The outbreak of mpox on the African continent – that spurred the WHO into declaring it an international public health emergency last week – has scientists comparing it to the early days of HIV, but expressing concern about the unknowns of the variants.
However, local scientists have reassured South Africans that there is no need for panic in this country right now, and that the declaration was all about giving the continent the tools it needed to fight disease.
The declaration must accelerate access to testing, vaccines and therapeutic drugs in the affected areas, experts urged, and expedite campaigns to reduce stigma surrounding the virus.
More resources for research were also vital, they said, with “massive unknowns” about the new variant spreading between people in the Democratic Republic of the Congo, reports The Guardian.
As of 4 August, there had been 38 465 cases of mpox and 1 456 deaths in Africa since January 2022, including more than 14 000 cases and 524 deaths just in the DRC this year.
The “public health emergency of international concern”, the category used in the past for Ebola outbreaks, Covid-19 and a 2022 mpox surge, was “very worrying”, said WHO Director-General Tedros Adhanom Ghebreyesus, who also highlighted the emergence of clade Ib in the east of the DRC and its detection in neighbouring countries.
The WHO has released $1.5m from its contingency fund and plans to release more, he said, calling for donors to step up to fund the rest of the $15m needed for its efforts in the region.
Low risk in SA
South African scientists have sought to quell any panic that might be arising, saying the risk in this country still remains low.
There have been 24 cases and three deaths, 19 recoveries and two active cases undergoing isolation reported here so far, reports Health-e News, but most of the reported cases have made full recoveries and the government has prioritised contact-tracing.
The NDoH says it is evaluating several pharmaceutical interventions, including additional treatments and vaccines, with decisions being guided by the latest data available.
Spokesperson Foster Mohale told News24 the department was collaborating with the WHO country office, the National Institute for Communicable Diseases (NICD), and the Border Management Authority to enhance epidemiological surveillance, contact tracing, and health screening for early detection of new cases.
“We encourage businesses and organisations with operations in the affected countries to take measures to ensure their employees who regularly travel to and from South Africa are well informed of mpox and fit to travel,” he said.
Dr Jacqueline Weyer, head of the Centre for Emerging Zoonotic and Parasitic Diseases, (NICD), said that a Public Health Emergency of International Concern (PHEIC) as declared by WHO, is a mechanism under the International Health Regulations used to improve coordinated responses for the containment of outbreaks. This same instrument was used in the Covid-19 response.
“When a PHEIC is declared there are increased requirements from countries to demonstrate their commitment to outbreak responses, and increased access to resources for the outbreak. The latter would include support for enhanced surveillance and access to vaccines and therapeutics,” she said.
NICD executive director Professor Adrian Puren added his reassurances, saying the country has access to treatment and vaccination.
Deadlier strain
Dr Chris van Straten, global health adviser clinical governance at International SOS, a company that protects global workforce from health and security threats, told Health-e News that the reason scientists and WHO are concerned is because the outbreak seen in the DRC is something different.
“It’s not the strain we’re seeing in South Africa, which is clade 2. It (clade 2) is less transmissible and less dangerous. We need to keep an eye on the spread of clade 1b. In Africa we need more tests, we need to know where the cases are,” he said.
He said that as evidenced with all viruses, including Covid, the more people get infected, the higher the real risk of the virus changing, circulating, and becoming stronger.
“It gets easier to spread and become a more dangerous virus. What worries WHO, doctors and scientists is that the virus seems to be spreading faster and has killed a lot more people than the other types of mpox.
“I am worried that people want to sexualise this – yes, it can be transmitted by sex. In the DRC a lot of people were infected through sex workers. But a number of children have also been infected – they got really sick and died. It was from family contacts, sharing utensils, towels and a close living environment,” he said.
Why is the WHO stepping up?
Straten said it was about giving Africa the tools to fight the disease.
“The disease is now spilling over to countries which have never seen mpox before, so people won’t have antibodies. There are a lot of potential patients with HIV or malnutrition and weakened immune systems. We are worried that it could spread even further.”
Puren said it was important for African countries to get support from other regions of the world.
“The areas of complexity will be getting vaccines. At the moment, only those who are seriously sick will be vaccinated. It will not be a straightforward roll-out, as happened during Covid-19 where everyone was eligible for vaccination,” he added.
What the declaration means for SA
Straten said Ministries of Health were working hard to figure how far the disease has spread.
“The reason South Africa is affected is that there are a lot of business people travelling back and forth from the affected countries … a lot of movement between Kenya, Uganda and South Africa.
“I am worried for young children and pregnant women. This is not a call for alarm… it is really a call to action,” he said.
Similar to early days of HIV
Trudie Lang, a professor of global health research at Oxford University, said: “I have heard so many people refer to this as being very similar to the early days of HIV.”
This was particularly the case, she added, because the virus appeared to be spreading via sexual networks, with “vulnerable, young, exploited sex workers” at high risk. A “high level of stigma” would require public health campaigns to ensure people understood and sought treatment.
While data have yet to be analysed and published, Lang said the frontline teams she spoke to reported a high number of pregnancy losses because of the virus, and babies being born with mpox lesions due to transmission in the womb.
There were “massive unknowns”, she said, including the number of cases outside hospitals.
“What I’m truly worried about is the amount of cases that are not severe. If people have a milder infection that is potentially hidden, especially if it’s a sexually transmitted genital infection, they can be walking around with it. The big question that we’ve got is when is it most infectious, and when is it being transmitted?”
Lang added that if the virus arrived in Europe or the US, it would probably be easily contained with vaccination, as in the 2022 mpox outbreak. “This will happen very fast in Europe, but not (…) in these really impoverished areas in Africa.”
Dr Ayoade Alakija, the chair of Africa Vaccine Delivery Alliance and of the diagnostics non-profit organisation Find, said the declaration “should focus minds and loosen purse strings so that the response recovers from a sluggish start”.
“Most vaccines and treatments have been pre-ordered by rich countries and as yet only one diagnostic test exists.
“Without fair access to testing, it is also unclear how viruses like HIV may impact the severity and transmission of mpox. Not focusing on tackling the virus in the DRC has led almost inevitably to spillover to neighbouring countries and the longer action is delayed, the more likely it will spread in Africa and beyond.”
Dr Boghuma Titanji, an assistant professor of medicine at Emory University in Atlanta in the US, said she hoped the declaration would prompt African governments to allocate funds to fight the outbreak.
The African Union approved $10.4m (£8m) for Africa CDC’s response at the beginning of August, but Kaseya has suggested the continent will need about $4bn.
No money
However, despite the pleas for action and financial help, there are scant funds available to tackle the potentially lethal virus, reports Bloomberg in News24.
So far, the WHO has released $1.45m from its contingency fund for emergencies, and there is the approved $10.4m from the AU’s existing Covid funds for the Africa CDC. The largest sum could come from Gavi, the Vaccine Alliance, which has said it could tap into its new $500m emergency fund for vaccinations.
But that is still far short of the $4bn estimated for the continent to combat mpox.
The DRC alone has said it requires 3.5m vaccine doses, and its public health minister, Roger Kamba, put the cost at hundreds of millions of dollars. The price of the shots is about $100 a dose, unaffordable for many countries.
The challenge in securing money to fight the mpox outbreak is playing out against a backdrop of very limited funding for a range of deadly diseases, said Peter Sands, executive director of the Global Fund to Fight Aids, Tuberculosis and Malaria.
Not another Covid
Meanwhile, in the first case outside Africa, Sweden confirmed a case of mpox a day after the WHO declared the disease a global public health emergency for the second time in two years, reports News24.
The person was infected with the Clade 1 variant while staying in a part of Africa where there was a large outbreak of the disease, said Olivia Wigzell, director-general at the Swedish Public Health Agency.
The WHO said the outbreak is “not another Covid-19”, because much is already known about the virus and the means to control it.
While more research is needed on the Clade 1b strain that triggered the declaration of an international health emergency, the spread can be reined in, said the WHO’s European director, Hans Kluge, in an AFP report on News24.
“We know how to control mpox – and, in the European region, the steps needed to eliminate its transmission altogether,” he said, adding that the risk to the general population was low.
“Are we going to go into lockdown …as if it’s another Covid-19? The answer is clearly no.”
Clade 1b is spreading mainly through sexual transmission among adults, he said, but it was also possible that someone in the acute phase of infection, especially with blisters in the mouth, might transmit the virus to close contacts by droplets, in the home or in hospitals.
“The modes of transmission are still a bit unclear. More research is required,” he said.
WHO spokesman Tarik Jasarevic said the agency was not recommending mass vaccination, “only in outbreak settings for the groups who are most at risk”.
There are two subtypes of mpox: the more virulent and deadlier Clade 1, endemic in the Congo Basin in central Africa, and Clade 2, endemic in West Africa, said Catherine Smallwood, WHO Europe’s emergency operations programme area manager, and the split of Clade 1 into 1a and 1b reflects “change in the evolution of the virus”.
Clade 1b is a new offshoot of Clade 1, which is now called Clade 1a.
“Clade 1a traditionally has outbreaks resulting from infections from sick animals, with some limited follow-on transmission between humans at the household level, or within communities. But with Clade 1B, we have not isolated or detected zoonotic transmission of Clade 1b.
“So, it seems to be a strain of the virus that’s circulating exclusively within the human population.”
Experts are trying to work out if there is a difference in disease severity between Clades 1a and 1b.
Jasarevic said results from effectiveness studies indicated that a good level of protection was provided against mpox after vaccination. However, it takes several weeks to develop immunity after being vaccinated.
Not our problem
The mpox outbreak is yet another example of how infectious diseases perceived to be “someone else’s problem”, and affecting mainly poor, developing countries, may suddenly pose unexpected global threats, other examples of neglected diseases including the West Nile, Zika and Chikungunya viruses, say other experts.
The virus, first discovered in 1958 (in captive monkeys, hence the original misnomer “monkeypox”) with the first human case identified in 1970, was, for decades, largely neglected by the scientific and public health communities, regarded as an uncommon infection in remote rural areas in tropical Africa without relevance for the rest of the world.
When a massive mpox outbreak hit developed countries in 2022, increased research funding led to a surge in scientific studies. On just one medical search engine, there’s been more research produced since April 2022 than in the preceding 60 years.
The 2022-23 global mpox outbreak happened despite repeated calls from African researchers for increased global investment in diagnostic, therapeutic and infection prevention tools for mpox.
The WHO’s declaration of the current upsurge of mpox in central Africa requires a coordinated international response, write Wolfgang Preiser, Cheryl Baxter and Jean Nachega in The Conversation, a team of infectious disease researchers who have worked on HIV, SARS-CoV-2 and other viral infections.
Mpox’s recent history is yet another reminder that an infectious disease in one corner of the world should not be regarded as someone else’s problem, as it can suddenly start to spread fast and far.
It also highlights global inequities in resource allocation and access to vaccines, diagnostics and treatments.ges and vaccination in at-risk groups.
Upsurge in Africa
As the continent which includes the areas where mpox has been endemic for a long time, Africa now presents a complex mosaic:
• cases arising from the endemic, largely zoonotic, pattern that used to be predominant in the past
• cases linked to the 2022 global outbreak, for example in South Africa
• most worryingly, ever increasing numbers of MPXV clade Ib infections reported from the DRC.
The ongoing outbreak has the potential to fuel a large pandemic.
• It has a distinct epidemiological pattern with sustained chains of human-to-human transmission, often via the sexual route.
• It may have increased transmissibility (we don’t know yet).
• The virus which causes it is the newly defined clade Ib lineage. It displays mutations that are the hallmark of human-to-human spread that is estimated to have been happening since September 2023.
• Case numbers are rising rapidly, even though many suspected cases are probably not tested and thus not counted as confirmed. Complicating matters, a commonly used test was found to miss infections with this lineage of the virus.
• It affects mostly adults.
• The case fatality rate is higher than it was in the 2022 global outbreak.
Already, this outbreak has resulted in cases occurring in several neighbouring countries with no previous record of mpox.
Wolfgang Preiser – Head: Division of Medical Virology, Stellenbosch University; Cheryl Baxter – Head Scientific Research Support, Stellenbosch University; Jean Nachega – Professor of epidemiology, Stellenbosch University.
News24 article – Sweden confirms first case of mpox, also first outside Africa (Restricted access)
News24 article – Mpox emergency response constrained by scarce financing (Restricted access)
News24 article – Health department confirms control over mpox outbreak (Restricted access)
The Lancet Global Health article – The surge of mpox in Africa: a call for action (Open access)
News24 article – Mpox ‘not the new Covid’, says WHO as cases surge (Restricted access)
See more from MedicalBrief archives:
Mpox now declared a global emergency
Urgent global action needed stop Mpox pandemic
Call for action as DRC mpox spreads via heterosexuals
WHO ends mpox global health emergency