Mpox is a ‘milestone’ outbreak for Africa

The response to the mpox outbreak in Africa is a first in many ways — and represents a new method of confronting health emergencies for the continent. It’s the first time the Africa Centres for Disease Control and Prevention declared a continental health emergency and created a continental incident management team. And it’s the first time Africa will have one collective plan and budget for a health response. It’s “a testimony that Africa can lead a response and can be supported by partners,” Africa CDC’s Director-General Dr. Jean Kaseya said during a press briefing on Tuesday. This is a new approach for a continent that has, at times, previously suffered from poorly coordinated health responses that sometimes devolved into turf wars. But this approach also works to create new systems as an answer to the failures of the international community to prioritize the health of the continent’s population — leading to long delays in access to medical countermeasures for outbreaks, like vaccines, and allowing diseases such as mpox to circulate largely unabated. The mpox outbreak is a pivotal moment for Africa CDC to further solidify its leading role on the continent, with its new structure and greater autonomy. The continent has reported over 18,900 suspected cases this year, and over 540 deaths. It’s a “milestone” moment for public health on the continent, Dr. Githinji Gitahi, chief executive office of Amref Health Africa, told Devex. ‘Why did we end the first one?’ Africa CDC has been on a yearslong journey to becoming more autonomous from the African Union. It was launched in 2017 as a specialized technical institute of the AU — and was initially weighed down by bureaucracy, making it sometimes sluggish in its response to rapidly evolving health emergencies. In early 2022, the AU voted to increase Africa CDC’s autonomy to allow it to evolve into a Pan-African public health agency. This included the ability to declare a public health emergency of continental security. But, in some ways, this was stepping on the toes of the World Health Organization, which had been working with African countries for decades in responding to health emergencies — and also has the mandate to declare emergencies at the international level. Because of this, WHO initially had hesitations in 2022 around Africa CDC declaring continental emergencies, calling it an “unprecedented arrangement” that could lead to “duplicated roles.” But the AU ultimately granted Africa CDC this power last year. The mpox outbreak is the first time it’s exercised it and is a test of whether those predictions were accurate. Experts say Africa CDC’s declaration on Aug. 13 — which was followed by WHO declaring it a public health emergency of international concern, or PHEIC, one day later — has been crucial in elevating the importance of the mpox outbreak. This includes prompting conversations around vaccine access and the local manufacturing of vaccines. “It’s given a push, in the sense that people are much more involved in the outbreak response,” said Dr. David Munganga, medical manager at the Alliance for International Medical Action’s Emergency and Opening Services, which is a medical humanitarian organization. And there’s hope this time around that these declarations will adequately serve the African continent — unlike the last mpox PHEIC, Gitahi said. In May 2022, as mpox spread outside Africa, WHO declared a PHEIC, which was officially ended in July 2023. “The PHEICs that the WHO global really focuses on a lot is when there is a threat outside Africa, not within Africa,” Gitahi said. “After Mpox was managed in the other countries, the PHEIC was lifted.” Ending it was premature, he said, because the spread of the virus was still an emergency in Africa. But the global spotlight turned elsewhere, and the work of authorizing vaccines, researching therapeutics, and working to end the disease at its source in the DRC wasn’t prioritized, Gitahi said. “Why did we end the first one? And yet, the threat was still existing in the continent of Africa,” Gitahi said. “Until we actually take effort to make sure that Mpox ends in the Congo, the threat of Mpox in the world will remain — and we haven’t bothered to do that.” Cases continued to rise in the DRC — and now cases in Africa have more than tripled compared to the period when the PHEIC was declared in 2022, spilling over into African countries that previously didn’t have cases. That has led to the current predicament the continent faces: A health emergency with a rapid increase in cases, waiting for vaccines to arrive, no therapeutics specifically approved for the disease, and limited resources. And even though mpox was first reported in Africa in 1970, a new variant called Clade 1b emerged last year in the DRC. “This disease is not well known, and we need to be involved in research so we can evolve the knowledge about how to effectively manage this disease,” Munganga said, adding that there are questions around how it evolves, clinical signs, and transmission. WHO has yet to issue an emergency use license for mpox vaccines — which is necessary before organizations such as Gavi, the Vaccine Alliance can procure them en masse — but the process is ongoing. Kaseya said WHO’s Tedros Adhanom Ghebreyesus told him he gave the go-ahead to Gavi and UNICEF to procure vaccines in advance of the conclusion of the licensing process, which is expected in the coming weeks. Separately, the governments of the Democratic Republic of Congo and Nigeria have already granted regulatory approval for the vaccines, meaning they aren’t dependent on the emergency use listing. Nigeria became the first African country this week to receive 10,000 doses. Kaseya said that Africa CDC is working with the DRC government, which has the majority of mpox cases, to ensure vaccines will land in the country next week. Africa CDC’s declaration has helped mobilize resources and ensure African governments activate emergency operation centers — giving more power to ministries of health to take action, Gitahi said. Varying levels of response have been activated in countries including Burundi, Kenya, Rwanda, Uganda, and Côte d’Ivoire, according to WHO. A continental response is also crucial for a disease like this so that countries don’t feel stigmatized and face border closures. “It’s a key milestone for Africa CDC and for public health in Africa,” Gitahi said. A new chapter This outbreak is also a new chapter in Africa CDC and WHO’s relationship in other ways. The two traditionally have had overlaps that resulted, at times, in inefficiencies, wasted time and resources, conflicting messages, and confusion. In 2023, the two organizations committed to working more cooperatively through a Joint Emergency Preparedness and Response Action Plan. It aims to leverage the strengths of the two organizations and avoid unnecessary overlap. A major strength of Africa CDC, as a part of the AU, is it has political clout and the ears of heads of state — which helps influence policy and muster political support. Its decision to make the emergency declaration was done in consultation with the continent’s political leadership. It also represents the entire continent, whereas WHO AFRO largely represents sub-Saharan Africa, while WHO’s regional office for the Eastern Mediterranean covers North Africa and parts of the Horn of Africa. But WHO’s decades-long history managing outbreaks across the continent is part of its strength — through its country offices and long-standing relationships with ministries of health. And so this outbreak will serve as a testing ground for how effectively these coordination changes have been implemented. “Because it’s the first time, you know, we’ll expect some challenges on the way,” Kaseya said. The first continental incident management team for a health emergency was recently created for mpox and is composed of groups including WHO, Africa CDC, UNICEF, Médecins Sans Frontières, the World Food Programme, the International Organization for Migration, and the International Federation of Red Cross and Red Crescent Societies, Kaseya said. The continent will learn lessons from this new team on how to manage future outbreaks, he added. WHO said the initial six months of the response is expected to cost $135 million across all international partners — but it’s currently underfunded. Africa CDC, on the other hand, has said it needs an estimated $245 million and has received less than 10% of that — about $20 million, Reuters reports. “The lack of funding is really a big, big issue, because the needs are huge,” Munganga said. And while coordination is happening smoothly now, the real test will occur when large amounts of funding come in, Gitahi said, such as when vaccine rollouts commence. “In many cases, conflict only arises when money comes,” he said. “When the funders start saying: ‘We are going to give $100 million.’ Then we are like: ‘Ok, does this go to Africa CDC or WHO AFRO?’” But beyond these two organizations, national governments are supposed to lead responses within their borders, with United Nations agencies and nongovernmental organizations playing a supportive frontline role in areas including case management, vaccine distribution, and community engagement alongside domestic health care workforces. ‘Disparate attempts’ Still, much more is needed to improve coordination. “Disparate attempts are being made to address Mpox but co-ordination needs to improve,” Kaseya wrote to health ministers last week. It’s a challenging outbreak, Munganga said. The current response is focused in the DRC, which presents a lot of logistical challenges and health system gaps. For example, many remote areas aren’t connected to health centers by good roads, he said. And there’s a massive need to increase access to testing. There’s also the need to improve cross-border point surveillance, Munganga said, which involves dealing with bureaucracy and authorizations from multiple countries. “If we want to implement something like a transborder intervention from South Kivu, DRC, to Burundi, we will face all kinds of challenges,” Munganga said. Responders also face an uphill battle as misinformation swirls, including false information that mpox is a COVID-19 side effect, that WHO is planning a “mega lockdown,” and that health authorities are exploiting this outbreak for profit. DRC also has a strong history of vaccine hesitancy. “We need to engage with community leaders and be transparent,” Munganga said, adding that it’s important this work starts now. “If we do not provide information to people, they will probably collect fake information from other sources.”