Treaty Kings: A return to vaccine inequity and monopoly in the 2024 Mpox outbreak, By Adaeze Oreh

…whilst external support is welcome to close existing vaccine availability and research gaps, the continent needs to do more for itself. The 10,000 doses delivered to Nigeria, out of the 750,000 doses promised Africa from Spain, France, Germany, and USA, remains a far cry from the 10 million doses stated by Africa CDC to be the volume needed to curb the outbreak… African nations need to therefore redouble efforts to build domestic capacity for the manufacturing of pharmaceuticals, such as vaccines and therapeutics.

Last week, Nigeria became the first African country to receive vaccines against mpox, a viral disease whose rapid spread led the World Health Organization (WHO) to announce the ongoing upsurge in several African countries to be a public health emergency of international concern (PHEIC) under the International Health Regulations (2005) (IHR). This announcement indicates its marked potential to spread rapidly across Africa and even outside the continent.

As alarming as the announcement might have been, and the media interest generated thereafter, it is not the first time that mpox is being referred to as a public health emergency of international concern. In fact, almost exactly two years ago, in July 2022, there was a spread of the milder Clade II strains of the virus to nearly 100 countries in Africa, Europe, United States, Australia and Asia, with about 140 deaths recorded.

Africa Centres for Disease Control and Prevention (Africa CDC) has also announced over 22,800 suspected mpox cases with about 622 deaths on the continent – a 200 per cent jump in cases – in less than one week. This Clade Ib strain that is largely responsible for the ongoing outbreak is particularly worrisome, given its higher transmissibility and potentially worse clinical severity.

In 2023, epidemiologists, including the immediate past Director General of Nigeria Centre for Disease Control and Prevention (NCDC), Dr Ifedayo Adetifa, surmised that “whereas the severity of mpox during the 2022 global outbreak was generally mild, it would be unwise to assume that future outbreaks would be similarly tame.” In the somewhat prophetic Lancet article, Adetifa and colleagues argued that “with ever increasing travel and trade, it is probably just a matter of time until a traveller or small mammal carries the more dangerous Clade I virus, with its close resemblance to smallpox, to faraway places.”

Back in 2022–2023, the demographic affected appeared to be predominantly men who had sex with other men. However, the current 2024 global outbreak has crossed African borders, with mpox cases reported in Sweden, Thailand, and Pakistan, and impacting a broader demographic, primarily spreading through direct contact, and affecting men, women, and children. In the Democratic Republic of Congo, all the country’s 26 provinces have reported cases, with children below 15 years accounting for 66 per cent of reported cases and over 82 per cent of deaths, driven substantially by contact, malnutrition, and compromised immunity. Similarly, according to the NCDC, children aged 0–5 years are the most affected age group in Nigeria.

The Director General of WHO, Dr Tedros Ghebreyesus, surmises that truncating these outbreaks and saving lives would rely on “a coordinated international response.” Unfortunately, much of the global response neglected Africa, thus culminating in these recent global outbreaks.

Since 2017, when the virus resurfaced long after its first appearance in a nine-month-old boy in 1970, there has been scant investment in diagnostic, therapeutic, and infection prevention tools, despite repeated warnings from African researchers, until the 2022–23 global mpox outbreak occurred, and tellingly research and public health responses were mostly limited to high-income countries in Europe and North America.

Viral testing of the new mpox strain reveals mutations that propagate human-to-human spread, thus infecting infants, schoolchildren, and healthcare workers, who are treating mpox patients and in some cases, entire households. Infected newborn babies, miscarriages, and long-term complications, such as blindness, have been reported. As the current outbreak unravels, scientists from the University of Oxford have described the rapidly spreading Clade I variant as “the most dangerous strain yet,” raising concerns about the risk of an asymptomatic spread.

Since 2017, when the virus resurfaced long after its first appearance in a nine-month-old boy in 1970, there has been scant investment in diagnostic, therapeutic, and infection prevention tools, despite repeated warnings from African researchers, until the 2022–23 global mpox outbreak occurred, and tellingly research and public health responses were mostly limited to high-income countries in Europe and North America.

For Professor Dimie Ogoina, infectious diseases professor with Niger Delta University, and WHO IHR Emergency Committee chair, who reported the first case in West Africa in 2017, “without decisive action, history will repeat itself.”  Many lessons from COVID-19 have been forgotten, and once again, in low- and middle-income countries, vaccine monopoly is evident, with vaccines being sold to the highest bidder. In addition, despite the changing face of the virus with regards to burden, geographic expansion, transmission, and rising case fatality rates, funding for mpox remains elusive to African researchers. Immediate steps should, therefore, be taken to sustainably curb the escalating burden of this rapidly changing viral illness.

First, whilst external support is welcome to close existing vaccine availability and research gaps, the continent needs to do more for itself. The 10,000 doses delivered to Nigeria, out of the 750,000 doses promised Africa from Spain, France, Germany, and USA, remains a far cry from the 10 million doses stated by Africa CDC to be the volume needed to curb the outbreak. These vaccines are however widely available in up to 70 countries outside Africa, inoculating low-risk populations at $50 – $75 per dose, whilst African countries with rising numbers of cases, such as DRC, Burundi, Kenya, and Rwanda, are yet to receive the vaccines pledged to them. African nations need to therefore redouble efforts to build domestic capacity for the manufacturing of pharmaceuticals, such as vaccines and therapeutics.

Secondly, less than 40 per cent of cases on the African continent are tested and laboratory confirmed, which indicates a significant problem of underreporting. African public health professionals have the skill sets but lack the requisite financial and technical support for enhanced diagnostic capabilities to drive local research. African governments must intentionally and strategically invest in health security by developing their public health institutes, while leveraging mutually respectful foreign partnerships. Otherwise, public health research will continue to be led by foreign scientists, perpetuating the continent’s dependence on foreign research findings and therapeutics.

Despite the millions of dollars channelled into vaccinating high-income populations during the 2022–2023 mpox outbreak, the virus is back and has returned with a vengeance. Clearly, a threat to health anywhere, is indeed a threat to health everywhere. Africa’s neglect during the last global outbreak of mpox has come back to bite, and unless we are collaboratively aggressive, we cannot fight the ongoing battle against infectious diseases…

Thirdly, a de-siloed approach to the consideration of vulnerable groups is vital to vaccine distribution. High costs, and regulatory bottlenecks, have hindered equitable vaccine access. Vaccinations ought to have gone beyond the global North, targeting higher-risk populations such as children, health workers, laboratory personnel, sex workers, and people with multiple sexual contacts in the affected African countries. Not doing so enabled the viral mutation that led to the current outbreak. The United Kingdom, United States of America, and European counterparts need to lead from the front by abiding with the terms of the pandemic treaty negotiations, challenging profit-inclined obstacles from big pharma, and tackling these recurring vaccine inequities.

Finally, in the absence of vaccines and drugs, there should be a more deliberate effort to raise community awareness on the infection, risks of transmission, and methods of prevention. Additionally, providing supportive care, such as enhanced nutrition, and mental health services at primary healthcare levels can reduce morbidity and mortality, given the negative effects of malnutrition, and stigma on mpox. Rivers State was one of the Nigerian states listed by NCDC to have confirmed cases in the ongoing outbreak. To address this, the Health Ministry is aggressively disseminating information locally on mpox, convening community town hall meetings for citizen awareness, especially regarding safe practices concerning interactions with wildlife, building the capacity of community health workers, including infection prevention and control staff, surveillance officers, home management and safe burial teams.

Diseases and epidemics have effectively demonstrated that they know no boundaries, as evidenced by COVID-19, and now, mpox. More than a billion people travel by air each year, and in just 24 hours an individual with a contagious illness can travel to virtually any part of the world, with dire consequences for unprepared medical systems.

Despite the millions of dollars channelled into vaccinating high-income populations during the 2022–2023 mpox outbreak, the virus is back and has returned with a vengeance. Clearly, a threat to health anywhere, is indeed a threat to health everywhere. Africa’s neglect during the last global outbreak of mpox has come back to bite, and unless we are collaboratively aggressive, we cannot fight the ongoing battle against infectious diseases – regardless of where we may be.

Together, we just might be able to.

Adaeze Oreh, a consultant family physician, public health expert and advocate for affordable universal healthcare for all Nigerians, is the Honourable Commissioner for Health in Rivers State, Nigeria.