After monkeypox cases exploded last month in countries such as Portugal, Spain and the United Kingdom – where outbreaks usually do not occur – a rapid, global response followed, including the distribution of vaccines in some countries. But outbreaks of monkeypox have been occurring for years in parts of central and western Africa, leaving African researchers there discouraged that such agents have not been made available in their countries, where the disease’s toll is highest. They point out that they have long warned of the possibility that the monkeypox virus, which behaves in new ways, could spread more widely.
There have been more than 3,000 confirmed cases of monkey pox in countries outside Central and West Africa so far this year, but no deaths have been reported. In Africa, however, health officials have reported more than 70 deaths they suspect were caused by monkey pox. This is likely an undercount due to limited testing and surveillance capacity, said Dimie Ogoina, an infectious disease physician at Niger Delta University in Amassoma, Nigeria.
While frustrated that monkeypox has so far been largely ignored by western countries, Ogoina is concerned that the current global outbreaks still won’t improve the situation for Africa. “If we don’t get the world’s attention to this, many of the solutions will address the problem in Europe, but not in Africa,” he says.
Experience with outbreaks
Before this year, only a handful of monkey pox cases had been observed outside of Africa; these were linked to animal imports from the continent or to travelers who had been there. The largest of these outbreaks was a short-lived outbreak in the United States in 2003, which stemmed from imported animals and sickened more than 70 people.
Meanwhile, some African countries have been dealing with monkeypox outbreaks since scientists identified the first human case in the Democratic Republic of the Congo (DRC) in 1970. While researchers still don’t know exactly which animals naturally harbor the virus, they do know that it circulates among many rodent species and can be passed from animals to humans. A significant outbreak began in Nigeria in 2017, with more than 200 confirmed and 500 suspected cases of monkey pox. Over the past decade, the DRC has seen thousands of suspected cases, as well as hundreds of suspected deaths. In Central Africa, the strain of monkeypox virus that has infected humans is more virulent, with a mortality rate of about 10%.
For Adesola Yinka-Ogunleye, an epidemiologist at the Nigeria Center for Disease Control in Abuja, the current global outbreaks have created a certain sense of déjà vu. Before the outbreak in Nigeria in 2017, the virus appeared to be confined to rural areas, where hunters would come into contact with animals. It would make its presence known with fever and characteristic fluid-filled ‘pox’ lesions on the face, hands and feet. After 2017, they and other epidemiologists warned:1 that the virus spread in an unknown way: It appeared in urban environments and infected people sometimes had genital lesions, suggesting that the virus could spread through sexual contact. With the virus now spreading in Western cities through what appears to be close contact with sexual partners, “the world is paying the price for not responding adequately” in 2017, she says.
At the same time, researchers warn that monkeypox cases in sub-Saharan Africa have been rising for years. In part, this is because countries have stopped giving vaccines against smallpox, which is caused by variola, a virus closely related to the virus that causes monkeypox. Smallpox was eradicated in 1980 and vaccination was discontinued, meaning that the percentage of the population susceptible to it — and thus to monkey pox — has increased (see ‘Monkeypox on the rise in Africa’).
Since that time, some countries have held up national stockpiles of smallpox vaccines because health officials worried that labs that keep samples of variola could accidentally release it, or that the virus could be used as a weapon. Countries such as Canada, France, the United Kingdom and the United States have used these stocks in a ‘ring vaccination’ strategy to protect the close contacts of a person infected with the monkeypox virus. Recognizing that there have been many cases of men who have sex with men (MSM) to date, authorities in several Canadian cities and in the UK have gone a step further and started offering the vaccines to their MSM communities. .
Steve Ahuka, a virologist at the University of Kinshasa, says these vaccines would be useful to tackle the outbreaks in Africa – but countries there don’t have large supplies and Western countries have not donated their injections for use against monkeypox. Both Ahuka and Yinka-Ogunleye say that if they had vaccines, they would at the very least recommend vaccinating primary care workers and lab technicians. other researchers Nature spoke with also said the injections could help curb monkeypox in Africa if given to people with compromised immune systems and those who frequently encounter wildlife.
A lack of investment
Some health officials in sub-Saharan Africa are concerned they may be left behind, judging by their experience of vaccine inequality during the COVID-19 pandemic. While the number of cases is rising, only 18.4% of people in Africa have been vaccinated against the coronavirus SARS-CoV-2, compared to 74.8% in high-income countries elsewhere.
World Health Organization (WHO) member states have pledged more than 31 million smallpox vaccine doses to the smallpox emergency agency – but these have never been distributed to Africa for use against monkeypox. Part of the reason, says Rosamund Lewis, WHO’s tech chief for monkeypox, is that some of the agency’s pledged supply consists of “first-generation” vaccines; these can have serious side effects and are not recommended for monkeypox, which is less deadly than smallpox. (Lewis declined to specify the exact composition of the WHO’s pledged stock.)
She also cites “regulatory issues” as some member states have licensed the vaccines only for use against smallpox, not monkeypox. (While the vaccines are considered safe and effective for use in people with smallpox infection, they have undergone limited testing against monkeypox.)
“The investment may not have been what we would like, but it hasn’t been nothing,” Lewis said of efforts to tackle monkey pox in Africa. She adds that WHO is coordinating with African countries experiencing monkeypox outbreaks to improve surveillance and diagnostics.
In recent weeks, the WHO has recognized the disparity in the global attention monkeypox is getting. On June 17, the agency announced it would no longer report monkey pox cases and deaths separately for sub-Saharan Africa and the rest of the world, as a result of the “united response needed”. And after researchers published a proposal to rename Monkeypox’s virus strains — currently called the West African clade and the Congo Basin clade — WHO Director-General Tedros Adhanom Ghebreyesus came in support of the changes, to reduce stigma. Reduce. He promised “to make announcements about the new names as soon as possible”.
But even if Sub-Saharan Africa buys vaccines, vaccination alone won’t eradicate monkeypox, says Oyewale Tomori, an independent virologist in Ibadan, Nigeria. He warns that vaccination will only be effective if health officials understand the pathogen’s local epidemiology — and there are still many questions about how isolated cases of the disease have continued to crop up in affected countries in sub-Saharan Africa. He recommends supporting research to examine the animal reservoir of monkeypox so that health officials can devise more precise measures to curb the spread of the virus. “Without addressing the fundamental problems, you end up using all your monkeypox vaccines,” he says, rather than addressing the root of the problem: wildlife-human contact.
Equally important are strategies to speed up monkeypox testing because the sooner a case can be confirmed, the sooner public health officials can begin containment measures, Ogoina says. This progress cannot come soon enough for sub-Saharan Africa, he adds. “Isolated solutions that solve the problem only for developed countries and leave developing countries out of the equation will put us through the same cycle again,” he warns, pointing to past outbreaks where a pathogen keeps reappearing. “It’s just a matter of time.”