Was the response to monkeypox a success?

The viral disease that infected a number of people across various countries caused significant alarm for its potential to spread rapidly. However, with case numbers now under control, Ben Hargreaves takes a look at what lessons can be learnt from the outbreak.

The Public Health Emergency that was declared in the US due to the spread of the monkeypox virus, now known as mpox, ended on the 31st of January. The US Department of Health and Human Services (HHS) secretary, Xavier Becerra, announced at the beginning of December 2022 that the department would not seek to extend this period of emergency against the infectious disease. Instead, the US government would continue “working closely with jurisdictions and partners to monitor trends, especially in communities that have been disproportionately affected.”

At its height, the virus had been reported to have caused infections in more than 50 countries across five regions, with the US alone seeing nearly 30,000 cases, to date. There were fears that the mpox outbreak could lead to a pandemic, which could have been devastating, with the globe still recovering from the peak of COVID-19. Instead, the situation was managed through a combination of the availability of vaccines and work at the community level to protect those people most at risk.

Taking stock

It was almost exactly three years ago that COVID-19 was first detected. The 27th of December marked the UN’s first International Day of Epidemic Preparedness, where António Guterres, secretary general of the UN, stated: “COVID-19 will not be the last epidemic or pandemic humanity faces. As a global community, we must heed the harsh lessons of COVID-19 and make bold investments in pandemic preparedness, prevention, and response.”

In terms of how the global community could better prepare, Guterres outlined the broad requirements, which included better surveillance to monitor potential threats, more resilient health systems with universal health coverage, a well-trained, well-equipped, and well-paid health workforce, and more equitable access to life-saving technology. The latter point was one of the major challenges when COVID-19 arrived, as there were no suitable vaccines ready against the virus, a vaccine had to be developed quickly and production had to be scaled rapidly. 

Building a stockpile

The outbreak of mpox in May 2022, only two years after the emergence of COVID-19, acted as a test to apply the knowledge gained from the pandemic to counter an emerging threat. However, with mpox, there were some significant advantages from the beginning. The most important was the existence of vaccines and treatments that had proven efficacy against smallpox.

Jynneos (also known as Imvamune or Imvanex) and Acam2000 are both smallpox vaccines approved by the US Food and Drug Administration (FDA), while the former also holds approval in Europe. There also existed Tpoxx (tecovirimat), which is approved in both regions as a treatment for smallpox. The availability of these vaccines and treatments meant that they could be immediately tested for efficacy against mpox. As a result, authorities were able to quickly approve Jynneos as a vaccine for mpox, while Tpoxx had already received approval in Europe at the start of the outbreak, and now also holds compassionate use protocol in the US for non-variola orthopoxvirus infections, including mpox.

Phil Gomez, CEO of SIGA, which is the company behind Tpoxx, spoke with pharmaphorum, explaining how the mpox outbreak unfolded and what was learnt from combatting its spread. Gomez explained that one of the major lessons from both COVID-19 and mpox was in understanding the importance of being prepared, both for viruses that have been eradicated, and those that are not widely circulating. He continued to say that one of the best ways to achieve this is through strategic production and stockpiling of available treatments and vaccines.

“With a national stockpile in place, we were able to support a rapid response to distribute the treatment to patients under compassionate use protocol. The response to mpox also provided important insights about the importance of preparedness in response to a viral outbreak and reinforced the importance of a strategy for pandemic preparedness that includes developing and stockpiling treatments and vaccines for several families of viruses of concern,” Gomez stated.

Community outreach

However, one of the criticisms of the early response to the spread of mpox was the slow response directed towards the virus, particularly in regard to vaccinating those most at risk. Accompanying such claims were the suggestion that limited data collection, testing, and proper intervention allowed infections and deaths to rise, especially among vulnerable communities and racial/ethnic minorities.

Research published, which raised such criticisms, concluded, “the engagement with the LGBTQ community and racial and ethnic minorities must be supported at all stages of the response, from crafting and delivering prevention messages to developing national guidelines. This community engagement will be effective only if we create conditions in which communities are empowered to make decisions, provide recommendations, and manage resources.”

President Biden reacted by naming Robert Fenton as the White House National Monkeypox Response Coordinator and Demetre Daskalakis as the White House National Monkeypox Response Deputy Coordinator in August 2022. The appointment of Daskalakis, who is a physician and gay health activist, allowed the administration a direct line to the community most impacted, and the response team took action based on that feedback.

In an update provided in September, Daskalakis stated that the team had focused on making sure people received both doses of the vaccine against mpox. In addition, he outlined that the response team had adopted a similar approach used in encouraging uptake of PrEP (pre-exposure prophylaxis) that “increases who is eligible for vaccination and encourages vaccine providers to minimise the risk assessments of people seeking vaccine. Fear of disclosing sexuality and gender identity must not be a barrier to vaccination.” Due to these actions, and others, the number of cases of mpox in the US has fallen rapidly, down from over 450 cases per seven day daily average to the present situation of an average of two cases per week, as at the time of reporting.

A measure that may have escaped notice, but which was part of the campaign against mpox, was the renaming of the virus itself. The WHO recommended the name change from monkeypox, as a result of discussions with global experts because “racist and stigmatising language online, in other settings and in some communities, was observed and reported to WHO.”

Being able to target specific populations was difficult for COVID-19, due to the breadth of the population affected, but was also hindered by the deluge of misinformation that emerged during important stages of the pandemic. Guterres stated as much when describing the barriers to prepare against the next pandemic, stating “we must fight the scourge of misinformation and pseudoscience with science and fact-based information. A pandemic cannot be fought country by country. The world must come together. COVID-19 was a wake-up call. “

Overall, the mpox strategy can be deemed a success, though not a complete one, with case numbers being minimised in the US and Europe. However, experts continue to warn that the world must be prepared for the next epidemic or pandemic outbreak. When Gomez was asked how best to prepare for this situation, he responded that “countries should encourage and fund research that can lead to new treatments and vaccines for all virus families of concern. It is also important that countries have efficient distribution and emergency use authorisation plans and regulatory capabilities, and procedures that support rapid response to an emerging risk.”