Lawmakers and administration officials have spent much of the past few years talking about “the next pandemic” and what the country will do when it comes. But now that monkeypox is spreading exponentially throughout the United States, public health officials agree on one thing — the government didn’t move fast enough.

Since the first case this year was detected on May 18, the Centers for Disease Control and Prevention has recorded more than 350 cases of monkeypox across the U.S. as of Wednesday. Though the disease is less deadly than COVID-19 and is not considered a pandemic, physicians and government officials say they are concerned about the disease’s community spread. 

The U.S. has vaccines stockpiled to treat orthopoxviruses like monkeypox, but supply is limited. Currently, the U.S. has just 56,000 doses of the preferred vaccine, Jynneos. It also took more than a month from the first detected case for the CDC to expand its testing capabilities for monkeypox to commercial laboratories.

“Even though we had ample warning for this, we’ve had a very delayed and I would say overall inadequate response,” said Jay Varma, an epidemiologist and former COVID-19 adviser for New York Mayor Bill de Blasio.

“History may not repeat itself, but it certainly rhymes. And that’s what we’re seeing with monkeypox,” Varma said, comparing the early days of the monkeypox outbreak to March 2020, the beginning of the COVID-19 pandemic.

On Tuesday, officials announced the Biden administration would launch a national monkeypox vaccination campaign focusing on the most vulnerable and make vaccines and treatments more widely available. The CDC also on Tuesday activated its Emergency Operations Center to handle the ongoing monkeypox outbreak.

The vaccination effort will initially focus on protecting those most at risk of contracting the virus and prioritize areas of the country with the highest number of cases. With monkeypox, vaccination after exposure can help slow the spread of the virus despite exposure.

The Department of Health and Human Services plans to make 56,000 doses of the preferred monkeypox vaccine, Jynneos, available immediately and expects a total of 1.6 million doses to be available in the country by the end of the year. The U.S. has tens of millions of doses of another smallpox vaccine, ACAM2000, on hand, but that shot has more dangerous and severe side effects.

Up until now, monkeypox vaccine supply has been scarce in U.S. cities. Both New York City and Washington, D.C., began offering the vaccines to men who have sex with other men or may have been exposed to the virus. But so many people immediately signed up for shots in D.C. that D.C. Health had to shut access about 10 minutes after making shots available. New York City began distributing vaccines to the LGBT community last week, but by June 24, they were already out of supply and asking the CDC for more doses. 

As the vaccination effort scales up, some are sounding the alarm on the lack of monkeypox testing across the country, which could slow the overall response and allow for more spread.

On June 22, the Biden administration announced that the CDC has begun shipping monkeypox tests to five commercial lab companies across the country to increase monkeypox testing capabilities. A test takes a sample from a skin lesion and is relatively simple to perform. Now the five lab companies — Aegis Sciences, Labcorp, Mayo Clinic Laboratories, Quest Diagnostics and Sonic Healthcare — are equipped to produce the test.

“These are the correct actions to take. But we’ve been asking for these actions for some time. And it wasn’t as if it was like they had to create the test from scratch,” said Amesh Adalja, a doctor and infectious disease specialist at the Johns Hopkins Center for Health Security in Baltimore.

Lindsey Dawson, an associate director of HIV policy and director of LGBTQ health policy at the Kaiser Family Foundation, agreed that more testing is crucial and said the 300-plus cases now in the U.S. are likely “the tip of the iceberg.” She likened the monkeypox response to the HIV response, and said it’s important for trusted messengers to engage with their communities about monkeypox to help get the word out.

So far, monkeypox has primarily impacted men who have sex with men. In areas of the country where being LGBTQ is more stigmatized, it’ll be hard to reach those who need the vaccine, Dawson said. 

On top of all that, local public health departments are already strained by COVID-19 and lack the ability to respond to another viral outbreak, Adalja said. He argued that the monkeypox outbreak makes a strong argument for more public health funding.

“Public health preparedness goes through cycles of boom and bust, panic and neglect. And many of us have this hope that COVID-19 would change that,” Adalja said.

Outlook

Monkeypox is much less severe than COVID-19. So far, no one in the U.S. who has contracted the virus during the current outbreak has needed hospitalization or died. Many people infected with monkeypox have mild illness and don’t need additional treatment. The CDC says people at high risk for severe disease include those with preexisting conditions, pregnant women, people with a risk of skin conditions and kids under age 18.

The agency advises physicians to look for the classic monkeypox rash and obtain swabs from that or obtain swabs if they observe a rash that could be consistent with monkeypox. The co-occurrence of a sexually transmitted infection does not rule out co-infection with monkeypox.

On June 23, the World Health Organization held an emergency meeting to discuss the current  outbreak and determine whether the events constitute a public health emergency of international concern. The organization determined that the ongoing global spread of monkeypox does not currently merit that designation — but the spread of the virus raises serious concerns and requires a coordinated global response.

“This is clearly an evolving health threat,” said WHO Director-General Tedros Adhanom Ghebreyesus in a statement. “It requires our collective attention and coordinated action now to stop the further spread of monkeypox virus.”

But the WHO could revisit this decision. When the organization first met to discuss the threat of COVID-19 it did not declare the virus a public health emergency of international concern but then assembled and made that declaration a week later.

“The most worrisome scenario is one in which you know, monkeypox becomes entrenched in the U.S., similar to, say, you know, syphilis or HIV,” Varma said.

Carlos del Rio, a professor of medicine in the division of infectious diseases at Emory University School of Medicine in Atlanta, said that’s a very likely possibility at this point. He anticipates monkeypox will become a normal part of life in the U.S. and western Europe, and that cases could climb precipitously throughout the summer.

“It’s very likely that this virus will become endemic — that we’re not going to be able to necessarily control it and that we’re going to start seeing, you know, more and more community transmission,” del Rio said.