Health experts say government should start the roll-out of mpox vaccines to targeted groups without delay as a third man (40) died of mpox at his home in Ladysmith, KwaZulu-Natal, another two new cases were confirmed in Mamelodi and Johannesburg, and a new strain was identified in the DRC.
This brings the total number of laboratory-confirmed cases of mpox to 16 and confirmed deaths to three, reports News24. Neither of the two latest cases had any international travel history, said Health Department spokesperson Foster Mohale.
“All (16) cases are males, between 23 and 43-years-old. The department, working with provinces and other stakeholders, has embarked on a health education (initiative) with funeral parlours on how to handle the human remains of the demised,” added Mohale.
Experts have warned that although South Africa has received enough medication to treat 10 cases of severe mpox, the global drugs used to treat the disease are not yet registered for use in this country.
They said if the outbreak continues, the absence of registration for a vaccine and the treatment could become a serious issue and a giant obstacle to arresting cases.
Mohale said the first batch of mpox-specific treatment – Tecovirimat – for treating patients who experience severe health complications, had arrived last week, and that processes were under way to secure more treatment and a vaccine.
Tecovirimat, also known as TPOXX or ST-246, is not for sale and will only be available for patients who are hospitalised, reports Health-e News.
“It is very difficult to get access to mpox treatment and the country has received limited stock. The Health Department will make it available to physicians dealing with patients with severe cases of mpox,” said Professor Tulio de Oliveira, director of the Centre for Epidemic Response and Innovation (CERI) at Stellenbosch University.
“In the past three years since mpox emerged as a global pathogen, much of the transmission of the disease is related to sexual intercourse. We know now by doing genomics that this strain in South Africa comes from the global outbreak of mpox that started in 2022. It was mostly transmitted by men who had sex with other men.”
Mohale told News24 the batch of medication contains “10 doses for now, for all severe health complications”.
However, most of the cases reported so far have been mild and have been managed with “supportive treatment”, he added.
“We are expecting more stock, and our response with treatment is informed by the rate of infections.”
News24 understands the medication is being used under a Section 21 application to the South African Health Products Regulatory Authority (SAHPRA).
A vaccine being used in other countries to prevent mpox is also not registered in South Africa.
SAHPRA spokesperson Madimetja Mashishi said there had been no application to register Tecovirimat in this country.
“However, named-patient Section 21 authorisations have been granted to applicants (treating practitioners) for Tecovirimat, and a bulk stock Section 21 authorisation was also granted to the Health Department …for the the importation of WHO-donated Tecovirimat,” said Mashishi.
In the US, Tecovirimat is indicated for the treatment of smallpox, and in the European Union, for smallpox, mpox and cowpox.
The US Centres for Disease Control website states that because there are “not enough data to say whether Tecovirimat is safe and effective for treating people who have mpox, it is still considered an investigational drug for the disease”.
Mashishi said there had not yet been any registration nor Section 21 applications to approve vaccines for mpox.
Mohale said there were currently no mpox vaccines in South Africa, and that regulatory approval would depend on where the vaccine had been registered “and which country’s dossier will be used by our regulator to review”.
The WHO recommends Tecovirimat for the treatment of severe cases, such as in people with a CD4 count of less than 350, Health Minister Joe Phaahla previously said.
“As far as the mpox vaccine is concerned, options are being considered on which population groups should be targeted. South Africa is trying to source vaccines from WHO member countries with stockpiles which exceed their needs, as well as from GAVI (the Vaccine Alliance).”
The National Institute for Communicable Diseases’ Nevashan Govender said two vaccines “have been granted indications for mpox, but do not have WHO prequalification approval yet”.
“These are MVA-BN and LC16m8. LC16m8 is not recommended for use in severely immunocompromised people. MVA-BN is being used globally, including for people with HIV and other immunocompromised individuals, and is being administered in the Democratic Republic of Congo for all age groups, including children, the elderly (and) pregnant women.”
Locally, a special technical working group of the National Advisory Committees on Immunisation was working on recommendations to the national Department of Health to consider the MVA-BN vaccine for both pre- and post-exposure administration for high-risk groups.
University of KwaZulu-Natal infectious disease specialist Dr Richard Lessells said Tecovirimat was the most widely used medication for mpox. However, it was not registered in South Africa and special approval must be given by SAHPRA for it to be used.
“Patients are given a two-week course in general, but treatment can be longer in cases of severe disease,” he said.
“The reality is that we don’t know how well it works. There have been trials, but no results have been reported yet. We do know that doctors and scientists around the world are reporting positive results… and that we should use it in severe cases and in patients at risk of developing severe disease.”
However, the lack of availability of Tecovirimat could become a stumbling block if South Africa experiences a widespread outbreak.
“For now, it’s not a major barrier. We have a small stock available and there are not that many cases. But if things expand, South Africa would need to expedite the approval process,” Lessells said.
He added that vaccines had been used successfully overseas to offer protection to groups at highest risk of infection.
“Some countries might have a surplus supply that they would be willing to donate to South Africa. The Health Department will also need to consider the right strategy to deploy vaccines, such as what groups to prioritise. This will not be like Covid-19, where vaccines were offered to the general population. Vaccination should be targeted for those at highest risk of infection and those at risk of developing severe illness.”
Infectious diseases specialist Professor Linda-Gail Bekker, the director of the Desmond Tutu HIV Centre at the University of Cape Town, said South Africa should not drag its heels in approving a vaccine for mpox.
“We should not wait for a (large-scale) outbreak before we declare it a potential public health risk. Isn’t it better to think about vaccinating populations we know are at risk, (rather than waiting)?”
She said there were factors the Health Department would need to consider before rolling out a vaccination campaign, including who would pay for the jabs and how they would be sourced.
“It’s likely that there will be people willing to pay for the vaccine, or potentially even medical aids willing to cover the cost for their clients. And the department is not likely to have to roll it out to everyone,” she said.
“Prevention is always better than cure. How many cases do we have to have before we act?”
Meanwhile, the SABC reports that South Africa’s Border Management Authority (BMA) has initiated screening measures at all ports of entry, including air.
BMA spokesperson Mmemme Mogotsi said the process would apply to travellers.
“BMA Port Health officers are trained to be vigilant in their observation for any lesions and other symptoms. Should there be a case … needing further referral to a health facility, arrangements have been made with ambulance services from the Department of Health.”
Clade 1 spread in DRC
Further north, an outbreak in the Democratic Republic of the Congo (DRC) continues to spread, with a case reported in North Kivu province, the first in this particular region.
The DRC’s outbreak began in late 2022 and involves the clade 1 mpox virus, which is different from the clade 2 strain circulating globally, including in South Africa.
CIDRAP reports that the outbreak is notable, because it is the first in Africa – where much of the disease activity has been related to zoonotic spread – to involve sexual spread.
One of the country’s hot spots has been Kamatuga in South Kivu province, where a novel clade 1 virus emerged with mutations that make the virus more adapted to circulation among humans. Sequencing suggests, however, that viruses from other parts of the country don’t have the mutations.
The case in North Kivu province involves a 19-year-old woman whose illness was confirmed in Goma on 1 June. Investigators found that she had sexual contact with a person with a suspected infection who had been in South Kivu province.
So far this year, 7 851 mpox cases have been reported in the DRC, 384 of them fatal. With the case from North Kivu province, illnesses have now been reported in 23 of the country’s 26 provinces. The disease is spreading through various contact forms, including sexual, non-sexual, household and healthcare.
Children are still the most affected age-group, with 39% of cases in under-fives. The disease was fatal in 240 of those cases.
Cases spread in US
In the United States, the Los Angeles Department of Public Health posted an alert last week about a rise in cases, with 10 illnesses reported in the past fortnight.
For comparison, it said during the previous several weeks it was averaging about two cases a week.
News24 article – Another KZN man dies of Mpox, Gauteng detects two more cases (Restricted access)
SABC News article – BMA implements Mpox screening at ports of entry
IOL article – Mpox in SA: 20 suspected cases reported in Gauteng (Open access)
CIDRAP article – Mpox spreads to another DR Congo province (Open access)
See more from MedicalBrief archives:
Donated mpox jabs arriving soon – Phaahla
Mpox case confirmed in Gauteng