National

The much-feared twindemic — or even tripledemic — of respiratory viruses is here, but Americans are too COVID-fatigued to care.

The big picture: Flu in the southeast and RSV infections in multiple regions are filling up hospital wards and causing some facilities to cancel elective surgeries and bring back triage tents.

Though less lethal than COVID-19, the viruses pose a major threat to children and immunocompromised adults. And we're just in November, with the threat of new COVID variants still looming as people plan indoor gatherings and firm up holiday travel. 

Yes, but: Americans are good at normalizing risk and have been less and less willing to change their personal behavior since the pandemic's Delta wave. 

The creeping threat of another viral outbreak has also been pushed aside by elections, the economy, war and natural disasters.

"If you don’t have children and are a young healthy adult, it's going to be hard to convince you to mask up to protect the population at large," said Yale infectious diseases specialist Scott Roberts.

Driving the news: Much of the current focus is on RSV, or respiratory syncytial virus, which is affecting high numbers of children and has been straining hospitals for weeks.

Boston Children's Hospital postponed some elective surgeries to ease the crush, while Johns Hopkins Children's Center began using triage tents to manage caseloads the way that it did during the worst of the pandemic. 

Children's National Hospital in Washington, D.C., at one point in October had 18 children waiting for a pediatric intensive care unit bed, according to the Washington Post.

Meanwhile, seasonal flu has been surging through the southeast, hospitalizing thousands and stressing some emergency departments and urgent care centers. 

Some surveys suggest as many as four in 10 Americans are uncertain about or don't plan to get a flu shot this season. 

The intrigue: COVID is actually the least worrisome piece of the triple threat right now. Cases are down, the new variants seem no deadlier than Omicron, and there are plentiful treatments and vaccines.

And yet COVID remains on track to be the third leading cause of death in the U.S. this year, behind heart disease and cancer, per the Peterson-KFF Health System Tracker, which projects 230,000 U.S. lives were lost to the virus in 2022 through September alone.

Go deeper: Public health experts say another year living with the pandemic threat has left many Americans resolved to use their personal experience as a guide. The question is whether they can sort through ailments with similar symptoms — and see past themselves.

"It’s important more than ever, not to go to family functions if you are sick even if you test negative for COVID," said Courtney Gidengil, a pediatric infectious disease physician and director of RAND Corp.'s Boston office. "You might have the flu, you might have RSV and it’s important to be thoughtful about that."

“The way I thought about it three years ago where everybody’s behavior impacts the risk of everyone else's was appropriate and felt very right during the heat of the pandemic before we had the kinds of tools we have now," said Bob Wachter, chair of the department of medicine at the University of California, San Francisco. "At this point, I don’t pass moral judgment on people. People are exhausted, they want to get back to their lives."

The bottom line: Public opinion polls show about 20% of Americans still worry about the pandemic and public health more broadly, said Ipsos pollster and senior vice president Chris Jackson. 

Reaching the rest to message a new threat will be difficult, because of people's tendency to look inward. "It does come down a little bit to understanding and social trust, which has been fraying for many years," he said.

Plus, he said, "Americans are so tired of being scared that even when they see [a health threat] their eyes glaze over." 

Tina Reed and Caitlin Owens contributed to this report. 

America shrugs off its twindemic

Americans are too COVID-fatigued to care.

Illustration of a person with a suitcase walking towards a door with a large warning sign above it.

Public health

Health

Axios Science

Hundreds of millions of people around the world lack reliable access to safe water  — an escalating crisis with a potentially profound impact on their mental health.

Why it matters: Similar to food insecurity, water insecurity has been linked to depression, anxiety, and increased rates of violence — and is considered one of the greatest threats facing humans, several scientists tell Axios.

Water insecurity can be caused by numerous factors, including geology, poor infrastructure, high demand from a population or industry, racism, or extreme drought or intense flooding fueled by climate change.

"A lot of water insecurity data worldwide measures household water connections or the percentage of homes that have piped water," says Natalie Exum, who studies the health impacts of water insecurity at Johns Hopkins University. 

"We’re not capturing a lot of the stress and burden" that comes with it, she says.

A challenge is zeroing in on who is experiencing water insecurity — and how it affects their mental health.

What's new: Northwestern University researchers sought to better understand who is water insecure by going beyond "measuring water in terms of what we can touch ... to measuring individual experiences," says study co-author Sera Young, associate professor of anthropology and global health. 

Her team surveyed 45,555 adults in 31 low- and middle-income countries in sub-Saharan Africa, North Africa, Asia and Latin America, between Sept. 4, 2020, and Feb. 24, 2021.

Those surveyed were asked 12 questions about their experience, including how often they worried about not having enough water or changed their diet because of drought or floods, and how access affects their emotional health.

The team found 14% of those surveyed were water insecure, ranging from 4% in China to 64% in Cameroon. This means an estimated 436 million adults — out of 3 billion represented in those regions — were water insecure during that time period. 

Yes, but: The number of countries examined in that study is small and the questions didn't capture some key dimensions like water quality, says Amber Wutich, president's professor of anthropology at Arizona State University.

But, she says it's a "very good first step" toward the much-needed effort of quantifying the global extent of water insecurity at an individual level.

The big picture: Water insecurity occurs worldwide, including in high-income countries or nations with high rainfall totals, Young says.

This includes the U.S., where climate change, an aging pipe system and systemic racism play a large role.

Certain municipalities intentionally excluded low-income areas from participating in centralized water infrastructure — impacting mostly Black, Native American, and Hispanic populations, Wutich says. "We're living with the legacies of those decisions, and some of those decisions are still happening today."

Colonias, small communities built with substandard homes just north of the U.S.-Mexico border, have "never had secure water access," Wutich says.

In Jackson, Mississippi, citizens "have been relegated to a life of boil water orders, walking long distances with jugs or catching rainwater in buckets for everyday use," Axios managing editor Delano Massey wrote for Editor and Publisher.

The impact: Mental health outcomes from water insecurity are still being studied but many scientists think "experiences of resource insecurity seem to track closely with PTSD, anxiety and depression," Wutich says. 

The role of climate change in water insecurity — and its impact on mental health — is an area of intense interest.

The latest IPCC report released earlier this year found that "climate change is expected to have adverse impacts on wellbeing and to further threaten mental health."

Droughts, floods and other climate-related exposures "were associated with psychological distress, worsened mental health, and higher mortality among people with pre-existing mental health conditions, increased psychiatric hospitalizations, and heightened suicide rates," scientists wrote last year.

A small study in Ethiopia found "water insecurity leads to extreme worry and fatigue."

But there are multiple mechanisms for how climate change can affect someone's health, says Tarik Benmarhnia, a UC San Diego professor who studies the impact of climate change on health. 

Extreme weather events can directly cause distress or trauma if someone witnesses injuries or death. But these events can also affect other mental health factors, including employment, housing and nutrition, says Alessandro Massazza of the Wellcome Trust.

Drought, for example, can "lead to mental health issues through economic, food and water insecurity but also indirectly through conflict and war," Benmarhnia says.

We need to be "specific about the mechanism so we can formulate very specific policies." 

Much of what is known about climate change and mental health comes from studies in Europe, North America and Australia, not those often most at risk, Massazza recently wrote.

"In the most affected communities, we don't have data," Benmarhnia says.

In sub-Saharan Africa, food and water insecurity data in communities is collected through surveys conducted by public health officials. "But mental health data typically collected is very limited."

What to watch: Research is growing into better measuring water insecurity, technologies to address access, and more knowledge over the relationships among water insecurity, climate change, and mental health.

The bottom line: "Five years ago this was totally ignored. But now in 2022 it is on the agenda of many institutions and organizations," Benmarhnia says. 

"It has been identified as a big, big challenge."

Water insecurity is stressing mental health

Water insecurity has been linked to depression, anxiety, and increased rates of violence.

Illustration of an ice cold bottle of water in a glass case in a dried out landscape. 

Water insecurity

A look at the scientific breakthroughs changing the world, explorations in space and in worlds beyond our own and the threats posed to us by our own planet, both out of our control and of our own making.

Science

Californians on Tuesday voted in strong numbers to ban the sale of flavored vapes and menthol cigarettes. But the Supreme Court may yet have the final say on the matter. 

The big picture: California joined a handful of other states and cities that have leapfrogged the Food and Drug Administration on banning all flavored e-cigarettes that are popular with youths, as well as menthol cigarettes.

The move "will send a clear message to the federal government" on the need for action, Matt Myers, president of the Campaign for Tobacco Free Kids, told Axios.

Yes, but: R.J. Reynolds Tobacco Company last month asked the Supreme Court to review its challenge to a similar ban in Los Angeles County, arguing that local and statewide bans infringe on the federal government's authority to regulate tobacco products.

Justices haven't signaled whether they'll take the case.

There are also a handful of active legal challenges in circuit courts brought by vapor companies against the FDA for denying their products' marketing orders.

Zoom out: The FDA has been weighing individual companies' applications to market e-cigarette products, so far only approving tobacco-flavored products. 

The California result saw 62% of voters opt to uphold a 2020 state law banning flavored products that tobacco interests challenged, forcing a popular vote.

The other side: Vaping interests say the statewide ban harms millions of adult smokers in California who used e-cigs as a cessation device and may be forced to go back to cigarettes.

The ballot did not make exceptions for products that the FDA can approve for modified risk use, to wean smokers off cigarettes, Greg Conley, director of legislative and external affairs at the American Vapor Manufacturers Association, told Axios.

By the numbers: The ballot measure, Prop 31, will cost California as much as $100 million in decreased tobacco tax revenue.

As of late September, the tobacco industry spent more than $22 million trying to defeat the measure.

Health organizations and the California Democratic Party, with significant help from philanthropist Michael Bloomberg, spent more than $6 million to support it.

Editors note: This article has been corrected to reflect the correct name of the president of the Campaign for Tobacco Free Kids.

California's flavored vape ban prevails but court challenge looms

If the U.S. Supreme Court decides to take up a tobacco company's petition, California's ballot measure might be in flux.

Illustration of a juul device forming a "no" symbol with a cloud of vapor around it

Vaping

Data: #WeCount/Society of Family Planning; Map: Jacque Schrag/Axios

The number of abortions performed in the U.S. fell by about 6% after the Supreme Court overturned Roe v. Wade, according to data from the Society of Family Planning.

The big picture: Many states in which abortion remains legal saw significant increases in the number of procedures performed, suggesting that plenty of women traveled out-of-state to obtain access.

By the numbers: There were roughly 5,000 fewer total abortions, nationwide, in both July and August — the two months following the court's ruling — than there were in April. 

But in states with bans and severe restrictions, there were about 8,000 fewer abortions each month — a decrease of 95%. Abortions also decreased, albeit more modestly, in states with less severe restrictions.

In states with few restrictions on abortion, there was an 11% increase in the total number.

The intrigue: North Carolina, Kansas, Colorado and Illinois saw the largest  increases.

Even some states with restrictions — but not total bans — saw increases in the number of abortions performed, specifically states close to others where abortion is now illegal.

Several states — including Oklahoma, Alabama, Arkansas and Texas — have experienced a decline in the number of monthly abortions to 10 or less.

America's red-state abortion wipeout

Several states saw the number of abortions drop to less than 10 a month.

Abortion

Policymaking

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Politics & Policy

The dangers posed by growing outbreaks of opportunistic fungi that kill 1.6 million people globally every year require new drugs, diagnostics and surveillance programs, a CDC scientist tells Axios.

Driving the news: The pandemic accelerated the rise of drug-resistant fungi in health care settings, and global warming has expanded the range of fungi growth in certain areas — problems flagged by the WHO, which released its first-ever list of dangerous fungi last week.

What's happening: Fungi are "smart, tough organisms that are here to stay" and are evolving to take advantage of a growing immunocompromised population living in a world increasingly hospitable to certain pathogens due to climate change, says Tom Chiller, head of the CDC's Mycotic Disease Branch.

"It could be a new species emerges and finds a niche in the environment and then happens to find an opportunistic host, and suddenly you see this new, weird infection," Chiller says.

"We're in an era now of unprecedented emergence of fungal diseases not only in humans but also in agriculture and animal husbandry," says Cornelius Clancy, infectious disease doctor and professor of medicine at the University of Pittsburgh.

Zoom in:  "In recent years, the epidemiology has shifted. We've seen the emergence of new fungi that previously were not recognized as causes of human infections or rare cases that have now become more prominent, and also the emergence of antifungal drug resistant fungi," Clancy tells Axios.

Chiller points to Candida, which is in our mouth, intestines and skin but can sometimes invade the bloodstream and cause sepsis and other complications. Over the past decade, though, Candida auris has become more drug resistant and shown new characteristics, Chiller says. "This is a Candida that's actually transmitting, from patient to hospital environment to patient. ... That was really a sea change for us."

Another threatening development is seen in Sporothrix brasiliensis, a dimorphic fungus that usually exists in different forms as either a mold that can be infectious when it's in the outside world or as a yeast once it's inside a human or animal body and not infectious to others.

However, Chiller says there have been cases in Brazil where cats with S. brasiliensis give it to the vet via "spores flying out of their lesions into the vet's eyes, and these veterinarians were coming down with ocular sporotrichosis ... We've never heard of a dimorphic transmitting like that."

Between the lines: Humans and fungi are both eukaryotes, which makes it harder to target drugs for fungi without hurting human cells as well, and complicates efforts to create diagnostics that can easily identify the difference.

What's next: Chiller and Clancy say they are hopeful a new class of fungal drugs will be created — as some fungi have become resistant to all of the available classes of drugs. There have been some positive developments in the pipeline.

More effort is needed as well for diagnostics and a global surveillance system. They hope the WHO's fungal priority pathogens list will provide impetus.

Go deeper: The growing threat of drug-resistant, invasive fungi

Invasive fungi recognized as a global threat

WHO issued its first-ever pathogen list of dangerous fungi.

Source: WHO's fungal priority pathogens list

Fungus

Pfizer and its partner BioNTech said Thursday they have started evaluating a combination COVID 19-flu vaccine using the companies' Omicron booster.

Why it matters: A combined vaccine could simplify immunizations and simultaneously fight two respiratory diseases that require repeated vaccinations. 

Moderna and Novavax are also developing combination COVID and flu shots. 

Details: Pfizer and BioNTech aim to enroll 180 U.S. volunteers between the ages of 18 and 64 for an early-stage trial to assess the safety, efficacy and optimal dosage. The first participant received a dose of the combination shot this week.

The candidate vaccine combines an mRNA influenza vaccine with the companies' COVID-19 shot based on the BA.4 BA.5 variants.

Between the lines: While COVID case counts remain low in the U.S., public health efforts are increasingly focused on new ways to address multiple threats, like a "tripledemic" of more transmissible variants, a major uptick in RSV cases and worse-than-usual flu season.

Go deeper ... Flu season arrives early with highest severity in over a decade

Pfizer and BioNTech study COVID-flu combo vaccine

A combined shot could fight two respiratory diseases that require repeated vaccinations.

Illustration of two different syringes twisting together

COVID-19 vaccines

Coronavirus

Requests for self-managed abortions via pills increased in 30 states following the Supreme Court's decision to overturn Roe v. Wade, with the largest surges seen in states with total or near-total bans on abortion, according to a new study published Tuesday in the Journal of the American Medical Association.

Driving the news: In states with total abortion bans, 62.4% of respondents cited "current abortion restrictions" as a reason for their request after the Supreme Cort decision, compared to 31.4% before.

Why it matters: Abortion medication has been in high demand as a self-administered option amid GOP-led states' bid to restrict abortion access. The FDA-approved drug is less costly than clinical procedures and doesn't require travel, relieving some of the financial barriers that often weigh on people.

Details: The study examined requests in the 30 states where Aid Access — a telemedicine service that provides self-managed abortions through pills mailed to people in the U.S. — is accessible outside the formal health care system. 

Between September and May before the Dobbs decision was leaked, Aid Access received an average of roughly 83 requests per day. 

During the period of time from May to June 24 between the leak and the formal decision, that number increased to about 137. 

From June 24 through August after the decision was formally announced, it rose to nearly 214.

Alabama, Arkansas, Louisiana, Mississippi and Oklahoma had the largest increases in requests per week per 100,000 women.

What they're saying: "Every state, regardless of abortion policy, showed a higher request rate during the periods after the leak and after the formal decision announcement, with the largest increases observed in states enacting total bans," the study said.

When Texas enacted its abortion ban last fall, "I said the need for abortion won’t go away just because it’s restricted, and that self-management stepped in as a potential option for people who could not go to a clinic," Abigail R.A. Aiken, assistant professor at the University of Texas Austin’s LBJ School of Public Affairs and lead author of the study, said in a statement.

"[W]hat this new data also shows is that when respondents have other options available to them, they still value the ability to manage abortion on their own terms."

Worth noting: Almost half of U.S. states had laws in place making it illegal to access pills via mail even before the fall of Roe.

Attorney General Merrick Garland has said that states cannot ban abortion pills because they are approved by the Food and Drug Administration, which says it can be used in the first 10 weeks of pregnancy and allows doctors to prescribe the medication online.

Mail-order abortion pill requests surged after Roe reversal, study finds

States with total or near-total bans on abortion saw the largest increases in requests.

Photo of a hand raising an abortion rights sign against the backdrop of the U.S. Capitol

An abortion rights demonstrator holds a sign near the U.S. Capitol during the annual Women's March in Washington, D.C. on Oct. 8, 2022. Photo: Roberto Schmidt/AFP  via Getty Images

Axios Explains: Abortion

New research showing racial disparities in regional anesthesia use has major implications for Black women — especially in pregnancy and childbirth, medical experts and reproductive health advocates tell Axios.

Why it matters: Black women have a long history of experiencing medical maltreatment, the legacy of which remains today in implicit biases and systemic inequities that worsen health outcomes. They are three times more likely to die from pregnancy-related complications compared to white women, according to the Centers for Disease Control and Prevention. 

Driving the news: A new study, which reviewed the records of nearly 57,000 adults who had surgery between 2016 and 2021, found that people of color were 29% less likely to receive regional anesthesia compared to white patients.

Patients with Medicaid insurance were 39% less likely to receive regional anesthesia than those with private insurance.

Women were 11% less likely to receive regional anesthesia than men.

The big picture: The finding that Black women are less able to access anesthesia has particularly dangerous consequences in pregnancy and childbirth, one of the most painful and oft life-threatening operations in medicine.

Black women have a 53% increased risk of dying in the hospital during childbirth compared to white women — no matter their income level, type of insurance or other social determinants of health, according to another recent survey that analyzed 9.5 million hospital deliveries between 2007 and 2018.

Anesthesia is "really interwoven with obstetrics ... Epidurals provide great pain relief when they work and also when people get C-sections," Alexander Beletsky, resident physician at the Riverside Community Hospital and the lead author of the anesthesia study, told Axios. 

Researchers have also shown that the use of epidurals in childbirth is associated with a decreased risk of severe maternal morbidity. 

Between the lines: The maternal health care system in the U.S. has long failed Black women, according to Jamila Perritt, an obstetrician-gynecologist who heads the group Physicians for Reproductive Health.

J. Marion Sims, who is often called the "father of modern gynecology," repeatedly experimented on enslaved women without anesthesia in the 1800s, spurred by racist beliefs that Black people have a higher tolerance for pain.

A 2016 study found that roughly half of the medical trainees surveyed endorse the same kind of false beliefs about biological differences between Black and white people.

What they're saying: "There's an emerging amount of evidence pointing at implicit biases that providers may have and how that may affect ... particular regions or areas of care like obstetrics," Beletsky added.

Nobody should be expected to go through these procedures without anesthesia, Venicia Gray, senior manager for maternal and infant health at the nonprofit National Partnership for Women & Families, told Axios.

Both studies, which were recently presented at the American Society of Anesthesiologists' 2022 annual meeting, "just compound on the result of systemic racism that leads people to accept any number of false racial stereotypes," Gray said.

"With this maternal health crisis, there are really some strategies that remain largely overlooked, and that includes adequately and intentionally addressing the structurally based inequities of unmet social needs and really working to dismantle the racism and the misogyny, frankly, that drive them."

Worth noting: The fall of Roe will likely increase maternal mortality rates, said Robert White, an anesthesiologist at Weill Cornell Medicine and the lead author of the study that analyzed hospital deliveries.

States with more restrictive abortion policies already have higher maternal mortality ratios, higher racial disparities in public funding for maternal care and fewer social safety nets like Medicaid expansion or paid leave, according to White.

"So at the end of the day, it's: how do you want to die?" Gray said. "Which is a scary, terrible thing to say. But that's kind of the stark reality."

Something to watch: More people are turning to home births, birthing centers, doulas and midwives in a bid to avoid discrimination in hospital settings, and that trend will likely continue, Gray noted.

Go deeper: White House issues first-ever proclamation on Black maternal health

Anesthesia use disparities could negatively affect Black maternal health, experts say

A new study found that people of color were 29% less likely to receive regional anesthesia compared to white patients.

Illustration of a hospital emergency room with different colored shapes around it. 

Photo illustration: Brendan Lynch/Axios. Photo: Linh Ta

Health care

A North Dakota judge affirmed on Monday his previous decision to temporarily block the state's abortion ban while an abortion clinic's legal challenge plays out, AP reports.

Why it matters: The move comes after the state Supreme Court ordered the judge to reevaluate whether he made the "appropriate" decision in rejecting the North Dakota attorney general's request to let the trigger ban take effect amid the lawsuit brought by the Red River Women’s Clinic of Fargo.

The law bans abortions except in cases where the procedure is needed to prevent a pregnant person's death.

The state Supreme Court issued the order after agreeing with North Dakota Attorney General Drew Wrigley's argument that Judge Bruce Romanick failed to consider the clinic's likelihood of prevailing in the suit.

Driving the news: Romanick upheld his earlier ruling on Monday, which stated that he cannot consider the clinic's chances of winning without hearing proper arguments from both sides, per AP.

The big picture: The Red River clinic, the last remaining abortion provider in North Dakota, closed its sole location in Fargo after the U.S. Supreme Court overturned Roe v. Wade. The clinic moved across the state line to nearby Moorhead, Minnesota. 

Its lawsuit argues that the ban violates the North Dakota constitution.

Go deeper: Dozens of clinics stopped offering abortions after Dobbs decision

Judge upholds decision to temporarily block North Dakota's abortion ban

Photo of abortion rights protesters holding signs that say "My abortion saved my life"

Abortion rights advocates protest in front of the Supreme Court on June 26, 2022 in Washington, D.C. Photo: Anna Moneymaker via Getty Images

Just 15% of Republicans have a "great deal" of confidence in scientists to act in the best interest of the American people, according to the Pew Research Center.

Why it matters: Democrats and Republicans disagree on the role of scientists in public policy — and that divide has only grown wider since the COVID-19 pandemic.

By the numbers: Democrats have higher trust in scientists than Republicans.

41% of Democrats and those who lean toward the Democratic Party have a great deal of confidence in scientists. Nearly all (89%) have at least a fair amount of confidence. About 1-in-10 Democrats have a negative view of scientists.

15% of Republicans and Republican leaners have a strong level of confidence in scientists when it comes to the public arena. About 36% have little or no confidence in scientists.

A majority (63%) of Republicans did have a fair amount of confidence in scientists to act in the best interests of the public.

The big picture: Democrats and Republicans have been "at odds over science-related questions" during the pandemic, especially when it comes to the coronavirus threat, public policy response, mask-wearing and vaccines, according to Pew.

Go deeper: Fauci: Republican detractors are "criticizing science"

Methodology: Figures in the story come from a new Pew Research Center survey that was conducted from Sept. 13 to 18, 2022. About 10,000 panelists responded out of 11,687 who were sampled.

Just 15% of Republicans have "great deal" of confidence in scientists

Democrats and Republicans disagree on the role of scientists in public policy, and the divide has only grown wider.

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, testifies.

Anthony Fauci, director of NIAID, testifies before Congress. Photo: Tom Williams/CQ-Roll Call, Inc via Getty Images

Data: CDC, U.S. Census; Chart: Erin Davis/Axios Visuals

Monkeypox cases may be slowing in the U.S., but the perils of communicating who is most at-risk and getting those people the resources they need is still challenging public health officials and providers.

Why it matters: Monkeypox infections are seen primarily among men who have sex with men, but emphasizing that transmission route risks stigmatizing gay and bisexual men.

The head of the World Health Organization urged men at risk to reduce the number of sexual partners "for the moment" while WHO officials emphasized that monkeypox can infect anyone in close contact with an infected person.

Monkeypox messaging debated as outbreak enters new phase

Monkeypox messaging debated as outbreak reaches new phase

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