By Spencer Kimball

Health Secretary Xavier Becerra’s emergency declaration will help mobilize more resources to fight the outbreak, which has spread swiftly since the U.S. confirmed its first case in May.

The U.S. has confirmed more than 6,000 monkeypox cases over the past two months, more than any country in the world.

The U.S. has distributed more than 600,000 vaccine doses and has ramped up testing, but lawmakers and local communities have criticized the pace of the response.

Men who have sex with men are at highest risk right now, but anyone can catch monkeypox and the virus could start to spread more broadly.

The Biden administration is declaring monkeypox a public health emergency as the U.S. outbreak has grown into the largest in the world, the nation’s top health official said Thursday.

Health and Human Services Secretary Xavier Becerra’s emergency declaration will help mobilize more resources to fight the outbreak, which has spread swiftly since health authorities in Boston confirmed the first U.S. case in May. The last time the U.S. declared a public health emergency was in response to Covid-19 in January 2020.

The U.S. has confirmed more than 6,600 cases of monkeypox in 48 states, Washington, D.C., and Puerto Rico as of Thursday, according to the Centers for Disease Control and Prevention. The real number of infections is likely higher than the official data because patients can only get tested after they develop a rash, which can take a week or more after the initial exposure to the virus.

“In light of all of these developments and the evolving circumstances on the ground, I want to make an announcement today that I will be declaring a public health emergency,” Becerra told reporters during a call on Thursday.

Monkeypox is rarely fatal and no deaths have been reported in the U.S. so far, but patients often suffer debilitating pain from the skin rash caused by the virus. Eight people have died from the disease across the world during the current outbreak, primarily in Africa where the health systems aren’t as robust as the U.S. Spain and Brazil reported the first confirmed deaths from the virus outside Africa over the weekend.

Monkeypox is primarily spreading through skin-to-skin contact during sex at the moment. Gay and bisexual men are at the highest risk of infection right now, public health officials say. About 98% of patients who provided demographic information to clinics identified as men who have sex with men, according to the CDC. But anyone can catch the virus through close physical contact with someone who is infected or contaminated materials.

Scientists and public health officials are worried that monkeypox could circulate permanently in the U.S. if swifter action is not taken to contain the outbreak.

The WHO declared monkeypox a global health emergency last month. More than 26,000 monkeypox cases have been reported across 87 countries, according to CDC data. The U.S. makes up 25% of confirmed infections worldwide. Health authorities in the U.K. first alerted the world to the outbreak in May after confirming several cases there.

The global outbreak is highly unusual because monkeypox is for the first time spreading widely in North America and Europe where the virus is not normally found. Historically, monkeypox has spread at low levels in remote parts of West and Central Africa where rodents and other animals carry the virus. Transmission between people was relatively rare in the past, with the virus typically jumping from animals to humans.

State and local emergencies

Lawmakers in Congress and local communities have criticized the pace of the federal government’s response, but Becerra said last week that HHS has done everything it can to ramp up resources to fight the outbreak. The health secretary said states need to do more to prevent transmission, and Congress needs to pass funding to support the response to the outbreak.

The largest outbreaks in the U.S. are in New York, California, Illinois, Florida, Georgia, Texas and D.C. New York, Illinois and California declared state emergencies before the federal declaration.

Public health officials are concerned that the virus could start to spread more within households across the broader population as infections rise. Though physical contact during sex is the primary mode of transmission right now, people can also catch monkeypox through hugging, kissing, and contaminated towels and bedsheets.

The CDC last month confirmed the first U.S. cases of monkeypox in children, a toddler in California and an infant whose family was traveling in D.C. The infant’s family is not U.S. residents. The children have symptoms but are in good health and are receiving the antiviral treatment tecovirimat, according to the CDC. The young kids likely caught the virus through transmission within their family, according to the CDC.

Monkeypox can also spread through respiratory droplets when people have lesions in their mouth, but this requires prolonged face-to-face interaction, according to the CDC. Health officials do not believe monkeypox is spreading through small aerosol particles like Covid. Respiratory droplets are heavier so they do not stay airborne for as long, while Covid is an airborne virus, which is one of the reasons it is so contagious.

Monkeypox typically began with symptoms similar to the flu and then progressed into a painful rash that can spread over the body. But symptoms in the current outbreak have been unusual. Some people are developing a rash first, while others get a rash without any flulike symptoms at all. Many people have a localized lesions on the genitals or anus, according to public health officials.

Patients typically recover in two to four weeks without additional medical treatment, according to the CDC. But some people are admitted to the hospital because the rash is so painful.

In 2003, the U.S. had a small monkeypox outbreak with dozens of confirmed and probable cases across six states. The people fell ill after contact with pet prairie dogs. The pets were infected after they were housed near small mammals imported from Ghana. The U.S. outbreak in 2003 was the first time monkeypox was reported outside Africa, according to the CDC.

Public health authorities are also worried that as monkeypox spreads in the U.S., the virus could become established in animal populations which would make the virus even harder to eliminate from the country.

Vaccine, testing and antiviral supply

The federal government has delivered more than 600,000 doses of the monkeypox vaccine, called Jynneos, to state and city health departments since May. CDC Director Dr. Rochelle Walensky acknowledged last month month that demand for the vaccine is outstripping supply, leading to long lines at clinics and protests in some cities.

HHS made 786,000 doses available for local authorities to start ordering last Friday, which may help alleviate the supply problems. Dawn O’Connell, who heads office responsible for the strategic national stockpile, said HHS is shipping doses within 30 hours of states ordering them.

The U.S. has ordered more than 5 million additional doses with deliveries scheduled through the middle of 2023. Another 11.1 million doses are in bulk storage in Denmark with the manufacturer Bavarian Nordic, according to HHS. But those doses need to be filled and finished before they can be administered which will require additional funding from Congress, according to HHS.

The Food and Drug Administration approved Jynneos in 2019 for adults ages 18 and older who are at high risk of exposure to monkeypox or smallpox. Jynneos is the only FDA approved monkeypox vaccine in the U.S. It is administered in two doses 28 days apart.

The U.S. also has more than 100 million doses of an older generation smallpox vaccine, called ACAM2000, that is likely effective against monkeypox. But ACAM2000 can have serious side effects and is not recommended for those with weak immune systems such as HIV patients, pregnant women, and people with eczema and similar skin conditions.

The U.S. does not currently have real-world data on how effective the vaccines are at preventing disease in the current outbreak, according to the CDC. The vaccination campaign is focused on people with confirmed or presumed exposures and men who have sex with because they face the highest risk of infection.

The U.S. has ramped up testing capacity to 80,000 per week after bringing several commercial labs onboard last month. Becerra said last month the current demand for testing is a fraction of the total capacity the U.S. now has.

The U.S. also has 1.7 million courses of the antiviral treatment tecovirimat in the strategic national stockpile. Health-care providers are using tecovirimat to treat monkeypox patients, but prescribing the drug has an additional layer of bureaucracy because the FDA has only approved it for smallpox. The CDC cut down on red tape last month to make it easier for physicians to prescribe tecovirimat.