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WHO declares monkeypox Public Health Emergency

“There’s clear risk of further international spread, although the risk of interference with international traffic remains low for the moment”

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Sign being carried during the Berlin Pride parade on July 23, 2022. (Washington Blade photo by Michael K. Lavers)

The World Health Organization’s Director-General Dr. Tedros Adhanom Ghebreyesus declared the escalating global monkeypox outbreak a Public Health Emergency of International Concern (PHEIC) on Saturday. This is an escalated status but below the requirements needed for a declaration of a pandemic, in part over its low death rates.

Currently, the vast majority of reported cases are in the WHO European Region. “WHO/Europe remains committed to partnering with countries and communities to address the outbreak with the required urgency,” Dr. Tedros said during a media briefing.

In laying out reasons for the declaration the WHO head noted; “We have an outbreak that has spread around the world rapidly through new modes of transmission, about which we understand too little,” Tedros said. “I know this has not been an easy or straightforward process and that there are divergent views.”

There had been reservations by the health agency’s expert committee who said the monkeypox outbreak did not yet amount to an international emergency in a meeting in June. Tedros had reconvened that committee in a special session this past Thursday.

“A month ago, I convened the Emergency Committee under the International Health Regulations to assess whether the multi-country monkeypox outbreak represented a public health emergency of international concern,” Tedros told reporters. “At that meeting, while differing views were expressed, the committee resolved by consensus that the outbreak did not represent a public health emergency of international concern.”

“At the time, 3040 cases of monkeypox had been reported to WHO, from 47 countries. Since then, the outbreak has continued to grow, and there are now more than 16 thousand reported cases from 75 countries and territories, and five deaths,” he added.

“In light of the evolving outbreak, I reconvened the committee on Thursday of this week to review the latest data and advise me accordingly. I thank the committee for its careful consideration of the evidence, and issues,” Tedros continued.

“On this occasion, the committee was unable to reach a consensus on whether the outbreak represents a public health emergency of international concern. The reasons the committee members gave for & against are laid out in the report we are publishing today.”

“Under the International Health Regulations, I am required to consider five elements in deciding whether an outbreak constitutes a public health emergency of international concern.”

“First, the information provided by countries – which in this case shows that this virus has spread rapidly to many countries that have not seen it before. Second, the three criteria for declaring a public health emergency of international concern under the International Health Regulations, which have been met. Third, the advice of the Emergency Committee, which has not reached consensus. Fourth, scientific principles, evidence and other relevant information – which are currently insufficient and leave us with many unknowns. Fifth, the risk to human health, international spread and the potential for interference with international traffic,” Tedros told the press laying out the foundation to his decision.

“WHO’s assessment is that the risk of monkeypox is moderate globally and in all regions, except in the European region where we assess the risk as high,” he said adding “There is also a clear risk of further international spread, although the risk of interference with international traffic remains low for the moment.”

“So 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.” The WHO chief then noted “For all of these reasons, I have decided that the global monkeypox outbreak represents a public health emergency of international concern.”

WHO Director-General Dr. Tedros Adhanom Ghebreyesu
(Photo credit: WHO)

Tedros then pivoted to WHO recommendations for the international public health community in addressing the outbreak.

“Accordingly, I have made a set of recommendations for four groups of countries: First [group], those that have not yet reported a case of monkeypox, or have not reported a case for more than 21 days. Second [group], those with recently imported cases of monkeypox and that are experiencing human-to-human transmission. This includes recommendations to implement a coordinated response to stop transmission and protect vulnerable groups; to engage & protect affected communities; To intensify surveillance & public health measures; To strengthen clinical management & infection prevention & control in hospitals & clinics to accelerate research into the use of vaccines, therapeutics & other tools; And recommendations on international travel. The third group of countries is those with transmission of monkeypox from animals to humans and the fourth is countries with manufacturing capacity for vaccines and therapeutics.”

Tedros acknowledged the work of the committee saying: “I thank the Emergency Committee for its deliberations and advice. I know this has not been an easy or straightforward process, and that there are divergent views among the members. “The International Health Regulations remains a vital tool for responding to the international spread of disease. But this process demonstrates once again that this vital tool needs to be sharpened to make it more effective.”

“Although I am declaring a public health emergency of international concern, for the moment this is an outbreak that is concentrated among men who have sex with men, especially those with multiple sexual partners,” he said. “That means that this is an outbreak that can be stopped with the right strategies in the right groups.”

“It’s therefore essential that all countries work closely with communities of men who have sex with men, to design & deliver effective information & services, and to adopt measures that protect both the health, human rights & dignity of affected communities,” Tedros said and then warned, “”Stigma and discrimination can be as dangerous as any virus.”

The WHO Director-General’s full statement is linked here: (WHO)

The Centers for Disease Control and Prevention released a statement saying that the agency was “supportive” of WHO’s emergency declaration and hoped it would galvanize international action to stamp out the outbreaks. The U.S. has reported more than 2,800 monkeypox cases and sent more than 370,000 vaccine doses to U.S. states reporting cases.

Speaking with reporters Friday, Jennifer McQuiston the Deputy Director for High Consequence Pathogens and Pathology at the Centers for Disease Control and Prevention said that two cases of the monkeypox virus have been diagnosed in children.

“We became aware of these cases just this week, and we’ve been working with the jurisdictions to understand more about these cases,” McQuiston said.

In a Washington Post Live session Friday, CDC Director Walensky, while discussing the highly contagious Omicron BA.5 coronavirus variant and the ongoing monkeypox outbreak, noted that the CDC was made aware of the cases adding that both children “are doing well.” 

McQuiston said that the agency determined that both cases were “likely the result of household transmission” and “had no contact with each other.”

The agency is now aware of at least eight cases in people who identify as cisgender women, McQuiston said. Most cases so far have been among men who have sex with men. The number of cases as of July 22 is a total of 2,891 in the U.S. in 44 states and territories including the District of Columbia.

“There is no evidence to date that we’re seeing this virus spread outside of those populations to any degree, and I think that the primary drivers for this infection in the U.S. remain in the gay, bisexual, and men who have sex with men communities right now,” McQuiston added.

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As monkeypox spreads, Delaware looks to expand vaccine access

Those exposed to virus prioritized in limited distribution

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(Image courtesy of the U.S. Centers for Disease Control and Prevention)

The Delaware Division of Public Health on Aug. 4 confirmed the fourth, fifth, and sixth cases of monkeypox in the First State. Less than a month after the state announced its first case of the virus, the spread of monkeypox in Delaware mirrors trends across the country in what the U.S. Department of Health and Human Services has now declared a public health emergency.

Three Delawarean men ages 42, 24, and 19 were diagnosed with the most recent cases of the virus — none of whom reported close contact with an individual diagnosed with monkeypox, and all of whom are now self-isolating.

In an Aug. 4 press release, DPH noted that it intends to expand vaccine distribution, offering vaccines to high-risk groups with or without exposure to the virus.

Currently, the state only offers post-exposure prophylaxis, vaccines implemented after an individual comes into contact with a virus. Those who have had direct contact with individuals with confirmed cases of monkeypox are currently prioritized in the state’s limited post-exposure vaccination.

Groups that might be prioritized upon increased vaccine access include individuals who have had intimate contact with someone diagnosed with monkeypox within two weeks, individuals with multiple sexual partners within three weeks, individuals who have had intimate contact through dating apps, parties or clubs, and individuals who are HIV-positive or are currently receiving pre-exposure prophylaxis for HIV, according to the news release.

Some researchers suggest current monkeypox cases are underrepresented in public health statistics nationwide. Although monkeypox has been declared a national health emergency, Delaware has yet to make a similar declaration on the state level. DPH noted that health officials will continue to monitor public health conditions.

DPH encouraged Delaware residents and visitors to avoid close contact with those who have symptoms related to monkeypox, limiting their number of sexual partners, and cleaning their hands with soap and water or hand sanitizer regularly. DPH also urged those experiencing symptoms associated with monkeypox to contact their health care provider immediately, make a list of intimate contacts in the last three weeks and self-isolate until symptoms subside.

For more information, individuals can contact the DPH hotline for monkeypox-related questions and concerns on weekdays from 8:30 p.m. to 4:30 p.m. at 866-408-1899, or email  [email protected]. Information concerning monkeypox prevention programs and resources can be found at de.gov/monkeypox.

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Biden names White House National Monkeypox Response Coordinators

Governors of New York, Illinois, California declare ‘States of Emergency’

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President Joe Biden meets with his national security team on July 1. (Official White House Photo)

The White House announced Tuesday that President Biden has named FEMA’s Robert Fenton as the White House National Monkeypox Response Coordinator and Dr. Demetre Daskalakis as the White House National Monkeypox Response Deputy Coordinator.

The president’s actions come as the governors of New York, Illinois and California have declared ‘States of Emergency’ as the case numbers of global cases of infection also caused World Health Organization’s Director-General Dr. Tedros Adhanom Ghebreyesus to declare the escalating global monkeypox outbreak a Public Health Emergency of International Concern.

The White House notes that Fenton and Daskalakis will lead the Administration’s strategy and operations to combat the current monkeypox outbreak, including equitably increasing the availability of tests, vaccinations and treatments.

Both men have extensive experience in infection disease outbreaks and response. The White House statement laid out their qualifications:

Fenton and Daskalakis combined have over four decades of experience in Federal emergency response and public health leadership, including overseeing the operations and implementation of key components of the Biden Administration’s response to the COVID-19 pandemic, and leading local and Federal public health emergency efforts such as infectious disease control and HIV prevention.

Both played critical roles in making COVID vaccines more accessible for underserved communities and closing the equity gap in adult vaccination rates, through the implementation and execution of FEMA mass vaccination sites in some of the country’s most underserved communities, and working with trusted members of local communities to build vaccine confidence.

Robert Fenton currently serves as Regional Administrator for FEMA Region 9 in the American West, with nearly 50 million people in his area of responsibility. One of the Nation’s most experienced and effective emergency management leaders, Robert Fenton has twice served as Acting Administrator of FEMA and led multiple challenging prevention, response and recovery operations throughout his long and distinguished career, including for natural disasters, disease outbreaks, and complex humanitarian operations. 

Demetre Daskalakis, a leading public health expert, is currently Director of the CDC Division of HIV Prevention. Widely known as a national expert on health issues affecting the LGBGQIA+ communities, his clinical practice has focused on providing care for the underserved LGBTQIA+ communities. He previously oversaw management of infectious diseases for the New York City Department of Health and Mental Hygiene, one of the largest departments in the nation – including in serving as incident commander for the City’s COVID-19 response.

Both the U.S. Secretary of Health and Human Services and the President’s chief medical advisor issued statements applauding Biden’s actions.

“We look forward to partnering with Bob Fenton and Demetre Dasklalakis as we work to end the monkeypox outbreak in America,” said HHS Secretary Xavier Becerra. “Bob’s experience in federal and regional response coordination, and Demetre’s vast knowledge of our public health systems’ strengths and limits will be instrumental as we work to stay ahead of the virus and advance a whole-of-government response.”

“Bob Fenton and Dr. Daskalakis are proven, effective leaders that will lead a whole of government effort to implement President Biden’s comprehensive monkeypox response strategy with the urgency that this outbreak warrants,” said Dr. Anthony Fauci, Chief Medical Advisor to the President. “From Bob’s work at FEMA leading COVID-19 mass vaccination efforts and getting vaccines to underserved communities to Demetre’s extensive experience and leadership on health equity and STD and HIV prevention, this team will allow the Biden Administration to further accelerate and strengthen its monkeypox response.”

The Centers for Disease Control and Prevention as of Monday reported that there were 5,811 confirmed cases of the monkeypox virus in the United States.

Statement from GLAAD President and CEO Sarah Kate Ellis:

“The White House appointments today reflect the seriousness of the monkeypox (MPV) outbreak and should be a call for all appropriate federal and state officials to urgently commit necessary resources to educate the public and counter MPV. We must get more vaccines to vulnerable people, especially sexually active gay and bi men, and accelerate all efforts to inform the public to track, test, treat and contain this virus as quickly as possible. Bob Fenton’s experience shows this can be done. Dr. Demetre Daskalakis is a longtime LGBTQ and HIV health advocate whose work will be critical to ensure the federal government responds to the needs of the medical community and the LGBTQ community in equitable ways.”

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With time, the Monkeypox vaccine provides good protection

In clinical trials, recipients who were HIV negative had an 83 percent immune response 28 days after one dose compared to 98 percent with two doses at 42 days.

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A review of academic literature published in the Journal of Internet Medical Research last year determined, when it comes to information about health topics, social media is not the place to turn. (Unless you follow me, of course!) One study found 87 percent of health-related posts contain misinformation. More than 40 percent of posts about vaccines contain incorrect information.   

These findings are, perhaps, not surprising. But they are important to keep in mind as we doom-scroll for information about monkeypox. 

I’ve already seen a number of posts on Twitter claiming to have monkeypox breakthrough infections after vaccination. One author said they developed a monkeypox rash two weeks after vaccination. While this person’s experience was not likely a breakthrough case, the post brings up important questions. How much protection does a person have after being vaccinated and when? And, as some cities move to a one-dose regimen due to vaccine supply, what does research say about the number of doses needed to protect a person?

Monkeypox rashes and lesions can take up to three weeks to develop after exposure to the virus, which means it is possible the Twitter user mentioned above was exposed before vaccination or shortly after. The time following vaccination and when you are exposed to the virus matters in terms of the amount of protection you have. 

Simply put: vaccines do not offer protection immediately after being administered. Remember what we learned when getting our COVID-19 vaccines: no matter which vaccine you received, you were not fully protected until two weeks after the final dose. For the monkeypox vaccine the time to protection is actually longer. Clinical trials indicated it takes up to four weeks for patients to develop strong protection. In fact, two weeks after the first dose, the immune response was just 29 percent! Take extra care during this period to prevent spread.  

Now, what about one dose versus two? With limited monkeypox vaccine supply, cities and states should consider limiting doses to one per person to protect more people.

The U.S. Food and Drug Administration (FDA) approved a vaccine, Jynneos, developed by the U.S. government and Bavarian Nordic in 2019 to protect against both monkeypox and smallpox. The FDA recommended a two dose regimen, four weeks apart. This regimen outperformed an older smallpox vaccine (ACAM2000) for producing an immunological response. The Jynneos vaccine also has fewer side effects and is much safer.

Unfortunately, the Jynneos vaccine is in very short supply. Bavarian Nordic, the only manufacturer of the vaccine worldwide, says it can produce 30 million doses of Jynneos annually, meaning with a full regimen less than 15 million patients worldwide will have full protection. That’s why cities like Washington, D.C. and New York have chosen to move to a single-dose regimen. The United Kingdom and some countries in Europe have done the same.  

This approach is the right one. 

In clinical trials, recipients who were HIV negative had an 83 percent immune response 28 days after one dose compared to 98 percent with two doses at 42 days. HIV positive recipients had a 67 percent immune response 28 days after one dose. It was 96 percent 42 days after two doses. 

While that data indicates a two-dose regimen is best, with supplies limited, a one-dose regimen for most people is a reasonable approach. That strategy allows double the group of individuals to be immunized — even though there is slightly lower efficacy. A recent article in Science highlighted this important point. Jynneos’ CEO, an immunologist, said one dose of the vaccine conferred a “robust immune response.” 

There is one caveat, however. Based on the clinical trial data, we might need to stick with the original two-dose regimen for people who are immunocompromised or live with HIV (irrespective of immune status).

In the face of what appears to be a public health system in disarray, Americans need to be partners in fighting the virus’ spread. Get vaccinated when available. Individuals who are most at risk should sign up now to receive a vaccine. Second, understand it takes time after receiving the vaccine to develop immunity whether you are HIV positive or not. Understand monkeypox symptoms, the timing of symptoms and how to reduce your risk. And, of course, take care when it comes to social media. Spread truth.

Dr. N. Adam Brown is a practicing emergency medicine physician, founder of a healthcare strategy advisory group ABIG Health, and a professor of practice at the University of North Carolina’s Kenan-Flagler Business School. Previously he served as President of Emergency Medicine and Chief Impact Officer for a leading national medical group. Follow him on Twitter @ERDocBrown.

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