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The COVID lessons the U.S. still needs to learn to tackle monkeypox

COVID-19 and monkeypox are pretty different diseases. But the parallels between the nation’s yearslong, languishing response to the coronavirus pandemic and the emerging monkeypox outbreak are many – and potentially agonizing.

“Without even finishing the COVID pandemic, we’re already facing monkeypox,” said Dr. Caitlin Rivers, a senior scholar at Johns Hopkins University’s Center for Health Security and a founding member of the CDC’s Center for Forecasting and Outbreak Analytics.

Health secretaries declared both viruses to be public health emergencies, inviting greater coordination, pushing for more urgent action and freeing up more funding and resources at the federal, state, local and tribal levels. But despite all that, the U.S. response to the monkeypox virus (or MPXV) has been criticized in ways that are hauntingly familiar, said Dr. Saskia Popescu, an infectious disease epidemiologist and assistant professor at the Schar School of Policy and Government at George Mason University.

“We’re seeing a lot of Groundhog Day,” she said. “The lessons we thought we’d learned with COVID haven’t made as much of a difference as we would have liked.”

While COVID circulates through respiratory aerosols that linger in the air after someone coughs or sneezes, monkeypox is usually spread through close, physical contact, including sex, or shared clothes or bedding. When most of the confirmed MPXV transmissions were being identified among men who have sex with men, public health officials failed to work effectively with the LGBTQ community, Popescu said, just as they failed during the early days of coronavirus pandemic to include historically marginalized communities where infection rates, hospitalizations and deaths were disproportionately high.

Fumbled messaging around prevention and interventions created avoidable confusion over what people need to do to protect themselves and others, especially when explaining nuanced risk and infectious diseases, said Dr. Joshua Barocas, who studies modeling of social determinants of health and disparities at the University of Colorado.

From masks to vaccines to which patients are considered at risk, Barocas said some public health officials, including those in the federal government and at the CDC, used language that failed to acknowledge the unknown and what can happen when a highly dynamic virus shifts and changes the rules of engagement. That rigidity – sounding more sure of something than they really are – may serve short-term benefits, but in the long term, it can confuse and discourage the public from trusting updated advice, he said.

“When we speak in absolutes and don’t give ourselves wiggle room, we trap ourselves in the corner,” Barocas said. He said he fears the United States already has.

One grim reality of the competing crises is that the health care providers who are needed to protect the U.S. from these pathogens are exhausted, he said. While the Biden administration may tout bringing in more tests to detect MPXV and vaccines to prevent its spread, Barocas said, “​​you can’t run tests and you can’t provide treatment if you don’t have a workforce.”

That also fosters disparities, Barocas said, because the tools to avoid another pandemic are only effective if someone is there to deploy them. Otherwise, he said, they sit idle while people suffer, especially in Black and brown communities: “We’ve made all these things more available, but that does not mean we’ve made them accessible.”

Weakened by COVID, public health systems struggle to meet a second challenge

In mid-May, an ill patient arrived at Massachusetts General Hospital in Boston where he was diagnosed with a rare virus – monkeypox.

In a teleconference two days later, senior officials from the Biden administration and the public health sector offered an update, cautioning that “there could be additional cases in the coming days” with rising surveillance and testing, but the virus “appears to be a low risk to the general public at this time.” Officials on that May 20 call spoke of “stopping outbreaks at their sources.” Unlike COVID, the monkeypox virus “is not a new disease,” one official said, adding that vaccines, treatments and tests already existed to contain it and prevent further spread.

The U.S. last confronted a major monkeypox outbreak in 2003 – a time when American public health infrastructure had not yet been decimated by the coronavirus pandemic, workforce burnout and decades of budget cuts and lack of investment.

Back then, contact tracers quickly mapped out how the virus entered the country through imported pets. People in six states who were infected or exposed were identified, isolated and, if necessary, treated. In total, dozens of people got sick nationwide.

READ MORE: What are monkeypox symptoms? Here’s what you need to know

Today, more than 10,000 people in virtually every state in the U.S. have been infected with MPXV, according to the latest data from the Centers for Disease Control and Prevention. Confirmed cases in the U.S. alone are doubling every eight days, said Dr. Theresa Chapple, an epidemiologist and public health expert in Illinois. Epidemiologists say that estimate very likely undercounts actual infection rates.

People who are sick with monkeypox typically develop a painful, itchy rash on or near their genitals that can also appear on their hands, face, feet or chest, according to the CDC. Their symptoms also may include fever, muscle aches and headaches, swollen lymph nodes and fatigue. While few people have died during this latest outbreak, the virus can lead to blindness and severe scarring. And public health experts say this suffering can be prevented.

Compared to when COVID first began, there are fewer people today who are trained to stop those cases from overwhelming communities. Hundreds of public health workers have retired, been fired or resigned. Many of those people left state and local public health departments “due to burnout, due to treatment by the public, due to politicization of public health,” Chapple said.

“Now, we’re faced with something we should have been able to jump on and fix and slow and stop, but we can’t because we don’t have the people right now,” she said.

While the Biden administration has prioritized funds to bring people back into those roles, it’s not happening fast enough, according to Barocas. To him, it’s like the U.S. is back where it started two years ago.

“All that infrastructure is already there, and yet, we’ve squandered everything we’ve learned,” Barocas said.

What issues likely lie ahead

It is too soon to know how the U.S. will gain the upperhand on the MPXV outbreak, Rivers said, but more publicly available and transparent data could be “crucial” to help gain an advantage. In addition to investigating every positive case, Rivers said data about community transmission and vaccine distribution are vital to understanding how to locate the greatest needs and narrow the deepest disparities.

The CDC does not hold authority to release that monkeypox data – that belongs to public health leaders at the state and local levels. But just as with COVID, when that data is made public, it can help inform people’s decisions about the risks of navigating daily life. Above all else, “eliminating transmission within the U.S. should be our goal” for the U.S. public health infrastructure, Rivers said.

WATCH: As monkeypox cases rise, so do concerns about disparate access to care

Popsecu said U.S. health officials also still need to work with international partners “who have been working with monkeypox for decades.” In 1970, health officials diagnosed the first case of human monkeypox in the Democratic Republic of the Congo, according to the World Health Organization. Subsequent outbreaks largely have been confined to West and Central Africa, with the largest outbreak occurring in 2017 that included 500 suspected cases in Nigeria.

In the United States, greater coordination and integration could make a difference, said Dr. Luciana Borio, who directed medical and biodefense preparedness at the National Security Council and served as acting chief scientist for the Food and Drug Administration. After years of neglect and lack of funding at the state and local levels, Borio said it is not enough for the White House to install top-level leadership, she said. Instead, “you need to have strong components at every level of government.”

“At the end of the day, you can’t keep adding at the top,” she said. “The work happens at the departments and agencies, and really, it happens at the local level.”

Thinking about where the outbreak stands and where its current trajectory is heading, Chapple said her “brain goes to two different places.”

“We could either be turning a corner and making progress, or we could be further in the hole and have a horrible fall,” she said. “I have no idea.”

To stop this virus from becoming endemic, Chapple said public health officials need to relay messages in a way that the public doesn’t rest on a false sense of safety, assuming that only men who have sex with men remain vulnerable to MPXV infection: “This is the current landscape, but this doesn’t mean this is where it stops.”

A recent report of a daycare worker with monkeypox in Illinois exposing young children to the virus showed that people can also get sick through shared bedding and food utensils, highlighting that, “in an outbreak situation, information changes on a near-daily basis,” Barocas said.

Communication must be proactive, not reactive, while also being “concise and empathetic,” said Dr. Katelyn Jetelina, an epidemiologist and public health expert based in San Diego. That includes being honest about what we know – and don’t know – about the effectiveness of the MPXV vaccine: “In crisis communication, that’s really important, and was missed during COVID and is still being missed during monkeypox.”

“We need consistent messaging that shows this is evolving,” Barocas said, later adding, “We’re really lucky with monkeypox. We have tools. We need to draw from our COVID experience.”