Monkeypox — A sobering watchdog for pandemic preparedness and sexual health system capacity

Distribution of monkeypox cases by country during the 2022 pandemic.

From the Centers for Disease Control and Prevention.1 Data are as of October 17, 2022. The size of the circles reflects the relative number of cases in each country.

Between May and mid-October 2022, clinicians diagnosed more than 72,000 cases of monkeypox in 102 countries not normally affected by the virus (see map).1 This new pandemic has strained public health and healthcare systems already affected by Covid-19. It also highlights the lessons learned—and sometimes ignored—from HIV and Covid-19 and illustrates the inadequacy of sexual health infrastructure and pandemic preparedness in the United States.

In the current pandemic, we strongly believe that monkeypox should be considered a sexually transmitted infection (STI).2 Virus can be isolated from semen and rectal and oral fluids, and most patients have had anogenital or oropharyngeal lesions, often associated with HIV or other STIs.2,3 Whether monkeypox should be categorized as an STI is a controversial issue. Although recent epidemics of monkeypox in sub-Saharan Africa have been characterized by genital ulcers in some patients and a shift in the affected population from children to young adults, little attention has been focused on sexual transmission, despite calls by African researchers to investigate this issue.4 The virus is also transmitted through non-sexual contact with lesions, possibly through contact with the mucosa of infected individuals without lesions and, much less frequently, through fomites and perhaps respiratory secretions.

The general tendency to categorize infections as STIs or non-STIs is oversimplified. Many common STIs can be transmitted through nonsexual contact, and people with some STIs, such as syphilis, usually have nongenital lesions. Human papillomavirus, HIV, herpes, syphilis, and potentially gonorrhea are transmitted through modes of contact other than vaginal, anal, and oral sex. Conversely, many infections that are not usually classified as STIs can be sexually transmitted (eg, Shigella, Zika, and Ebola). The current monkeypox pandemic probably would not have occurred in the absence of sexual transmission—unlike recent outbreaks of Ebola or Zika, for example—and people can greatly reduce their risk of monkeypox by changing their sexual behavior. Therefore, we believe it is appropriate to consider monkeypox an STI, while recognizing that not every case is sexually transmitted and not every monkeypox outbreak is primarily gender driven.

Public health communications related to monkeypox proved equally controversial. The current pandemic is concentrated among men who have sex with men (MSM), including those who have HIV or use pre-exposure prophylaxis for HIV. Among US cases for which data are available, 98% were in people assigned male at birth, and 93% were in gay or bisexual men.5 Some public health officials and community representatives have expressed concern that reports highlighting the concentration of monkeypox in this population are stigmatizing. This fear is well-founded, given the widespread discrimination against MSM. However, both the HIV and Covid-19 pandemics have shown the need to provide the public with clear and accurate information that prepares individuals and communities at increased risk to protect themselves. Additionally, a commitment to providing complete and accurate information in partnership with affected communities is essential to maintaining public trust. The fight against HIV was shaped by leaders in the MSM community who demanded truth and transparency. We believe that the monkeypox pandemic similarly requires clear communication. Scientists must also be humble and communicate uncertainty. We don’t know how this pandemic will play out. Monkeypox can spread to other populations, including women from marginalized groups, or become endemic. Society needs to be aware of these possibilities and their implications.

Lessons from Covid-19 informed the monkeypox response. At the beginning of the monkeypox pandemic, access to care was limited by insufficient supplies of tests and vaccines, burdensome approval processes for testing, and burdensome documentation requirements to obtain treatment. Progress in addressing these issues has been rapid. Commercial laboratories have increased PCR testing for monkeypox, and federal agencies have lowered barriers to access to tecoxiramit. Many regions have strengthened components of their public health systems in the wake of Covid-19. Surveillance systems are better; communication within health departments and between health departments, the Centers for Disease Control and Prevention, health organizations, and the public has improved; many health organizations are better prepared for public health emergencies; and the infrastructure for vaccine management and administration is stronger. Although the supply of monkeypox vaccine in the United States was initially insufficient, the increase in intradermal immunizations, which require smaller amounts of vaccine than subcutaneous injections, expanded the effective supply.

Other lessons not learned. Pandemics have increased in frequency, severity and scale, but institutions in the public and private sectors remain ill-prepared for them. Research shows that the effects of pandemics tend to become concentrated over time in vulnerable and marginalized populations, thereby exacerbating inequality. Monkeypox cases in the U.S. are increasingly concentrated among blacks and Hispanics, but the United States has underinvested in developing and implementing innovative strategies to reach these groups early—the wise approach from economic, political, moral, and ethical perspectives. of disease control. It is also clear that the best biomedical tools, such as vaccines and antivirals, must be implemented alongside policies and programs that help people reduce risk and use these tools effectively. Yet politicians and communities are often slow to adopt these interventions.

Research and experience also show that protecting Americans requires support for pandemic prevention and control in low- and middle-income countries where most pandemic pathogens are emerging. But the United States has done little to strengthen surveillance systems and ensure equitable access to testing, treatment, and vaccines for monkeypox (and Covid-19) in such countries. Although high-quality data are needed to inform clinical and public health decision-making, the United States has not done enough to integrate research efforts with pandemic preparedness and response—a conclusion supported by the lack of definitive efficacy data as of the JYNNEOS vaccine as well as tecoxiramit, the primary biomedical interventions in monkeypox.

Finally, the US response to monkeypox has been hampered by an inadequate public health infrastructure. Public health agencies lack funding sources that can be deployed rapidly in an emergency for case investigation, contact tracing, disease surveillance, community vaccination events, and related activities. Emergency response requires a well-resourced, stable and well-trained public health workforce that can be mobilized quickly.

The new pandemic has also highlighted the inadequacy of the country’s sexual health infrastructure. Before the Covid-19 pandemic, the three most common reportable diseases in the United States were STIs. STIs resulted in nearly $16 billion in direct medical costs in 2018. In King County, our Sexual Health Clinic—the only one in the state—is the largest clinical center for the diagnosis and treatment of monkeypox in Washington State. We quickly scaled up vaccination activities to immunize approximately 350 patients per day, almost all of them MSM or transgender people. Many sexual health clinics across the country have taken similar initiatives. But many cities have virtually no dedicated sexual health services. This gap has implications that extend beyond monkeypox. This undermines our ability to address the rapidly increasing rate of congenital syphilis in the United States and prevents us from taking full advantage of scientific advances to control HIV.

Sexual health clinics are essential, but effective control of STIs requires integration of public health systems and approaches, the wider health system and the efforts of affected communities. Although women and children bear the brunt of the long-term consequences of STIs, infections such as HIV, syphilis, gonorrhea and monkeypox disproportionately affect MSM and transgender people. Addressing this discrepancy requires systematic questioning of all patients about their gender identity, sexual orientation, and sexual behavior; recording this information in searchable fields in secure electronic health records; and using the resulting data to provide high-quality STI care, including the delivery of vaccines, testing, treatment and re-exposure prophylaxis to people who need them. It also requires engaging with communities to reach Black and Latino MSM and forming partnerships to develop outreach activities and clinical infrastructure that meet the needs of the most affected populations.

The number of new cases of monkeypox in the United States and many other countries is now declining. But it is too early to declare victory. Public and private sector leaders must also learn from this new pandemic. Coming in the wake of Covid-19 and more than 40 years of HIV control efforts, the monkeypox pandemic is another signal event that underscores the urgent need to build and maintain public health and clinical infrastructure that strengthens pandemic prevention and response and allows us to effectively counter the growing STI epidemics.

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