A doctor examines a teen boy with suspected mpox in Manfuette in the Republic of CongoCredit: Melina Mara/The Washington Post via Getty Images
As the World Health Organization (WHO) declared mpox a public health emergency of international concern, experts speaking at the press conference warn that current statistics for Africa are likely to reflect only the tip of the iceberg, thanks to health system weaknesses, and testing and surveillance disparities.
The WHO declaration followed the Africa Centres for Disease Control’s first ever declaration of a Public Health Emergency of Continental Security on 13 August.
Concerns are heightened by increasing evidence of mpox-HIV co-infection, which is mirroring the historical spread of HIV on the continent via transport corridors and sexual networks, raising the risk of infection among women and children.
Dimie Ogoina, chair of the International Health Regulations (2005) emergency committee of independent experts, sounded these warnings during this week’s WHO press conference to announce the decision.
Ogoina sketched a picture of a complex and multi-faceted mpox challenge: “The current upsurge of mpox in parts of Africa, along with the spread of a new sexually transmissible strain of the monkeypox virus, is an emergency not only for Africa, but for the entire globe,” he said.
“But given the number of clinically compatible cases that aren’t being tested, it is likely that these figures are a significant underrepresentation. In Burundi, for example, we have a really concerning situation where more than half the districts in the country are seeing cases, suggesting ongoing, unrecognised transmission,” said Ogoina.
WHO Director-General Tedros Adhanom Ghebreyesus said the organization would fund US$1.45 million of the cost of the initial US$ 15-million regional-response plan and urged countries and other donors to step up to close the gap.
The more lethal clade lb strain of the virus is prevalent in the Democratic Republic of the Congo (DRC), which is worst affected with around 14,000 confirmed cases, followed by Burundi, with about 100 confirmed cases. The strain has also spread to Rwanda (four cases), Uganda (two cases) and Kenya (one case), and Sweden (one case) which along with Burundi, have not previously recorded any cases of mpox.
South Africa is experiencing the spread of the Clade ll variation which caused the global outbreak in 2022-2023, with 24 cases and three deaths recorded. Cases are also being recorded in Cote d’Ivoire.
WHO Africa’s regional emergency director Abdou Salam Gueye confirmed that there was reason to believe that contact-based, community transmission of mpox was occurring in both DRC and Burundi.
In South Africa, the majority of mpox patients identified as men who have sex with men (MSM) and were either living with unmanaged HIV, had only recently been diagnosed or had advanced HIV disease.
In DRC, the authors of a Nature Medicine1 report in June this year noted the threat of cross-border spread of the new Clade lb strain. They said the rising number of cases acquired through sexual transmission, especially in high-risk populations such as sex workers in the mining region of eastern DRC, which attracts workers from Burundi and Rwanda, underscored the urgency for control strategies.
Speakers at the press conference drew parallels between the mpox outbreaks and the COVID-19 pandemic, saying the response was being hindered by African countries’ lack of access to essential vaccines, diagnostics and laboratory capacities. They appealed to countries with stockpiles of mpox vaccines and other resources to work with WHO, Gavi the Vaccine Alliance, and UNICEF to make donations to countries most in need.
Currently, two mpox vaccines are recommended by WHO’s Strategic Advisory Group of Experts on Immunization and approved by WHO-listed national regulatory authorities, as well as by individual countries including DRC and Nigeria.
Maria van Kerkhove, WHO’s director of Epidemic and Pandemic Preparedness and Prevention, said the rapidly changing dynamics of mpox demanded a better understanding of its epidemiology, including transmission patterns, both contact and sexual, and populations at risk.
“This will help us to use the limited resources we have, including vaccines, in the most targeted, appropriate ways,” she said, adding that it was possible to halt transmission, with concerted efforts using multiple approaches.
