State and federal health agencies are gearing up to respond to a new strain of mpox — the virus formerly known as monkeypox — if the new strain spreads to the United States. 

But this time, they are doing so with fewer resources.

Both an mpox public health emergency declaration and federal pandemic preparedness law were still in effect in 2022, the last time the U.S. faced a widespread mpox outbreak. That gave the federal government and state health departments more resources and flexibility than it has now to deal with an outbreak. 

Last month, the World Health Organization declared a public health emergency of international concern, the highest alarm under international health law, over the new mpox strain. The strain, known as clade 1b, has been rapidly circulating in central Africa and has been detected in Sweden and Thailand.

The new strain differs from the 2022 world outbreak of the clade IIb mpox strain, which U.S. officials treated with two doses of the JYNNEOS mpox vaccine. Much like the COVID-19 vaccines, the mpox shot JYNNEOS prevents severe infection, hospitalization and death from mpox, but doesn’t fully prevent transmission, according to the Centers for Disease Control and Prevention.

Clade 1b is endemic in the Democratic Republic of Congo, and the strain is more widespread than any other outbreak. Clade 1b usually causes a higher percentage of people with mpox to get severely sick and die, compared to clade IIb, according to the CDC.

While clade 1b has not yet been detected in the U.S., state and federal health officials are gearing up for what could be a potentially worse outbreak than in 2022 by leaning on the lessons it learned two years ago.

“It’s a different ballgame than in 2022, in some ways that are better and in some ways that are TBD,” Jen Kates, senior vice president and director of global health and HIV policy at KFF, said. She noted that public health jurisdictions today are already armed with mpox vaccines and treatments, unlike in 2022.

Budgeting for vaccines

The State Department says it’s been preparing for clade 1b’s emergence in the U.S. since December 2023 through increased monitoring of wastewater and other surveillance systems. But access to public health surveillance systems has waned since the COVID-19 public health emergency ended.

And the 2022 mpox public health emergency allowed the federal government to more easily free up resources to produce and distribute vaccines to high-risk groups at no cost. 

The federal government ended the emergency declaration in 2023, but JYNNEOS vaccine maker Bavarian Nordic privatized the vaccine earlier this year. Now states must order it on the commercial market. State health officials said the budget is more of a concern now that vaccines are privatized. 

Crystal La Tour Rambaud, the manager of the vaccine preventable disease program of the Pima County Health Department in Tucson, Ariz., said that between the mpox vaccine and new RSV vaccine, costs are adding up.

“It’s just added a lot onto the plate in just a couple years, where the budget hasn’t changed significantly,” La Tour Rambaud said.

As a result, the Pima County Health Department is reassessing whom they offer free vaccinations to, and in some cases, only offering free shots to the uninsured. Insured individuals can get vaccinated at commercial pharmacies, she said. 

Under the current structure, those with public or private insurance can access the mpox shots without any cost barrier, because the CDC’s vaccine advisory panel has recommended the vaccine.

But the only way uninsured adults can get the shot at no cost is if their jurisdiction has used federal funds to purchase the vaccines.

Raynard Washington, the director of the public health department in Mecklenburg, N.C., said the department has been able to use some of STD and HIV funds for mpox response, but are still stretched too thin.

The pandemic preparedness law expired in September 2023, but Congress extended seven provisions of that law via the March government funding bill until the end of 2024. This included policies to help activate personnel during a public health emergency, among others. 

The CDC recommends health departments report all mpox cases to the CDC within 24 hours and promote vaccination in their communities. Under a declared public health emergency, the government can waive certain authorities to streamline disease reporting, sending funds to jurisdictions, for example.

Even though there is no public health emergency in effect now, Washington said that in Mecklenburg, “overall, the system is probably better prepared now than we were in 2022” because they’ve dealt with mpox before. Public health departments already have vaccines on the ground and people in the community who have been vaccinated. 

The Mecklenburg health department is pushing for the reauthorization of the federal pandemic preparedness law as well as giving CDC the authority it needs to collect data, from both health care systems and laboratories so it could share that information to jurisdictions.

But because there is a new strain of mpox, it’s possible they’ll have to change their response.

“We might be starting back at ground zero again, depending on how this all plays out,” Washington said.