The Resurgence of Mpox in Africa
Introduction
Mpox, originally known as monkeypox, is a transmissible disease caused by the monkeypox virus, a species of the genus Orthopoxvirus. The World Health Organization (WHO) identifies two distinct clades of the virus: clade I (with subclades Ia and Ib) and clade II (with subclades IIa and IIb). Common symptoms include skin rashes, enlarged lymph nodes, fever, headache, muscle ache, back pain and low energy.
A rising mpox outbreak is raising concerns over a multi-country epidemic or potentially a new pandemic. In 2024, more than 17,000 suspected (2863 confirmed) cases of mpox were reported across Africa, primarily in the Democratic Republic of the Congo (DRC). This marks a significant increase over prior years. Concerningly, the outbreak has recently spread to 4 previously unaffected African countries: Burundi, Kenya, Rwanda, and Uganda.
On August 13, 2024, the Africa Centres for Disease Control and Prevention (Africa CDC) announced the pandemic a Public Health Emergency of Continental Security. The next day, WHO Director-General Tedros Adhanom Ghebreyesus classified this event as a Public Health Emergency of International Concern (PHEIC).
Current Global Governance
Under the 2005 International Health Regulations (IHR), the WHO Director-General has the authority to decide if an event is a PHEIC. To make this decision, the Director-General must consider the advice of the Emergency Committee (EC), which consists of technical and scientific experts with adequate geographic representation, including at least 1 member from an affected state.
The IHR assigns the EC the responsibility in evaluating whether an event is extraordinary and if it poses a public health risk to other states due to the international spread of disease and may necessitate a coordinated international response. When the resurgence of mpox in 2024 was deemed a PHEIC, the EC Chair Dimie Ogoina declared that all EC members acknowledged that the 3 criteria had been met.
Outbreak Status
The current epidemiological characteristics in the DRC vary significantly from the 2022 clade II global epidemic, which persists at a lower level. The 2022 mpox epidemic (clade II) was mainly transmitted through sexual contact between men who have sex with men, predominantly affecting adult men, with a low case fatality risk of less than 1%. Conversely, the DRC is experiencing a substantial number of cases in children due to clade I, with over 50% of reported cases and most deaths occurring in children under 5 years. Although confirmatory testing is rare, these infections are presumed to be clade Ia, which is prevailing in the region.
Moreover, new clusters of transmission connected to heterosexual contact have developed, which was unusual in the 2022 clade II pandemic. These infections are associated with a novel lineage, clade Ib, often present with whole-body rashes or prolonged genital lesions and has a rising case fatality rate—up to 5% in adults and 10% in children. Reports also show pregnancy loss in infected individuals. These demographic patterns, including new transmission modes, such as household and heterosexual contact, significantly contribute to spread, require a different approach to risk assessment and reduction compared to the 2022 outbreak.
Cases of clade Ib have spread internationally recently, with reports from the Central African Republic, Burundi, Rwanda, Congo, Kenya, and Sweden. Notably, Kenya has reported cases that spread through Uganda, while Burundi shows indications of community transmission.
The clause Ib case in Sweden was reported to have originated from an affected African region, but no further details have been revealed. With continued dissemination, the pandemic’s geographic footprint will expand to new countries and regions. Some public health officials noted that clade Ib may have pandemic potential, which is supported by media reports. Despite limited data available, clade Ib is spreading distinctively and may shift as cases escalate.
A coordinated international response is imperative. According to WHO, the DRC is encountering a lack of treatment kits and vaccines, compounded by other public health concerns, outbreaks and instability. Africa CDC has established a financial appeal and announced a Public Health Emergency of Continental Security on August 13, 2024. Africa CDC Director-General Jean Kaseya emphasises the importance of solidarity, noting disparities and lack of support during the previous mpox PHEIC, particularly as cases declined in the Global North. This underlines the vital demand for a coordinated international response which will only grow if the epidemic continues to spread. The DRC has been battling this outbreak for a long time without adequate support, and the situation is now affecting neighbouring countries and potentially beyond.
Global Health Law in Transition
Recently adopted modifications to the IHR enhance States Parties and WHO’s duty to facilitate and overcome barriers to the distribution of health products such as diagnostics, treatments, and vaccines. The revisions further enable the Director-General to look into the accessibility of these health products when offering proposals to countries. Unfortunately, the amended IHR is unlikely to take effect until at least the latter half of 2025, and WHO has stated that the Director-General has yet to publicly release these modifications. Simultaneously, discussions for a new Pandemic Agreement, which intends to eliminate limitations to countermeasures during PHEICs, remain on hold and postponed to 2025.
During this transitional period, there are few legally obligatory measures to safeguard from failures of the global health governance and cooperation that occurred during COVID-19, such as vaccine nationalism and limited access to diagnostics, vaccines, and therapeutics. Strong global leadership and guidance are essential.
Existing Mpox Strategies are Insufficient
The EC for the previous clade II multi-country mpox epidemic convened throughout 2022 and 2023. WHO Director-General Tedros ruled that occurrence was a PHEIC and presented provisional guidelines for its surveillance and protection. The decision was only effective until May 2023, and the EC proposed that ongoing, non-acute standing recommendations would be more suitable.
A subsequent mpox special review committee suggested that the “historical neglect” and “perennial inequity” in access to diagnostics, therapeutics, and vaccines could also be rectified with standing recommendations. This was the second instance that standing recommendations had been implemented under the IHR, following a precedent set for COVID-19 earlier in the same month.
The inadequate international action in response indicates that standing recommendations might not possess the normative weight required to compel the global response to prevent the growth of new mpox outbreaks. Although these recommendations were initially due to cease on August 20, 2024, the WHO Director-General has extended them for another year. Moreover, WHO recently established its strategic framework for 2024-2027 to strengthen the approach of mpox prevention and control for a prolonged period.
Despite this, the global response has been insufficient, and the framework does not substitute existing IHR processes which intend to notify the global community to prepare for and tackle extraordinary events with potential risk of international spread and necessitate a coordinated emergency response.
The WHO Director-General is anticipated to issue temporary recommendations for this PHEIC in the days to come. WHO estimates that the response will acquire US $15 million and has allocated an initial US $1.5 million from its Contingency Fund for Emergencies. Likewise, the Africa CDC predicted that 10 million vaccines would be necessary to prevent this outbreak, with the European Union and pharmaceutical company Bavarian Nordic investing 215,000 vaccines. These commitments are undoubtedly lacking and countries, specifically those in the Global North, must urgently address this shortfall.
Although the PHEIC was established during an international legal period, countries should embrace the amended IHR’s principles of equity and solidarity by collaborating with WHO and Africa CDC to ensure equitable availability to diagnostics, treatments, and vaccines. The world must not wait for new laws to transition from charity to self-sufficiency. Inaction would perpetuate disparities in prioritising health emergencies and deciding whose lives are saved, undermining international law and revealing empty promises, thus exposing the world at greater risk to current and future outbreaks.
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