Post by Nadica (She/Her) on Aug 16, 2024 2:14:52 GMT
This Mpox Outbreak Isn't Like the Last One - Published Aug 15, 2024
In May 2023, the World Health Organization released a statement declaring the end of mpox—formerly known as monkeypox—as a public health emergency. Just over a year later, the agency has been forced to backtrack, with a far more serious epidemic brewing across much of sub-Saharan Africa.
Statistics show that more than 15,000 mpox cases and 461 deaths have been reported on the African continent since January, spreading out of countries such as the Democratic Republic of Congo (DRC), where mpox has long been endemic, to 13 other African nations: countries like Rwanda, Kenya, Burundi, and Uganda, where the disease has never previously made an impact.
In the eyes of scientists like Boghuma Titanji, an associate professor in infectious diseases at Emory University who studies mpox outbreaks, this new, deadlier outbreak represents the consequence of the world’s health watchdogs failing to do enough last time round.
It was the summer of 2022 when the spread of mpox first set alarm bells ringing. Suddenly a virus which had always been predominantly contained within parts of West and Central Africa was suddenly going worldwide. Between early 2022 and December 2023, there were 92,783 confirmed cases of mpox across 116 countries, leading to 171 deaths.
Despite these numbers, its perception as a public health threat swiftly faded. “Ninety-five percent of the cases during the 2022 outbreak were among men who have sex with men, reporting exposure through sexual or close contact with another infected person,” says Titanji. “It was an outbreak that was very focused, which allowed vaccinations to be prioritized among that network.”
Countries in the global north successfully scrambled to suppress the outbreak within their own borders. Meanwhile, Titanji says, ramping up viral surveillance among the African nations who had been battling a steady rise in mpox cases for the past four decades soon slipped down the priority list, allowing a potentially more problematic variant to emerge undetected.
Mpox exists in two main subtypes, clade 1 and clade 2. Between them, clade 1 is believed to be up to 10 times more deadly, particularly among population groups with weakened or developing immune systems such as children under the age of 5, pregnant women, and immunocompromised people. That’s the viral strain behind this new outbreak, and why infectious disease scientists are so alarmed. (A separate outbreak spreading in South Africa among people living with HIV is thought to be linked to clade 2.)
“The 2022 global outbreak was clade 2, and mortality was less than 1 percent,” says Jean Nachega, a Congolese infectious disease doctor and an associate professor of medicine at the University of Pittsburgh. “Now we’re talking about a strain which can have up to 10 percent mortality.”
While the previous outbreak predominantly affected homosexual populations, data indicates that the new strain is also being transmitted far more broadly, perhaps initially through sexual networks and then being passed on to family members. Last month, Nachega and others published a paper in the journal Nature Medicine demonstrating how an outbreak of mpox began in the small mining town of Kamituga in eastern DRC through sex workers before being transmitted to nearby Rwanda, Uganda, and Burundi as the infected individuals returned home to visit their families.
“This region is rich in minerals and mining sites,” says Nachega. “A significant number of the workers come from these countries. They get their paycheck at the end of the month, relax with commercial sex, and then return to their country of origin to visit their family, and so spread the disease regionally.”
For Nachega, these patterns of behavior indicate a particularly concerning aspect of how mpox has adapted in recent years. Mpox outbreaks were traditionally mediated through wild animal bites, consuming infected meat, or so-called spillover events where rural populations living in close proximity to infected animals would contract the disease. However, it now appears that the virus has evolved into an illness which is not only sexually transmitted but can be easily passed on to family members or anyone who comes in contact with an infected person’s body fluids, allowing it to spread far more widely.
“It’s kind of becoming the new HIV,” says Nachega. “When I finished medical school, the HIV pandemic was taking off. We don’t want to see this become another pandemic of a sexually transmitted infection. So that’s why we need to stop this clade 1 outbreak regionally before it gets to the levels of the 2022 one, which ended up going around the globe.” On Thursday, Sweden confirmed its first case of clade 1 mpox, in a person who had been infected while traveling in Africa.
To stop mpox from spreading further, Titanji says, a massive surveillance program is needed, involving a combination of contact tracing, isolation, and testing followed by large-scale immunization campaigns. Existing vaccines can be used both to prevent people contracting the virus and to stop infected individuals from spreading it further. However, carrying out such a program poses both logistical and financial challenges.
Armed conflict is raging in the eastern DRC, where the majority of the cases have been identified, while nations like Burundi lack the resources to carry out the necessary surveillance. “Of the 15,000 cases that have been reported, only about 10 to 20 percent are actually getting confirmatory testing for mpox, because many of these countries don't have access to testing tools,” says Titanji.
While the company Bavarian Nordic has an effective vaccine for mpox, the current pricing points, which reportedly range between $70 and $300 per dose, are unaffordable for many countries given the many doses required to combat the threat. Earlier this month, both Bavarian Nordic and the European Commission's Health Emergency Preparedness and Response Authority announced a collaboration which will see 215,000 vaccine doses donated to the African continent, but Nachega says that this is a mere fraction of the number required to truly suppress the outbreak.
“To control this outbreak in high-risk populations, the DRC needs 10 million doses,” he says. “So those 215,000 doses are better than nothing, but there has to be some creative way of ramping up vaccine production in the next couple of months if we want to make a meaningful difference in terms of controlling this disease. It’s also going to take some time and much negotiation about who’s going to pay. People affected in these countries can’t afford the vaccines if there is no donation or subsidies from governments or philanthropic organizations.”
At the same time, Titanji says, there are still some important scientific questions to be answered regarding the mpox fatalities so far. While sex is one mode of transmission, the virus can also be passed through physical contact once it has taken hold in a community. Because of this, data has shown that more than 70 percent of the mpox cases in DRC and 85 percent of deaths are in children under the age of 15.
“The mortality in children is higher, because their immunity is still developing,” says Nachega. “The younger you are, the more vulnerable you're going to be.”
Titanji believes that studies are needed to determine whether the clade 1 viral strain itself is as virulent as has been assumed. She suggests that the higher fatality rate of the current outbreak could reflect the fact that the virus is now spreading through a wider population and reaching children in rural populations who live farther from health care facilities.
While this current outbreak has yet to reach the US, Titanji says that it is vital for higher income countries to act much more decisively in addressing the spread of the disease in sub-Saharan Africa compared to 2022, when the majority of resources were devoted to local efforts.
“We live in a very interconnected world,” she says. “This outbreak was bound to happen.”
In May 2023, the World Health Organization released a statement declaring the end of mpox—formerly known as monkeypox—as a public health emergency. Just over a year later, the agency has been forced to backtrack, with a far more serious epidemic brewing across much of sub-Saharan Africa.
Statistics show that more than 15,000 mpox cases and 461 deaths have been reported on the African continent since January, spreading out of countries such as the Democratic Republic of Congo (DRC), where mpox has long been endemic, to 13 other African nations: countries like Rwanda, Kenya, Burundi, and Uganda, where the disease has never previously made an impact.
In the eyes of scientists like Boghuma Titanji, an associate professor in infectious diseases at Emory University who studies mpox outbreaks, this new, deadlier outbreak represents the consequence of the world’s health watchdogs failing to do enough last time round.
It was the summer of 2022 when the spread of mpox first set alarm bells ringing. Suddenly a virus which had always been predominantly contained within parts of West and Central Africa was suddenly going worldwide. Between early 2022 and December 2023, there were 92,783 confirmed cases of mpox across 116 countries, leading to 171 deaths.
Despite these numbers, its perception as a public health threat swiftly faded. “Ninety-five percent of the cases during the 2022 outbreak were among men who have sex with men, reporting exposure through sexual or close contact with another infected person,” says Titanji. “It was an outbreak that was very focused, which allowed vaccinations to be prioritized among that network.”
Countries in the global north successfully scrambled to suppress the outbreak within their own borders. Meanwhile, Titanji says, ramping up viral surveillance among the African nations who had been battling a steady rise in mpox cases for the past four decades soon slipped down the priority list, allowing a potentially more problematic variant to emerge undetected.
Mpox exists in two main subtypes, clade 1 and clade 2. Between them, clade 1 is believed to be up to 10 times more deadly, particularly among population groups with weakened or developing immune systems such as children under the age of 5, pregnant women, and immunocompromised people. That’s the viral strain behind this new outbreak, and why infectious disease scientists are so alarmed. (A separate outbreak spreading in South Africa among people living with HIV is thought to be linked to clade 2.)
“The 2022 global outbreak was clade 2, and mortality was less than 1 percent,” says Jean Nachega, a Congolese infectious disease doctor and an associate professor of medicine at the University of Pittsburgh. “Now we’re talking about a strain which can have up to 10 percent mortality.”
While the previous outbreak predominantly affected homosexual populations, data indicates that the new strain is also being transmitted far more broadly, perhaps initially through sexual networks and then being passed on to family members. Last month, Nachega and others published a paper in the journal Nature Medicine demonstrating how an outbreak of mpox began in the small mining town of Kamituga in eastern DRC through sex workers before being transmitted to nearby Rwanda, Uganda, and Burundi as the infected individuals returned home to visit their families.
“This region is rich in minerals and mining sites,” says Nachega. “A significant number of the workers come from these countries. They get their paycheck at the end of the month, relax with commercial sex, and then return to their country of origin to visit their family, and so spread the disease regionally.”
For Nachega, these patterns of behavior indicate a particularly concerning aspect of how mpox has adapted in recent years. Mpox outbreaks were traditionally mediated through wild animal bites, consuming infected meat, or so-called spillover events where rural populations living in close proximity to infected animals would contract the disease. However, it now appears that the virus has evolved into an illness which is not only sexually transmitted but can be easily passed on to family members or anyone who comes in contact with an infected person’s body fluids, allowing it to spread far more widely.
“It’s kind of becoming the new HIV,” says Nachega. “When I finished medical school, the HIV pandemic was taking off. We don’t want to see this become another pandemic of a sexually transmitted infection. So that’s why we need to stop this clade 1 outbreak regionally before it gets to the levels of the 2022 one, which ended up going around the globe.” On Thursday, Sweden confirmed its first case of clade 1 mpox, in a person who had been infected while traveling in Africa.
To stop mpox from spreading further, Titanji says, a massive surveillance program is needed, involving a combination of contact tracing, isolation, and testing followed by large-scale immunization campaigns. Existing vaccines can be used both to prevent people contracting the virus and to stop infected individuals from spreading it further. However, carrying out such a program poses both logistical and financial challenges.
Armed conflict is raging in the eastern DRC, where the majority of the cases have been identified, while nations like Burundi lack the resources to carry out the necessary surveillance. “Of the 15,000 cases that have been reported, only about 10 to 20 percent are actually getting confirmatory testing for mpox, because many of these countries don't have access to testing tools,” says Titanji.
While the company Bavarian Nordic has an effective vaccine for mpox, the current pricing points, which reportedly range between $70 and $300 per dose, are unaffordable for many countries given the many doses required to combat the threat. Earlier this month, both Bavarian Nordic and the European Commission's Health Emergency Preparedness and Response Authority announced a collaboration which will see 215,000 vaccine doses donated to the African continent, but Nachega says that this is a mere fraction of the number required to truly suppress the outbreak.
“To control this outbreak in high-risk populations, the DRC needs 10 million doses,” he says. “So those 215,000 doses are better than nothing, but there has to be some creative way of ramping up vaccine production in the next couple of months if we want to make a meaningful difference in terms of controlling this disease. It’s also going to take some time and much negotiation about who’s going to pay. People affected in these countries can’t afford the vaccines if there is no donation or subsidies from governments or philanthropic organizations.”
At the same time, Titanji says, there are still some important scientific questions to be answered regarding the mpox fatalities so far. While sex is one mode of transmission, the virus can also be passed through physical contact once it has taken hold in a community. Because of this, data has shown that more than 70 percent of the mpox cases in DRC and 85 percent of deaths are in children under the age of 15.
“The mortality in children is higher, because their immunity is still developing,” says Nachega. “The younger you are, the more vulnerable you're going to be.”
Titanji believes that studies are needed to determine whether the clade 1 viral strain itself is as virulent as has been assumed. She suggests that the higher fatality rate of the current outbreak could reflect the fact that the virus is now spreading through a wider population and reaching children in rural populations who live farther from health care facilities.
While this current outbreak has yet to reach the US, Titanji says that it is vital for higher income countries to act much more decisively in addressing the spread of the disease in sub-Saharan Africa compared to 2022, when the majority of resources were devoted to local efforts.
“We live in a very interconnected world,” she says. “This outbreak was bound to happen.”