African countries affected by the latest mpox outbreak are racing to mobilise funds and urgently deploy medical countermeasures, including vaccines, as cases continue to rise.
But at the same time, there is an undeniable feeling of déjà vu, write Janeen Madan Keller and Javier Guzman in Health Policy Watch, as global efforts fall short of what is needed to mount an urgent, well-co-ordinated response to curtail the crisis.
And while the world learned several lessons from Covid-19, barring some areas of incremental progress, these lessons have yet to be translated into concrete actions.
Three issues pose the key challenges. These include the dynamics of the emergency declarations issued by the WHO and African Centres for Disease Control and Prevention (Africa CDC), the incremental progress of surge financing, and the slow and fragmented start to procurement and delivery of medical countermeasures.
When the Africa CDC officially declared the outbreak a Public Health Emergency of Continental Security (PHECS) on 13 August, it was the first time a regional institution had made such a declaration, marking a significant milestone in the empowerment of African institutions to lead and co-ordinate responses to public health threats.
The WHO’s declaration of a public health emergency of international concern (PHEIC) the next day, meant as a signal to donors to step up resources to curtail an outbreak, was made earlier than in previous outbreaks.
During the 2022 mpox outbreak, the declaration came after at least 16 000 cases had been reported across 75 countries.
In contrast, the 2024 declaration was made before the virus had spread beyond Africa, signalling a more proactive approach.
While the regional and global declarations were aligned in this case, questions remain about what happens if decisions do not sync up – and emphasise the need to improve the WHO “trigger” mechanism for a PHEIC.
It needs to shift from a binary approach (global declaration vs no declaration at all) to a tiered system reflecting the severity of a pathogenic outbreak, along an “epidemic scale”, like hurricane or earthquake scales, which can serve as a more nuanced trigger for different types of responses.
Mpox vaccine needs vs donations and deliveries
The need for adequate surge or at-risk financing is arguably one of the most salient lessons from Covid-19. G7 and G20 leaders have recognised its importance, and several funds and initiatives, including various Development Finance Institutions and the Africa Epidemics Fund, have signalled support, yet there is still little, if no, money flowing.
Gavi’s $500m First Response Fund that makes resources immediately available for outbreak response is an exception. The Fund was approved by its board in June 2024, so Gavi could theoretically start drawing on these resources.
However, these funds can only be used for vaccines, not other medical countermeasures, and regulatory barriers are creating hurdles. The mechanism can only procure vaccines that have received WHO emergency use listing, even though two available mpox vaccines (MVA-BN and LC16m8) have already been approved by several well-resourced regulatory authorities.
In the short term, Gavi and other global health initiatives should revise procurement policies to recognise approvals from WHO-Listed Authorities – a new framework established by WHO to identify mature regulatory bodies operating at an advanced level of performance.
Surge financing should also be deployed to contract for manufacturing capacity. Specifically, Denmark’s Bavarian Nordic and Japan’s KM Biologics that produce the two mpox vaccines recommended by WHO could use third party facilities to ramp up production.
The current outbreak underscores the need for donors to continue to work towards a more co-ordinated and coherent surge financing facility covering a range of health products and uses (this could entail building upon existing mechanisms rather than creating new ones).
Mpox vaccine donations to date
We already have safe, efficacious vaccines to prevent mpox. But at roughly $100 a shot for Bavarian Nordic’s two-dose regimen (MVA-BN), the vaccine that has been the most widely used in Europe and the Americas, these are expensive for Africa.
The immediate priority should be getting as many of the 10m doses needed, as estimated by the Africa CDC, procured and delivered to affected countries at the epicentre of the outbreak.
Donated doses can help fill immediate gaps. The DRC, whose regulator recently granted emergency use for two vaccines, now expects to receive some 315 000 donated MVA-BN doses from the European Union and the United States – with doses from the US reportedly due to arrive early as next week.
Additional announcements are trickling in, with a reported 3.5m donation by Japan of its one-dose LC-16 vaccine, produced by KM Biologics and approved for use in children, as a significant step forward.
Now is the time for other countries holding mpox vaccine stockpiles to step up, and share supply with the most affected countries – so as to curtail further spread.
But dose donations will require extremely close co-ordination to manage the myriad legal, regulatory, logistical barriers involved. In leading this effort, Africa CDC should partner with Gavi, the Vaccine Alliance, drawing on its experiences of co-ordinating Covid vaccine donations.
Last week, Bavarian Nordic indicated it has capacity to manufacture 10m doses by the end of 2025, including up to 2m doses by the end of 2024. Activating pooled procurement mechanisms, backed by financing from donors alongside African regional entities and countries, to coordinate purchasing should be a critical component of the global effort.
Bavarian Nordic has also reportedly entered into an agreement to transfer vaccine manufacturing technology to selected African manufacturers, according to Africa CDC Director Jean Kaseya.
While this would be an important move, announcements around diversifying manufacturing via technology transfer agreements will not produce the doses needed in time to halt the outbreak.
Challenges of conflict, logistics and systems
Delivery of medical countermeasures was another shortcoming of the Covid response. Specifics of the current outbreak pose particular challenges for delivery: transmission mechanisms and target populations differ from previous mpox outbreaks; there is ongoing conflict in the most affected areas, like eastern DRC; and vaccines must either delivered in multiple doses (MVA-BN) or in the case of the the Japanese-made LC16 vaccine, using an intradermal method of administration with which many vaccinators are unfamiliar.
Global health institutions, including Gavi, Unicef and the WHO, also need to work closely with other partners, including humanitarian organisations and multilateral development banks, like the World Bank, to leverage their financing to support delivery and related response needs.
Finally, there are additional R&D needs. Usage of Bavarian Nordic’s MVA-BN vaccine is currently limited to adults, underscoring the urgency to broaden usage to children and adolescents, who are disproportionately affected by this outbreak. Apart from vaccines, R&D is needed for rapid, point-of-care diagnostics and treatments.
While these immediate priorities should be top-of-mind, longer-term efforts can help in the future. Gavi’s new Vaccine Investment Strategy, approved by its board in June 2024, includes plans to establish a global stockpile.
World leaders must respond to the calls for strong co-ordination and immediate access to medical countermeasures. Otherwise, the evaluations and after-action reviews of the international response to this outbreak will read as the same story of inequitable access that characterised the Covid-19 pandemic.
Janeen Madan Keller – Policy Fellow and Deputy Director of the Global Health Policy programme, Centre for Global Development.
Javier Guzman – Senior Policy Fellow and Director of the Global Health Policy programe, Centre for Global Development
Health Policy Watch article – The Global Response to Mpox: A Feeling of Déjà Vu? (Open access)
See more from MedicalBrief archives:
No need to panic, say SA experts as DRC buckles under mpox spread
Urgent global action needed stop Mpox pandemic
Don’t delay mpox vaccine roll-out, experts urge health authorities