Chandrakant Lahariya | Monkeypox’s challenge: It’s also an opportunity

On July 23, the World Health Organisation (WHO) declared the monkeypox disease as a “public health emergency of international concern” (PHEIC). This is the highest level of health alarm which the WHO is mandated to raise under International Health Regulations (IHR) 2005. The PHEIC is declared by the director-general of WHO based upon the recommendation of the IHR (2005) emergency committee. In the last 13 years, for a total of seven times, the WHO has declared diseases as PHEIC — swine flu H1N1 in 2009; twice for Ebola virus, first in 2014 and then in 2019; polio virus in 2014; Zika virus in 2016 and Covid-19 in 2020.

However, monkeypox was the first and only time that the IHR emergency committee had not advised yet the WHO director-general, who decided to designate it as PHEIC and is fully empowered to do so. This is also the first time that three PHEIC — polio since 2014, Covid-19 since 2020 and now monkeypox (2022) — are ongoing in parallel.

It is important to understand what makes a PHEIC. The answer is in the IHR (2005) definition of a PHEIC, which implies a situation that is serious, sudden, unusual or unexpected, that carries implications for public health beyond the borders of affected nations; and may require immediate international coordinated actions.

In this backdrop, since the reporting of the first case of the monkeypox disease on May 6, 2022 in the UK, the disease has spread to around 70 other countries outside Africa. Most of these countries had never reported monkeypox cases in their settings, until this year. Around 17,000 cases have been reported till now. This is the biggest outbreak ever of the monkeypox disease since it was first reported in humans in the 1970s.

The ongoing monkeypox outbreak situation clearly is sudden and unexpected and has implications beyond national borders and requires coordinated actions. Yet, the members of IHR emergency committee were split in opinion, and those not in favour of declaring it a PHEIC argued that the global risk remained “moderate” and unchanged in the past one month since the first meeting of the committee in June; and the majority of cases were in 12 countries; most cases in males having sex with men (MSM) and LGBTQ; severity of disease low and public health measures are effective in tackling the situation. Making such a decision and declaring a PHEIC can always attract controversies. The agencies entrusted with such decisions have the risk of being criticised. However, the benefit of declaring monkeypox a PHEIC are clearly greater.

The world is still struggling with Covid-19 — the disease declared as a PHEIC on January 30, 2020 and then turned into a pandemic — has somewhat worried people. Do we, at an individual level, really need to worry or panic about monkeypox? The short answer is “no”.

The first thing is that even though monkeypox has been declared as a PHEIC, all experts agree that the chances of it becoming a pandemic are very low. The reasons include that it is not a new virus. It was known for 50 years ago, and we have a reasonable scientific understanding of it. This disease spreads only through close personal and intimate “skin-to-skin” contact, so the rate of its spread is low. The monkeypox virus is stable and does not change (contrary to SARs CoV2, which has a high tendency to mutate and create variants). There are vaccines and medicines against the disease, which can be deployed.

A majority of symptoms of the monkeypox disease are similar to any other viral illness, including fever, body aches, muscle pain and backache. The two specific symptoms are pox marks or rash which occurs around face, neck and genitals; and the enlargement of lymph nodes/glands in the body. However, every individual with such symptoms does not raise suspicion of monkeypox. It should be suspected if the person has returned from travelling to a country affected by the disease; within country travel history to areas where cases have been reported or the person had come in direct contact with a confirmed monkeypox patient. Interestingly, while the disease is called monkeypox, it is not spread by monkeys. It was just that the virus was first detected in Copenhagen, Denmark, in a group of laboratory monkeys.

Going by the lackadaisical response of most countries to the epidemic and pandemic threats in the past, designating monkeypox as a PHEIC compels countries to take some necessary actions, coordinate with other countries and mandates them report to WHO about any new case immediately and about the actions taken. A PHEIC becomes a call for increasing financial and other resources to respond to the challenge. It also opens opportunities for TRIPS waivers for available vaccines and therapeutics which can be used against monkeypox.

As of now, the Central and state governments in India appear to be prepared for responding to the monkeypox emergence. However, India cannot be complacent, and it is a wake-up call and an opportunity for the governments to fulfil all health sector promises made during the Covid-19 pandemic period. The monkeypox as a PHEIC is also a reminder that though Covid-19 is on a receding path, we shouldn’t return to “business as usual”. Recognising the inevitably of epidemics and pandemics, there is a need for continuous efforts and measures to strengthen disease surveillance, early case detection and contact tracing, training of health workforce in emerging and re-emerging diseases, building the laboratory capacity, investing in research and development for vaccines and therapeutics; sustained international collaboration. More specifically, with the emergence of zoonotic diseases — diseases which spread from animals to humans — it is time for a “One Health” approach where coordinated actions are taken to protect the health of humans, animals and the environment.

India has a huge capacity for high quality, large volume and low-cost production of vaccines and medicines. It is also an opportunity for India to show global health leadership. The government should collaborate internationally and take the necessary steps for production of vaccines and medicines that can be used for monkeypox. That way, if and when needed, the vaccines and therapy would be easily available not only to our own population but also to other low-income and middle-income countries, including in Africa, where the monkeypox is endemic. In short, declaring a PHEIC does alter things much for ordinary people, but the responsibility and accountability of governments increases manifold, which is a “sine qua non” for the prevention of outbreaks, epidemics and pandemics.