Rich countries are rushing to get doses – but African countries say they should get the vaccines first for a disease endemic to the continent. 

A plan by the World Health Organization (WHO) to create a vaccine sharing mechanism that will attempt to provide equitable access to vaccines effective against monkeypox disease will only be acceptable if the sharing of vaccine doses begins in Africa – where the disease burden is highest, says Dr. Ahmed Ogwell Ouma, Acting Director of the Africa Centres for Disease Control and Prevention (Africa CDC).

Ouma told Health Policy Watch on Thursday that while the Africa CDC supports making the vaccines available, they should be distributed first where the disease is endemic:

“When the smallpox vaccines are released to address monkeypox, it should start here in Africa where burden is larger, the risk is higher and the geographical spread is also known,” Ouma said.

Nine countries in west and central Africa are endemic zones for the zoonotic disease – with 1597 cases – 1488 suspected and 109 laboratory-confirmed- since the beginning of 2022.  A total of 66 deaths have been reported by Africa CDC – although WHO recently put the death toll at 72.

Either way, that is a case fatality ratio (CFR) of  4.1% or more on the continent, including all suspected cases. Some studies have shown Monkeypox mortality rates as high as 10% in the Democratic Republic of Congo – where the most virulent clade of the virus is in circulation.  

Meanwhile, another 1900 Monkeypox cases of the less virulent West African clade have been reported in Europe, the Americas, the Middle East as well as two African countries outside of the endemic zone; no deaths have so far been reported (see graphic below). 

WHO planning ‘fair’ monkeypox vaccine allocation system – will rich countries adhere? 

WHO’s Director General Dr Tedros Adhanom Ghebreyesus said this week that the agency would develop an allocation system to fairly distribute Monkeypox vaccines to targeted groups at risk. 

It is “essential that vaccines are available equitably wherever needed. To that end, WHO is working closely with our Member States and partners to develop a mechanism for fair access to vaccines and treatments,” Tedros told journalists at a Tuesday press conference. 

However, the worry is that rich countries may snap up a limited supply of available vaccines – while strategies to target African countries where the virus is endemic lag behind – much as COVID vaccinations in Africa did. 

WHO’s European Regional Director Dr Hans Kluge, also alluded to those concerns at a press conference on Wednesday. 

As rich countries rush to secure monkeypox vaccines, African countries that have been living with the disease for decades risk being ignored, Kluge warned. 

“Targeted vaccination, either before or after exposure to the virus, can benefit contacts of patients, including health-care workers. Yet, we are already seeing a rush in some quarters to acquire and stockpile these,” Kluge said.

“Once again, a ‘me first’ approach could lead to damaging consequences down the road, if we do not employ a genuinely collaborative and far-thinking approach. I beseech governments to tackle monkeypox without repeating the mistakes of the pandemic – and keeping equity at the heart of all we do,” Kluge said.

The irony is that targeting monkeypox in countries where it is endemic would likely be a more effective strategy, in public health terms, experts also have warned.  

“Whatever vaccination happens in Europe, that is not going to solve the problem,” Francois Balloux, an infectious disease expert at University College London, told the Associated Press.

Smallpox vaccines are thought to be about 85% effective against monkeypox, according to WHO. One vaccine against monkeypox exists, but so far it is only approved in Canada and the United States.

Monkeypox is also spreading in Africa, albeit slowly

Africa CDC and WHO confirmed that the new wave of monkeypox also now appears to be spreading outside of Africa’s endemic zone, with fresh cases reported in Ghana and Morocco — two countries where it is not typically seen. 

As of Thursday, Africa CDC had recorded 1597 cases of monkeypox — 1488 suspected and 109 laboratory-confirmed. A total of 66 deaths have been reported. That is a case fatality ratio (CFR) of  4.1% including all suspected cases. 

Dr Matshidiso Moeti, WHO’s Africa director, meanwhile said that monkeypox cases have now been confirmed this year in eight African countries – including Morocco and Ghana where there had been no previous reports. 

While some 1536 suspected cases have been reported in Africa since the beginning of this year, there are now also 36 confirmed cases in Nigeria, 10 in the Democratic Republic of the Congo, eight in the Central African Republic, as well as 5 cases in Ghana,  3 in Cameroon and 2 in the Republic of Congo, and 1 in Morocco. Additionally, Ethiopia, Guinea Liberia, Mozambique, Sierra Leone, Sudan and Uganda, all countries with no previous incidents, have also now reported suspected cases, according to WHO AFRO. 

Africa CDC classifies Monkeypox risk as moderate.

Not a single dose of vaccine available in Africa 

Despite the public alarm, Africa CDC classified Africa’s monkeypox risk as moderate and urged countries to put their emergency operation centers on alert while also calling for the prioritization of a “One Health” approach to controlling predominantly animal sources of the disease.

And despite Africa’s long history with the disease, Oumam told Health Policy Watch the continent does not have a single dose of smallpox vaccine available on the continent to fight the disease.

So African CDC’s recommendations right  now are focused on the use of non-pharmaceutical methods, such as sharing information and raising public awareness among health workers.

“Our core response to monkeypox is non-pharmaceutical activities where we engage with the public. We give them information on what they need to do to protect themselves, and also increase the index of suspicion of our health workers so that they’re able to pick out any possible case as early as possible, isolate them and provide them with the management that they need,” Ouma told Health Policy Watch.

Developing vaccines to protect Africans could have prevented outbreak 

Meanwhile, Professor Emmanuel Nakoune, acting director of the Institut Pasteur in Bangui, Central African Republic, attributed the current disease outbreak to a global decision to stop smallpox vaccination following its eradication. If this hadn’t been done, he said, monkeypox outbreaks would have been preventable.

“So it means that this is a virus that was there all along, but it was controlled by the smallpox vaccination because those two viruses are from the same family. So what we could have done, perhaps, was to anticipate and prevent the propagation of monkeypox — was to recognize that it is a public health issue in Africa,” Nakoune said.

Public health officials should have anticipated and developed vaccines that could protect the African population, considering the index case in the latest outbreak was an imported case that may have been prevented if there had been the development of vaccines, and attempts were made to contain monkeypox.

“Unfortunately, this wasn’t done and today, we have to live with this. Once again, we are learning a lesson that when there are new diseases which happen wherever, anywhere, it’s very important that efforts be made to find solutions and prevent these diseases from taking root all over the world,” he said.

Similarly, Dr Peter Fonjungo, director of the U.S. Centers for Disease Control and Prevention’s efforts in the Democratic Republic of the Congo, recommended more preparedness and  lab surveillance. 

“This really helps us in early detection, and also in infection prevention control,” he said, “especially for those healthcare workers so that we can limit the spread of this virus.”

WHO’s mapping availability of vaccine supplies 

In a statement, WHO’s headquarters told Health Policy Watch that its plans for the doses will involve working closely with its member states and partners to determine what kind of coordination mechanism would work best to ensure fair access to vaccines and treatments. 

“We are currently mapping the availability of current supplies and planned production, the needs, support countries with information and advice so they are ready to use the vaccines, and a fair allocation approach based on need,” a WHO spokesperson said. 

However, regulatory, legal, operational, technical and other issues would first have to be clarified before a vaccine sharing program can be set up, the global health body says.

As in the COVID pandemic, it’s already clear that rich countries won’t wait for those processes to take unilateral action.

According to the pharma company Bavarian Nordic, the United States has recently ordered the equivalent of 13 million doses of its JYNNEOS^®smallpox vaccine, the only FDA-approved vaccine against monkeypox, in addition to 1.4 million doses already stockpiled.  Bavarian Nordic, has a production capacity of only about 40 million doses annually.

An antiviral agent known as tecovirimat that was developed for smallpox also was licensed by the European Medical Association (EMA) for monkeypox in 2022, based on data in animal and human studies. However, Tecovirimat is not yet widely available, according to an analysis by the global health analytics firm Airfinity.