On the heels of the World Health Organization (WHO) declaring the monkeypox outbreak a Public Health Emergency of International Concern, President Biden officially declared monkeypox as a national public health emergency on August 4th, 2022. The monkeypox outbreak comes in the midst of the co-occurring COVID-19 pandemic and the national opioid epidemic. With these ever-increasing public health needs and chronic underfunding of local health and state health departments, how does this new emergency public health declaration impact the public health system? Questions also arise regarding the challenges health departments are experiencing and the level of concern we all face.

What is monkeypox?

According to the Centers for Disease Control and Prevention (CDC), the monkeypox virus is very similar to the virus that causes smallpox but it is clinically milder and rarely fatal. The most prominent identifier of monkeypox is a rash that looks like pimples or blisters that appears on the genitals, anus, or other parts of the body (eg, hands, feet). Other symptoms may include: fever, chills, swollen lymph nodes, exhaustion, muscle aches, headache, and respiratory symptoms. These symptoms may appear prior to a rash, after the development of a rash (typically one to four days later), or may be nonexistent. After initial exposure to the monkeypox virus, the symptoms typically start within three weeks with the illness typically lasting between two to four weeks.

Monkeypox is not a new virus; rather, it was first discovered in 1958 with the first recorded human case in 1970. Monkeypox is spread through close, personal contact (eg, direct contact with monkeypox rash, scabs, or fluid, touching objects, or contact with respiratory secretions), direct contact during intimate contact, or pregnant women spreading the virus to their fetus from the placenta. The virus can be spread to others as soon as symptoms begin until the rash has fully healed with a fresh layer of skin.

How serious is monkeypox?

The current monkeypox outbreak went on radar in early May 2022 when cases began appearing in countries where the disease was not endemic. The first case in the United States (US) was recorded on May 17th, 2022. Since then, cases have been steadily increasing with over 15,909 monkeypox cases reported in the US as of August 23rd, 2022. This makes the current outbreak the largest in US history.

What challenges is the public health system experiencing?

Much like the challenges and flaws that have been present throughout the COVID-19 pandemic, there are current problems with politicization of the virus, slow response efforts, and a shortage of materials and staff needed to prevent, test for, and treat monkeypox. Yet, unlike COVID-19, monkeypox is not a new virus that requires new scientific advances in terms of vaccines, tests, and treatments.

Some smallpox vaccines that have been around for years, like JYNNEOS, are also approved for monkeypox. In fact, the US was supposed to be prepared for such an outbreak by having doses of the vaccine available in the Strategic National Stockpile. It was estimated that the US should have 132 million JYNNEOS doses on hand for 66 million at-risk people in 2019. However, over 20 million doses were left to expire in 2017 and the US only purchased just over 1 million additional doses in 2020. As a result, only about 2,400 usable doses for about 1,200 people were available at the start of the monkeypox outbreak. Chronic underfunding, mismanagement, and lackadaisical attitudes have made the US drastically unprepared for the monkeypox outbreak.

The limited supply of monkeypox vaccines means that only those at high risk of getting monkeypox or those with a confirmed case of monkeypox are eligible for the vaccine. Further, jurisdictions must request vaccines, with some not requesting their allocated amounts, some not receiving the amount requested, and others already at their allocated amount and still not meeting the demand. This means the demand for the vaccine is outpacing the supply and some areas will have quicker access than others. In response, the US Food and Drug Administration (FDA) issued an emergency authorization for the JYNNEOS vaccine to be delivered intradermally in an effort to increase the total number of doses available. The Biden-Harris Administration aims to keep expanding access to vaccines, increasing testing capacity, and engaging stakeholders.

There are also challenges in diagnosing monkeypox cases. Unlike a new COVID-19 specimen that can be shipped with cold packs for laboratory testing, a monkeypox specimen must be shipped with dry ice to preserve it. There is a current shortage of dry ice and not all facilities have dry ice on hand ready for shipment. The lack of resources means the shipping of specimens to laboratories can be delayed for days and can ultimately render the specimen unusable for testing and delay test result notifications.

This lack of resources is coinciding with a lack of staff availability. Epidemiologists who are already stretched thin from COVID-19 are having to balance the ongoing response while learning about and staying up-to-date with the status of the monkeypox outbreak. It also remains unclear what funding is available for monkeypox and how costs are being covered. The current shortage of supplies, the variation in local responses, and equity challenges hinder the ability of the public health system to respond to the monkeypox outbreak.

Even though some communities are disproportionately affected by monkeypox, such as men who have sex with men, anyone can get monkeypox. It is important for health departments to provide a balance of targeted communication and stigma reduction communication strategies. Yet, it does beg the question whether the slow and inadequate response to the monkeypox outbreak has occurred because the community disproportionately affected are those who identify as bisexual, gay, nonbinary, and transgender. This idea is supported by the longstanding historical neglect of the health needs of this community (eg, the AIDS crisis). One begins to wonder whether the federal response did not act fast enough nor at full capacity, and whether now it is too little too late to control the outbreak.

What does this mean for governmental public health?

The COVID-19 pandemic and the monkeypox outbreak have revealed deep systemic issues in our public health system. However, some of the mistakes and challenges that have been occurring during the COVID-19 pandemic can no longer be explained away by being blindsided by a virus that did not have a current vaccine or treatment. Vaccines and treatment for monkeypox were available, yet the US response has failed to contain the monkeypox outbreak. This further reveals that right now we must strengthen our public health system, invest in critical infrastructure, practice clear communication, and commit attention and resources to high risk communities and areas, including other countries, to be prepared for the next infectious disease outbreak. It was a crucial first step to make monkeypox a national emergency as it frees up federal money and resources; yet, to maintain any hope of containing the outbreak, testing still needs to be ramped up, antivirals need to be made more accessible, and the supply of vaccines needs to increase.

As for local and state-level health departments, they are scrambling to address the current monkeypox outbreak while still managing their COVID-19 response, addressing the opioid epidemic, and handling their foundational capabilities. Our public health system is strained with health departments overworked, understaffed, and underfunded. Even though there has been poor support from the federal government (eg, unclear communication, slow responses, and a lack of supplies), the local-level public health workforce must prioritize the timely reporting of case data and advocate for their community. The groups most at-risk simply cannot be ignored and they need to feel supported by their local health departments. Communication efforts cannot be avoided in fear of stigmatizing men who have sex with men but instead must be realistic and informative. Additional efforts also need to be made to inform and support individuals with monkeypox because isolating for up to four weeks is simply not feasible for most people. At every step of the way, health departments need to be there for every member of their community.

The US public health system was not ready to address the monkeypox outbreak, but this does not mean it is impossible to change and be prepared for the next infectious disease outbreak. The first, and the most crucial, recommendation to improve the public health system is to address its chronic underfunding by increasing investments in public health and strategically allocating this money. Public health funding must be proactive, rather than reactive, by addressing critical infrastructure, emergency preparedness, and foundational capabilities. However, political boundaries hinder the ability to increase public health funds. For example, the Biden-Harris Administration has recently called for billions of dollars of funding for pandemic preparedness but this has not been received by Congress. Investing in public health is a necessity to protect lives, but increasing public health spending is not an easy task to pass through Congress. 

Not only is funding a crucial component in maintaining and improving the public health system, but the system itself must be functioning in order to effectively use these funds. The second key recommendation is restructuring components of the public health system to address the systemic issues that have shown themselves throughout the COVID-19 pandemic and monkeypox outbreak response. A great example of this is the need to make changes within the Centers for Disease Control and Prevention (CDC). The CDC is a key organization involved in the distribution of public health funds, as well as preparedness and response programs. Dr. Walensky, the director of the CDC, has declared that the CDC needs to be overhauled due to the slow response and public mistakes (eg, problems with testing and communication) it made during the COVID-19 pandemic. She has admitted that the CDC must refocus itself on responding quicker during emergencies, prioritizing public health needs, and communicating with the public and state and local authorities. It will be a long, arduous process to improve the public health system, but addressing the problems and planning to make changes is the first step in the right direction. For right now, this means the public health system remains overworked and underfunded in the wake of the COVID-19 pandemic. Despite being ready or not, the response to the monkeypox outbreak must be enhanced in order to have hope of containing the outbreak.

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