Health in Africa: Mpox and the Public Health Emergency of International Concern

The mpox case surge in Africa has been declared a Public Health Emergency of International Concern (PHEIC) by the WHO. A new clade of the virus has emerged since the 2022 outbreak which has led to a rapid increase in cases. Professor Salim Abdool Karim, who is the the chair of the Africa CDC’s Emergency Consultative Group and the director of CAPRISA, the Center for the AIDS Programme of Research in South Africa, joins Gavin Cleaver and Maneet Virdi to lay out in clear terms what's happening in Africa, what the PHEIC means, and what the future could look like.

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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.

Maneet: Hello and welcome to the Lancet voice. It's September 2024. I'm Minit Virdi, Senior Editor at The Lancet, and I'm here with my co host Gavin Cleaver. This is the first in a new series of podcasts where we examine health in Africa by speaking to people from across the continent. Last month, the World Health Organization declared MPOCs a public health emergency of international concern, following an outbreak in the Democratic Republic of the Congo which spread to other countries.

We're joined today to discuss MPOGS by Professor Salim Abdul Karim, who is the Chair of the Africa CDC's Emergency Consultative Group and the Director of the Centre for the AIDS Programme of Research in South Africa.

Gavin: Professor Salim Abdul Karim, thank you so much for joining us again on the podcast. You're a regular guest of ours and we we really appreciate it. We're here today to talk about the Mpox outbreak, which was just declared a public health emergency of international concern. Tell us a little bit about what your role is in, in Africa during this outbreak.

Salim: For the past Two and a half years, I have served as special advisor on pandemics to the Director General of the World Health Organization to Tedros. And among my responsibilities is to work with the pandemic hub of the WHO and to assist more broadly on pandemics and pandemic preparedness. Within AFRICA, I have played various roles in supporting the AFRICA CDC in its efforts relating to pandemics and pandemic preparedness, including having served on the coronavirus task force during COVID 19 and most recently in MPOCS, I chair a committee of the Africa CDC, which has a, an unusual name.

Emergency consultative group, which is basically 20 of Africa's leading scientists. They are clinicians and scientists in virology, mainly in bacteriology. And our responsibility as this committee is to advise the director general of the Africa CDC on whether to declare. Particular disease or challenge as a public health emergency of continental security.

So that's our responsibility. We met on Monday what's it now, three weeks ago. And on, I think it was the 12th of August, we met. And we reviewed all of the available data that was available on MPOS in Africa. And we then engaged with the data and had extensive discussions. And at the end of that meeting resolved to recommend to the Director General of the Africa CDC to declare such a public health emergency.

And I was impressed that the very next day he called a press conference at which he announced the public health emergency of continental security and I presented the rationale that for our recommendation at that press conference. And then the very next day, the WHO had its committee meeting and it declared MPOGS a public health emergency of international concern, which I think it very clearly is.

So in terms of process, we now have probably the highest level of alert that we can have for MPOGS in terms of its potential as a pandemic or global threat. 

Maneet: In July 2020, WHO declared mpox a public health emergency. This led to a global response, including public health campaigns and repurposing of smallpox vaccines.

By May of 2023, WHO declared mpox The end to the public health emergency. But here we are again in August of 2024, just over two years later with both WHO and the Africa CDC declaring MPOCs a public health emergency. So why is MPOC spreading so fast for two public health emergencies to be declared in just two years?

Salim: When we were looking at OX in 2022, the C of the virus that was spreading the strain of the virus that was spreading was the C two B. That's the c strain was first described spreading in Nigeria in 2017, and when it spread in 2022. It spread very rapidly across the globe. There were over 100, 000 cases, and it spread principally within the community of men who have sex with men.

That became quite a concern, because we've seen from other viruses that spread in, in through sexual transmission like that, that it can, go far and wide. The reason that the public health emergency was lifted in May of 2023 is that the cases started declining as rapidly as they rose a year earlier.

So in effect the emergency and the rapidly rising cases was dissipating. And that could largely. Because of change in behavior, it occurred largely because of public health measures and access to vaccines within that community. So we saw, in effect, all of those actions together bring this virus under control.

Now, a year and a bit later, after that first mpox public health emergency was lifted, we now have a different set of strains, different clades that are spreading. So it's not the same. That's the previous one. So some people have said, why did you lift the first one? It's a different, this is a different clade.

What we are seeing now is the spray the spread of clade 1A and clade 1. Now it should be pointed out that when the public health emergency was lifted in May, 2023, the number of MPOX cases. In the, in Africa and in particular in the Democratic Republic of Congo, the DRC, the number of cases in the DRC was steadily going up.

So even though it was coming down in the rest of the world, it was going up. As going up because of clade 1 infections. Roughly around September, October last year. a new clade emerged. Now we don't know if this new clade had been simmering underneath all this time and just, we only picked it up then, but that's when it was first identified.

And this was now a new clade 1b. Some clade we hadn't really seen before. And clade 1b was spreading much more rapidly. And in particular, It had spread in commercial sex workers in the South Kio district or province of the DRC. So that now pointed to this new pla being sexually transmitted through heterosexual transmission.

And because of that concern, we now we know from past experience with gonorrhea and HIV and so on. When something spreads heterosexually, it has the potential to spread far and wide on the continent. What was particularly concerning was that in 2023, the average number of cases per week in the DRC were in the region of around 280 cases per week.

In 2024 that went up to over 500. Now that concerned us. So now we have a situation where we have more cases, so we have a higher burden of illness, which is putting a stress on the healthcare system, especially because South Kirov Where clade 1b is spreading is in the midst of a war. Government forces are fighting rebel forces.

The healthcare is under stress. We can't even get the specimens from the doctors to the lab. We can't even get reagents and diagnostic tests to the lab because of this political instability there. But the rise in cases was concerning. And not only was the rise in cases concerning, that, and that the burden is high.

It was also that the number of cases was still increasing, so it's a high burden, our cases, and it's increasing. And on top of all of that, we were quite concerned when we looked at the case fatality rate. So unlike the first public health emergency, which was due to the clade 2b variant, the case fatality rate was below 1%.

The situation now, in the DRC, is that our case fatality rate is 3%. And that that concerned us. Now, there are many challenges to the accuracy of those indicators, but at 3%, we couldn't ignore that. And then finally, the, the straw that broke the camel's back on MMOPS in our perspective was that In July and August of this year, four countries that had previously not reported mpox cases had now started reporting cases of mpox, and they all had this clade 1b, this new clade.

So now We have high burnout in cases, we have a rising number of cases, we have a higher than expected case fatality rate, and this virus is spreading to countries that didn't have MPOCs before. And this particularly is now taking its toll in those countries, and those were just imported cases. And of course, it also, we had two imported cases, one in Sweden and one in Thailand.

Then in Burundi, in the last two weeks, three weeks, we've seen now local spread of this in Burundi. So now we have person to person transmission of this particular variant of mPOT. In Burundi as well, so if it can spread like that, our concern is that it could spread much further, and the best time to stop a pandemic is when it's starting, and so that's why we felt we needed to act before it became, a much bigger problem, and we needed to act, and we needed to act concertedly in the DRC to stem the tide of infections in the DRC.

Gavin: What changes then when you say, okay, we need to act now in the DRC what extra resources are brought to bear? How does the kind of situation play out? 

Salim: So there are three main benefits of declaring a public health emergency, continental security. The first is that the African Union itself.

mobilizes its own resources, and they, I think, have put about 10 million into the pot. It just turns out that the DRC itself mobilizes resources from its own budget as well to contribute to this, and external donors have now stepped in to contribute as well. So there's been resource mobilization. The second is that it allows for a much more coordinated and a concerted effort.

Because what's happening is that individual donors are coming and going and players are doing what they're doing and there's no concerted action to fix the problem. Now we do have that. So all the players in the DRC have met together. They've now had several meetings under the auspices of the Minister of Health.

There's a clear plan that's been put on the table. We have a continental plan that has now been put out for comment. There's been now a whole set of activities for concerted action. And then the third is that We hope that it would lead to much greater global solidarity because we don't have access to the vaccines in Africa and the vaccines themselves cost between a hundred dollars to two hundred dollars a dose.

So there's no way we're going to be able to afford buying, millions of doses of the vaccine. We will need. Those doses to be donated or the prices drop to a level where they are affordable. And we hope that this declaration will create that kind of global solidarity that would enable us to have access to more diagnostics and more vaccines.

Maneet: You mentioned mobilization of resources, but despite the urgency, international response has been slow. Echoing some of the inequities that we saw during the COVID 19 pandemic on vaccinations. I know you've touched on this, but in a little bit more detail and pox vaccines are available. So why are they taking so long to reach the countries in Africa that need them the most?

Salim: It seems that humanity is destined to repeat its mistakes. It seems like we didn't learn from the experiences of COVID 19. And we believed in COVID 19, that if we try to contain this virus in our own bodies, that we wouldn't need to worry about it. Omicron threw that concept out the window. It was just a matter of time before Omicron spread to every corner of this earth.

And so we feel to understand when we dealing with a pandemic, the whole world is at risk. And then we have to take, we have to deal with this problem as a global problem, not as a country problem. And having not learned that lesson. I'm deeply saddened, especially because in most countries in Europe, in the U.

S., they have large stockpiles of mPoS vaccine. They're just sitting on it. They're waiting for it to come to their shores to make the vaccines available to their own people. They haven't really undertaken what I would have thought they would do. Which is to reassess their priority usage of those vaccines and keep the doses that they think they will need for their local transmission programs, but then make the excess available to Africa so that they could never get to their shores.

And I think that's the sad part. That they haven't seen the benefit. of making their resources available to stopping and slowing the spread of this virus right here in Africa. And I think we've seen that problem observed very clearly in the negotiations on the pandemic treaty, where, there's still no agreement on making biological countermeasures available to poor countries.

Right now, If we look at where we stand, our single biggest obstacle is actually the intellectual property pretensions that are being given to the companies that are making these vaccines. And we tried to do this in COVID 19 under the WTO, use the provisions of the TRIPS agreement. South Africa and India put forward.

That the exemption in the TRIPS agreement, that is a provision in the TRIPS agreement in the presence of a pandemic to waive intellectual property protection so that, countries that can make vaccines can do and there is the capacity to do that in Africa, which is current because of the intellectual property protections.

And we find exactly the same, but we couldn't do it, the WTO knowing now, and because countries like Germany. Insisted on protecting their local pharmaceutical companies and now we're facing the same problem all over again We are making the same mistakes again 

Gavin: How optimistic do you feel about the next steps in africa?

And what do you think those next steps are? 

Salim: So i've been working With and providing advice to the team that's in the drc and at the africa cdc And I have to say, I am very optimistic at the moment and I'm optimistic because the government of the DRC and some of its neighbors have are coming to an agreement to allow a political solution for us to get into the South Kivu District and to implement public health measures.

So there's some kind of discussions around the truth, around some kind of allowing health care workers in the presence of all of the conflict to get on with doing what we have to do. At the same time, there's agreement to mobilize just over 10, 000 community health care workers. And those health care workers are critical because, how do you slow the spread of mpops on the ground?

Case detection. It's all about case detection. You have to identify every case, because that's where the public health measures have to be implemented. To do that, you need to engage with communities. You need to educate them. They need to know what a case of mpox looks like. They need to know if they've got it.

They need to go to a healthcare worker. We need healthcare workers to be aware, to look for it, diagnose it, send specimens to the labs, and importantly, for every case, We need to do the contact tracing. We need to trace the close contacts, the sexual contacts, and we need to do the education. So it's. Test, trace, educate.

Every exposed individual is educated not to engage in sexual intercourse or close contact with others if they've got lesions. And that's how we're going to slow the spread of this. Ideally, we would like to vaccinate all the close contacts. What is, what we used in the days of smallpox, now, I'm among those that remembers what we did in smallpox, but we use re vaccination.

Because mpox is a slow spreading virus, you can get ahead of it if you can go to the exposed individuals and the areas at risk and you do a ring vaccination, you just vaccinate all those individuals. That's a very judicious use of expensive vaccines. And it will slow the spread of this virus. So I think, given that's now being all put in play, and we are moving in that direction, to the test, trace, educate, vaccinate strategy, I feel that we have a chance to contain this situation in the DRC before it becomes a bigger problem globally.

Maneet: This is Africa CDC's first declaration of a public health emergency of continental security since its inception in 2017. Could you please expand on Africa CDC's role and how Africa CDC and WHO will work together to control the outbreak? 

Salim: There has been substantial discussion at the African Union and the Africa CDC about whether the Africa CDC should have this authority and it was agreed after extensive consultations that this would be built into the provisions of the Africa CDC.

So the Africa CDC has this authority to declare this. public health emergency of continental security. This is the first time that it's used to that authority and that power. And to some extent, we're learning as we go along. About, so what does that mean? Because we don't have a past to base it on.

And I think so far what it has done has been extremely positive. As I said, we've seen the mobilization of resources, we've seen vaccines being donated, albeit at too low a level, and we've seen plans now being implemented, activities on the ground. So I think all told this was An important step and indeed it bodes well for, future pandemics.

Let's remember that, Africa is a particularly high risk of MPOX and the reason is very simple. Everybody who is older than 40 years they don't worry about MPOX, right? Because we've had smallpox vaccine. And because you had smallpox vaccine, you are protected from MPOX. The challenge in Africa.

is that the proportion of the population that is below 40, that is proportion of the population that has no protection from smallpox vaccination, which stopped in the 1970s, that proportion is high. In the DRC, it's 85 percent of the population. So you basically have a situation where you have no protection.

From the smallpox vaccine. Whereas in Europe and other countries where the population is a more older population there, the faction that's unprotected is much smaller. So now you get some idea of the real challenge we are facing in Africa, that we work a very significant proportion of our population at risk.

So inbox is gonna keep coming back. It's gonna come back. Is, it'll just be a different variant the next time. We have got to do something to stop this problem in the long term. We can't fix it right now. Ultimately, we're going to have to give a vaccine to, most of the countries in Africa focusing on those below the age of 40.

Otherwise this threat will keep emerging. We'll be declaring public health emergency use of MPOGS every few years. So we need a long term solution, which is based, which has to be vaccine based, where we reduce the susceptible population, and so MPOGS, which will keep occurring because it's mainly a zoonosis, but at least we can control its person to person spread.

Gavin: That's great. Professor Salim Abdul Kareem, thank you so much for joining us again on the Lancet voice. It's always a pleasure to have you on and to hear your expertise. So thank you very much.

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