Inaction on Monkeypox tells us Ireland is not prepared for the next pandemic

Last week, the World Health Organisation declared monkeypox a “public health emergency of international concern”, the highest alert that they can issue. The last time such a warning was given was in 2020 for Covid-19. Since the current monkeypox outbreak began in May, there have been almost 30,000 confirmed cases in 88 countries (just seven of these countries had reported cases of monkeypox before this outbreak) and already, almost 100 cases have been reported in Ireland.

Despite these ever increasing numbers and calls for action from activist groups, Ireland’s Minister for Health and the Health Service Executive (HSE) have remained largely silent on the topic. Lessons hard learned on surveillance, adaptability and communication during the COVID19 pandemic ready appear to be already forgotten.

Unlike Covid-19, monkeypox is an old disease. It is caused by a close relative of the smallpox virus and was first described in humans in the 1970s. It is endemic in parts of Africa and despite its name, has a natural reservoir in multiple species including rodents. Symptoms associated with monkeypox infection include high temperature, headache, skin lesions and a rash that often begins on the face and spreads to other parts of the body including the mouth and genitals. Many of those affected have described significant pain.

[ The Irish Times view on monkeypox: cause for vigilance ]

While it is rare for deaths to occur due to monkeypox, it is an infectious, disfiguring disease with significant economic implications as people infected by monkeypox are required to isolate for 3 weeks.

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Monkeypox is not airborne and so does not spread as easily as Covid-19; it primarily spreads through skin to skin contact with an infected individual, although reports also suggest transmission can occur through large respiratory droplets or contact with a surface previously in contact with an infected lesion. Close contact during sex is a big risk factor for infection and the virus has been found in semen. Although the present monkeypox outbreak was first identified in men who have sex with men, there is risk that, unless contained, it will spread to other groups.

Because the monkeypox virus is not as infectious or as dangerous as Sars-CoV-2, the situation initially appears not as bleak as it was with Covid-19. We already have an effective vaccine that provides good protection against monkeypox. The vaccine was originally developed for smallpox and drives cross reactive protective immunity as both viruses belong to the same family and are similar in structure; thus, antibodies induced by the vaccine can protect against both viruses. However, delivery of the smallpox vaccine the general population was discontinued in the 1980s after smallpox was eradicated, so the majority of people will not have any level of vaccine induced-immunity against monkeypox. Meanwhile, the US, France and many other countries have stockpiled smallpox vaccines in case of bioterrorist attacks using smallpox.

The monkeypox virus has been circulating for decades in West Africa, but has been under-researched and largely neglected

The National Immunisation Advisory Committee (NIAC) has recommended that vaccination be offered to those at highest risk of infection — specifically men who have sex with men, as 98 per cent of cases so far have been in this group. It would seem prudent to act as quickly as possible on this advice in order to prevent the virus spreading to the whole population. The HSE says it has been working on implementing NIACs advice but despite the recommendation having been made nearly 3 weeks ago, no details about when vaccine roll-out will start, who will be responsible for administering the vaccine nor where the vaccinations would take place have been provided.

While Ireland has stalled at the planning phase of the monkeypox vaccination strategy, other countries, including our French and British neighbours have opened mass vaccination clinics for people at risk of being infected. Over 14,000 people have already been vaccinated in France.

While we wait for monkeypox vaccination clinics to open in Ireland, targeted communication around potential mitigation measures is important. It is critical to inform everyone, particularly those most at risk, gay and bisexual men and provide updates of developments around the infection, vaccine procurement and plans for vaccine roll-out. Several posts on Twitter and other social media platforms by campaign organisations including ACT UP and HIV Ireland reveal the frustration experienced by these groups at the lack of relevant messaging from the HSE.

[ Kathy Sheridan: Monkeypox trajectory is starting to seem unsettlingly familiar ]

Isolation of infected individuals is key to limiting the spread of monkeypox. We therefore should consider offering appropriate financial support to infected individuals so that they can isolate without personal economic loss. Support was provided during the Covid-19 pandemic but has not yet been considered for those affected by monkeypox. If monkeypox was infecting other communities, might Ireland’s response be more urgent and supportive?

The monkeypox virus has been circulating for decades in West Africa, but has been under-researched and largely neglected. It is frustrating that it took its appearance in Europe and the US before attention began to focus on this virus. Had the vaccine been more globally available, this current outbreak might have been prevented.

The apparent inaction and poor communication around monkeypox raises important questions about Ireland’s ability to prepare and respond appropriately to future epidemics. The next causative agent might be as infectious as Sars-CoV-2, as surprising as monkeypox and way more dangerous. Let us imagine an antibiotic resistant E coli getting loose in our hospitals for example ...

So, as a nation, we need to be much more nimble, versatile, interdisciplinary, informed and globally interactive. We need a pandemic preparedness plan that uses evidence based strategies for communication, surveillance, research, vaccine development, vaccine procurement, vaccine production and vaccine administration. Such a plan should be deeply informed by ethical considerations so that the inequity currently experienced by several groups on our island and globally is constantly addressed.

Jamie Sugrue is a postdoctoral researcher in viral immunology at TCD. Cliona O’Farrelly is professor of comparative immunology at TCD