Africa monitors mpox spread with growing concern: ‘This is no longer a problem for us, but for the world’

“Western countries are no longer safe,” says Jean Kaseya, director general of the African Centers for Disease Control and Prevention (CDC), the continent’s highest health authority. Thirteen African countries have so far confirmed cases of mpox, and two more (South Sudan and Chad) are pending confirmation. And experts fear it will spread to more places, faster. From Africa, the warning is clear: “This is no longer a problem for us, but for the world,” Kaseya stressed in a telephone interview.

Wednesday’s declaration of an international health emergency for mpox (as monkeypox was renamed to avoid stigma among sufferers) augurs echoes in Africa of the coronavirus pandemic, during which wealthy nations hoarded resources and vaccines. “Even in 2022 [when the WHO declared another emergency for an outbreak affecting a third of patients] the North kept doses and diagnostics to themselves,” Kaseya notes.

“We need Western solidarity to save lives around the world,” insists the CDC director-general, who warns that his experts are already studying — in addition to animal-to-human and human-to-human transmission of the virus —the possibility of human-to-animal transmission, something that could lead to a dangerous mutation.

Epidemiologist Salim Abdool Karim also describes the mood at Monday’s CDC meeting — a day before Africa’s top health authority declared a state of emergency — as one of “great concern.” A respected expert who leads the group of 20 scientists advising the CDC on the matter and who also works as an expert for the WHO and has been on the front line of public health problems such as HIV or coronavirus for 40 years, Karim notes that mpox has been “resurfacing from time to time” in the Democratic Republic of the Congo (DRC) for years, but that this combination of factors has never happened previously: firstly, the “incredibly high” number of cases detected (15,000 infections and 479 deaths so far this year, mostly in the DRC, although the actual numbers are likely to be much higher). These are, he stresses, more than three times as many as in 2022 when the WHO declared a first global health emergency for monkeypox.

The second factor, adds Karim, is the increase in mpox cases in a few weeks, especially driven by the DRC, and its spread to countries that had not reported recent cases such as Kenya and Uganda. The third, he concludes, is the mortality rate, which is “much higher than anticipated” at around 3%. This figure takes into account the number of deaths and the number of registered cases, but there is probably a large under-diagnosis, so many experts put it on hold.

The most worrying clade (variant) of mpox in Africa is 1b, the one that has recently emerged in the DRC and which appears to be more transmissible between people, more virulent, and more lethal, especially among children — 70% of the positives are in children under 15 years of age and 39% in children under five years of age, who account for 62% of deaths. According to the WHO, more than 100 laboratory-confirmed cases of Clade 1b have been confirmed in the last month in four countries bordering the DRC that had not previously reported any outbreaks: Burundi, Kenya, Rwanda, and Uganda. Clade 2, responsible for the global outbreak in 2022, which was transmitted mainly through sexual intercourse, continues to circulate, albeit with less virulence, in countries such as South Africa and Egypt.

Transmission of the new variant can occur from person to person through close contact with someone infected: face-to-face, talking or breathing in close proximity (from droplets excreted), skin-to-skin contact, mouth-to-mouth, or mouth-to-skin contact. Karim comments that variant 1b appears to be transmitting in heterosexual relationships, as a large number of CRD diagnoses are occurring among people working in prostitution. “We are concerned that this could mean widespread spread, especially if a good number of patients have mild or no symptoms.”

DRC humanitarian crisis

An added problem for Africa in fighting the epidemic, experts agree, is the reporting of cases: the DRC is immersed in a humanitarian crisis and a conflict that has been ongoing since the late 1990s, further aggravated from 2022. In this context it faces constant public health problems, such as measles (300,000 cases last year resulting in 6,000 deaths, according to Doctors Without Borders) and extremely precarious public health systems. To make matters worse, the area that is the focus of the current mpox outbreak, South Kivu, is one of the most impoverished in the country, where hundreds of thousands of displaced people live in overcrowded camps. “[In these areas of DRC] there are no adequate staff or resources for contact tracing, nor is there capacity for sufficient laboratory testing,” says Isidro Carrión, a Doctors Without Borders epidemiologist who has worked in DRC on several occasions in recent years.

Greg Ramm, director of the NGO Save the Children in DRC, describes overcrowded health centers around Goma (the capital of North Kivu province), where there is insufficient space for patients to isolate themselves and insufficient protective equipment for doctors and nurses dealing with possible contagions. “There is also a lack of resources to communicate to communities how the disease is transmitted, what the symptoms are, and how to prevent it.”

“The virus is walking at a steady pace”

Luis Flores, a research associate at the Centre de Recherche en Sciences Naturelles in Lwiro, saw firsthand how monkeypox transmission began last October in Kamituga, an isolated mining town in the DRC. “We saw that the transmission was not only sexual, as happened in Europe; sick children started to appear. The effects on infected people are terrible; it is not only in the genital areas as happened especially in the 2022 outbreak in Western countries, it is all over the body, like the old smallpox,” he explains.

Flores, who was part of the team that sequenced Clade 1, states that nothing is being done in the affected regions: “There is a lot of chaos, the virus is spreading through the community, there is practically no diagnostic capacity. We have been seeing it for months and no measures have been taken; there has been no ring vaccination in the area, not even for the health workers who treat sick people.”

The researcher describes Kamituga as a very densely populated area that is very difficult to access — it takes more than two days to reach — with a lot of prostitution and “ideal conditions” for a virus of these characteristics to spread.

The Spaniard, who is setting up a laboratory at the center where he works in the small town of Lwiro, has watched the advance of the virus with concern: “It walks, and it does so at a steady pace. I’m surprised we haven’t learned from covid. It has spread outside DRC and in a few months, if nothing is done, it will jump to other countries.”

Lack of vaccines

“We have been warning of the shortcomings in the response to this epidemic and the catastrophic consequences it can have in such vulnerable communities and, therefore, in neighboring countries with very fragile health systems,” says Carrión. “In Europe, there is a lot of talk again about the virus, about the need for vaccines... but we must not forget that [in Africa] there are already thousands of people suffering from the disease without adequate treatment.”

Kaseya, the director-general of the CDC, assured in his press conference Tuesday that the continent needs more than 10 million doses of vaccine against mpox, but that it has barely 200,000. WHO Secretary-General Tedros Adhanom Ghebreyesus is currently campaigning among vaccine manufacturers to speed up production. The WHO’s declaration of an international emergency is expected to facilitate some procedures, but international collaboration will be needed to get the doses to countries such as DRC.

The challenge in sourcing the necessary vaccines, however, will be in supply. A spokesperson for the Global Alliance for Vaccines and Immunization (GAVI) explains: “There are still a few weeks to go before the WHO approves any vaccine for emergency use and, even then, it will take time for manufacturers to be able to supply doses in large quantities.” In the short term, acknowledges the large public-private partnership, the best way to get vaccines to the countries that need them will be through donations.

Karim qualifies that vaccines will not, in any case, be the main element in Africa to control the virus, which has for years been present and “under control” in countries such as DRC. “Public health measures are needed: well-informed health professionals, information campaigns, capacity to identify and isolate cases, and a lot of contact tracing.” It is vital to stop the spread of mpox forcefully, he warns, “before it becomes a global problem.”

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