The World Health Organization has declared MPOX a global public health emergency for the second time in two years, due to a sharp rise in cases and deaths in several countries in East and Central Africa. The announcement came a day after the Africa Centers for Disease Control and Prevention declared MPOX a continent-wide public health emergency.
While many countries outside of Africa have quickly contained the MPOX pandemic that began in 2022, a large outbreak continues in the Democratic Republic of Congo in Central Africa. Unfortunately, the strain circulating there is more lethal than those that previously spread to the United States and Europe. In recent months, this strain has spread from the Democratic Republic of Congo to four other countries in East and Central Africa.
Formerly known as monkeypox, Mpox is an infectious disease very similar to but much milder than smallpox that is thought to have originated in rodents and non-human primates in Africa. Mpox is spread by close contact with an infected person, including through sexual intercourse or skin-to-skin contact. Pregnant people can also transmit the virus to their children during pregnancy and after birth. The most common symptom of Mpox is a blister-like rash that usually lasts for 2-4 weeks. Other symptoms include fever, fatigue, muscle aches, cough, and sore throat.
For decades, MPOX has caused sporadic cases and outbreaks in Nigeria, the Democratic Republic of the Congo, and other African countries. There are two main lineages of MPOX: lineage I, which causes more severe disease and has historically been restricted to Central Africa, and lineage II, which has historically caused infections in West Africa.
In May 2022, MPOX cases caused by clade II suddenly began to be recorded in countries outside of Africa. In July of the same year, the World Health Organization declared the pandemic a Public Health Emergency of International Concern for the first time. By May 2023, approximately 90,000 MPOX cases and more than 150 deaths had been recorded in more than 100 countries.
Fortunately, public health agencies around the world acted quickly to improve disease surveillance efforts, raise awareness and encourage safe sex practices, especially among high-risk populations such as men who have sex with men. Between May 2022 and May 2023, there were more than 30,000 and 25,000 MPOX cases in the United States and Europe, respectively, and authorities distributed more than 1 million doses of vaccine. As a result, MPOX infections in most countries have declined rapidly. In May 2023, the World Health Organization lifted the state of emergency.
Although the World Health Organization no longer considered MPOX an international health emergency at the time, cases continued to be reported in countries around the world. According to a situation report published by the World Health Organization, in June 2024, 175 cases had been reported in North, Central, and South America, 100 in Europe, and 11 in Southeast Asian countries.
The outbreak in the Democratic Republic of the Congo remains particularly bad. Unlike other parts of the world, the MPOX strain causing infections in the Democratic Republic of the Congo is the more severe lineage I. As of May 2024, 7,851 MPOX cases and 384 deaths have been reported in the country.
Vox has been reporting enthusiastically on the outbreak of mpox, formerly known as monkeypox, in 2022. See our previous coverage here.
Over the past few months, mpox I lineage has spread from the Democratic Republic of Congo to four East African countries (Burundi, Kenya, Rwanda, and Uganda), raising fears that a more deadly mpox pandemic may be on the way, leading the Africa Centers for Disease Control and the World Health Organization to designate the ongoing mpox outbreak as a health emergency.
Africa CDC is the public health agency of the African Union, representing 55 African countries. This is the first time the agency has designated any outbreak a continental emergency. Other African countries are also facing a resurgence of MPOX outbreaks caused by lineage II viruses. In May, a total of 465 MPOX cases were recorded across African countries, increasing by 22% to 567 in June.
“We are today declaring this a public health emergency for the security of the continent and will mobilize our institutions, collective will and resources to take swift and decisive action,” Africa CDC Director-General Jean Kaseya said at a press conference on Tuesday.
But outbreak response efforts in the DRC and other African countries are again being hampered by the same challenges health authorities have faced during previous outbreaks and pandemics, including COVID-19: a lack of global solidarity and a reluctance to share life-saving resources. While vaccination has been rapidly rolled out in the United States and Europe in 2022, vaccines are only just beginning to trickle in the DRC. But there are still only a few hundred thousand doses available for a population of more than 100 million.
National governments and multilateral organizations such as the African Union are slowly working to improve domestic public health infrastructure and technical capacity and reduce dependency on donor countries. The unprecedented move by the Africa CDC to designate the MPOX outbreak as a regional health emergency signals the continuation of these efforts, but it is unclear whether this designation will spur a rapid influx of resources needed to respond to the MPOX outbreak.
The origins and unknowns of Mpox
Mpox was first discovered in a group of monkeys at a Danish research facility in 1958, but the first human Mpox case (in a nine-month-old infant) was recorded in the Democratic Republic of Congo in 1970. Researchers and doctors have not been able to determine exactly how the infant became infected, but close contact with an infected monkey may have been the source of the infection. Small rodents, monkeys, and mammals can transmit the virus to humans, but outbreaks usually begin when humans transmit it to each other.
Further human MPOX cases were documented in the Democratic Republic of Congo in 2005, and since then thousands of suspected cases have been reported every year. Since 2017, MPOX infections have also become frequent in Nigeria.
Although mpox has been around for a long time, there are still many unknowns about how the virus spreads and why it suddenly spread across the world in 2022. What researchers do know is that the virus has been mutating rapidly in recent years.
Interestingly, and perhaps worryingly, most of the genetic mutations have no effect at all, but some may make the virus more lethal or more effective at spreading. When geneticists compared the 2022 mpox genome with samples collected in 2017, they found that about 40 genetic mutations had occurred. Some researchers suggest that these mutations make the virus more susceptible to human-to-human transmission, but there seems to be no firm consensus yet.
An entirely new mpox clade I variant, tentatively designated clade IB, was discovered in the Democratic Republic of Congo in September 2023. The World Health Organization has not confirmed whether this new variant causes more severe disease or spreads more easily.
Rosamund Lewis, the World Health Organization’s technical lead on MPOX, argues that the global surge in MPOX isn’t due to a genetic mutation. Rather, she suggests that the virus just happened to start infecting new populations — sex workers and men who have sex with men — which in turn helped fuel its spread. MPOX is reminiscent of the origins of HIV, when chimpanzees jumped ship to humans in southwestern Cameroon before taking root in the bustling urban center of Kinshasa, the capital of the Democratic Republic of Congo, and among its many sex workers.
Sexual transmission among adults may be only one of the main causes of MPOX infection: in the Democratic Republic of Congo, about 70% of MPOX cases recorded this year occurred among children who may have been infected through close contact with infected animals or infected household members.
One of the biggest risk factors for severe MOX infection and death is existing HIV infection. Unfortunately, Africa has more people living with HIV, approximately 25.6 million, than any other region in the world, meaning many African countries are at risk of experiencing more deadly epidemics than other parts of the world. The double burden of MOX and HIV was also a major factor in the Africa CDC declaring the MOX epidemic a continental emergency, explained Kaseya.
There is a shortage of MPOX vaccine. Would emergency designation help?
At least two vaccines are effective against smallpox: Jynneos (also known as Imvanex in Europe), manufactured by Bayern Nordic AG in Denmark, and LC16, manufactured by KM Biologics in Japan. The U.S. Food and Drug Administration approved the Jynneos vaccine for use against variola and smallpox in 2019. LC16 was developed for smallpox, but is also effective against it.
As MPOX cases began to be recorded in the United States and Europe in 2022, health authorities quickly distributed millions of doses of existing vaccines. But for the first two years of the pandemic, no vaccine was available in the Democratic Republic of Congo.
The Democratic Republic of Congo, like most countries in Africa, does not have the infrastructure to manufacture its own vaccines, nor can it afford to buy millions of doses. (The mpox vaccine costs just under $100 per dose, and the Democratic Republic of Congo’s GDP per capita is just $649, according to Kaseya.) So these countries have had to rely on donations from the United States, Europe and other countries. In response to the COVID-19 pandemic, the Africa CDC has begun leading efforts to fill this critical gap, but progress has been slow.
In this vacuum, authorities in the DRC and other African countries have continued to respond to the outbreak without a vaccine. The first shipments of the MPOX vaccine began arriving in the DRC only last month. But Lewis said the country only received 200,000 doses, forcing officials to scramble to put together a plan for how to use limited resources. Kaseya did not elaborate on how Africa CDC would assist in the process.
Donor governments have been providing technical and financial support to the response to the MPOX epidemic in Africa, and last week the United States Agency for International Development (USAID) announced a $10 million funding increase to support the MPOX response in the Democratic Republic of Congo.
It is unclear whether the new emergency designation will affect the availability of the MPOX vaccine. Still, Africa CDC and the World Health Organization are increasing funding for the MPOX response. Earlier this month, the African Union released $10.4 million in funding for the MPOX response. The World Health Organization has committed $1.45 million in emergency funding, with more due in the coming days, according to WHO Director-General Tedros Adhanom Ghebreyesus.
“This is a fight for all Africans and we will fight it together,” Kaseya said.
Update, Aug. 14, 3:30 p.m.: This article, first published on Aug. 13, has been updated to reflect news of the WHO emergency declaration.
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