Monkeypox appears to be establishing itself as a prominent danger to high-risk populations such as children, immune-compromised people and pregnant women, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus warned.

Already, WHO said authorities confirmed cases involving two children in the UK and a child each in Spain, France and the Netherlands.

Tedros, however, defended last week’s decision by a WHO emergency committee not to declare monkeypox as a public health emergency of international concern (PHEIC). Only three of the 14-person emergency committee felt the outbreak should be declared an emergency, Tedros told a media briefing Wednesday. 

“While the emergency committee did not advise that the current outbreak represents a Public Health Emergency of International Concern, they acknowledged the emergency nature of the event and that controlling the further spread requires intense response efforts,” he said. “They advised that I should reconvene them quickly based on the evolving situation, which I will do.”

In contrast, the US Center for Disease Control and Prevention (CDC) activated its Emergency Operations Center (EOC) on Tuesday to ensure “an aggressive public health response” to the outbreak.

As of one week ago, the WHO reported there were 3,413 laboratory-confirmed cases of monkeypox and one death from the virus reported from among 50 countries, with 86% of the new cases occurring in Europe. The highest numbers of cases were reported in Germany, Spain and the UK.

In Africa, one death was reported in Nigeria. Though it has been hit with an outbreak since 2017, the nation reported more cases than usual this year.  

Vaccine shortage

Amid the public health crisis, the world has been grappling with a global shortage of vaccines that are effective against monkeypox. The nations that have them generally have limited supplies to fight a smallpox outbreak.

The only one that is licensed for use by adults against both monkeypox and smallpox –  Bavarian Nordic’s Jynneos vaccine – is in particularly short supply, and there is limited clinical data about its efficacy as the only evidence is from animal studies.

While more supply of Emergent BioSolutions’ ACAM2000 vaccine is available, it is only licensed for smallpox, has more side effects and cannot be used by immunocompromised people – including people with uncontrolled HIV.

Another vaccine called LC16m8 is licensed for smallpox – but only in Japan.

The US and Canada have made doses of the Jynneos vaccine available to health clinics for people with known exposures to the virus and those who are considered to be at “high risk,” which is currently defined as men who have sex with men with multiple recent sexual partners living in areas where there has been high transmission among this particular population.

The US CDC announced on Tuesday it had 56,000 doses available immediately, but that a further 240,000 would be available in coming weeks and 750,000 more by the end of August.

The CDC's initial priority for the available 56,000 #monkeypox vaccine doses is for close contacts of those with the virus. Also prioritized: men who have sex with men who have had multiple sexual partners in venues where the virus has spread or who live in high-spread areas. 3/ pic.twitter.com/wZdhnUaaBv

— Benjamin Ryan (@benryanwriter) June 28, 2022

There remains some concern, however, just as there has been with COVID-19 vaccines, that the monkeypox vaccines will be monopolised by wealthy countries that can afford them and corner the market.

Even Spain, which is facing the biggest outbreak in the world at present, has only been able to give 71 vaccines to close contacts, according to La Vanguardia. These were made available to Spain from the European Union’s smallpox response stockpile.

However, Dr Mike Ryan, WHO’s executive director of health emergencies, told the media briefing that countries such as the US that have vaccine stockpiles in case of smallpox have agreed to share these with other countries in need.

“But again, we must remember that these products have been licenced in the main for the use of smallpox,” Ryan cautioned. “In one case, they’ve been licenced for monkeypox but based on animal models, and, I believe, immuno-bridging data from the smallpox side of things.”

He called for more clinical data to be collected at the same time that vaccine use is expanded, as has been the case during the Ebola outbreaks. In particular, he says, there has been no evidence of the vaccine’s effectiveness in treating high-risk groups.

Four-step approach

Tedros also called on all countries facing monkeypox outbreaks to take a series of public health steps.

First, he said, surveillance of the virus must be increased through much more testing. The next step, he said, is to follow WHO best-practice guidance in managing their responses.

Third is to actively engage communities such as LGBTQI groups to educate people about how to protect themselves, he said. And the fourth step, he said, is “to provide equitable access to countermeasures, like vaccines and antivirals.”

Dr Ibrahima Soce-Fall, WHO’s assistant director-general for emergencies response, said monkeypox already is a “multi-country, multi-regional emergency,” with Europeans facing the high risk. He said WHO regions can activate emergency measures to address it.