“Western countries are no longer safe,” says Jean Kaseya, director general of the Africa Centres for Disease Control and Prevention (CDC), the continent’s top health authority. Thirteen African countries have so far confirmed cases of mpox, with two more (South Sudan and Chad) awaiting confirmation. And experts fear it will spread to more places, more quickly. From Africa, the warning is clear: “This is no longer a problem for us, but for the world,” Kaseya said in a telephone interview.
The declaration on Wednesday of an international health emergency due to mpox (as monkeypox was renamed to avoid stigma among those who suffer from it) brings echoes of the coronavirus pandemic in Africa, where the North has hoarded resources and vaccines. “Even in 2022 [cuando la OMS declaró otra emergencia por un brote que afectaba a una tercera parte de pacientes] The North kept doses and diagnoses for itself,” he laments.
“We need Western solidarity to save lives around the world,” insists Kaseya, who warns that his experts are already studying, in addition to the transmission of the virus from animal to human and from human to human, the possibility of the virus being transmitted from human to animal, something that could lead to a dangerous mutation.
Epidemiologist Salim Abdool Karim also describes the mood at the CDC meeting on Monday – the day before Africa’s top health authority declared a state of emergency – as “very concerned”. A respected expert who leads the group of 20 scientists advising the CDC on the matter, who also works as an expert for the WHO and has been on the front lines of public health problems such as HIV or coronavirus for 40 years, he notes that MPOX has been “resurfacing from time to time” in the DRC for years, but that this combination of factors had never occurred: one, the “incredibly high” number of cases detected (15,000 affected and 479 deaths so far this year, most in the DRC, although the real figures are likely to be much higher). These are, he stresses, more than three times as many as there were in 2022 when the WHO declared a global health emergency for monkeypox.
The second worrying factor, Abdool Karim adds, is the increase in MPOX cases in just a few weeks, driven especially by the DRC, and its spread to countries that had not reported recent cases, such as Kenya or Uganda. And the third, he concludes, is the mortality rate, “much higher than anticipated”, around 3%. This figure takes into account the number of deaths and the number of registered cases, but there is probably a great underdiagnosis, so many experts put it on hold.
The most worrying mpox clade (variant) in Africa is 1b, the one that recently emerged in the DRC, which appears to be more transmissible between people, more virulent and more lethal, especially among children (70% of positive cases 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 cases of clade 1b have been confirmed in laboratories in the last month in four neighbouring countries of the DRC that had not previously reported any outbreaks: Burundi, Kenya, Rwanda and Uganda. Clade 2, the one responsible for the global outbreak in 2022, which was mainly transmitted through sexual relations, continues to circulate, although with less virulence, in countries such as South Africa or Egypt.
The new variant can be transmitted between people through close contact with someone infected: being face to face, talking or breathing close to each other (through droplets excreted), skin to skin contact, mouth to mouth or mouth to skin. Abdool Karim says that variant 1b appears to be transmitted in heterosexual relationships, as a large number of DRC 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.”
A humanitarian crisis
An added problem for Africa in fighting this epidemic is, experts agree, the reporting of cases: the Democratic Republic of Congo is immersed in a humanitarian crisis and a conflict that has dragged on 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) with 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 poorest in the country, where hundreds of thousands of displaced people live in crowded camps.[En estas zonas de DRC] There is neither adequate staff nor resources for contact tracing, nor is there capacity for sufficient laboratory analysis,” stresses Isidro Carrión, an epidemiologist with Doctors Without Borders who has worked in DRC on several occasions in recent years.
Greg Ramm, director of Save the Children in the DRC, describes overcrowded health centres around Goma (capital of North Kivu province), where there is not enough space for patients to isolate themselves or protective equipment for doctors and nurses dealing with potential infections. “There is also a lack of resources to communicate to communities how the disease is transmitted, what the symptoms are, how to prevent it.”
“The virus is moving forward at a steady pace”
Luis Flores, a research associate at the Centre de Recherche en Sciences Naturelles de Lwiro, witnessed first-hand how monkeypox transmission began last October in Kamituga, an isolated mining town in the DRC. “We saw that transmission was not only sexual, as happened in Europe; sick children began to appear. The image of infected people is terrible, it is not only in the genital areas as was the case especially in the 2022 outbreak in Western countries, it is all over the body, like old smallpox,” he explains.
Flores, who was part of the team that sequenced clade 1, says 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 this for months and no measures have been taken, no ring vaccination has been carried out in the area, not even for the health workers who treat sick people.”
The researcher describes Kamituga as a very densely populated area, very difficult to access, which takes more than two days to reach, with a lot of prostitution and “the ideal conditions” for a virus of these characteristics to spread.
The Spaniard, who is setting up a laboratory at the centre where he works in Lwiro, a small town, has watched the advance of the virus with bewilderment: “It is advancing, and it is doing so at a steady pace. I am surprised that we have not learned from Covid. It has spread outside the DRC and in a few months, if nothing is done, it will jump to other countries.”
Not enough vaccines
“We have been warning about the shortcomings in the response to this epidemic and the catastrophic consequences it can have on such vulnerable communities and, therefore, on neighbouring countries with very fragile health systems,” laments Carrión, from Doctors Without Borders. “In Europe, there is a lot of talk again about the virus, about the need for vaccines… but we must not forget that [en África] There are already thousands of people suffering from the disease without adequate treatment.”
CDC Director General Jean Kaseya said at his Tuesday press conference that the continent needs more than 10 million doses of the MPOX vaccine, but has only 200,000. For reference, in Spain, with 47 million inhabitants, 40,610 people have already been immunized. Dr. Tedros, WHO Secretary General, is currently campaigning among vaccine manufacturers to speed up production. The WHO’s declaration of an international emergency will supposedly facilitate some procedures, but international collaboration will be needed to get the doses to countries like DRC.
The challenge in getting the necessary vaccines, in any case, will be in supply. A spokesperson for the Global Alliance for Immunization and Vaccination (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, this large association of public and private entities acknowledges, the best way to get vaccines to the countries that need them will be donations.
Epidemiologist Salim Abdool Karim points out that vaccines will not be the main element in Africa to control this virus, which has been present “under control” for years in countries such as DRC. “Public health measures are needed: well-informed health professionals, information campaigns, the ability to identify and isolate cases, and a lot of contact tracing.” It is urgent to stop the spread of mpox in a decisive manner, he warns, “before it becomes a global problem.”
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