For the second time in two years, the World Health Organization has taken the extraordinary step of declaring a global emergency. This time the cause is monkey pox, which has spread in a few weeks to dozens of countries and infected tens of thousands of people.
WHO director-general Dr Tedros Adhanom Ghebreyesus on Saturday overruled a group of advisers, who could not reach a consensus, and declared a “public health emergency of international concern”, a designation which the WHO currently uses to describe only two other people. diseases, Covid-19 and polio.
“We have an outbreak that has spread around the world rapidly through new modes of transmission, about which we understand too little, and that meets the criteria” for a public health emergency, Dr Tedros told reporters. It was apparently the first time that the director-general had sidelined his advisers to declare an emergency.
The WHO statement points to a risk to public health that requires a coordinated international response. The designation can lead member countries to invest significant resources in controlling an outbreak, get more funding for the response and encourage nations to share vaccines, treatments and other key resources to contain the outbreak.
It 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 these emergencies as opaque and inconsistent.
At a meeting in June, WHO advisers concluded that while monkeypox was a growing threat, it was not yet an international emergency. The group was unable to reach a decision on Thursday, Dr Tedros said.
“This process demonstrates once again that this vital tool must be fine-tuned to make it more effective,” he added, referring to the WHO’s deliberations.
Monkey pox has been a concern for years in some African countries, but in recent weeks the virus has spread around the world. Some 75 countries have reported at least 16,000 cases so far, about five times the number when WHO advisers met in June.
Almost all infections outside of Africa have occurred among men who have sex with men. The outbreak has encouraged many in the LGBT community, who have charged that monkeypox has not received the attention it deserves, as it did in the early days of the HIV epidemic.
The WHO statement is “better late than never,” said Dr. Boghuma Titanji, an infectious disease physician at Emory University in Atlanta.
But with the delay, “it can be argued that the global response has continued to suffer from a lack of coordination with individual countries working at very different paces to address the problem.”
“There is almost a capitulation that we cannot prevent the monkeypox virus from establishing itself more permanently,” he added.
Dr. James Lawler, co-director of the Global Center for Health Security at the University of Nebraska, estimated it could take a year or more to bring the outbreak under control. By then, the virus is likely to have infected hundreds of thousands of people and become permanently established in some countries.
“Now, unfortunately, we’ve missed the boat on being able to put a lid on the outbreak sooner,” said Dr. Lawler. “Now it will be a real fight to be able to contain and control the spread.”
The longer the outbreak lasts, the more likely it is that the virus will move from infected people to animal populations, where it could persist and sporadically trigger new infections in people. This is one of the ways in which a disease can become endemic in a region.
As of Saturday, the United States had recorded nearly 3,000 cases, including two children, but the true toll is believed to be much higher as testing is only expanding. Britain and Spain have roughly the same number of cases, with the rest spread across about 70 countries.
Many of those infected in these countries report no known source of infection, indicating undetected community spread.
WHO advisers said in late June they were not recommending an emergency declaration in part because the disease had not moved beyond the primary risk group, men who have sex with men, to affect pregnant women, children or older adults, who are at greater risk of serious illness if infected.
In interviews, some experts said they disagreed with the rationale.
“Do you want to declare an 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,” he added. “But we know that if we let this happen and we don’t do enough, then it will happen at some point.”
A similar WHO committee that 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 then suggested that the WHO consider creating an “intermediate alert level” for outbreaks of moderate concern. The organization may need this system as outbreaks become more frequent.
Deforestation, globalization and climate change are creating more opportunities for pathogens to move from animals to people. Now, an emerging virus can quickly transcend national borders to become a global threat.
But most public health authorities remain equipped only to treat chronic diseases or small outbreaks.
The devastation of the Covid pandemic and the rise of monkeypox should serve as a warning to governments to prepare for new epidemics without warning, said Tom Inglesby, director of the Johns Hopkins Center for Health Security from 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 demand a lot of attention and constant resources,” he said. “We need global approaches to the production and storage of vaccines and therapeutics that do not yet exist.”
Monkey pox has periodically broken out in some African countries for decades. Experts have sounded the alarm about its potential as a global threat for years, but their warnings fell on deaf ears.
Vaccines and drugs are available largely because of fears of a bioterrorism attack with smallpox, a close relative of the monkeypox virus.
But access to a drug called tecovirimat has been blighted by bureaucracy and time-consuming government control of supply, delaying treatment by days or even weeks for some patients.
Doses of Jynneos, the newer and safer of the two vaccines available, have been severely restricted, even in the United States, which helped develop the vaccine.
As of Friday, New York City had reported 839 cases of monkeypox, almost all of them in men who have sex with men, according to the city’s Health Department. In late June, the city began offering the monkeypox vaccine, but sold out with only about 1,000 doses available.
The supply has grown slowly since then to around 20,000 doses. The city offered another 17,000 first-dose appointments Friday evening, but those also filled quickly.
“Vaccine supplies remain low,” the city’s health department website said Saturday.
Containing the virus may be even more difficult in countries with limited or no supply 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.
The lack of response coordination has also missed opportunities to collect data in large multinational studies, especially when disease surveillance tends to be patchy.
“This inability to characterize the epidemiological situation in this region poses a substantial challenge to designing 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 has been endemic, suggested that a painful rash can develop all over the body within a week or two of exposure.
But many patients in the current outbreak have developed lesions only in the genital area. Some, especially those who develop sores in the throat, urethra or rectum, have experienced excruciating pain.
“I was actually afraid to use the bathroom,” said one recent patient, Gabriel Morales, 27, a part-time model based in New York City. “I can’t even describe it. It looks like broken glass.”
Many other patients have experienced only mild symptoms, and some have not had the fever, body aches or respiratory symptoms typically associated with the disease.
Severe cases may only be detected in endemic regions of Africa, and the current outbreak provides a more accurate picture of the disease, Dr. Eckerle said. Or the virus itself may have changed significantly, as has the symptom profile it causes.
According to preliminary genetic analyzes of samples from infected patients, the monkeypox genome appears to have picked up nearly 50 mutations since 2018, more than the six or seven that would have been expected to accumulate in that period.
It is not clear whether the mutations have changed the mode of transmission, severity or other qualities of the virus. But early analysis suggests that monkeypox may have adapted to spread more easily between people than before 2018.
Coordinating the response between nations would help address many of the uncertainties surrounding the outbreak, Dr Eckerle said: “There are so many open questions.”
Joseph Goldstein and Sharon Otterman contributed to the report.