Public Health Emergency
The World Health Organization (WHO) has declared the mpox (previously known as monkeypox) upsurge in the Democratic Republic of Congo as a public health emergency of international concern (PHEIC), the highest level of alarm under the International Health Regulations (2005) (IHR). The WHO Director-General Tedros Adhanom posted on the social media platform X and said, “Today, the Emergency Committee on #mpox met and advised me that in its view, the situation constitutes a public health emergency of international concern. I have accepted that advice.” Dr. Tedros also stated, "The potential for further spread in Africa is worrying” and “it’s clear that a coordinated international response is essential to stop these outbreaks and save lives”. This declaration was made after a meeting with an International Health Regulations (IHR) Emergency Committee consisting of independent experts on August 14, 2024. The announcement aligned with the view of the Africa Centres for Disease Control and Prevention (Africa CDC), which declared the ongoing outbreak a Public Health Emergency of Continental Security (PHECS) on August 13, 2024. According to scientists from Africa CDC, the speed at which the virus spreads is alarming. Hence, the CDC also issued a level 2 travel notice for DCR and neighboring countries, advising travelers to practice “Enhanced Precautions” including getting vaccinated with the JYNNEOS vaccine, avoiding contact with wild animals, and with people showing signs of mpox.
Currently, 17,541 mpox cases and 517 deaths have been reported in Africa. That’s a significant increase compared to 14,957 cases in 2023 and 7,146 cases in 2022. DRC becomes the epicenter of the disease, accounting for 96% of the cases and 97% of the deaths. While most cases were reported in DR Congo, mpox was seen in 12 more African countries including Burundi, Kenya, Rwanda, and Uganda, most of which have not documented 1b cases before, raising worldwide concerns about whether mpox will become a pandemic just like Covid-19.
Moreover, this is not the first time that mpox has been declared a PHEIC. On July 23 2022, the WHO declared mpox to be a PHEIC following the outbreak during May of the same year. The virus affected all six WHO regions, and in total, 110 countries reported 87, 000 cases caused by clade 2 affecting homosexual and bisexual men mostly. Thus, it is the second time in two years WHO declared mpox as a global emergency. However, this new strain called 1b is linked to more severe diseases, and easier transmission; therefore, it has the potential to spread to a wider area and affect more people than the 2022 outbreak.
However, as global cases began to decline, Africa failed to receive the necessary support that the outbreak required. Fortunately, Dr. Tedros seems adamant about giving the current outbreak the attention it necessitates. In his opening remarks at the media briefing following the IHR Emergency Committee meeting, Dr. Tedros reported that the WHO was working closely with the affected countries. The WHO has already drawn up a response plan requiring an initial US$ 15 million. US$ 1.5 million has already been released from the WHO Contingency Fund for Emergencies with plans to release more in the following days.
What is mpox?
Mpox, previously known as monkeypox, is a highly contagious disease, in other words viral infectious illness, caused by the monkeypox virus, abbreviated as MPXV. MPXV is an enveloped double-stranded DNA virus belonging to the Orthopoxvirus genus in the Poxviridae family, which contains viruses such as variola, cowpox, and vaccinia. Plus, mpox is in the same virus family as the virus that causes smallpox, although mpox’s symptoms are less severe than smallpox.
The two genetic clades of mpox are clade I and clade II, which are endemic in Central Africa, especially DRC, and West Africa, mainly Nigeria, respectively. A clade can be defined as a group of organisms that includes all evolutionary descendants from a common ancestor.
Notably, the global outbreak in 2022-2023 was caused by the clade IIb strain, whereas the recent outbreak is regarding a new variant of clade I, the Ib strain which seems to spread more easily mainly through sexual networks, according to WHO. Importantly, clade I is associated higher possibility of developing severe illness and higher mortality rates compared to clade II. For instance, clade I killed up to 10% of patients in some outbreaks, whereas clade II’s fatality rate is below 0.2%. Nevertheless, the mortality rate of this latest outbreak is around 4%.
The virus was discovered in Denmark in 1958 in monkeys when two outbreaks of a pox-like disease happened in groups of monkeys held for research, hence named “monkeypox”. However, since the source of the disease is unknown, the disease is renamed “mpox” to avoid misinterpretation. Still, scientists think African rodents and non-human primates may carry the disease and infect humans.
On the other hand, the virus was first reported in a nine-month-old boy in DRC in 1970 as a first human case.
The disease is zoonotic, meaning it can be transmitted to humans from animals. Mpox has been identified in small rodents, monkeys, and other mammals living in Central and West Africa.
Mpox can be contracted through direct contact with infected animals and contaminated materials. Person-to-person transmission occurs through direct contact with infectious skin as the virus enters the body through broken skin, mucosal surfaces, or respiratory tract. Mpox can also be contracted through prolonged face-to-face interactions, contact with bodily fluids, and intimacy with infected persons. Animal-to-human transmission may happen from bites, scratches, or animal meat of rodents and primates. Particularly, the transmission of clade II was driven by sexual contact primarily among men with men, while clade I seems to spread sexually. People with mpox can infect others until a new skin layer forms and rashes and sores recover. Plus, the disease can also be passed to the baby from the infected mom.
Children, pregnant women, and people having weak immune systems are more susceptible to the disease.
Typically, the symptoms of mpox last for two to four weeks, which typically emerge within a week after exposure. Symptoms include rash, fever, enlarged/swollen lymph nodes, sore throat, headache, muscle aches, back pain, and low energy according to WHO. Patients usually experience flu-like symptoms, skin rash, and mucosal lesions. The rash appears as a flat sore and then evolves into a blister with liquid inside that may be itchy or painful. Initially, the rash generally forms on the face and extends all over the body, especially to the palms of the hands and soles of the feet, turning into macules, papules, vesicles, and pustules, in order. The lesions, then, dry, sink in the center and eventually crust over before falling off as the person recovers.
The incubation period, the time for symptoms to arise after infection, is usually 6 to 13 days but can expand to 5 to 21 days. In some cases, though, the infected person may not display any symptoms.
Mpox can lead to serious complications including skin damage, pneumonia, corneal infection with loss of vision, pain or difficulty swallowing, vomiting, and diarrhea.
For diagnosis, a polymerase chain reaction (PCR) test is used for the detection of the viral DNA of the virus. Specimens taken from the rash output the most accurate results. Notably, blood tests are not utilized for the diagnosis of mpox since they cannot distinguish between orthopoxviruses.
Treatment
The key for treating mpox lies in preventing further complications and dealing with the rash. However, to limit infection, it is crucial for infected persons to self-isolate. One other way for people to protect themselves from the disease is vaccination. Currently, the only FDA and EMA-approved mpox vaccine is MVA-BN® (marketed as JYNNEOS® in the US). The Modified Vaccinia Ankara-Bavarian Nordic is a non-replicating smallpox vaccine. The JYNNEOS vaccine provides protection against both clade 1 and 2 mpox when inoculated 2 doses 4 weeks apart. CDC reports demonstrate the high effectiveness of the vaccine since less than 1% of fully vaccinated people get the infection, and even if they get mpox, the symptoms are milder. While there are existing vaccines, there is a need to increase access to them, WHO said.
According to the Center for Infectious Disease Research and Policy at the University of Minnesota, 10 million vaccine doses are required to battle mpox outbreaks in Africa, with which Africa CDC agrees.
As an immediate response to the outbreak, the European Commission's Health Emergency Preparedness and Response Authority (HERA), has decided to procure and donate 175,420 doses of it to aid Africa. Additionally, the pharmaceutical company Bavarian Nordic will donate 40,000 doses to HERA, as Danish biotech firm Bavarian Nordic plans to ramp up its production of mpox, which may reach 10 million doses by the end of 2025. In addition, global vaccine company Gavi also approved that they prepare up to $500 million to spend on giving mpox vaccines to African countries.
Recently, the Africa Centers for Disease Control and Prevention (DCD) disclosed that vaccination will begin within days starting from DRC and Nigeria, and other affected countries as vaccines from the EU, Bavarian Nordic, the US, and Japan will arrive soon.
Previously, the US promised to donate 50,000 doses of vaccine to DRC, while the UK pledged £3.1 million to contain mpox.
Moreover, WHO director-general Dr. Tedros invited vaccine manufacturers to “accelerate vaccine access for lower-income countries which have not yet issued their own national regulatory approval”, highlighting that they are working “with all partners to facilitate equitable access to diagnostics, vaccines, supplies for clinical care and other tools" under emergency use listing (EUL) call last week. EUL will enable partners such as the UN Children’s Fund (UNICEF) to gather and cooperate for vaccine distribution.
Dr. Tedros also guaranteed WHO’s commitment to “coordinate the global response, working closely with each of the affected countries and leveraging our on-the-ground presence to prevent transmission, treat those infected and save lives”.
A New Pandemic?
On August 15th, the first mpox Ib case outside Africa was identified in Sweden in a person who had just returned from their trip to Africa and was diagnosed with mpox in Stockholm. Swedish public health agency noted that the infected person “does not affect the risk to the general population". Despite, nearly 300 cases of clade II mpox were detected in Sweden from the 2022 outbreak earlier, this is the first-ever case of mpox clade I.
Both the Philippines and Pakistan announced that the mpox cases that they tested were verified to be clade II from last year’s outbreak. In Thailand, a European man who has arrived from Africa has been suspected and the tests to determine the type of mpox are ongoing meanwhile the patient remains in quarantine and 43 people in contact are being monitored, but experts predict it is probably clade II.
In Argentina, a cargo ship in the Paraná River sailing from Brazil was quarantined after a crew member was suspected of mpox, showing “cyst-like skin lesions”.
South Korea started to monitor travelers from high-risk countries including Rwanda, Burundi, Uganda, Ethiopia, Kenya, the Democratic Republic of Congo, Congo, and the Central African Republic as a preventive measure.
China also announced that it will screen people and goods for mpox for the next six months as Asian countries start to report cases.
On August 15th, 2024, Turkish Ministry of Health informed that no cases of mpox were detected in Türkiye in 2024, further adding that there is no need for extra precautions or restrictions for now via social media platform, X. The Ministry mentioned that they meticulously follow the progress and spread of the disease with the science committee, and conduct the necessary investigation. On August 14, Turkish Minister of Health Kemal Memişoğlu also stated that there shouldn’t be any state of alarm regarding the disease in Türkiye.
On the other hand, travel bans seem unlikely to be applied as European health authorities have decided not to impose border controls since the risk of a global mpox pandemic is regarded as “low”.
African people are against these travel bans though. As Africa CDC’s head Jean Kaseya emphasizes, Africa needs solidarity and appropriate international medical support, instead of travel bans imposing unfair treatment. Kayesa also remarked that they have been negotiating with vaccine manufacturer Bavarian Nordic regarding local production which would decrease prices and make vaccines more accessible. The company said it would focus more on mpox production and might be able to supply 2 million doses this year.
To protect from the disease, distancing, hygiene, and engaging in safe sex, are among some prevention methods to bear in mind, as The Congolese virologist Prof Jean-Jacques Muyembe mentions.
Additionally, according to Africa CDC public awareness and education about the spread of the disease should be raised, and the fact that close contact with the infected person, even breathing the same air as them, is enough for the transmission should be underscored to better fight mpox.
WHO does not recommend the use of masks or mass vaccination, but rather vaccination in outbreak regions for the groups at most risk such as healthcare workers if at risk of exposure, and sex workers.
As WHO Europe Reginal Director Dr. Hans Kluge tells BBC “Experts know how to control mpox, regardless of the variant through non-discriminatory public-health action and equitable access to vaccines”, adds that the risk for the disease to spread to the general public worldwide is low unlike to Covid 19.
While mpox spreads rapidly in Central Africa and some countries outside Africa with imported cases, WHO stresses it is not the “new COVID” and recommends targeted vaccination to combat the disease. However, as usual, “Stopping these outbreaks will require a tailored and comprehensive response, with communities at the center,” Dr. Tedros says.
Ultimately, it is hoped that the outbreak will lead to more research, accelerated vaccine production, and international solidarity.
Written by: Ayşe Defne Orhan, Leyla Hacıoğlu