The World Health Organization (WHO) has declared the global monkeypox outbreak a Public Health Emergency of International Concern (PHEIC). The outbreak has now spread to 75 countries with more than 16,000 cases officially recorded.
The declaration of a PHEIC came directly from the WHO’s Director-General Tedros Adhanom Ghebreyesus, after an emergency meeting of experts failed to come to a consensus as to whether the spread of monkeypox currently fit the emergency classification. Only six of the 15 members of the expert panel supported the monkeypox PHEIC declaration, however, the Director-General disagreed with those recommendations and cast the deciding vote.
“… in short, we have an outbreak that has spread around the world rapidly, through new modes of transmission, about which we understand too little, and which meets the criteria in the International Health Regulations,” said Director-General Tedros in a recent press conference. “For all of these reasons, I have decided that the global monkeypox outbreak represents a public health emergency of international concern.”
The disagreement amongst the emergency committee regarding the PHEIC largely hinged on the idea that the declaration could actually hamper response efforts by stigmatizing the disease and drawing resources away from where they are most needed. The monkeypox outbreak is currently primarily spreading in LGBTI+ communities, and some members of the panel expressed concern that a PHEIC could further marginalize those communities.
“The stigma, marginalization, and discrimination that a determination of a PHEIC may generate against the currently affected communities, especially in countries where homosexuality is criminalized, LGBTI+ communities are not well established and engaged in a dialogue with governments,” a report from the emergency meeting stated. “Communities in some countries have reportedly indicated that minimizing stigma associated with monkeypox – which unlike HIV infection may be a visible condition– requires developing novel approaches, which could be challenging in the context of a PHEIC.”
A recent epidemiological report produced by the WHO has revealed, as of the 21st of July, there have been 15,328 confirmed cases of monkeypox across 74 countries. The report indicates 98.8% of cases with available data are male, and 98.1% of those men identify as either homosexual or bisexual.
Monkeypox is not a sexually transmitted disease but it is thought to be primarily spread by respiratory droplets and close contact. A new study published in the New England Journal of Medicine has tracked more than 500 cases from this current outbreak to offer the first robust look at the clinical appearance of this disease.
"It is important to stress that monkeypox is not a sexually transmitted infection in the traditional sense; it can be acquired through any kind of close physical contact,” explained John Thornhill, an author on the new study from the Queen Mary University of London. “However, our work suggests that most transmissions so far have been related to sexual activity – mainly, but not exclusively, amongst men who have sex with men. This research study increases our understanding of the ways it is spread and the groups in which it is spreading which will aid rapid identification of new cases and allow us to offer prevention strategies, such as vaccines, to those individuals at higher risk.”
The research indicates the virus has a median incubation period of seven days, although this can span as little as three days and as many as 20 days. The first symptoms are fever, lethargy and headache, with pox-like lesions appearing later on the hands, feet and genitals.
Unexpectedly, not all cases were found to develop widespread lesions. Thornhill said about 10% of cases only developed a single genital lesion, making the disease seem symptomatically similar to other sexually transmitted diseases. Thornhill warns of not confusing monkeypox for other diseases such as syphilis or herpes.
While it is important to stress the vast majority of currently confirmed cases have been likely attributed to close sexual contact, a small number of cases have emerged with unknown routes of transmission. The WHO report cites 72 confirmed cases of monkeypox in children, around a third of which are in infants under the age of four.
One particular case study, recently outlined in a Eurosurveillance report, discussed a child in the Netherlands who appeared at an emergency room with monkeypox. Thorough contact tracing could not ascertain how the child contracted the virus and the researchers hypothesized respiratory transmission may have played a role.
A statement from WHO Director-General Tedros indicated his PHEIC declaration is intended to focus a global response on the virus in the hopes this outbreak can be contained. The currently available smallpox vaccine is thought to be effective against monkeypox, and if supplies can be directed to the appropriate groups then monkeypox may be overcome.
"That means that this is an outbreak that can be stopped with the right strategies in the right groups,” said Director-General Tedros. “It’s therefore essential that all countries work closely with communities of men who have sex with men, to design and deliver effective information and services, and to adopt measures that protect the health, human rights and dignity of affected communities. Stigma and discrimination can be as dangerous as any virus. In addition to our recommendations to countries, I am also calling on civil society organizations, including those with experience in working with people living with HIV, to work with us on fighting stigma and discrimination.”
In many ways the declaration of a PHEIC is a largely symbolic gesture, but in reality it tends to bolster the WHO’s ability to bring assorted health agencies around the world together for a singular cause. The PHEIC process is relatively new, first developed following the 2002 SARS outbreak.
Since its formal institution in 2009, there have been seven PHEICs declared. The new declaration means there are currently three ongoing PHEICs: polio, COVID-19 and monkeypox.