The World Health Organization, faced with a new, rapidly spreading monkeypox epidemic, declared a health emergency of global concern on Wednesday. The last time the WHO made such a call was in 2022, when the disease was still known in English as monkeypox before health authorities, in response to complaints about the use of the word “mono,” recommended its current English name in 2022, mpox.
At the time, the outbreak ended up affecting nearly 100,000 people worldwide, mostly gay and bisexual men, including more than 32,000 in the United States.
This time, the WHO’s decision was prompted by a growing monkeypox crisis concentrated in the Democratic Republic of Congo. It has recently spread to another dozen African countries. If not contained, the virus could spread again around the world, experts warned.
On Thursday, Sweden reported the first case of a more deadly form of monkeypox outside Africa, in a person who had traveled to the continent. “Imported cases like the current one may continue to occur occasionally,” the country’s public health agency warned.
“There needs to be a concerted effort by all stakeholders, not just in Africa but everywhere,” Dimie Ogoina, a Nigerian scientist and chair of the WHO’s emergency committee on monkeypox, said Wednesday.
In Congo alone, 15,600 cases of monkeypox and 537 deaths have been recorded, most of them among children under 15, indicating that the nature of the disease and its mode of spread may have changed.
Here’s what you need to know.
Is this the virus we saw in 2022?
This is a different version of the monkeypox virus.
Monkeypox is a close relative of the smallpox virus. There are two main types: clade I, the version that is dominant in the Congo, and clade II, one form of which caused the 2022 global outbreak. (A clade is a group of genetically and clinically distinct viruses.)
Overall, monkeypox clade I is thought to cause more severe disease and have a much higher mortality rate, which is one of the reasons the WHO is sounding the alarm now. Authorities hope to contain this outbreak before it spreads to other continents.
At first, the infection may seem like a common respiratory illness, but later it develops into a rash on the mouth, hands, feet, or genitals. The virus spreads mainly through direct contact with the skin or fluids of an infected person, or with contaminated bedding and other objects.
Scientists learned during the 2022 outbreak that monkeypox can spread even in the absence of symptoms. In addition, the rash can be confused with other diseases such as measles or chickenpox, especially in young children.
Who is getting infected this time?
In the 2022 outbreak, monkeypox spread around the world primarily among gay and bisexual men. Behavioral changes in that community helped contain the virus, and vaccination then, or now, will help protect them.
Until recently, most cases in the Congo were due to eating contaminated meat or close contact with infected people and animals. But last year, scientists discovered a new subtype of monkeypox, clade Ib, which appears to spread from person to person primarily through heterosexual transmission.
Most cases have been observed in prostitutes, truck drivers and other transient workers.
“Sex is probably the primary driver, and then the secondary driver is close contact and households,” said Jay Varma, chief medical officer at SIGA Technologies, which makes tecovirimat, a drug used to treat monkeypox infection.
As with many other infections, most people with healthy immune systems are unlikely to become seriously ill from monkeypox. People with weakened immune systems, including those living with HIV, are at increased risk of severe illness and death.
Older adults, who tend to be more susceptible to infections, may at least be somewhat protected by their childhood smallpox vaccines, which were discontinued in the United States in 1972.
Most of the deaths in Congo have occurred in children under the age of 15, perhaps because their health may already be compromised by poor medical care, malnutrition and the many other pathogens they face.
Has the outbreak spread to the United States or Europe?
Many countries around the world, including the United States, have continued to have patients with clade IIb monkeypox, the version that caused the 2022 outbreak.
There have been about 740 cases of monkeypox in the United States so far this year, more than double the number at this time last year, according to the Centers for Disease Control and Prevention.
Only one case of the most severe clade I infection has been reported in Europe: in Sweden, in a person who had travelled to Africa. Other “imported” cases seem likely. But experts tend to worry more about community transmission.
“I don’t think the risk right now to Americans is high at all, but what this tells us is that we need to be vigilant,” said Trish Perl, an infectious disease physician at UT Southwestern Medical Center.
But past epidemics, including monkeypox, illustrate that an uncontrolled outbreak anywhere in the world can eventually spread everywhere, Varma said. Since December, the CDC has twice warned doctors and the general public to remain alert for signs of monkeypox.
“I think it’s just a matter of time before we start seeing cases in North America, Europe, etc.,” he said, referring to the deadliest viral subtype. “Unless we invest in disease control everywhere, we will continue to be at risk all the time.”
Will the monkeypox vaccine continue to protect?
Two doses of the Jynneos monkeypox vaccine should protect against all versions of the virus, experts said.
Jynneos, made by Bavarian Nordic, was used in 2022 in the United States and Europe. The vaccine, originally developed against smallpox, should protect against monkeypox and all other members of that virus family, said Boghuma Titanji, an infectious disease physician at Emory University in Atlanta.
Several studies have shown that antibodies elicited by the Jynneos vaccine wane and may be undetectable after a year. But other research has found that two doses effectively prevent severe disease, Titanji said.
In the United States, however, fewer than one in four people recommended for vaccination have received two doses.
“People were less interested in coming back and getting that second dose, or even starting the process of their vaccination,” Titanji said. “Maybe we will see an increase in the vaccination uptick, and this will serve as a reminder for people to come and get vaccinated.”
In 2022, the federal government provided the vaccines at no cost. Jynneos is already commercially available, and some insurance companies may cover the cost.
For some patients, the vaccines may prove too expensive, Perl said. If monkeypox cases were to increase, the U.S. government could again offer the vaccines for free, according to a federal official familiar with the situation.
Is the US prepared for another monkeypox outbreak?
Yes and no.
Scientists have learned a lot about the virus in 2022 and have identified vaccines and treatments. But they don’t fully understand how the deadliest virus in Africa is spreading, especially among children, or who is most at risk.
“This is quite crucial when designing a response strategy,” Titanji said.
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In the United States, few resources are devoted to fighting sexually transmitted infections, said David Harvey, executive director of the National Coalition of STD Directors.
Authorities have failed to address issues that hampered the response in 2022, including low vaccine uptake and “a scandalously underfunded STD public health system,” Harvey said.
“Today we are concerned about an outbreak of monkeypox,” he added. “We are already dealing with syphilis, and tomorrow there will be another outbreak of an STD.”
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