Last month, a rapid global response followed the outbreak of monkeypox cases in countries such as Portugal, Spain and the United Kingdom , which do not normally occur – including the distribution of vaccines in some countries. But monkeypox outbreaks have been erupting in parts of Central and West Africa for years, frustrating African researchers there because their countries, which have not provided such resources, have the highest number of monkeypox deaths. They note that they have long warned that the monkeypox virus has the potential to spread more widely in new ways.
So far this year, countries outside Central and West Africa have had more than 3,000 confirmed cases of monkeypox, but no deaths have been reported. In Africa, however, health officials have reported more than 70 deaths, which they suspect are caused by monkeypox. Dimi Oguna, an infectious disease doctor at Niger Delta University in Amasoma, Nigeria, said it could be an underestimate due to limited testing and surveillance capabilities.
While he is frustrated that The West has so far largely ignored monkeypox, Ogoina fears that the current global outbreak will not improve the situation in Africa. "If we don't bring the world's attention to this, many solutions will solve Europe's problems, but they won't solve Africa's problems," he said.
1. The experience of the outbreak
Prior to this year, only a few cases of monkeypox were observed outside Africa; These are all related to animals or tourists imported from the European continent. One of the largest outbreaks was a brief outbreak in the United States in 2003 that originated from imported animals and caused more than 70 people to fall ill.
Meanwhile, some African countries have been responding to monkeypox outbreaks since scientists detected the first human case in the Democratic Republic of the Congo in 1970. While researchers still don't know which animals naturally carry the virus, they do know that the virus spreads in many rodents and can spread from animals to humans. In 2017, there was a major outbreak in Nigeria, with more than 200 confirmed cases of monkeypox and 500 suspected cases. Over the past decade, there have been thousands of suspected cases and hundreds of suspected deaths in the Democratic Republic of the Congo. In Central Africa, strains of monkeypox virus infecting humans are more virulent, with a mortality rate of about 10%.
For Adesola Yinka-Ogunleye, an epidemiologist at the Nigerian Centre for Disease Control in Abuja, the current global outbreak has brought a certain sense of déjà vu. Before the 2017 outbreak in Nigeria, the virus appeared to be limited to rural areas, where hunters would come into contact with animals. It shows its presence through fever and obvious fluid-filled "pox" lesions on the face, hands, and feet. After 2017, she and other epidemiologists warned that the virus was spread in an unknown way: it appeared in urban settings, and infected people sometimes developed genital lesions, suggesting that the virus could be transmitted through sexual contact. As the virus now spreads in Western cities through what appears to be close contact with sexual partners, "the world is paying the price for not responding adequately," she said.
2. Decreased immunity
Meanwhile, researchers warn that monkeypox cases in sub-Saharan Africa have been on the rise for years. In part, this is because countries have stopped vaccinateing people against smallpox, which is caused by smallpox, a virus closely linked to the virus that causes monkeypox. Smallpox was eradicated in 1980 and vaccination stopped, meaning that the proportion of people vulnerable to smallpox – and thus monkeypox – has been rising.
Since then, some countries have maintained national stockpiles of smallpox vaccines because health officials fear labs that keep smallpox samples may inadvertently release smallpox samples or that the virus could be weaponized. Countries, including Canada, France, the United Kingdom and the United States, have been using these stockpiles as a "ring vaccination" strategy to protect close contacts of people infected with monkeypox virus. Acknowledging that many cases have occurred so far in men who have sex with men (MSMs), authorities in several cities in Canada and the United Kingdom have gone a step further and have begun to provide vaccines to their D-Men communities.
Steve Ahuka, a virologist at the University of Kinshasa, said the vaccines would help respond to outbreaks in Africa — but African countries don't have large stockpiles and Western countries don't donate vaccines to fight monkeypox. Both Ahuka and Inka-Oglieye said they would at least recommend vaccinating frontline health workers and lab technicians if they had a vaccine. Other researchers interviewed by The Nature journal also said that if the vaccine is given to people with compromised immune systems and people who are regularly exposed to wildlife, it could help curb monkeypox in Africa.
3, lack of investment
Some health officials in sub-Saharan Africa fear they will continue to be left behind, given their experiences with vaccine inequalities during the COVID-19 pandemic. Despite the rising number of cases, only 18.4% of people in Africa have been vaccinated against the novel coronavirus, compared to 74.8% in other high-income countries.
WHO member states have pledged to provide the agency with more than 31 million doses of smallpox vaccine for smallpox emergencies, but the vaccines have never been distributed to Africa to fight monkeypox. Rosamund Lewis, who heads monkeypox technology at the World Health Organization, said part of the reason is that some of the reserves promised by the agency are made up of "first-generation" vaccines; These drugs can have serious side effects and are not recommended for monkeypox, which has a lower fatality rate than smallpox.
She also referred to "regulatory issues" because some member states have approved vaccines to be used only to prevent smallpox, not monkeypox. (Although these vaccines are considered safe and effective for people infected with smallpox, they have limited testing for monkeypox.) )
"The investment may not have met our expectations, but it hasn't been for nothing," Lewis said of efforts to tackle monkeypox in Africa. She added that WHO has been coordinating with African countries with monkeypox outbreaks to improve surveillance and diagnosis.
In recent weeks, the World Health Organization has recognized that monkeypox is receiving unequal attention around the world. On June 17, the agency announced that it would no longer report monkeypox cases and deaths separately in sub-Saharan Africa and other parts of the world, reflecting "the need for a unified response." After researchers published a proposal to change the name of the monkeypox virus strain — now known as the West African branch and the Congo Basin branch — WHO Director-General Tedros Adhanom Ghebreyesus stepped forward to support the changes to reduce stigma. He promised to "announce the new name as soon as possible."
However, Oyewale Tomori, an independent virologist in Ibadan, Nigeria, said that even if sub-Saharan African countries were vaccinated, vaccination alone would not eradicate monkeypox. He warned that vaccination would only be effective if health officials understood the local pathogen epidemiology – and there are still many questions about how isolated cases of the disease continue to emerge in affected countries in sub-Saharan Africa. He suggested supporting research investigating monkeypox animal hosts so that health officials could devise more precise measures to curb the spread of the virus. "If you don't address the underlying problem, you end up using all the vaccines for monkeypox," he said, rather than addressing the root cause of the problem — the contact between wildlife and humans.
Equally important, Ogoina said, is strategies to speed up monkeypox detection, because the sooner a case is confirmed, the sooner public health officials can begin containment countermeasures. He added that sub-Saharan Africa will soon make these advances. "Isolated solutions that only solve problems for the developed countries and ignore the isolated solutions in the developing countries will put us through the same cycle again," he warned. He was referring to past outbreaks in which pathogens continue to re-emerge. "It's only a matter of time."
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