Monkeypox: an African perspective

What's happening with monkeypox in Africa? Why wasn't monkeypox tackled when we had the chance? What will the PHEIC declaration change? Prof. Yap Boum, Epicentre Representative for Africa, the research arm of Medecins sans Frontieres, joins Gavin and guest host Dr. Miriam Lewis Sabin to discuss.

You can read The Lancet's collection of articles on monkeypox here.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to The Lancet Voice. It's August 2022, and I'm Gavin Cleaver. This time around, I'm here with Dr. Miriam Lewis Sarban, North American Executive Editor at The Lancet. Welcome on board, Miriam. 

Miriam: Hi, Gavin. It's great to be here. 

Gavin: You're about to hear Miriam and I chat with Professor Yap Boom, who is the Regional Representative for Africa for Epicenter, the research arm of Médecins Sans Frontières.

We're going to talk to Yap about monkeypox in Africa. Monkeypox has of course made many headlines since it hit Europe and it was declared a public health emergency of international concern. But so often in the coverage, the African perspective has been lost. Of course, monkeypox has been known about and endemic in many African countries for a long time.

So we wanted to ask Yap, what's the situation in Africa? And how do you feel about the PHEIC declaration?

Perhaps we can start by talking about what sort of virus monkeypox is and what kind of endemicity has looked like in Africa in the last few years. 

Yap: The interesting bit with the monkeypox is I recall when it kind of restarted. In the West, there was, there was one of my friend who has her auntie who was remembering that this disease has been there for long, for very long time.

So in, in our setting, and I'm, our setting, I mean Cameroon, I mean Central African Republic, I mean DSC, it's something that has been there for some time, for, for many years, actually. It's a virus that we all see in those three countries where it has been, there have been an endemic, but now the main country, let's say the country that has reported most of the case has been the Democratic Republic of Congo and then the Central African Republic.

And since the beginning of the year, I think Cameroon has reported around 40 new cases. 

Gavin: From what I can make out from the reports, it does seem that there was a change in the virus around 2017 that seems to have been detected first in Nigeria. Perhaps you can tell us a little bit about that. 

Yap: The monkeypox, like many of all the other virus, it's quite, has its own dynamic.

As with COVID, we've been talking about a different variant. But for the monkeypox, we've seen what we call a re emergence, actually. because it has been quite dormant. We were having quite a number of cases that were appearing, especially in DSC before the nineties, as, as you mentioned, and then between 96 and, and, and so on in 2005, they start, reappearing more and more in in DRC.

And then we start having some some case appearing in other countries, including Nigeria, but not only. At that point, We kind of resume or let's say increase the surveillance around monkeypox because in many countries, when you have a confirmed case of monkeypox, you raise some alert, which will help you to implement a surveillance system to look for the contact and to see how you can actually manage those cases, despite the fact that we don't have at that time, neither treatment, neither vaccine.

But at least it was critical to make sure that the, the case well controlled and isolate from the other. 

Miriam: And yeah, I'm wondering if you could tell us a little bit more about, you know, how the epidemiology has changed. So who was affected, you know, originally for the years that it's been endemic and.

How that seems to have changed now. Also, you know, here we're, we're hearing about, you know, two different strains of monkeypox with different mortality rates between Central and Western Africa. I wondered if you could share with our listeners a little bit about that. 

Yap: Yes. In the, in the surveillance, I think we have different time period and we, we have all what was happening between, around the 19th where we were having some, some case mainly in the SE as mentioned, but then I think since 2005.

This is definitely when the case started to rise, especially in D. S. C. Basically, the case were mainly in the remote place, in the forest, because initially we were having animal to human transmission. So it was many people who were going in the, in, in the bush, who were eating some of those animals. There was quite a number of animals, some rodents, some squirrel, and so also some primates that seems to, to act as what we call a reservoir in the sense that we found the virus in, in those animals.

So it appeared that the people who were living close to those animals. Or because of the different challenge, including the war in some of the country, like in D. C., like also in Central African Republic, the population were pushed to go, go to the, to the forest and getting close and close to those animals.

And then while preparing them while eating them, they were getting the transmission. And It's, I think it's some in 2005 or so where they were around more than thousand suspected case that was in DSC and it was slowly but surely increasing. In 2020, they report around a bit less than 5000 suspected case in DSC with around 170 deaths, which is quite an important number.

And After that, we have the different transmission when the virus appear actually in the West, in France, in Spain, in in the U. S., in many of the Western country, where it was actually more of a human to human transmission, and it was targeting a specific population of men who were having, who have sex with men.

So that's when that has been the game changer. moving out of Africa and targeting a very specific population. 

Gavin: Yeah. So what's your perception of what's happened in Europe over the last three to four months since the virus has arrived in many countries around the world? 

Yap: Well, there are many points. The first one is, of course, we are in a COVID 19 era.

So whichever virus appears, it raises A lot of fear among the population, among the stake, the stakeholder, and that's what happened. People were saying that the monkeypox will be the next COVID 19, which is definitely not the case because this is two different virus and the impact is also different. But what is, what is important is actually how this new, this epidemic has been managed.

Since it has gone out of Africa, which has been there for some time, you, you've seen an important willingness and resource mobilized to actually improve or increase it. the surveillance increased the availability for treatment for vaccine, knowing that those treatment and vaccine were not specifically made for monkeypox, but for smallpox, but we've seen that they have around 80 percent efficacy for some of them.

So it was quite. surprising at some point to see all those vaccine and drugs be made available for those new patients. Not, not that they don't deserve to have them. Of course they do. But those who were, who are living in endemic countries also need them. And it's quite surprising that those drugs and vaccine has been stocked in some of those stock stock stockpile in the U.

S. and many other countries, and they are made available now only when The disease is challenging the West. So that reminds us a lot of inequity that we've seen already during the COVID 19 pandemic. 

Miriam: You know, something that's been really striking is, I think for a lot of folks in the West, the word or the name monkeypox is completely new to them.

Whereas, you know, in your experience and in Central and Western Africa, this is not new at all, as you've said. And there have, in fact been, you know, the possibility for vaccination and treatment and surveillance. And so, you know, just to go a little bit, dig a little deeper on this. Why do you think nothing had been done for so long about this, knowing that there was pandemic?

potential for monkeypox? 

Yap: That's an interesting and very pertinent question. And the question means why having all those, those of vaccine and even drugs that were stuck somewhere, why all those have not been made available in country where the monkeypox were present and where it was known to be present.

So why most likely because the people We'll make the decision on who get the drugs and the vaccine. We're not concerned about the people living in those endemic countries. If they were, they will have used those vaccine and those drugs to be made available in DSC, in CAR and in Cameroon, which was not the case.

So I think it's simply, if I can really put simply in a bracket. It's a question on making a decision based on the interest and the interest for those stakeholders. It's their population. That's why they will keep even what is happening now. Even what is happening now, you see the people having access to the vaccine in France, in many of those countries, but still you haven't heard that there is a mass.

vaccination campaign for people who are in endemic region in CAR or in DSE, as far as I know. 

Gavin: Yeah. So what have, what have kind of recent outbreaks and efforts looked like in Africa since since monkeypox has turned up in so many other countries? What's it like at the moment where you are? 

Yap: So at the moment, what is happening is that you know, to implement a proper surveillance system.

Which means, when you have one case, you raise an alert, and you go and see the case, you isolate the case, you do the management, you do what we call the contact tracing to ensure that all the people around that case are doing well, you follow them for a period of time, all that requires resources. Fund, which were not available.

So it was really hard for most of the Minister of Ministry of Health or of the endemic country to actually to properly implement the servants. Now that it's all over the the world, some fund are being made available, some funds from the COVID-19 can also be used to support some of those investigation.

And even some funds are being made for research in the Central African Republic. There was a clinical trial on the one of the drug, the tecovirumat. It's a bit difficult to pronounce. And the first part happened during the early this year with 14 patients that were included. And the second, the second part of the trial will surely start around August of September.

But this will be more possible. with the funds that have been made available because it's becoming a global concern. Well, it was not the case. The fund was not there. So the country were obliged to figure out how to do the survey entry with the very small mean they have. And because it is not. As challenging of as c or as Ebola as the other.

Of course, ministry of Health and government have to prioritize. So eventually the monkey box does not appear as a priority in this country because one, they will, they will usually occur in remote places. Two, because the number of death. Though it was quite high in DSE was lower than the other disease, Ebola and so on, and more importantly, because there is there were no fund for that.

Miriam: You know, hearing you, you know, talk about you mentioned Covid Covid 19. And while this is very, very different, of course, as a pathogen from COVID 19, you know, you've touched on points that I think some people had hoped that we had learned as a global community, you know, such as the importance of strengthening public health surveillance everywhere worldwide, getting, you know, treatment.

and vaccination where it needs to be in an equitable manner and increasing research capacity. It sounds like that you're saying that that's helping that's a, it's helping a bit now. Do you think that's a result of the WHO declaring this a public health emergency of international concern? 

Yap: Yes, I, I think that declaration will, will definitely help in, in one in mobilizing and, and to ensure that in countries where the WHO is present and where the monkeypox is endemic, at least they will push the ministry of health, but more importantly, they will push the different partners who are in those countries to also support the monkeypox, which is a good thing.

The, the, the challenging, the challenging things or the bad things is that what we've seen is that we, we, we haven't really learned the lesson from the COVID 19 in terms of equity. Because we are going back to the same, same story while we should realize if we haven't yet that we are interdependent, definitely interdependent because now the monkey box that we are seeing a spreading trading in the West and changing the transmission, the population and so on, most likely if we have done properly all the research on the vaccine, on the treatment, on the diagnostic as well, then definitely we will be better equipped to respond to what is happening now in Spain.

So you see how research in DSC or in Central African Republic or even in Cameroon could impact. the way the response can be implemented globally. And one good point that we've seen in COVID, it's about, it's around the diagnostics. Early in the pandemic, we realized in Cameroon, for example, that we were not able to implement molecular testing everywhere.

So we actually implement operational research to evaluate the different rapid diagnostic tests. And based on those results, we decided to use them all over our countries. And I recall at that time, the performance of the tests were found too low as compared to WHO standard and many other standards, but we decided to use them.

And which is now spread and used almost everywhere. I think it's something that we should take advantage and do the same for monkeypox. Because we need to have, the first thing is how can we make a reliable test in the middle of nowhere in an endemic zone? Because in Spain, we can easily run a PCR. Same thing in France.

But if you go in the east of of Central African Republic, or even on DSE, or even in Cameroon, where you find the case, it will take you one hour, or no, let's say one day. to have the sample reaching the main lab that is the only lab able to run that PCR and to get the results. So we should take some of the good lessons.

From COVID and Ebola in terms of research and personal research to find local solution that can help countries to have the adequate and optimal response to that new epidemic. 

Gavin: Yeah, I meant to ask, how do you feel about the management of monkeypox around the world so far? And were you kind of more hopeful that less that lessons would be learned from from the COVID pandemic and kind of worldwide management?

Yap: Well, you know, I'm basically an optimistic, so I always want to hope that things will be better, things will be different. But that's not the trend that we are seeing if you look at the distribution of vaccine against monkeypox. As I mentioned earlier, I hope that the WHO and many other stakeholders and foundation and NGOs will push for more equity.

And I also hope that the big funder for research, I'm just thinking on top of my head at the Bill and Melinda Gates Foundation and some of those one will prove avail more funding for the research be done in the endemic country on monkeypox, but not only. Because now we are focusing on monkeypox, there might be some other disease like Lassa fever, for example, that is present in Nigeria, in Liberia, in some of those countries where we don't have enough funding to do research.

But until the Lassa fever will move from Nigeria to London, at that point, we'll put all our eyes on it. So I think it's critical now to sit around a table and to figure out what are the actual traits. That we are seeing in Africa, for example, because we know that those, those disease, mainly those zoonoses are the one that will spread globally.

If we tackle them now by providing the resource to do adequate operational research, then we'll be in a better position. to respond to the next epidemic, to the next pandemic. 

Gavin: You mentioned before, of course, how this is a very different disease to COVID. Nevertheless, how concerned are you about this particular outbreak?

How do you feel about it at the moment as a danger? 

Yap: Oh, currently, I don't feel it as a big danger because when we follow the number of cases, which is, which are increasing, that's, that's definitely. But we have a low number of death, which is always reassuring. But still, still. We have a small number of death.

We have the target population that is pretty young, more or less, in average. So we don't know what will happen if that virus start transmitting in a different population, which could be more vulnerable. So actually in the position of saying we should definitely increase the surveillance, but we should also increase the research on providing tools for a better and safer diagnostic and to ensure that the vaccination is available to those.

at risk, but also those who could be the most vulnerable that you might not know for now. 

Miriam: Yeah. So, so to touch on that, and you mentioned this earlier that the current epidemic in in Western countries is mainly affecting men who have sex with men and transgender. Women, you know, and and there have been discussions here that there's been a lack of of equity or there was a lack of too slow a response in addressing monkey pox because of those communities being marginalized communities.

Now, I, I wonder in in Cameroon, for example, where you are, you know, the issues of. MSM or even, you know, transgender people may be highly stigmatized in some countries. Of course, as you know, in Africa, it's, you know, maybe illegal completely. What are you seeing or hearing in, in the press or in other sectors regarding transmission that may be happening, but may not be.

above ground able to be properly tested or examined because of stigma. And are there any concerns about risk to these populations? 

Yap: Definitely. Definitely. That's an important challenge. As per now, the zone where the doge disease are endemic is in the remote place. And then we are talking mainly about an animal to human transmission and then human to human transmission in those places.

We did not have until this outbreak, the stigmatization of men having sex with men or the women who have sex with women. So now that we might having some of those important case that is going to raise. Another challenge that you've mentioned on stigma, we have to be very careful on how we provide access to diagnostics, access to treatment for those, for those population, but we are not starting from scratch.

Though it is illegal in many African countries, including Cameroon, there are some specific programs that were built for HIV, for example, HIV, hepatitis C, and so on, where we kind of provide access to care for those specific population. I'm talking about Cameroon, but that's the same thing in Uganda, in many of those countries.

And it is so important to have the proper communication so that whoever is having any of those symptoms don't keep those symptoms because the person will fear that by talking about it, it to be stigmatized as an homosexual, especially in those countries. But there are some channels, some channels where we can provide access to care, to, to, to men who have sex with men.

and so on. 

Gavin: So predictions, they're obviously a fool's game, but how do you think the next few months are going to look for this monkeypox outbreak? 

Yap: I think we might, we will continue to have an increased number of, of case until we reach what we want to call the herd immunity. One, because of transmission, two, because of the vaccine.

So we hope we'll get there not, not too far. And my hope is that we'll have a better distribution of the vaccine that will have better results for the drugs that will be made available for people who are in need in the West, but also for those who are in the need. in the endemic countries in Africa. And then we'll keep on pushing for that.

We'll also push for those clinical trial to, to, to be implemented and to get the result so that we can, we have evidence because we need. More and more evidence, not only on how the drugs works, but also the acceptability we've just mentioned the issue of stigma. We need to figure out what is the adequate communication to give provide confidence to the suspected case so that they can have, they can have access to treatment.

Now, where we will have to be very vigilant in how the virus is. will mutate and which population it will touch, which might be more vulnerable. I think that's where we have to be more, we have to be very vigilant. And in terms of vaccination now, the target, it's mainly men who have sex with men because they represent 95 percent of the risk population of getting the disease.

But we should think. about the population that could be at risk of developing severe form, which might not be that population at all. It might be the elders, it might be something else. I think it's important that we open our mind and through research to see, okay, Let's follow up closely what is happening in other population and avoid a stigma because that way we can have a significant number of challenge, including death, 

Miriam: you know, in regard to to diagnosing.

Monkeypox. I wonder if you could speak a little to, you know, what some of the challenges are there because it sounds like, you know, the way monkeypox presented even a few years ago was was different in what's being described now in this current outbreak rash may be in different places and so forth.

Could you tell us a little bit about that and and how that may be, you know, continuing to complicate it. Thank you. Diagnostic 

Yap: is the entry point in the sense that the early you can make a good diagnostic, the better you can control the spread of the disease and the spread of the, of the virus. But for now, we have two different words.

You have Africa, where in many of the countries where it's endemic, you have one, maybe two labs who are currently running the PCR to confirm the case of monkeypox, and you have the West, where you have a large number of lab that can run the PCR for those ones. So the challenge are not the same, but in one way or the other, and based on the lesson that we got from COVID, we should move on providing the possibility Like now you have all the self testing for COVID 19, for example, how can we move as fast as possible to make those kind of tests available in the West, but also in the South?

Because if I can declare a positive case in IOS, which is in the central region of Cameroon, which is quite like three or four hours from Yaounde. If I can declare, confirm the case right there with a rapid test, then it, we are not talking about the same thing anymore. If I have to wait 24 hours and the person come to the hospital, we collect the sample, he went back home.

And when he goes back home, he goes back in his community to find it become a nightmare. then we can imagine how the disease can be spread. So I think it's critical to put all the different effort and the lesson learned. We've managed to learn some few things to bring all those people together and say, okay, this is what we need.

We have the institute pastor of Dakar who has developed an experience on designing on the manufacturing some rapid tests for, for many diseases, including COVID. I think those people should also be more sponsored so that they can provide us some tool that we can test in different study in different countries and then ensure that whoever is thinking that he has a can he by himself make a self testing.

And that, according to me, Maybe an important game changer in terms of dialectic, but also in terms of surveillance. 

Gavin: Thank you so much for your time and your expertise and for speaking with us on the podcast today.

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