. There have been no reported deaths outside of Africa but right on the heels of a multiyear, deadly, global pandemic, how is the U.S. repeating several of the same errors as it did during the early days of COVID?
Too little testing: Until recently, monkeypox testing was limited to a small number of government-run labs that are a part of the CDC’s Laboratory Response Network. This meant that providers were required to complete bureaucratic paperwork to receive permission to order a test. This slowed testing in the initial days of the outbreak. However, in recent days, five commercial labs have begun offering monkeypox testing which should help alleviate testing backlogs. Unfortunately, it may be too late to stop the virus from spreading: the virus is already spreading undetected in many communities as indicated by exceptionally high positivity rates — the rate at which those who are tested are positive. And for many of the confirmed cases, health officials don’t know how the person caught the virus. Those infected haven’t traveled or knowingly been in contact with another infected person.
Not enough vaccines: Unlike the onset of the COVID-19 pandemic, there are two vaccines that are effective (roughly 85% efficacy) at preventing monkeypox. First, there is an older smallpox vaccine which also works against the virus — however, it has a high risk of side effects and can’t be used on people who have HIV or are pregnant. Then there is a newer smallpox vaccine that also works on monkeypox, without the risks of the older vaccine. Though the U.S. has ordered nearly 7 million doses, it has struggled to expedite the acquisition and distribution process. In fact, 1 million doses that have already been purchased have been held up in a manufacturing facility in Denmark awaiting on FDA clearance. The CDC estimates that roughly 1.5 million American men are eligible for the vaccine based on their guidance.
As states and localities have received a slow drip of vaccines, appointments have been gobbled up faster than they can be set up. New York City, learning from lessons of COVID-19, has decided to give as many first doses as they can and worry about the follow up doses later. This goes against FDA guidance but is the type of response that is warranted in an emergency.
Limited access to treatments: An FDA approved smallpox antiviral drug, TPOXX, is presumed to work on monkeypox, but will require physicians to obtain special permission to use it on their monkeypox patients. The bureaucratic application process creates further delays in treating patients suffering from the symptoms of monkeypox: lesions, headaches and sometimes debilitating pain.
It’s important to note that this virus isn’t COVID-19. It’s not a novel, deadly virus without treatments or vaccines. There is no need for widespread masking or shutdowns. Indeed, the United States government has been forward looking enough to order monkeypox/smallpox vaccines and stockpile treatments, but now that the virus has presented itself, the government can’t seem to efficiently deliver on the last mile of getting the therapeutics to patients.
COVID-19 and monkeypox illustrate that the threat of diseases is ongoing — pathogens will continue to emerge and pose a threat to the public. It’s paramount that the U.S. invest in the pandemic preparedness infrastructure to meet demand as I outlined in an earlier paper. It’s time for the government to learn from its missteps and invest in the public health system, such as on the ground clinics, as well as supply chain infrastructure, and to embrace greater flexibility when combating novel threats.