Mpox in Africa: The Next Global Pandemic?

Mpox, previously known as monkeypox, is a viral illness caused by the monkeypox virus, a species of the genus Orthopoxvirus. There are two distinct clades of the virus: clade I (with subclades Ia and Ib) and clade II (with subclades IIa and IIb)1.

When the virus that causes mpox emerged as a major international health threat in 2022, countries worldwide, including the United States, quickly turned to vaccines originally developed for smallpox to contain the spread. However, the response in Africa, where the virus has a deep historical presence, lagged far behind. Despite being the region where mpox first emerged and continues to pose a significant health burden, Africa didn’t receive its first vaccine doses until 2024, exposing stark inequities in global health preparedness and response.

On September 13, 2024, the World Health Organization (WHO) took a significant step by authorizing the use of Jynneos, a smallpox vaccine manufactured by the Danish pharmaceutical company Bavarian Nordic, to combat mpox outbreaks in Africa2. This move was primarily administrative, meant to speed up the distribution of much-needed vaccines. Before that, Nigeria had received just 10,000 doses as a donation from the United States on August 27, and another 99,000 doses arrived in the Democratic Republic of Congo (DRC) on September 5. But these shipments barely scratch the surface of what is needed; millions more doses are required to address the rapidly expanding mpox outbreaks in Central Africa.

A Crisis in the Making: Mpox in the Heart of Africa

Mpox has long been a problem in Central Africa. The virus, which causes a range of symptoms including fever, muscle aches, and a hallmark rash that looks like blisters or pimples, was first identified in humans in 19703. For decades, sporadic cases were mostly linked to children exposed to wild animals, such as infected rodents or primates. While Western countries viewed mpox as a rare zoonotic disease, in countries like the DRC, it has quietly become an endemic public health threat.

The current crisis was set off by the emergence of new strains of the virus. Scientists categorize mpox viruses into two main clades, or groups of related viruses: Clade I and Clade II.

This outbreak subsided in 2023, after which the WHO declared an end to the public health emergency in non-African countries. But the virus never went away in Central Africa, where Clade I viruses continued to spread unchecked.

Now, a new variant of Clade I, dubbed Clade Ib, has become a major threat in the region. This variant first surfaced in September 2023 in the mining town of Kamituga, in eastern Congo, and quickly began spreading from person to person, mimicking the dynamics of the Clade II outbreak in Europe and the Americas. Clade Ib is now responsible for a surge of cases in Congo and beyond, spreading to four of its neighboring countries — Burundi, Kenya, Rwanda, and Uganda — and even appearing in Sweden and Thailand.

The Growing Toll and Limited Response

As of September 13, 2024, nearly 6,000 confirmed mpox cases and tens of thousands more suspected cases have been reported in 15 African countries, resulting in 724 deaths. Yet, public health responses and vaccine distributions have been inadequate. While countries like Japan, Spain, and the United States have pledged more vaccine donations, these contributions remain limited, and Africa still lacks the estimated 10 million doses needed to curb the outbreaks, according to the Africa Centres for Disease Control and Prevention (Africa CDC).

A primary challenge is the lack of understanding of how the virus is spreading in Central Africa compared to other regions. In Congo, for instance, more than half of the confirmed cases are in children under the age of 15, a demographic that has experienced worse outcomes compared to adults. The high number of pediatric cases is concerning and suggests that the virus is moving through different transmission routes, including household spread, potentially through close contact or respiratory droplets in crowded living conditions.

A Neglected Crisis: What Went Wrong?

The emergence of Clade Ib and the current crisis should have been anticipated, say many scientists. “As scientists, we’re not surprised [that this is happening] because we’ve been ringing the bell for some time,” says Jean Nachega, an epidemiologist at the University of Pittsburgh. “But it looks like not too many people were listening.” For years, research and development of vaccines, drugs, and diagnostics for mpox were underfunded and deprioritized, largely because the disease was viewed as a problem limited to remote African communities.

The consequences of this neglect are now evident. Although vaccines like Jynneos were designed to protect against smallpox — a closely related virus eradicated in 1980 — their effectiveness against the newly emerging Clade Ib is still uncertain. Meanwhile, newer, mpox-specific vaccines are in development, but they are not yet ready for human trials, making them unfeasible for the current outbreaks.

Beyond Vaccines: What Needs to Be Done?

In the wake of Africa’s struggle with mpox, it’s clear that the response cannot rely solely on vaccines. “We must do primary health care. We must do the basic things. It’s not just about vaccines,” says Ayoade Alakija, an infectious diseases physician and chair of the African Union’s Vaccine Delivery Alliance. That means investing in healthcare infrastructure, training local health workers, and implementing effective public health strategies, from educating communities on how to reduce transmission to ensuring rapid detection and isolation of cases.

There’s also a need for better treatments. Although a few antivirals developed for smallpox, like tecovirimat, are available, their efficacy against mpox remains questionable. Recent trials showed that tecovirimat did not significantly speed up recovery in patients infected with Clade I viruses compared to those given a placebo, highlighting the urgent need for targeted therapeutic options.

A Call for Global Action: Why Everyone Should Care

The uneven distribution of vaccines and resources not only places Africa at risk but the entire world. Infectious diseases do not respect borders, and as long as the virus continues to evolve and spread in one region, there is a risk of new variants emerging that could reignite global outbreaks.

“We can’t have another vaccine-based strategy,” Alakija warns. “We must do primary health care. We must do the basic things.” For that to happen, a coordinated global effort is essential. Only by ensuring that all regions are adequately equipped to handle public health emergencies can the international community truly protect itself.

As Nachega aptly puts it, “Nobody is safe until Africa is safe.” If the world fails to act, the consequences of this neglect could reverberate far beyond Central Africa.