New York State and City, respectively, have declared an Imminent Threat to Public Health (ITPH) and a public health emergency to combat the ongoing monkeypox outbreak. New York officials had to act because the city has become the epicenter of this new epidemic, and the federal response to a virus that could have easily been contained has been so anemic.

Monkeypox disease was first reported in humans in 1970, but prior to this past May, human monkeypox cases were seldom reported outside of Africa unless these people were travelers from endemic areas in West or Central Africa. In the current monkeypox outbreak, though, nearly all the cases and sustained chains of transmission are in countries that have not historically reported monkeypox. It appears that in nearly all cases, transmission has occurred through sexual activity between men.

The current tally is 23,351 confirmed cases and eight deaths in 83 countries, with 89 percent of cases concentrated in just 10 countries. The U.S. has the dubious distinction of being the world leader.

The CDC reports 5,800 U.S. cases, highly concentrated in a few areas. New York State accounts for a quarter of the nation’s cases (1,390), and nearly all those cases (94 percent) are in New York City. The metropolitan areas of Westchester, Nassau, and Suffolk Counties account for another 5 percent of New York State’s total. California ranks a distant second (827) among states, with the balance of cases concentrated in just a few others. Twenty-three states and Puerto Rico report 20 or fewer cases in each, and two states have no cases.

Features of the monkeypox virus and the disease it causes make it highly amenable to control with standard public health measures. Monkeypox is less severe and transmissible than Covid-19. It spreads through intimate contact, primarily skin-to-skin. Respiratory transmission is far less common and requires prolonged face-to-face contact. Unlike Covid-19, which can spread before symptoms are apparent, monkeypox is only transmitted after symptoms—rash, fever, lethargy—occur. And, perhaps most important, unlike Covid-19, for which there were no vaccines or treatments during most of the first year of the pandemic, approved vaccines and antivirals exist for monkeypox.

Monkeypox has a long incubation period of five to 21 days, which creates an opportunity to intervene with testing, vaccination, and contact tracing after exposures to known cases to interrupt the transmission train. Unfortunately, despite the first U.S. monkeypox case occurring in mid-May, the federal government’s response undermined the chance to contain the outbreak.

The Centers for Disease Control and Prevention waited until late June to expand monkeypox testing. As a result, through the end of June, the U. S. had tested only 2,009 suspected monkeypox cases. And despite owning 372,000 FDA-approved Danish vaccines, Biden administration officials reportedly left most of the supply in Denmark, ordering only small shipments of vaccines for importation. When the vaccines arrived, federal officials were slow to distribute them and sent them to the wrong places.

A June 28 White House announcement lauded President Biden’s efforts since the first U.S case six weeks before “to make vaccines, testing, and treatments available to those who need them as part of its whole-of-government monkeypox outbreak response,” but it also acknowledged that the administration had deployed only 9,000 doses and scaled up testing capacity to less than 10,000 tests per week nationwide. As of July 7, 56,000 doses of vaccine were available nationwide, and the federal government had allocated only 8,195 to New York State, with 5,989 of the doses going to New York City. A week later, New York City received an additional 14,500 doses and the rest of the State got 5,398 more. By July 27, the federal government had distributed a total of 336,710 vaccine doses nationwide. New York City only got 45,784 and the rest of New York State another 16,455.

In other words, two and a half months into a well-publicized outbreak, the city that has a quarter of U.S. cases and a large at-risk population had received only 13.5 percent of the vaccines. A city health department information page advises that “vaccination is free and available regardless of immigration status” but also notes that “all available appointments have been filled at this time.”

The city’s response has not been flawless, either. Instead of encouraging gay and bisexual men—the population that, to date, accounts for nearly all cases— to change, at least temporarily, their sexual behavior during the outbreak through abstinence or limiting relationships to known partners, the city health department issued an advisory in mid-July suggesting that having sex while infected with monkeypox could be made safer by avoiding kissing and covering sores.

Such advice is unrealistic and irresponsible. Health officials were reportedly worried about stigmatizing gay men. Yet such wishy-washy advice is hurting the very people that public officials are afraid of defaming. Officials had to target the gay and bisexual community with information about monkeypox symptoms and access to testing so that they could confirm their infection status and, if positive, avoid sexual contact until their infection clears. And informing the broader community of how the disease spreads would make them aware that, in the near term, safe sex is not a realistic option.

State and local officials can effectively combat an infectious-disease epidemic only if they have the tools—tests, vaccines, treatments—to do so. Unlike Covid-19, which was a brand-new disease with no available tests, vaccines or medications, all of these modalities were available for monkeypox. Unfortunately, the federal health authorities have been slow to make them available. The public health bureaucracy and especially the federal agencies charged with protecting the nation against communicable diseases must become nimbler and more responsive before the next pandemic hits.

Photo by KENA BETANCUR/AFP via Getty Images


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