Monkeypox: Another Public Health Crisis

The monkeypox outbreak made headlines this summer, causing public health concerns. Unlike the novel SARS-CoV-2 virus, the monkeypox virus has been known for decades. The disease is caused by infection with the monkeypox virus, is seldom fatal and has milder symptoms than similar smallpox infections [1]. Monkeypox was first observed in the 1950s in a group of monkeys in Copenhagen, Denmark, but until recently, it was rarely seen in Europe and the Americas, and always with a direct link to central Africa [2]. The current outbreak is distinct because it is globally spreading in local communities. In the U.S. only, there have been more than 27,000 confirmed cases by October 2022, with California and New York leading the number of cases, each with more than 4,000 cases, based on data from the Centers for Disease Control and Prevention (CDC) [3]. Fortunately, monkeypox is not nearly as fatal as COVID-19. As of October 2022, two U.S. deaths have been reported; globally, there have been 28 confirmed deaths. In the U.S., the majority of the confirmed cases are in men (95.2%), with 26- to 45-year-olds accounting for more than 67% of all cases. On average and based on the last reported demographic data, 37% of the confirmed U.S. cases were in white patients, 32% in Hispanic patients and 23% in Black or African American patients. However, data points to a three-way split in September, with the Black or African American contribution increasing alarmingly.

On the global platform, the U.S. is leading the number of cases by a staggering 37% of all the global reported cases, a sobering reminder of its lead on COVID-19 cases and deaths, which it has maintained. These numbers point to systematic shortcomings and repeated mistakes as we paddle through another public health emergency. The number of monkeypox cases has steadily increased throughout the summer. As the cases increase, so too does criticism about missed opportunities to contain the virus using the lessons learned from the COVID-19 pandemic. The situation is exacerbated by the fact that monkeypox has been a known illness for decades and many prior studies have been conducted to provide safe testing, effective vaccines and potential treatments for a surge in the number of cases. In fact, the U.S. has been stockpiling monkeypox vaccines for years as a bio-attack countermeasure that went unused by the U.S. or any other country.

Initially, there was an expectation that with the COVID-19 lessons fresh in everyone’s minds, there would be a swift and unified response to mobilize all available assets to contain the monkeypox virus in the early weeks and prevent it from becoming a public health threat. However, the actual response has been subject to many questions with repeated scenes of limited access to testing, tracing, and vaccines, compounded by a lack of reliable data to plan ahead. The Biden administration declared the U.S. monkeypox outbreak a public health emergency in early August 2022 to streamline some of the processes and provide better and faster care to patients. The Food and Drug Administration (FDA) has been revising its policies for vaccines and testing to improve access. Although these efforts have been helpful and essential, the delay has caused unnecessary suffering and enabled the virus to further circulate in communities. With the start of the new academic year, experts warned of the spread of the virus into other populations [4]. The question remains: What can be done and how can we help the situation? Those of us in the operations research and management sciences (OR/MS) community are trained to improve operations and management in complex environments when resources are limited. Have we been able to translate our expertise for the recent public health crisis? What have been the obstacles and what did we learn from the COVID-19 pandemic?

Data Access and Testing Troubles

It all begins with access to reliable data or lack thereof. One of the main limiting factors in the early weeks of the monkeypox outbreak was a lack of data on the number of cases, induced by extremely limited testing. Only select labs were authorized to administer tests, which hindered the tracking and diagnosis efforts [5]. Combined with a lack of proper contact tracing, the number of cases was grossly underestimated [6]. As more testing became available, the virus had already circulated significantly, causing a substantial jump in the number of cases. The delayed response in evaluating the number of cases and optimizing the infrastructure for a streamlined care process has also hindered doctors’ ability to effectively and efficiently provide care for patients, as “unnecessary regulations” and “daunting paperwork” delayed the treatment, diagnostics and vaccination process in the early weeks [7]. This early shortage and complexity in testing may have forced doctors to take additional, sometimes unnecessary, measures regarding potential monkeypox cases, including being forced to refer patients to public health facilities for testing in the early stages and becoming more selective in testing due to the amount of time and paperwork needed to prepare a patient for testing. In addition, uncertain and sometimes very long wait times for test results delayed treatment. The complications cautioned doctors to provide treatment to patients without a positive test result due to the amount of time required.

In addition to limited access to symptomatic tests, performing asymptomatic tests in monkeypox can be complex. As opposed to COVID-19, in which the virus is usually present in the respiratory system and asymptomatic testing is possible, current testing methods for monkeypox rely on the presence of symptoms and specimens gathered on the skin where rashes or lesions are present. This makes testing for asymptomatic patients increasingly difficult. The limitation not only hinders data and tracing but also restricts the possibility of providing proper care for asymptomatic patients or those unable to provide a positive test result. Subsequently, the average wait times for patient care increased, resulting in some being denied access to care and thus making contact tracing exceedingly difficult. This is all while experts have expressed the necessity for increased testing to provide practitioners with quick and reliable evidence for monkeypox diagnosis and treatment.

The limited access to tests is reflected in the positivity rate of monkeypox. On average, 1 of every 3 tests has been positive, with the positivity rate even hitting more than 50% in July 2022. This number has improved with an average of 22% positivity rate during the month of September. The lack of access to testing was initially due to limited testing capacity. However, currently, the CDC reports a testing capacity of nearly 80,000 specimens per week in the U.S. Out of this available capacity, only a maximum of 20% was utilized. The low utilization rate is possibly due to operational constraints such as the lengthy and cumbersome process for testing referrals and mismanagement in allocating the resources where they are needed the most.

Monkeypox Vaccine and Treatment

The U.S. response to vaccination allocation has been another point of controversy, with many of the lessons from COVID-19 going unnoticed. Early efforts in vaccination include using smallpox vaccines, citing previous findings that these vaccines are nearly 85% effective against monkeypox [8]. Although vaccination was part of the initial response to the outbreak, shortages in supplies, delayed supervision of vaccine supplier capability and orders, and expired vaccine stockpiles hindered early efforts to contain the outbreak. According to The New York Times, the U.S. has lost nearly 20 million doses of the new smallpox vaccine because of long wait times for FDA approval of new vaccines that can replace the current vaccines, as well as the vaccines’ shorter life spans. The majority of the stored vaccines expired without replacement, leaving the U.S. stockpile at around 2,400 usable doses [9]. The CDC has developed an action plan for providing more vaccines, but the plan spans to mid-2023, indicating potential and probable vaccine shortages for vulnerable groups at risk of contracting monkeypox. The vaccination rates have improved, with more than 900,000 doses administered by early October, but challenges in access remain. The upcoming shortage periods have resulted in clinical proposals to reduce the injected dose of the vaccines for each individual and more shallow injections to potentially immunize greater numbers. Considering that the vast majority of current monkeypox cases include men who have sex with men, vaccination efforts for groups at high risk of infections should be prioritized. However, experts warn that it is likely that other populations are also infected with the virus, even though the testing data does not yet show it [10].

Treatment access and availability have also been limited. There are ongoing studies to provide treatments and drugs specifically for monkeypox, but existing drugs that are approved for the treatment of smallpox are argued to be effective against monkeypox. While this is good news, reports suggest that between lengthy testing, time-consuming paperwork for patients and doctors to get approval for prescribing the drugs, having drugs shipped to the patients from the national stockpile, and the scarcity of the drugs in the face of the rising number of cases, the wait times have been more than two weeks for some patients [11].

The response to the current monkeypox outbreak has suffered from lags, unnecessary complications and scarcity of vital resources, including vaccines and medication. The lessons from the COVID-19 pandemic in response, prevention and treatment have not been fully utilized, and the lack of data availability for experts has further delayed our reaction to containing monkeypox.

Data Analysis

For our community at INFORMS, the lack of data has been one of the most limiting factors along with the complex dynamics in the U.S. healthcare system. The current publicly available data is at the state level, with some data delays before publication, and it lacks enough details for in-depth analysis. The data-gathering systems, similar to those for COVID-19, are also subject to local policies and are different from state to state, prompting the CDC to halt release of some data due to inconsistency in collection. The same state-level limitations also apply to testing and vaccination eligibility and data. Despite the challenges, the opportunities for improving access and efficiency are abundant. The limited access to testing despite capacity can be improved with better resource allocation and more efficient processes. Vaccination eligibility is currently limited, varies state by state and focuses on a small population. patients who are in at-risk groups or act as “super-nodes” in the chain of infections will improve overall immunity given the limited availability of vaccines. Simultaneously, the increase in positive cases in Hispanic and Black or African American communities indicates an increasing disparity in this population and points to lack of proper use of available resources to improve access and efficiency. Vaccine and test distributions, resource management, allocation and scheduling optimization for testing schemes are all domains where the OR/MS community can play an outstanding and crucial role, in the recent monkeypox outbreak and any similar possible incidents in the future. As more vaccines are provided and obstacles for getting medications to patients are navigated, it is imperative to employ all the expertise gained during the COVID-19 pandemic to ensure that the curve is flattened and challenges regarding testing and vaccine shortages in the near future are resolved.

References

1. https://www.cdc.gov/poxvirus/monkeypox/about.html
2. https://www.smithsonianmag.com/history/what-you-need-to-know-about-the-history-of-monkeypox-180980301/
3. https://www.cdc.gov/poxvirus/monkeypox/response/2022
4. https://www.politico.com/newsletters/politico-pulse/2022/08/12/monkeypox-likely-infecting-new-groups-experts-say-00051347
5. https://www.voanews.com/a/us-monkeypox-response-draws-criticism-/6682866.html
6. https://www.hsph.harvard.edu/news/features/tracking-and-responding-to-global-monkeypox-virus-outbreak-bill-hanage/
7. https://www.washingtonpost.com/health/2022/07/15/monkeypox-response-vaccine-treatment-obstacles-adams/
8. https://www.nature.com/articles/d41586-022-01587-1
9. https://www.nytimes.com/2022/08/01/nyregion/monkeypox-vaccine-jynneos-us.html
10. https://www.politico.com/newsletters/politico-pulse/2022/08/12/monkeypox-likely-infecting-new-groups-experts-say-00051347
11. https://www.nytimes.com/2022/08/06/health/monkeypox-treatment-tpoxx.html