Rapid review on monkeypox policies among the G20 nations: relevance to policy and practitioner

Introduction

Monkeypox is a viral zoonotic disease. Monkeypox virus is an enveloped double-stranded DNA virus that belongs to the Poxviridae family's Orthopoxvirus genus.^1,2 Monkeypox was first identified in humans in 1970.³ Monkeypox had been recorded in various Central and Western African nations prior to the 2022 outbreak.⁴

Monkeypox symptoms typically last 2-4 weeks and are self-limiting. In recent years, however, the case fatality ratio has hovered around 1-10%.⁵ Human cases of monkeypox have been reported in 11 African countries since 1970.⁴ Nigeria documented 446 suspected cases and 199 confirmed cases from 18 States during 2017 to 2021.⁶ Monkeypox was first detected in the United States of America (USA) in 2003.⁷ Monkeypox was recorded among Nigerians travelling to Israel, the United Kingdom (UK), Singapore, and the United States between 2018 and 2021.^8–11 However, many instances of monkeypox were discovered in several non-endemic countries in May 2022.¹²

Since January 1, 2022, 92 Member States from all six World Health Organization (WHO) regions have reported cases of monkeypox to WHO. A total of 57,995 laboratory confirmed cases including 18 deaths, had been reported as of September 12, 2022. Since May 13, 2022, a large majority of these cases have been reported from countries where monkeypox transmission has not previously been documented.¹²

Despite the fact that the WHO emergency committee voted against declaring monkeypox a public health emergency of international concern (PHEIC), the WHO Director General (WHO- DG) vetoed it during the second meeting of the International Health Regulations (2005) (IHR) Emergency Committee.¹³

Accordingly, in relation to the multi-country outbreak of Monkeypox, temporary recommendations were issued by the WHO-DG. Temporary recommendations were made based on the burden of disease, and the country's ability to Prevent, Detect and Respond.¹³ According to the recommendation, states with no history of monkeypox in the human population or no detection of a case of monkeypox for more than 21 days would be classified as group 1, while states with recently imported cases of monkeypox in the human population and/or otherwise experiencing human-to-human transmission of monkeypox virus, including in key population groups and communities at high risk of exposure, would be classified as group 2. States Parties with known or suspected zoonotic transmission of monkeypox, including those where it appears or has been reported, those where monkeypox virus has been documented in any animal species, and those where infection of animal species in countries may be suspected, including newly affected countries categorized as group 3 and group 4 countries with manufacturing capacity for medical countermeasures.¹³

WHO assesses the global risk as “Moderate”. Regionally, WHO assesses the risk in the European Region as “High” and as “Moderate” in the “African Region, Region of the Americas, Eastern Mediterranean Region and the South-East Asia Region”. The risk in the Western Pacific Region is assessed as Low-Moderate.

The 10 most affected countries globally (as on 02/09/2022) are: United States of America (n = 21,984), Spain (n = 6,749), Brazil (n = 6,033), France (n = 3,785), Germany (n = 3,533), The United Kingdom (n = 3,484), Peru (n = 1,808), Canada (n = 1,321), Netherlands (n = 1,195), and Portugal (n = 871). Together, these countries account for 88.9% of the cases reported globally.

Most of the G20 nations have reported monkeypox outbreak. European Union, USA, Germany, France, UK, Brazil, India, Canada and Spain are part of the G20 countries. Together, the G20 members represent more than 80% of the world’s Gross Domestic Product (GDP), 75% of international trade, and 60% of the global population. Policies framed and implemented in G20 countries for the prevention and control of monkeypox preparedness and response would have implications on rest of the world. Investment in prevention, diagnostics, therapeutics and vaccine is pivotal to achieve equity and solidarity globally.

This rapid review aims to map the monkeypox prevention and control policies planned and implemented in G20 nations in line with temporary recommendations issued by the WHO-DG.¹³

Methods

An initial scoping of literature was conducted to understand the various prevention and control measures to respond to the disease.¹⁴ Since the research question is broad, we did not follow the typical PICOS or the PCC framework and the approach has been demonstrated previously.^15,16 We could not register the rapid review protocol as the review was completed in six days timeframe. We have reported this review based on the “Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews”.^17,18,61

Results

We obtained 671 articles from the three databases (Medline through PubMed, Scopus and ProQuest), with 10 articles included in the review. Additionally, we identified 55 documents from the Gray literature. Figure 1 depicts an overview of the included literature.

Figure 1. PRISMA flowchart.

This review provides a description of monkeypox-related guidelines/policies/recommendations, as well as their implementation strategies/response indicators; we have categorized G20 nations into two groups based on their epidemiological status, transmission patterns, and capacities¹³ (Table 1). We found that the guidelines included information on vaccine, diagnosis, transmission mechanisms, risk minimization and communication strategies, travel advisory, surveillance and public health initiatives, clinical management, and infection prevention and control in the Extended data.⁶¹

Table 1 depicts the national guidelines of the 18 countries on the control, prevention, and management of monkeypox, most of which belonged to group 2 countries. However, we couldn’t retrieve guidelines from China and Argentina during our search.

Discussion

Monkeypox was declared as Public Health Emergency of International concern (PHEIC) by WHO during the second meeting of IHR.¹³ PHEIC is notified when an outbreak spreads across borders and necessitates a coordinated international response to contain it. States have a legal duty to respond to PHEIC in a reasonable timeframe under the 2005 International Health Regulations (IHR). In this context, states have a responsibility to design contextual and internationally coherent policies to prevent and control monkeypox globally. This review was planned to understand monkeypox prevention and control - policy adherence in line with temporary recommendations issued by the WHO-DG, and policy similarities/actions among countries to explore if there are any inter-country cooperation strategies that are planned for coordinated international response, and also to document the inter-country differences in policy implementation among G20 nations.¹³ Most of the G20 nations have reported a monkeypox outbreak. G20 nations adherence to the recommendations of WHO sets the commitment for global solidarity as G20 members represent more than 80% of the world’s GDP, 75% of international trade, and 60% of the global population. Policies framed and implemented in G20 countries for the prevention and control of monkeypox preparedness and response would have implications on prioritization of investments in manufacturing capabilities, enhancing the capacity of developed and developing nations in prevention, diagnosis, therapeutics and vaccines.

Coordinated response among states is the key component to contain the transmission of monkeypox. Depending on the availability of resources, some recommendations are followed by nations while others are not. Adhering to the recommendations given by the standard setting organizations like the WHO would facilitate in timely detection, response, and control of monkeypox. To bring a coordinated response, G20 nations are following temporary recommendations that are context specific to their nation. For instance, most of the G20 nations are following recommendations in case detection, contact tracing, surveillance, clinical care protocols, risk communication, IPC, distribution of PPE kits and vaccination (Table 6).

Vaccination is one of the most effective measures to avoid the transmission of monkeypox. Few countries such as the UK, USA, and Australia, have the capability in manufacturing vaccines, therapeutics, and advanced diagnostics for the disease.^52,53 However, there is a large gap exists worldwide in vaccination production and availability. Currently, some of the countries like South Africa, Brazil and India do not have any vaccines available. Furthermore, some countries are initiating actions for vaccine manufacturing and procurement, for instance, India has initiated vaccine production efforts, and endemic countries such as Africa seek help from WHO for the procurement of the vaccine.^54,55 Historical evidence also suggests that illness or poor health among the population has always shifted the balance of power, suggesting that world politics has had a significant impact on PHEICs.⁵⁶ For example, it wasn't until the devastating Ebola outbreak in West Africa in 2014-2016 spread throughout the population of rich countries that authorities ultimately accelerated the licensing of an Ebola vaccine, capping a decades-long endeavor.⁵⁷ To bridge the vaccine inequality gap among states, we need a coordinated global response from state parties in which additional resources are made available to support the management of monkeypox as a global concern. The resources for vigorous surveillance and training activities must also be provided to the endemic countries. During the coronavirus disease 2019 (COVID-19) discussion, Mr. Guterres, the United Nations Secretary-General stated, “history will judge the efficacy of the response not by the actions of any single set of government actors taken in isolation, but by the degree to which the response is coordinated globally across all sectors for the benefit of our human family”.⁵⁸

In addition, States Parties have always undermined the IHR's effectiveness by being non-compliant towards their proposed guidelines in accordance with agreed during previous outbreaks.⁵⁹ Hence, the G20 nations should set an example by complying to IHR recommendation as well as to support each other during a crisis by advocating for sharing PPE kits, vaccines, data-sharing technology, and risk-communication channels to curb the spread of disease. Also streamline the regulatory standards and procedures to procure medical countermeasures. Developed countries are responsible for funding research and facilities in developing countries, as well as supporting information exchange as outlined in the new pandemic treaty.⁶⁰ In this context, states have a responsibility to design contextual and coherent policies to prevent and control monkeypox globally in line with temporary recommendations issued by the WHO Director General.¹³ G20 nations advocating for inter-country cooperation will lead to coordinated international response and interruption of transmission of monkeypox. To best of our knowledge, this is the first review to collate the national guidelines published among the G20 nations and comparing them with WHO recommendations. Though we extensively searched for the eligible studies and gray literature, we only included the guidelines available on the public domain.

Conclusion

Cooperation among the G20 nations is important in the context of building international health system resilience especially in the context of pandemics and sharing of information. Some of the countries are following the WHO recommendations who have resources, and some are not following. It's important for the countries to support each other during the crisis as we are not safe until everybody is.

Data availability