As the World Health Organization’s emergency committee met on Thursday to consider whether to declare monkeypox a global crisis for the second time in weeks, some scientists said the striking differences between outbreaks in Africa and developed countries would complicate any coordinated response.
African officials say they are already treating the outbreak on the continent as an emergency. But experts elsewhere say the mild version of monkeypox in Europe, North America and beyond makes it unnecessary to declare a state of emergency, even if the virus is unstoppable. British officials recently downgraded their assessment of the disease because it was not serious enough.
“I remain concerned about the number of cases being reported in an increasing number of countries,” WHO Director-General Tedros Adhanom Ghebreyesus told the emergency committee during its meeting.
He said it was “good” to note a decline in monkeypox cases in some countries, but that the virus was still on the rise elsewhere and that six countries had reported their first infections last week.
Monkeypox has established itself for decades in parts of central and western Africa, where diseased wild animals occasionally infect people in rural areas in relatively contained outbreaks. The disease has been circulating in Europe, North America and beyond since at least May among gay and bisexual men. The epidemic in rich countries was probably caused by sex at two raves in Spain and Belgium.
Some experts worry that these and other differences could deepen existing health inequalities between poor and rich countries.
There are now more than 15,000 cases of monkeypox worldwide. While the United States, Britain, Canada and other countries have bought millions of vaccines, none have gone to Africa, where a more severe form of monkeypox has already killed more than 70 people. Rich countries have yet to report any deaths from monkeypox.
“What’s happening in Africa is almost entirely different from the outbreak in Europe and North America,” said Dr. Paul Hunter, a professor of medicine at Britain’s University of East Anglia who previously advised the WHO on infectious diseases.
The UN health agency said this week that outside of Africa, 99% of all reported cases of monkeypox are in men, and of those, 98% are men who have sex with men. However, the disease can infect anyone who is in close physical contact with a monkeypox patient, regardless of their sexual orientation.
“There are men in these very active gay sex networks who really, really don’t want people to know what they’re doing, and they don’t always know who they’re having sex with,” Hunter said.
Some of these men may be married to women or have families who don’t know about their sexual activity, which “makes contact tracing very difficult and even things like asking people to come in for testing,” Hunter said, explaining why vaccination may be the most effective way to stop the outbreak.
This is probably not the case in Africa, where limited evidence suggests that monkeypox is primarily transmitted to humans from infected animals. Although African experts acknowledge that cases may be underreported among gay and bisexual men, given limited surveillance and stigmatization of LGBTQ people, authorities rely on standard measures such as isolation and education to control the disease.
Dr. Placide Mbala, a virologist who directs the global health unit at Congo’s National Institute for Medical and Biological Research, said there are also notable differences between patients in Africa and the West.
“We see here (in Congo) very quickly, after three to four days, visible lesions in people who have contracted monkeypox,” Mbala said, adding that a person with so many visible lesions is unlikely to go outside, preventing further transmission .
But in countries including the UK and the US, doctors have seen some infected people with just one or two lesions, often on the genitals.
“You wouldn’t notice it if you’re just with that person in a taxi or a bar,” Mbala said. “So in the West, people without these visible lesions can silently spread the disease.”
He said different approaches are likely to be needed in different countries to stop a global outbreak, making it difficult to adopt a single worldwide response strategy, such as for Ebola and COVID-19.
Dr Dimi Agoina, a professor of medicine at Nigeria’s University of the Niger Delta, said he feared the world’s limited supply of the vaccine would lead to a repeat of the problems experienced during the coronavirus pandemic, when poor countries were left empty-handed after rich countries stockpiled most of the doses.
“It doesn’t make sense to just control the outbreaks in Europe and the Americas because you will still have the (animal) source of the outbreak in Africa,” said Ogoina, who sits on the WHO’s monkeypox emergency committee.
U.S. officials said this week that more than 100,000 doses of the monkeypox vaccine will be shipped to the states in the next few days, and several million more will be ordered in the coming months. So far, more than 2,000 cases have been reported in the US, with hundreds more being added every day.
Some American health experts have begun to question whether the outbreak has become widespread enough to make monkeypox a new sexually transmitted disease.
Declaring monkeypox a global emergency may also inadvertently exacerbate the vaccine hype, even though the disease is mild in most countries.
Dr. Hugh Adler, who treats monkeypox patients in Britain, said there are not many serious cases or infections, except among gay and bisexual people. However, he said it was disappointing that more vaccines were not available as the outbreak in the UK was doubling roughly every two weeks.
“If reclassifying monkeypox as a global emergency makes (vaccines available), then maybe that’s what needs to be done,” he said. “But in an ideal world, we should be able to make the necessary interventions without declaring an emergency.”