A Time for Solidarity and Equity
By Lawrence O. Gostin, J.D., Ashish K. Jha, M.D., M.P.H., and Alexandra Finch, L.L.M.
On August 14, 2024, the director-general of the World Health Organization (WHO) declared mpox in the Democratic Republic of Congo (DRC) and neighboring countries to be a Public Health Emergency of International Concern (PHEIC) under the 2005 International Health Regulations (IHR)— the WHO’s highest-level alert. The previous day, the Africa Centers for Disease Control and Prevention (Africa CDC) declared a Public Health Emergency of Continental Security (PHECS) — the organization’s first-ever declaration of a regional health emergency. This regional declaration and the WHO’s early response—issued without waiting for mpox to affect high-income countries—could offer a historic opportunity to mobilize lifesaving resources according to the principles of solidarity and equity.
Mpox clade I has been endemic in the DRC for more than a decade, with cases steadily increasing. In 2023, the country saw a sharp increase driven by a genetically distinct and more transmissible subtype, clade Ib. This year, the DRC has already reported more than 15,600 cases and 537 deaths. But because of insufficient surveillance, testing, and contact tracing, many more cases remain undetected. Cases have been reported throughout the DRC’s 26 provinces, initially spiking in Équateur Province and then expanding into South Kivu, which has been ravaged by armed conflict and social unrest — conditions that pose major challenges for health workers. Cases have been reported in Kinshasa, a city with more than 17 million inhabitants. Overall, at least 12 African countries have reported cases, including 4 that had had no reported cases before this outbreak.
Human-to-human transmission has primarily occurred within households, in health care settings, and by means of sexual contact, with the greatest risk seen among men who have sex with men (MSM) and sex workers. Evidence suggests that clade Ib is more likely to be lethal than clade IIb — the clade that drove the global mpox outbreak in 2022, affecting primarily MSM and causing nearly 100,000 cases and 208 deaths in 116 countries. Tragically, most cases and deaths in the current mpox outbreak have occurred in children, indicating that transmission is occurring by routes other than sexual contact.
The WHO previously declared a PHEIC for the clade IIb mpox global outbreak in 2022. Yet endemic mpox has not garnered the same attention and investment—a disparity that the concurrent regional and global emergency declarations should help to rectify. The rapid international spread of a new mpox subtype is of enormous concern. Though all countries should fortify their preparedness, the priority must be coordinated action and investments focused on response efforts in Africa. In light of deeply inequitable responses to Covid-19, the WHO adopted amendments to the IHR in May 2024, the most consequential of which embedded equity in the regulations as a principle guiding pandemic response. Although the amendments won’t come into effect until next year, the African mpox outbreak will put these legal obligations to their first crucial test.
There are currently two mpox vaccines recommended by the WHO’s Strategic Advisory Group of Experts on Immunization. On August 9, the WHO invited mpox vaccine manufacturers to apply for an Emergency Use Listing (EUL), which African countries and supporting partners such as Gavi could rely on in deploying vaccines. The United States and other high-income countries have substantial mpox vaccine supplies, but affected African countries have not had affordable access—an enduring indicator of inequity.
The PHEIC sets in motion binding legal obligations for international cooperation and rapid reporting of data, compliance with any relevant temporary recommendations from the WHO, and mobilization of funding for diagnostics, surveillance, and medical countermeasures. The PHECS empowers Africa CDC to coordinate the continental response. Since this is the first time that regional and international emergency declarations have been in effect concurrently, it is vital to harmonize the global mpox response and give full support to African countries and public health officials leading the response in their communities.
In our own country, the U.S. Centers for Disease Control and Prevention (CDC) has issued clinical guidance recommending further investigation in patients with suspected mpox who have recently returned from affected countries; it has also issued a level 2 travel alert. The White House has established an interagency response team, indicating heightened domestic concern. CDC modeling suggests that if clade Ib mpox seeded in the United States, household close-contact transmission would not result in a large number of cases. A separate modeling study, however, suggested that there would be an elevated risk of transmission among MSM, given relatively low uptake of the JYNNEOS mpox vaccine. Overall, low population-level orthopox immunity leaves the U.S. population vulnerable.
The IHR requires countries to avoid imposing unnecessary travel or trade restrictions and to base their response to a public health emergency on science and respect for human rights. Temporary recommendations from the WHO urge affected states to ramp up coordination, diagnostics and surveillance, risk communication, and preparatory vaccination efforts, and standing recommendations urge all countries to make countermeasures available and refrain from targeting African countries with travel-related health measures for mpox, among other advice.
Priorities for an effective global response should include major investments in health systems, including diagnostics, surveillance, and the health workforce; risk communication encouraging culturally appropriate behavior changes; equitable access to lifesaving countermeasures; and sustained financing and action in the region.
First, international financial assistance is urgently needed to support the African response on the ground and provide incentives for the development of safer and more effective countermeasures. The WHO’s Contingency Fund for Emergencies recently released U.S.$1.45 million and plans further allocations under the PHEIC. Yet these funding levels are insufficient to support a robust emergency response. The WHO’s regional response plan estimates that U.S.$15 million will be needed in the initial alert phase, and sustained financing will be required over time.
Second, testing and surveillance to monitor and inform our understanding of the ongoing outbreak are urgently needed. More comprehensive and accurate epidemiologic data are necessary for developing countermeasures, tailoring risk-communication strategies, and enabling a targeted response. Enhanced surveillance capacities will be especially important in border areas to prevent further international spread.
Third, international support is vital to facilitate equitable access to diagnostic kits and vaccines. When the WHO declared a PHEIC, the United States offered 50,000 vaccine doses, and the European Union and Denmark-based Bavarian Nordic agreed to distribute 200,000 doses. Yet these offers pale in comparison to Africa CDC’s assessed needs of 10 million vaccine doses. African regulatory authorities should rely on the WHO’s EULs to authorize vaccines that meet requisite safety and efficacy standards, and coordinate with key vaccine partners such as Gavi.
Fourth, as the epidemiology of mpox has shifted, concerns about human exposure to wild animals have been superseded by a focus on more prevalent behavioral risks among sexual partners and within households. Accurate, nonstigmatizing, and precise risk communication delivered by trusted community members will be important to mitigate further spread, especially for at-risk communities such as sex workers and MSM. Several African countries have enacted laws that criminalize same-sex sexual conduct, which can dissuade people from seeking vaccination or care.
Finally, this mpox PHEIC declaration is the third in 5 years—a clear acknowledgment of ongoing threats to health security. Each declared emergency spurs international action, which then wanes without bringing endemic disease to an end. Bringing sustained attention and investment to the DRC and its neighbors is good for the region and good for the world.
A response with staying power that builds resilient health systems will save countless lives in the DRC and beyond. The DRC has long faced the devastating effects of colonialization, exploitation, armed conflict, and political instability. But ending this mpox epidemic is also very much in the national interests of high-income countries around the world. The August 15 report of a case in Sweden, followed by the first case in Thailand on August 22, underscores the pandemic potential of mpox. The discontinuation of routine smallpox vaccination means that much of the global population has not been exposed to orthopox viruses. If we remain complacent, we face a real risk of a major global health event.
Source: nejm.org, August 28, 2024