Deep into their third year of fighting the COVID-19 pandemic, local and state public health workers are battered, depleted and, in many places, demoralized.
And now, they face a rapidly spreading new virus: monkeypox. The response requires delicate political maneuvering and already has run into shortcomings in testing, vaccines and anti-viral treatments — similar to the experience with COVID-19.
Some public health authorities worry about the continued ability of an exhausted and perennially underfunded public health system to meet multiple threats at once.
“Our staff is very professional and dedicated, and they are going to do what needs to be done,” said Patrick McGough, CEO of the health department in Oklahoma City and Oklahoma County. “Right now, our capacity is good, but like anything, if it gets overwhelming, if we have two or three things going on at the same time, it could get dicey.”
Echoing the early days of the COVID-19 pandemic, demand for monkeypox vaccine doses far outstrips supply, appointments have been difficult to get, and money and personnel have had to shift from other priorities. Public health workers face the additional challenge of warning the people most at risk for monkeypox without neglecting a wider public that is far from immune to the danger.
As of Wednesday, the U.S. Centers for Disease Control and Prevention reported just under 3,600 cases in the United States, almost all of them among gay and bisexual men, with outbreaks in all but a handful of states. Alarmed by the quick spread of the virus to dozens of countries in just a matter of weeks, the World Health Organization last week took the unusual step of declaring the virus a “public health emergency of international concern,” a designation it rarely confers but now has done three times in two years: for polio, COVID-19 and now monkeypox.
Monkeypox is generally not lethal but causes lesions — often quite painful — along with rashes, swollen lymph nodes and flu-like symptoms, including fever, chills, headaches and exhaustion.
While anyone can be infected by monkeypox, 97% of reported cases are among gay and bisexual men and other men who have sex with men, said Dr. Ashish Jha, the White House COVID-19 response coordinator, at a news conference Friday alongside officials from the Department of Health and Human Services and the CDC.
As of that date, Jha said, eight cisgender women and five transgender men had contracted the virus as well as two young children who were exposed through others in their households.
Jha said the Biden administration was considering following the World Health Organization’s lead and declaring monkeypox a public health emergency. The Washington Post reported that earlier this month, the White House privately informed Congress that it may need nearly $7 billion to address “the scope and urgency of the current situation.”
In the early going, the U.S. response to monkeypox has been hindered by some of the same problems as its initial COVID-19 approach.
That has been particularly true with the shortage of vaccine doses. All monkeypox vaccines are distributed from the Strategic National Stockpile, a federal storehouse of critical medicine and medical equipment available to the states during public health emergencies when supplies are otherwise limited or unavailable. The federal government is distributing the vaccine to the states using a formula that takes into consideration population and caseload.
As of last week, the federal government had shipped more than 310,000 doses of the vaccine, which was developed for smallpox, a closely associated virus. Patients need two doses, though because of the limited supply, some areas such as New York City are giving out only one dose for now to reach more people.
“I don’t have enough vaccine to get to people in an urgent way, in an equitable way,” Dr. Ashwin Vasan, health commissioner for New York City, said at a panel discussion earlier this month. “And so, we’re doing what we can with what we have and it’s not good enough for the demand we’re seeing. Appointments are getting snapped up, thousands, in 10 minutes.”
He acknowledged at the meeting that the city’s rollout of the vaccine had been rocky, with glitches on the website for making vaccine appointments. He said the city was working on improvements.
Gay rights advocates as well as health officials have complained that at least in the early going, New York City has not received vaccine dosages commensurate with the city’s outbreak. Nearly a third of monkeypox cases in the United States have been recorded in the city.
Other jurisdictions report shortages in vaccines.
“We received 250 doses, and that was gone in about three days,” said Dr. Kenneth Mayer, medical research director at Boston’s Fenway Institute, which provides medical care for the LGBTQ+ community. “Clearly, there are a lot of unmet needs.”
Jha said production of the vaccine by the Denmark company that manufactures it is ramping up. He expects the federal government soon will be able to distribute more than 700,000 additional doses.
As in the early COVID-19 days, monkeypox testing also been in short supply, likely resulting in a large undercount of cases. While only about 6,000 people could be tested after the first appearance of monkeypox in the United States in May, there is now the capability of testing 80,000 people a week, as more public labs and commercial labs are now receiving tests for analysis, Jha said.
Patients also face difficulty getting the one effective anti-viral treatment, known as TPOXX, that can treat the infection. There isn’t a shortage of the treatment in the National Stockpile, but because it is still in the testing phase and does not yet have approval from the Food and Drug Administration, providers are required to spend hours filling out forms to get the drug for their patients.
“The original documentation was over 90 pages long,” said Mayer.
Jha said at the news conference that the federal government was aware of that problem and was working to reduce the paperwork.
Jha expressed confidence that monkeypox could be contained. But local and state public health officials still worry about their capacity to respond to another public health emergency with COVID-19 on the rise yet again and public health still lacking resources despite big federal outlays during the pandemic.
“As for the workforce, people are getting tired, they are exhausted,” said Anil Mangla, epidemiologist for the health department in Washington, D.C.
When a new outbreak occurs, because of limited resources, public health agencies often must shift personnel from one need to another. David Harvey, executive director of the National Coalition of STD Directors, said he is witnessing that now, as health departments are moving staff from diseases such as syphilis and chlamydia to monkeypox to do the outreach, contact tracing and vaccine campaigns that are mounted in the face of new infections.
“Right now, monkeypox is taking priority and other [sexually transmitted infections] are getting limited attention,” Harvey said. “It’s tough going out there.”
While Congress has invested heavily in public health during COVID-19, federal funding has fallen into a familiar boom-or-bust cycle over the past few decades. In a crisis, the federal government sends money to address a specific crisis, but once the emergency ends, the money runs out and local and state agencies limp along with shoestring budgets until the next crisis.
“We have built our COVID response on the basis of emergency funds from the federal government,” New York City’s Vasan said this month during the panel discussion. “What we really need is a sustainable, well-funded, permanent public health infrastructure.”
Federal public health funding is often directed toward specific diseases, which prevents state and local health officials from using it to meet the need of the moment as it arises, said Meredith Allen, vice president for health security at the Association of State and Territorial Health Officials.
“If the funding is disease specific, it makes it difficult to deal with the next thing,” said Allen. “And the next thing will always come.”
Messaging: ‘It’s Tricky’
While much of the monkeypox response echoes the early COVID-19 days, public health officials face a different messaging challenge with the new virus.
Epidemiologists say the monkeypox virus is generally spread through skin-to-skin contact or through material, such as blankets and towels, that have touched lesions. It also may spread through particles expelled in respiration. Although monkeypox DNA has been detected in semen, it is not clear that it can be transmitted through those bodily fluids. That is why at present, the National Coalition of STD Directors is not calling monkeypox a sexually transmitted disease.
“We’re calling it a sexually associated infection,” said Harvey, the organization’s executive director.
That the overwhelming number of cases involve gay men has challenged state and local public health officials to strike a difficult balance in their response, particularly in their outreach. They want to educate the population most vulnerable to the virus without stigmatizing them. But they also want to educate the larger public, without causing alarm, about an infection that could afflict anyone.
“It’s tricky,” said Allen. “You want to be broad enough so you don’t miss cases, but you also need to be targeted enough to reach populations that are at elevated risk levels.”
But many in the LGBTQ+ population worry that monkeypox will be used by homophobic critics to stigmatize a community that already feels threatened, said Jason Cianciotto, vice president of communications and public policy for Gay Men’s Health Crisis, a New York City-based organization focused on the health of gay men.
“There was already tremendous fear and anxiety as our community is under attack in a way I haven’t seen since states were passing anti-marriage constitutional amendments,” he said.
Some LGBTQ+ advocates and public health experts have complained that some messaging by health agencies and media is too generalized, failing to identify who is most at risk and potentially missing those who are most vulnerable to the virus.
Local health officials, however, dispute that, saying they are using multiple means to reach men who have sex with other men.
“We are using a variety of ways of messaging, through nonprofits, social media, press releases, and, most importantly, we are going to events where there are a large amount of gay men,” said Mangla of Washington, D.C.
The city this week recorded 139 monkeypox cases, more than all but a handful of states.
At the panel discussion earlier this month in New York City, Vasan said his agency was targeting its monkeypox education to bars, clubs and massage parlors patronized by gay men, holding roundtables with community organizations and activists and handing out cards with information about the virus. He said the department had sent bulletins about monkeypox to more than 100,000 medical providers.
The need for that targeted outreach is clear, said Dr. Philip Huang, director of Dallas County Health and Human Services. He said many of the 52 cases in Dallas have been traced back to this year’s Fourth of July Daddyland Festival, “where thousands of men come for parties, dance events and pool parties where there is a lot of skin to skin and sexual contact,” he said.
He emphasized, though, that it’s not because of their sexual orientation that gay men are getting monkeypox in higher concentrations; it’s because many engage in behaviors that put them at higher risk of contracting the virus.
“There’s no predisposition for that population to get this,” he said, "but because of events like these, this is where we are seeing the cases."