Africa CDC declares mpox a public health emergency

The African continent is facing an unprecedented surge of mpox cases — with a worrying spread to countries which previously haven’t reported instances. With this in mind Dr. Jean Kaseya Director-General of the Africa Centres for Disease Control and Prevention declared the disease a public health emergency of continental security on Tuesday. The declaration “is not merely a formality” but a call to action to enhance the global response, mitigate the impact of the health threat, and protect public health while minimizing disruptions to travel and trade, Kaseya said. “It’s a recognition that we can no longer afford to be reactive. We must be proactive and aggressive in our effort to contend and eliminate this threat,” he said. While the outbreak is largely concentrated in the Democratic Republic of Congo, which accounts for more than 90% of reported cases, Africa CDC has reported that 16 African countries are reporting cases, and the disease has shown up in countries that haven’t previously been affected, including Burundi, Kenya, Rwanda, and Uganda. More than 14,000 cases and 511 deaths have been reported. The disease causes painful rashes and lesions, among other symptoms. While most patients recover within a month, it can also be fatal. In the next two weeks, Africa CDC plans to finalize a joint response plan from national response plans that will be submitted to an Emergency Consultative Group, or ECG — tasked with advising the agency on declaring a public health emergency — for review. The World Health Organization is also convening experts to decide whether this multicountry outbreak constitutes an international emergency. WHO’s regional Africa office had previously raised concerns about Africa CDC declaring emergencies because it could lead to “duplicated roles,” as WHO already has the right to declare emergencies at the international level. But Kaseya said WHO will continue to coordinate at an international level while Africa CDC leads the continental response. “African leaders see WHO as necessary but insufficient. Thus, declaring a regional emergency is a natural & important way for African countries to work together to contain outbreaks,” Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law, wrote on LinkedIn. A first for Africa This is the first time that Africa CDC has declared a public health emergency. It’s part of the new powers the agency has gained in recent years as it works to become more autonomous from the African Union. The declaration comes after wide ranging consultations with governments, partners and an ECG meeting that unanimously recommended it, Kaseya said. At the beginning of August, the AU approved $10.4 million for Africa CDC’s response to mpox, but Kaseya warned current projections show that the continent needs around $4 billion and the agency hopes the declaration will trigger global support. “Africa has long been a front line in the battle against infectious diseases, and we have often borne this burden with limited resources, but the fight against mpox requires a global response,” he said. “We need your support. We need your expertise. We need your solidarity.” From May 2022 to July 2023, mpox was declared a public health emergency of international concern by WHO, but Africa didn’t get appropriate support, and when this declaration ended, cases in Africa continued to increase, he added. “Today, we are facing a consequence of non assistance and not appropriate assistance to African countries when the public health emergence of international concern was declared,” he said. “We call upon our international partners to take this mpox as an opportunity to act differently.” Last Wednesday, WHO director-general Dr. Tedros Adhanom Ghebreyesus announced he’s urgently convening an emergency committee to meet to advise him on whether the outbreak should be declared a public health emergency of international concern. “The number of cases reported in the first six months of this year match the number reported in all of last year,” Tedros said during a press briefing last week. This emergency status is intended to increase global awareness and mobilize cooperation among stakeholders, he said. But not everyone thinks a declaration will achieve this desired effect. Global health specialist Madhukar Pai wrote on LinkedIn that he fears it could lead to wealthy nations hoarding vaccines and imposing travel bans on African countries, which will only get “token” donations. Kaseya warned against such actions. “There is no reason to close borders. There is no reason to stop trading. The only reason we have by declaring this public health emergency of continental security is to ensure that we have tools,” he said. WHO’s regional mpox response plan requires $15 million and the agency has released $1 million from its emergency contingency fund. “We need more support for this,” said Dr. Maria Van Kerkhove, acting director of WHO’s Department of Epidemic and Pandemic Preparedness and Prevention, during the press conference. “Financial support for mpox is required. We need to scale up the response to really tackle this as a multi-country outbreak.” The agency doesn’t recommend countries impose travel restrictions on countries where the virus is circulating, but does recommend increased cross-border collaborations on surveillance and case management. Sustained community transmission Mpox has been endemic in Central and West Africa since the 1970s. But between July 2022 and May 2023, the World Health Organization declared it a public health emergency of international concern as the disease spread globally. But when the international emergency ended, DRC continued to see a sharp rise in cases including transmission in crowded displacement camps. Traditionally, mpox has spread in DRC is through zoonotic spillover — such as in areas near forests where a child catches a rodent, or people eat bushmeat. Then, the virus spread to households and communities. But how it’s spread has changed and mpox cases have emerged in DRC in places previously unaffected by the disease. Last year, the World Health Organization documented the first cases of sexual transmission in the country. A new variant, which emerged last September, is linked to a significant increase in cases. Its transmission is linked to sexual contact and high population movement. Person-to-person transmission has been continuous since the detection of this new variant — the first documented sustained community transmission of the virus in DRC. Dr. Rosamund Lewis, WHO’s technical lead for the global mpox response, said during a press briefing that there’s no evidence as of yet that this new variant is more transmissible, but sexual interactions are “an efficient mode of transmission.” It’s impacted sex workers, students, business men, and people traveling across borders, she said. But beyond sexual contact, it’s also spreading through other skin-to-skin contact, close proximity airborne contact, and contaminated surfaces, such as bed sheets and towels. And because of this, in the parts of the country where mpox is endemic, children under 15 are the most affected and are four times more likely to die than adults. She said the case fatality ratio of reported cases in DRC is 3.6%. In South Africa, most of the cases are among men who have sex with men. Kaseya said during a press conference last week that cases increased 79% in Africa last year over the previous — and this year there is a 160% increase in cases over last year. Containment A lack of access to vaccines is hindering the continent’s response. Kaseya said that the manufacturer, Bavarian Nordic, has made 200,000 vaccine doses available to Africa. But he said this falls far short, as across the continent 10 million are needed. He also emphasized that the continent is not requesting donations, but wants to contribute to their purchase. There are ongoing negotiations with WHO and partners to discuss donations, Van Kerkhove said. This includes the governments of Japan, the United States, the European Union, and the manufacturers. WHO-listed national regulatory authorities have approved two vaccines for mpox. WHO has also triggered the process for emergency use listing of these vaccines, which will accelerate their use in countries which haven’t already been approved by national regulatory authorities. Countries haven’t been able to start widespread vaccination campaigns and only two African countries — Nigeria and DRC — have already approved mpox vaccines for emergency use, Lewis said. DRC alone needs 3 million mpox vaccines, Dr. Ngashi Ngongo, Africa CDC’s chief of staff, said. There’s a need for a phased approach of distribution, with hot spots and at-risk individuals, such as health workers, HIV positive individuals, and those who have had contact with cases, getting first supplies, he said. There’s also a need for increased virus surveillance, with information shared rapidly, Van Kerkhove said. This will help track the virus’ movement and the parts of the population it’s affecting, which will create a more tailored response. Other key elements of the response include identifying cases, tracing the people they’ve been in contact with, decentralizing laboratory diagnosis, ensuring people get treatment, putting in place measures to prevent further infection, and communicating with communities so they are aware how to stop transmission, experts said. Tracing contacts is perhaps the weakest link in many countries, Ngongo said, and there’s a need to mobilize more community health workers to become involved in these efforts. “That’s why you’ve seen the spillover of these cases in neighboring countries — because the contact tracing part of the surveillance has not been optimal up-to-date,” he said. Other key challenges include insecurity — such as cases in conflict-ridden eastern DRC, a limited understanding of the disease’s epidemiology, and the correlation between mpox and other conditions such as HIV, according to Africa CDC. Dr. Salim Abdool Karim, a South African epidemiologist and member of the Africa CDC ECG, said there is particular concern of more fatalities in Africa as there may be a correlation between having immune deficiency due to HIV and a fatal outcome from mpox.