The global spread of monkeypox, which has now reached more than 100 countries and caused nearly 60,000 confirmed cases, is like another round of “déjà vu.”
That was the assessment of Gregg Gonsalves, Ph.D., an associate professor of epidemiology at the Yale University School of Public Health and one of four global health experts speaking during a Sept. 15 panel hosted by the Duke Global Health Institute. Gonsalves described how lack of access to treatment and vaccines mirrors the inequities seen during COVID-19 and HIV/AIDS.
“We talk about neglected diseases, but we never say neglected by whom? That’s the crux of global health,” Gonsalves said during the event, part of DGHI’s Think Global series. “We can have the best medicines, the best tests, but it means nothing unless we get them in the hands of those who need access to them.”
The discussion, moderated by DGHI Director Chris Beyrer, M.D., explore the history of monkeypox, which was first identified among animals in Africa in 1958, and its recent emergence as a global health threat. Dr. Anne Rimoin and Dr. Dimie Ogoina, who have studied monkeypox cases in the Democratic Republic of the Congo and Nigeria, respectively, discussed the missed signs the virus was beginning to spread globally and recent changes in the disease’s epidemiology. The experts also emphasized the need for more equitable vaccine access to control the outbreak and discussed stigma surrounding the disease, which has spread predominantly among gay men in the United States.
Watch the full discussion below, or scroll down for highlights.
ABOUT THE SPEAKERS
Chris Beyrer (moderator) is the director of the Duke Global Health Institute and a professor of medicine in the Duke School of Medicine. He also serves on an ad hoc committee on monkeypox for the World Health Organization. He’s an expert on HIV/AIDS and infectious diseases epidemiology.
Gregg Gonsalves is an associate professor of epidemiology at the Yale University School of Public Health and co-director of the Global Health Justice Partnership. For more than 30 years, he’s worked on HIV/AIDS and other global health issues with several organizations.
Dr. Dimie Ogoina is an infectious disease physician at the Niger Delta University Teaching Hospital and a professor of medicine an infectious diseases at the Niger Delta University in Nigeria. He and his team at NDUTH diagnosed and managed the first case of monkeypox in Nigeria during an outbreak in 2017
Anne Rimoin is a professor of epidemiology at the UCLA Fielding School of Public Health, and the Gordon-Levin Endowed Chair in Infectious Diseases and Public Health. She’s an internationally recognized expert on emerging infections, global health, surveillance systems and vaccination.
On the nature of monkeypox and treatment disparities
“In the U.S. in 2003, we had a very limited outbreak, and it gave people a sense of we can control that. Fast forward to today, the cases globally are in places that have good diagnostics, and WHO (World Health Organization) has changed its definition of counting cases of monkeypox. It must be laboratory confirmed, but countries like the Democratic Republic of the Congo or others in the region may not have great surveillance, and the ability to test samples when they get them.”
“You just heard another global health disparity, which is testing and diagnostics; Nigeria hasn’t had access to the vaccine or antivirals at this point. Another issue we’ve learned with emerging infections, which was certainly true of COVID and HIV, is that the early period and response to a new outbreak is critical. You never get that early time back if you waste it.“
“We need to understand the natural history of monkeypox now that it has spread to the Global North, and a lot of things about this disease is changing. On the Nigerian outbreak, it was very unusual to see a transition of monkeypox, a condition known to affect predominantly young children now affecting young adults, mostly males.”
On public health responses in the U.S.
“Your health is up to you. Chris jokingly said earlier we don’t have a public health system in the United States, and that’s not far from the truth. This is an outbreak that we’ve been unable to contain. We think we have the tools because we have the most sophisticated health system in the world, but we can’t get our arms around HIV, Covid or monkeypox.”
“Our best opportunity to contain this monkeypox outbreak while it’s in our country is to look in our LGBTQ community. We’ve historically been a community with not a lot of vaccine hesitancy, higher rates of immunizations in Americans for Covid, and as Gregg said, there have been significant behavior changes in the gay community ,which is the reason why were’ seeing falling rates particularly in New York.”
On why global health officials weren't better prepared by past planning exercises
“One of the problems in terms of simulations is they don’t take into account different kinds of transmissions, and that’s the hubris we’ve had over and over again. I think our biggest problem with modeling some of this is we don’t have a good estimate of vaccine effectiveness. I hope this issue of hubris, in the future, is tempered a little bit.”
“I think it’s also important that simulation [helps with] understand an outbreak, ensure good readiness by health authorities or public health response teams. It’s important before simulations are applied in an epidemic response setting that stakeholders have a vote.”
On the limitations of contact tracing with monkeypox
“There’s a benefit to contact tracing, but the other problem, in this context, is we have a lot of anonymous exposures, asymptomatic transmission, so some of it is going to be complicated; there are limits. We can’t rest on contact tracing to take care of it because it won’t. I think the better way forward is to inform people of risks.”
“In the Nigerian context, there’s always a challenge of contact tracing relating to several factors, how people perceive the disease. [Some believe] monkeypox is not caused by a virus, but is a spiritual attack. And the stigma with sexual transmission is a challenge. Once you link the disease to sexual transmission, there’s a tendency for people to back out and become reluctant to tell you their sexual partners. That’s a challenge clinicians need to address with contact tracing.”
“We just did a paper on monkeypox and college campuses. The most important thing was getting people tested and to isolate. Even on a campus where you could do contact tracing, the biggest thing was getting people to come forward and getting tested."