Monkeypox, a relative of smallpox, is spreading at unnerving rates and in unprecedented places, including the US. More than 1,500 cases have been registered in over 30 countries, including in at least 17 US states and the District of Columbia. However, the biggest worry for Americans is not the disease: It’s that our response to it shows how little we have learned from Covid, and how much there is still to do to limit the risks from future pandemics.
An important early governmental failing in the Covid outbreak was the delay in facilitating testing. This blinded medical and public health experts to the proliferation of the virus in the crucial early months. Had interventions that were eventually adopted been implemented just a week or two earlier, they could have saved tens of thousands of lives.
The response to monkeypox has hardly been better. Testing for monkeypox is exclusively assigned to the Laboratory Response Network, which was established by the Centers for Disease Control and Prevention in 1999 and has members in most states and many military and federal facilities. However, most doctors have no idea how to access this network. When they do, they encounter a series of gatekeepers and a Byzantine system of online and paper-test ordering, sample packaging and shipping.
These failings are compounded by the CDC’s promulgation of excessively narrow case definitions. Clinicians and public health practitioners routinely secure testing only when a patient’s presentation corresponds with these definitions. Early on, doctors overlooked cases of Covid because the CDC’s definition required recent foreign travel by a patient as a prerequisite for testing. Now we have similarly focused narrowly in identifying signs and symptoms that warrant testing for monkeypox.
As a result, we are again flying blind into an emerging epidemic event, while using only a small fraction of our testing capacity. For example, official tallies last Friday counted 114 cases of monkeypox in Canada and 47 in the US. Either Canada has a per-capita incidence that is 20-fold higher than America’s, or the US is dramatically underdiagnosing cases compared with its neighbor to the north.
Officials need to move faster to detect and map the proliferation of new diseases through well-practiced surveillance efforts. This is especially important when, as with monkeypox, we have stockpiled effective vaccines that could be administered to people in contact with initial cases. Containment is possible, but only if cases are quickly identified. Rapid contagious proliferation cannot be contained by ponderous bureaucratic procedures.
We have never seen a global proliferation of monkeypox like this one. The mechanisms of its spread appear to be different from those in previous outbreaks, and clinical presentations are far from classic. But guidance to US doctors and public health officials continues to be rooted in historical understandings of the virus.
This too, regrettably, repeats our Covid experience. In 2020, historical bias and blind spots led the US to misjudge how Covid was being transmitted. Officials discounted aerosol infectivity, asymptomatic shedding of the virus, and transmission in children.
In health emergencies, the scientific community must adapt its behavior to be aggressively agnostic and inquisitive, it cannot be satisfied to presume that the past presages the future.
In addition, our understanding of transmission and our early warning of the disease would have been better, for both Covid and monkeypox, if the US participated more robustly in surveillance of diseases as they arise and spread abroad.
America’s health care and public health institutions must also increase collective vigilance for manmade biological threats. Poxviruses may be easily manipulated to enhance virulence and possibly transmission. Monkeypox is listed by the US government as a “select agent,” meaning that it may be particularly prone to use as a biological weapon.
But the initial national response ignored this risk, and several days passed before there was genetic-sequence data confirming that the outbreak was a probably a natural event ascribed to the more benign West African strain. Had this outbreak been the result of a foreign government or terrorist group spreading an engineered virus, America’s delayed recognition could have been catastrophic.
The US reaction to Covid was hobbled by early failings in communication — risks were downplayed, authoritative imparting of information was sparse, and misinformation was prevalent — that continue to influence the course of the pandemic today. The Covid response has been scattershot, with inadequate national leadership, federal bureaucratic competitions, stifled messaging from experts, uncoordinated state responses, and health-care agencies and corporations struggling to develop and adapt their own policies. So it has been with monkeypox.
Covid has killed more than a million Americans. Monkeypox may not kill a dozen. But the potential for an emerging poxvirus to become endemic should not be taken lightly, particularly before we have a full understanding of the epidemiological and clinical implications.
The first rule in handling health emergencies — and all potentially dangerous large-scale situations — is to assume the worst. Second, invoke procedures that are well rehearsed. Third, identify a leader and establish a unity of effort under that person.
Emergency responders, air-traffic controllers, nuclear regulators, military commanders and others recognize that success depends on such routinized practice, situational awareness, systematic processes, clear lines of authority, quick decisions and rapid absorption of lessons from previous failures. We have not learned these lessons for health emergencies.
The West African strain of monkeypox now circulating is familiar. America has stockpiles of vaccines. Traditional strategies of testing, contact tracing, isolation and vaccination may eventually contain the outbreak. But the bad habits manifested in the response to this virus put Americans at risk for other emerging infectious diseases that are inevitably coming.
Do we need another disaster like Covid before we bring the nation’s health security up to a standard that truly protects Americans’ health?
Bloomberg
