Mpox: A Public Health Crisis Unfolds
Mpox, previously known as monkeypox, has resurfaced as a significant global health threat. This year alone, over 900 individuals, predominantly children in Africa, have succumbed to the disease. Public health officials are sounding the alarm, cautioning that a new variant responsible for this toll could arrive in the United States at any moment.
The Return of Mpox
The mpox outbreak in the United States began in 2022, sparking widespread concern and mobilizing public health responses. U.S. authorities implemented a targeted vaccination campaign primarily focused on men who have sex with men, a demographic identified as most at risk. However, during this critical period, vaccines were not made available to African nations, where the disease is endemic. This oversight has facilitated the emergence of a more virulent variant, highlighting the need for a globally coordinated pandemic response.
Maria Van Kerkhove, the World Health Organization's incident manager for the global mpox response, remarked, “There’s plenty of blame to go around in terms of what could be done and how things could be done differently. But every single one of us needs to be asking that question.” This statement encapsulates the widespread frustration among public health officials regarding the global response to mpox.
The Global Response and Its Shortcomings
The Democratic Republic of the Congo (DRC) has been at the epicenter of this year's outbreak, yet its leaders were slow to accept vaccine donations. The World Health Organization (WHO) and Bavarian Nordic, the manufacturer of the mpox vaccine, have exchanged blame over delays in assuring the safety and efficacy of the vaccine to the DRC and other developing countries. Despite WHO's endorsement of the vaccine, lingering mistrust between African nations and Western authorities complicates the response.
The Africa Centers for Disease Prevention and Control reports that more than a dozen African nations have recorded over 38,000 suspected mpox cases since the start of the year, with the DRC accounting for the majority. The disease is known for causing painful rashes, and in vulnerable populations, it can be fatal. In August, the WHO and Africa CDC declared the outbreak an international public health emergency, as the new variant appears to be more transmissible and deadly than the strains that affected the U.S. in the past.
Regulatory Delays and Mistrust
Bavarian Nordic's CEO, Paul Chaplin, indicated that the company sought WHO approval for the vaccine in March 2023, which would have allowed for its importation into countries lacking local approval, including the DRC. However, Van Kerkhove stated that the WHO did not receive the necessary information from the company until late August, which prolonged the approval process. The breakdown in communication has raised questions about the readiness of global health systems to respond to emerging infectious diseases.
Dr. Jean Kaseya, director-general of Africa CDC, mentioned that DRC officials were awaiting WHO's endorsement of the vaccine. However, some experts argue that DRC's own health authorities share responsibility for the delay. Larry Gostin, director of the O’Neill Institute for National and Global Health Law, highlighted that the U.S. had attempted to donate doses to the DRC for years without success due to bureaucratic hurdles.
The Impact of Conflict and Displacement
The DRC is facing numerous challenges, including armed conflict, multiple health crises, and pervasive poverty. These factors have hindered the country’s ability to prioritize mpox control. The conflict in eastern DRC, particularly between the Congolese army and the M23 rebel group, has displaced over 1.3 million people. Health services have been severely disrupted, with health workers facing violence and health facilities being looted or damaged.
As the outbreak spreads, local and international health experts have noted an increase in mpox cases among displaced populations in Goma, North Kivu province. The situation is further exacerbated by high rates of sexual violence, particularly rape, in and around displacement camps, which facilitates the virus's transmission.
Vulnerable Populations and the Urgency of Vaccination
Recent reports indicate that the majority of mpox cases and fatalities are occurring among children under the age of 15, who contract the virus through close contact with infected family members or shared bedding. This vulnerability is compounded by malnutrition and limited access to healthcare services.
In response to the escalating crisis, the DRC received approximately 250,000 doses of the Jynneos vaccine in September, primarily donated by the European Union, with the U.S. contributing an additional 50,000 doses. An immunization campaign was initiated, but only a small fraction of the population has been vaccinated thus far.
Japan has pledged to provide 3 million doses of its domestically developed LC-16 vaccine, which is approved for children. The U.S. has committed just over 1 million Jynneos doses, and President Biden has allocated $500 million to assist in containing the outbreak.
However, Africa CDC estimates that a total of 10 million doses and $600 million are needed to effectively combat the outbreak. Although the agency has received financial pledges exceeding $800 million, the gap remains significant.
The Role of International Cooperation
The ongoing mpox crisis serves as a stark reminder of the necessity for global cooperation in public health. While countries like India, Sweden, and Thailand have reported isolated cases linked to travel, there have been no confirmed cases of the clade 1b variant in the U.S. yet. However, experts warn that it is only a matter of time before this changes.
Dr. Ashish Jha, dean of the School of Public Health at Brown University, anticipates that if cases emerge in primarily healthy young men, mortality rates will be low, akin to the patterns observed during the 2022-2023 outbreak. Nevertheless, vulnerable populations, such as those living with HIV or other immunocompromising conditions, could face severe risks.
The Centers for Disease Control and Prevention (CDC) is urging at-risk populations, including men who have sex with men and travelers to affected regions, to get vaccinated. The federal government is also increasing testing availability and providing guidance to healthcare providers on recognizing symptoms related to this outbreak.
Historical Context and Lessons Learned
Historically, mpox was identified in captive monkeys in Denmark in 1958, leading to its original name. In 2022, it garnered global attention when it began spreading beyond its endemic regions. The WHO's renaming of the disease to mpox in late 2022 aimed to dissociate it from stigmatizing associations.
While the WHO declared the 2022 outbreak over in May 2023, the lack of effective countermeasures in endemic regions like Africa was acknowledged. Competing global health priorities may have contributed to a diminished urgency surrounding mpox.
Stephanie Psaki, the White House global health security coordinator, noted that as the 2022 outbreak waned, other health issues took precedence, impacting the WHO's early endorsement of the vaccine.
(Patrick dnewshub)
Accountability and Future Directions
Experts, including those from the O’Neill Institute, have pointed to Bavarian Nordic's production practices, criticizing the company for failing to produce affordable vaccines accessible to African countries. Chaplin contended that the company is now better positioned to increase vaccine production but defended the price of the vaccine, citing the financial challenges of offering lower costs without sufficient volume sales.
Furthermore, Kaseya emphasized that African nations have historically been wary of vaccines that lack WHO endorsement, a sentiment compounded by mistrust stemming from inequitable vaccine distribution during the COVID-19 pandemic.
The resurgence of mpox underscores the urgent need for global collaboration in public health initiatives. As the situation evolves, it is crucial for international health authorities, governments, and pharmaceutical companies to address the gaps in vaccine distribution and develop effective strategies to combat emerging infectious diseases. The ongoing outbreak in the DRC serves as a sobering reminder of the vulnerabilities faced by communities in resource-limited settings and the critical importance of equitable healthcare access for all.
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