monkeypox
Patient in a clinical trial of Tpoxx, an antiviral treatment for the mpox virus, in the Democratic Republic of Congo.

With the number of new mpox cases continuing to rise, and many more potentially undetected, African countries affected by the latest outbreak are racing to mobilize funds and urgently deploy medical countermeasures, including vaccines.

But as the current epidemic unfolds, there is an undeniable feeling of déjà vu. Global efforts are falling short of what is needed to mount an urgent, well-coordinated response to curtail the crisis.

The world learned several lessons from COVID-19. But barring some areas of incremental progress, these lessons have yet to be translated into concrete actions.

Below we look at the global response to the latest mpox outbreak to date, zooming in on three specific dimensions that pose the key challenges. These include:  the dynamics of the emergency declarations issued by WHO and African Centres for Disease Control and Prevention (Africa CDC); the incremental progress of surge financing; and the slow and fragmented start to procurement and delivery of medical countermeasures.

Emergency declaration – empowered regional decision-making, but continuing issues with WHO’s ‘binary’ approach 

African Union states reporting mpox cases as of 20 August 2024; Africa CDC has taken a leading role in outbreak response.

On August 13, the Africa Centers for Disease Control and Prevention (Africa CDC) officially declared the ongoing mpox outbreak a Public Health Emergency of Continental Security (PHECS). This was the first time a regional institution had made such a declaration, marking a significant milestone in the empowerment of African institutions to lead and coordinate responses to public health threats.

The World Health Organization’s (WHO) declaration of a public health emergency of international concern (PHEIC) followed the next day. The decision, meant as a signal to donors to step up resources to curtail an outbreak, was made earlier than in previous outbreaks. In comparison, during the 2022 mpox outbreak, the declaration came after approximately 16,000 cases were reported across 75 countries. In contrast, the 2024 declaration was made before the virus had spread beyond Africa, signaling a more proactive approach.

While the regional and global declarations were aligned in this case, questions remain about what happens if decisions do not sync up.

This underlines the ongoing need to improve the WHO “trigger” mechanism for a PHEIC.  It needs to shift from a binary approach [global declaration vs. no declaration at all] to a tiered system reflecting the severity of a pathogenic outbreak, along an ‘epidemic scale‘ like hurricane or earthquake scales, which can serve as a more nuanced trigger for different types of responses.

Surge financing: incremental progress but not yet fully operational  

Mpox vaccine needs versus donations and deliveries to date.

The need for adequate surge or at-risk financing is arguably one of the most salient lessons from COVID-19. G7 and G20 leaders have recognized its importance and several funds and initiatives, including various Development Finance Institutions and the Africa Epidemics Fund, have signaled support, yet there is still little, if no, money flowing.

Gavi’s $500 million First Response Fund that makes resources immediately available for outbreak response is an exception. The Fund was approved by its board in June 2024, so Gavi could theoretically start drawing on these resources. However, these funds can only be used for vaccines, not other medical countermeasures, and regulatory barriers are creating hurdles. The mechanism can only procure vaccines that have received WHO emergency use listing, even though two available mpox vaccines (MVA-BN and LC16m8) have already been approved by several well-resourced regulatory authorities.

In the short term, Gavi and other global health initiatives should revise procurement policies to recognize approvals from WHO-Listed Authorities—a new framework established by WHO to identify mature regulatory bodies operating at an advanced level of performance.

Surge financing should also be deployed to contract for manufacturing capacity. Specifically, Denmark’s Bavarian Nordic and Japan’s KM Biologics that produce the two mpox vaccines recommended by WHO could use third party facilities to ramp up production.

The current outbreak underscores the need for donors to continue to work towards a more coordinated and coherent surge financing facility covering a range of health products and uses (this could entail building upon existing mechanisms rather than creating new ones).

Vaccine procurement: slow and fragmented response so far

Mpox vaccine donations to date.

We already have safe, efficacious vaccines to prevent mpox. But at roughly $100 a shot for Bavarian Nordic’s two-dose regimen (MVA-BN), the vaccine that has been the most widely used in Europe and the Americas, mpox vaccines are expensive for Africa. The immediate priority should be getting as many of the 10 million vaccine doses needed, as estimated by the Africa CDC, procured and delivered to affected countries at the epicenter of the outbreak.

Donated doses can help fill immediate gaps. The DRC whose regulator recently granted emergency use for two vaccines now expects to receive some 315,000 donated MVA-BN doses from the European Union and the United States – with doses from the United States reportedly due to arrive early as next week. Additional announcements are trickling in – with a reported 3.5 million donation by Japan of its one-dose LC-16 vaccine, produced by KM Biologics and approved for use in children, as a significant step forward.

Now is the time for other countries holding mpox vaccine stockpiles to step up, and share supply with the most affected countries – so as to curtail further spread.

But dose donations will require extremely close coordination to manage the myriad legal, regulatory, logistical barriers involved. In leading this effort, Africa CDC should partner with Gavi, The Vaccine Alliance, drawing on its experiences coordinating COVID vaccine donations.

Last week, Bavarian Nordic indicated it has capacity to manufacture 10 million doses by the end of 2025, including up to 2 million doses by end 2024. Activating pooled procurement mechanisms, backed by financing from donors alongside African regional entities and countries, to coordinate purchasing should be a critical component of the global effort.

Bavarian Nordic has also reportedly entered into an agreement to transfer vaccine manufacturing technology to selected African manufacturers, according to Africa CDC Director Jean Kaseya, speaking at a press briefing just this week. While this would be an important move, announcements around diversifying manufacturing via technology transfer agreements will not produce the doses needed in time to curtail the current outbreak.

Delivery of countermeasures challenged by conflict, logistics and health systems issues

Mpox vaccine options and characteristics.

Delivery of medical countermeasures was another shortcoming of the COVID response. Specifics of the current outbreak pose particular challenges for delivery: transmission mechanisms and target populations differ from previous mpox outbreaks; there is ongoing conflict in the most affected areas, such as eastern DRC; and vaccines must either delivered in multiple doses [MVA-BN] or in the case of the the Japanese-made LC16 vaccine, using an intradermal method of administration that a lot of vaccinators are not familiar with.

Global health institutions, including Gavi, UNICEF, and WHO, also need to work closely with other partners, including humanitarian organizations and multilateral development banks, like the World Bank, to leverage their financing to support delivery and related response needs.

Major R&D needs

Scientist runs a test on the mpox virus as part of a Nigerian-United Kingdom research collaboration.

Finally, there are additional R&D needs. Usage of Bavarian Nordic’s MVA-BN vaccine is currently limited to adults, underscoring the urgency to broaden usage to children and adolescents, who are disproportionately affected by the current outbreak. In addition to vaccines, R&D is needed for rapid, point-of-care diagnostics and treatments.

While these immediate priorities should be top-of-mind, longer-term efforts can help down the line. Gavi’s new Vaccine Investment Strategy, approved by its board in June 2024, includes plans to set up a global stockpile.

World leaders must respond to the calls for strong coordination and immediate access to medical countermeasures. If not, the evaluations and after-action reviews of the international response to this latest mpox outbreak will read as the same story of inequitable access that characterized the COVID-19 pandemic.

Janeen Madan Keller is a Policy Fellow and Deputy Director of the Global Health Policy program, Center for Global Development.

Javier Guzman is a Senior Policy Fellow and Director of the Global Health Policy program, Center for Global Development.

Image Credits: CDC, Africa CDC , Center for Global Development , CGD , Center for Global Development, Center for Global Development .

Sudan cholera
A new cholera outbreak is threatening the millions of internally-displaced Sudanese. Over 600 cases have been reported in the past week.

United Nations officials are expressing concern that a new cholera outbreak in conflict-ridden Sudan, declared 10 days ago, could widen dramatically in the wake of increased rainfall and flooding. Some 658 cases of cholera have been reported since 12 August, with 28 deaths, the World Health Organization (WHO) revealed in its latest situation report, published Friday. 

The last outbreak of cholera in May saw more than 11,300 cases and at least 300 deaths.

Twelve of Sudan’s 18 states are struggling to simultaneously contain outbreaks of three or more diseases. The worsening humanitarian situation, fueled by 16 months of fighting between the Sudanese Armed Forces and the insurgent Rapid Support Forces (RSF), crippling humanitarian aid deliveries, have left embattled health workers coping with outbreaks of measles, malaria, and dengue, along with the deadly diarroheal disease.  

Now, with heavy rains deluging the country, cholera cases have “surged,” said UN High Commissioner for Refugees (UNHCR) Representative in Sudan Kristine Hambrouck at a press briefing in Geneva on Friday.

“Risks are compounded by the continuing conflict and dire humanitarian conditions, including overcrowding in camps and gathering sites for refugees and Sudanese displaced by the war, as well as limited medical supplies and health workers. This is in addition to overstretched health, water and sanitation and hygiene infrastructure – all of which have been heavily impacted by the war,” she said.

Since the start of the devastating civil war in April 2023, the violence between the RSF (RSF) and the Sudanese Armed Forces have displaced over 10.2 million people internally – and forced another 2.1 million people into neighboring countries – creating the largest refugee crises in the world along with widespread hunger as well as widening pockets of outright famine in the western Darfour region. 

With large scale displacement, violence, and attacks on humanitarian aid, Sudan’s health system has quickly deteriorated. The WHO reports that over two-thirds of the country’s healthcare centers are not operational, and the ones still functioning are “at risk of closure due to shortages of medical staff, supplies, safe water, and electricity.” Furthermore, targeted attacks on hospitals, like June’s siege on the western Sudanese city of El Fashir, and its only maternity hospital, have left only 2% of the population with adequate healthcare.

“A new wave” of cholera roars through eastern provinces after heavy rains

Cholera oral vaccine Sudan
Already WHO has used over 50,000 oral cholera vaccine doses, and hopes to vaccinate more children in the coming weeks.

Just a few months into the fighting, in June 2023, cholera broke out in a dozen Sudanese states. Since then, these states have reported more than 11,000 cases and 316 deaths. At the country level, cases peaked over the winter of 2023.  But the country’s eastern Red Sea state, at the epicenter of the outbreak, continued to see new cases. 

Just south of the capital state of Khartoum, the Sudan Federal Ministry of Health officially declared a new outbreak in Al Jazirah in the Kassala state earlier this month, raising concerns for outbreaks in an area where aid workers are repeatedly denied access. 

“Of particular concern is the spread of the disease in areas hosting refugees, mainly in Kassala, Gedaref and Jazirah states. In addition to hosting refugees from other countries, these states are also sheltering thousands of displaced Sudanese who have sought safety from ongoing hostilities,” said UNCHR in a statement.

In Kassala’s refugee camps, “people live on top of each other, they are hugely overcrowded,” said Hambrouck. “The water systems that were in place do not have the capacity to respond, it really needs massive investments.”

Yet the risk of cholera is not constrained to within Sudan’s borders. In the neighboring countries of Chad and South Sudan, UNCHR has reported an elevated risk of cholera outbreaks in refugee sites amid the onset of the rainy season. 

Sudan cholera and measles outbreak
Twelve of Sudan’s 18 states are experiencing multiple disease outbreaks, including cholera.

“We are also concerned for the health and protection of Sudanese refugees who fled the country,” said Hambrouk. “Our teams have reported an increase in malaria cases…amid alarming rates of malnutrition, and cases of measles, acute respiratory infections, acute watery diarrhea, and the risk of outbreaks of cholera.”

WHO scaling up cholera immunization campaign – but malaria and measles also threaten

Despite these challenges, an initial vaccination campaign  in Kassala state successfully protected more than 50,000 people from cholera, with hundreds of thousands more doses on the way. 

“The vaccination campaign already started and we used the 51,000 doses that were already in the country,” said Dr Shible Sahbani, WHO Representative in Sudan. Speaking from Port Sudan, he confirmed that the inoculation campaign concluded in Kassala state on Thursday. “We were aiming to reach the 97 per cent of the target population,” he said, adding that the UN health agency has also secured the approval to procure an additional 455,000 doses of cholera vaccine – “good news in the middle of this horrible crisis.”

Sudan WHO representative cholera
Dr Shible Sahbani, WHO Representative in Sudan speaking from Port Sudan, discusses a new cholera vaccination campaign.

Malaria continues to be a leading infectious cause of morbidity and mortality in Sudan. In the past decade, malaria cases increased by more than 40%, most likely due to frequent flooding, population movement, and the emergence of a new, and more invasive mosquito vector, anopheles stephensi. The WHO reports that between November 2023 and July 2024, over 1.67 million cases have been reported from 15 states. 

This comes just two years after the WHO congratulated Sudan on its steps in vector control – efforts that have now been derailed by the civil war. 

The WHO situation report also highlights a concerning numbers of measles cases – nearly 5,000 of a disease that is vaccine-preventable since late 2023. Low immunization rates and hard-to-access areas in places like Darfur and Kordofan states means that the risk of measles remains high, prompting the WHO and its partners to gear up for a large-scale campaign in the coming months.

Yet concerns over funding and humanitarian access may hamper the global health agency and its partners to implement a campaign at that scale. Of the $ 1.5 billion required by UNHCR and other partners for the Regional Refugee Response Plan (RRRP) to provide assistance in countries bordering Sudan, just 22% has been received. The inter-agency response inside Sudan is only 37% funded.

Even with funding, an “immediate ceasefire” and unimpeded and safe humanitarian access is needed to ensure aid can reach those who need it, said UNICEF spokesperson James Elder at the Geneva press briefing. Recent US-mediated peace talk efforts fell through after both warring parties failed to show up for talks last week in Geneva.

Image Credits: WHO, WHO, WHO, WHO.

A nurse prepares a trial participant for various tests as part of a trial of drug-resistant TB drugs.

The World Health Organization (WHO) this week recommended three new regimens for multidrug-resistant or rifampicin-resistant tuberculosis (MDR/RR-TB) tuberculosis (TB) that are far shorter than the current regimens and can be taken orally.

The new regimens can cure patients in six to nine months rather than the usual 18 months and dispense with the painful injections that people with DR TB have had to endure as part of their treatment.

Almost half a million people contract MDR-TB/RR-TB every year, and many die from it – in part because it is hard for them to adhere to treatment.

“The use of new and repurposed medicines like bedaquiline, pretomanid, linezolid, and delamanid and the shift away from older injectable-based regimens has led to incremental improvements in the treatment success rate for people with MDR/RR-TB,” according to the WHO.

“Globally in 2022, in MDR/RR-TB patients who started treatment in 2021, the treatment success rate was 63%, reflecting a steady improvement from 50% in 2012 .”

Bedaquiline and delamanid are the first new TB drugs in 50 years.

Tested on wide range of patients

The WHO recommendations are based on results from the BEAT-TB clinical trial conducted in South Africa and the endTB trial conducted in seven countries between 2017 and 2023 by Médecins Sans Frontières’ (MSF), Partners In Health (PIH) and Interactive Research and Development (IRD), and funded by Unitaid.

Trial participants included children, adolescents, pregnant and breastfeeding women. 

“Clinicians can now offer these advances to nearly all patients, thereby increasing chances of cure while reducing exposure to treatment toxicity and reducing the spread of drug-resistant forms of TB in the community”, says Professor Carole Mitnick, PID Director of Research for the endTB project, co-Principal Investigator of the study, and Professor of Global Health and Social Medicine at Harvard Medical School. 

“With treatment complexity, duration, and toxicity reduced – and options increased – prospects for eliminating the gap between need (approximately 500,000 patients/year) and percentage treated (no more than 35%/year) are vastly improved,” she added.

Drug cost barrier

“WHO’s recommendations are a major step forward for the health of millions of patients affected by this form of the disease, which is particularly difficult to treat,” said Dr Lorenzo Guglielmetti, MSF’s director of the endTB project and co-principal investigator of the clinical trial.

“MSF carried out the endTB clinical trial – along with another TB trial called TB PRACTECAL – because the pharmaceutical industry failed to do so. Both trials have found better treatments for people with TB and influenced WHO recommendations and guidelines,” said MSF in a media statement released on Thursday.

“After several decades of therapeutic status quo – and for the second time in two years, along with TB PRACTECAL – new treatments evaluated by independent actors, including NGOs, have been rapidly incorporated by WHO into its recommendations for combating the scourge of MDR-TB,” added Guglielmetti. 

“It’s important to remember that the pharmaceutical industry, despite significant public financing, has only brought new drugs to market. They have not informed the use of these drugs in regimens. It has been left to NGOs to conduct controlled trials to inform practical use of, and innovations with, novel products.”

However, the success of the new guidelines rests on a reduction in the price of delamanid, which MSF described as “excessively high”. 

Japanese pharmaceutical corporation Otsuka produces delamanid through an exclusive licence with Viatris.

“We call on Otsuka and Viatris to stop blocking price-lowering generics from entering the market and to immediately share delamanid with every company interested in making more affordable quality-assured generic versions of this lifesaving TB drug,” said Christophe Perrin, TB advocacy pharmacist at MSF’s Access Campaign. 

“Otsuka and Viatris must also urgently drop their prices for delamanid so that many more people with DR-TB can access this lifesaving drug as part of shorter, all-oral regimens.”

Image Credits: TB Alliance.

Access to the internet offers educational opportunities, but excessive social media use can harm children.

As evidence mounts of the health harms of excessive social media use on children, governments and academics are mulling how to regulate and contain these harms – notably anxiety, depression and low self-esteem.

US Surgeon General Dr Vivek Murthy recently appealed to his country’s Congress to compel social media sites to carry warning labels about the potential negative effects on the mental health of teens and children. This approach is akin to that used in many countries to warn of the harms of tobacco products and alcohol.

A study of over 6,500 US teens adjusted for baseline mental health status found that those who spent more than three hours a day on social media faced double the risk of experiencing poor mental health outcomes including symptoms of depression and anxiety.

Excessive time online also cuts children off from friends and family, makes them less likely to exercise and increases their exposure to online marketing of unhealthy goods such as alcohol, cigarettes and gambling – as well as sexual predators.

But there are also educational advantages to online access, which complicates regulation. In addition, many parts of the world are still grappling with how to extend internet access to their citizens.

Approximately one billion children and young people under the age of 26 have access to the internet at home – approximately one-third of this age group and skewed in favour of high-income countries and households, according to UNICEF.

UNICEF: Children and young people with access to the internet at home

Public health approach

A viewpoint published in last week’s Lancet appeals for “a public health approach” to protect children from digital harms. 

“To build healthy digital environments for children now and future generations, we recommend a precautionary approach to governance that prioritises children’s health and wellbeing, recognises their desire to enjoy the benefits of the digital world, and allows children to have a role in shaping their digital futures,” urge the authors, Louise Holly, Prof Sandro Demaio and Prof Ilona Kickbusch.

“New algorithmic features are emerging at a rapid pace to capture children’s attention and increase platform use. Legislation is failing to keep up with these developments and children remain unprotected,” they note.

The authors suggest three broad areas for intervention: delaying the age at which children  use digital media and devices; health warnings on device packaging, digital apps, and websites and health promotion campaigns to raise awareness of the benefits of delaying digital technology use among young children. 

To achieve these, they suggest six strategies.

The first involves using the built-in technical features of smartphones and apps limit users’ time. 

“Regulations could require such time-limiting features to be strengthened to protect children and could also be set as a default on all devices, games, and apps so the onus is on users to reduce, rather than set or increase time limits,” they suggest.

The second involves increasing the cost of products such as games, apps and smartphones by taxation.

The introduction of “device-free spaces similar to smoke-free spaces” is their third suggestion.

The fourth strategy involves “comprehensive digital education”. In addition, UNESCO recommends that schools limit the amount of learning done on individual devices.

Fifth, they recommend changing the “norms around children using smartphones”, referring to how the French town of Seine-Port has banned the use of smartphones in public places after this was agreed via a referendum. 

Finally, they recommend creating offline alternatives for children such as  green spaces and sports facilities. Here they refer to Iceland’s “whole-of-society approach that includes increasing opportunities for children to engage in organised leisure activities” to reduce drug use.

Impact on girls

The US Surgeon General has also published an advisory on the impact of social media on young people highlighting its pernicious influence on girls.

“Social media may also perpetuate body dissatisfaction, disordered eating behaviors, social comparison, and low self-esteem, especially among adolescent girls,” it notes.

“One-third or more of girls aged 11-15 say they feel ‘addicted’ to certain social media platforms and over half of teenagers report that it would be hard to give up social media. “When asked about the impact of social media on their body image, 46% of adolescents aged 13-17 said social media makes them feel worse,” according to the advisory. 

“Additionally, 64% of adolescents are ‘often’ or ‘sometimes’ exposed to hate-based content through social media. Studies have also shown a relationship between social media use and poor sleep quality, reduced sleep duration, sleep difficulties, and depression among youth.”

Image Credits: UNICEF.

Prof Jean-Jacques Muyembe (left) and Africa CDC director general Jean Kaseya (right)

The Africa Centres for Disease Control and Prevention (Africa CDC) is in talks with Bavarian Nordic, the only global producer of an mpox vaccine, about technology transfer to enable African manufacturers to make the vaccine on the continent.

“I want to recognise and thank Bavarian Nordic for accepting to do the tech transfer in Africa, for Africa to manufacture the vaccine,” Africa CDC Director General Dr Jean Kaseya told a media briefing on Tuesday.

Kaseya added that Africa CDC aimed to have 10 million doses available by the end of 2025, and Bavarian Nordic “tell me the doses we are talking about are not a dream”. 

However, he acknowledged that this was a longer-term solution to the mpox outbreak affecting 12 African countries.

More immediately, the continent expects donations from wealthier countries during what Kaseya dubbed as the “emergency humanitarian era”. He thanked the European Union (EU) for assistance in procuring 215,000 vaccines.

In the past week, there has been an increase of 1,405 cases on the continent bringing the official total to 18,910 although Kaseya cautioned that surveillance was not optimal in some countries.

The biggest increase was in the Democratic Republic of Congo (DRC), the epicentre of the outbreak, which now has 17,794 cases (an increase of 1,030). 

However, armed conflict in eastern DRC is hampering efforts to curb the outbreak, and Kaseya thanked Angola’s president for his efforts to broker peace between the DRC and Rwanda, which has supported the M23 rebels in the DRC.

Cases in Burundi jumped from 265 to 572, while the Central African Republic also recorded more cases (up from 206 to 263) as did Nigeria, (from 24 to 39).

No new cases were recorded in Cameroon, Congo, Kenya, Rwanda, Uganda, South Africa, Côte d’Ivoire or Liberia.

There have been 541 recorded deaths.

Single incident management team

For the first time, the Africa CDC, the World Health Organization and UNICEF have united to form a single African incident management team to address the outbreak, which was declared a public health emergency of international concern (PHEIC) last week.

Professor Jean-Jacques Muyembe, general director of the Democratic Republic of the Congo Institut National pour la Recherche Biomedicale (INRB), told the Africa CDC briefing that better communication about the causes of mpox was necessary to prevent its spread.

Children to be warned against touching dead animals or eating jungle meat, he advised Almost 70% of mpox cases in the DRC involve children under the age of 16.

In addition, communities had to be educated about human-to-human transmission via bodily fluid, using all the lessons from  Ebola, HIV and COVID-19 including condom use and good hygiene. Mpox clade 2 has been spread primarily via sexual contact between men.

Muyembe also reported on a recent trial of an antiviral medicine, tecovirimat, to treat mpox. The trial was “discouraging” as tecovirimat failed to reduce the duration of mpox lesions in children and adults with clade I mpox in the DRC, he reported.

A small study with an increased dose of tecovirimat was currently underway.

However there was a 1.7% mortality rate in the trial – significantly lower than the mpox mortality of 3.6% in the DRC.

This mortality rate applied to all subjects regardless of whether they received tecovirimat or a placebo, indicating that “hospitalization and high-quality supportive care” improved outcomes regardless of treatment, according to a report from the US National Institutes of Health, which sponsored the trial.

More domestic resources

Over the weekend, South African President Ramaphosa – the African Union (AU) Champion on Pandemic Prevention, Preparedness, and Response (PPPR) – called on member states to devote more domestic resources to mpox.

Ramaphosa also urged the international community “to mobilise stockpiles of vaccines and other medical countermeasures for deployment in Africa” via Africa CDC.

“This is also an opportunity to call on the international community to finalise a fair and equitable pandemic agreement—a duty that must be pursued with urgency and a spirit of equity,” added Ramaphosa.

Deforestation drives vector-borne diseases
Oropouche virus, which causes similar symptoms to dengue, is now spreading in countries beyond Brazil’s heavily forested Amazon region. Cases have increased ten-fold since last year, prompting the CDC and PAHO to issue warnings.

A little known, but potentially lethal virus is spreading throughout Latin America and the Caribbean, prompting the US Centers for Disease Control (CDC) and other health agencies to issue warnings for travelers and clinicians.

Oropouche virus, an arbovirus like dengue, Zika, and chikungunya, is spread through certain midge or mosquito bites. Oropouche symptoms are similar to these other arboviruses with fever, rashes, muscle aches, and headaches common. Symptoms typically last 5 to 7 days, but more recently, the virus has been linked to severe fetal outcomes, including congenital abnormalities and death. 

While the virus was first detected in 1955 in the Caribbean nation of Trinidad and Tobago, the Americas saw few cases each year – and those that were reported were mostly concentrated in the  Amazon or other rainforests.  

Oropouche-carrying midge
Biting midges along with certain mosquitoes, are the primary vector for the disease.

Now, however, Oropouche cases have jumped dramatically. The Pan-American Health Organization (PAHO) has reported 8,078 confirmed cases since January – almost a ten-fold increase since last year – with Brazil’s endemic Amazon regions contributing most to the case count. Other countries, like Cuba and Bolivia, are reporting cases for the very first time.

Despite ongoing research, much about Oropouche virus remains unknown, including the factors behind this year’s unusually severe outbreak, which prompted The Lancet to label it a “mysterious threat.” Historically, no Oropouche-attributed deaths have occurred since the virus was discovered, yet this year has already seen the deaths of two otherwise healthy Brazilian women. 

PAHO notes that “although the disease has historically been described as mild, the geographic spread in transmission and the detection of more severe cases underscore the need for increased surveillance and characterization of possible more severe manifestations.”

Vertical transmission reported, travel-associated cases

Graph of Oropouche cases 2024
Brazil accounts for the majority of Oropouche virus cases, yet several countries are now seeing first-time transmission.

 

Brazil was the first country to report instances of vertical transmission – when a disease passes from mother to fetus – earlier this summer. The latest epidemiological alert notes four cases of infant microcephaly, and four suspected fetal deaths. 

The CDC has thus urged pregnant women to reconsider nonessential travel to Cuba and if unavoidable to strictly follow the CDC’s prevention recommendations, which include using insect repellent, and window and door screens. These recommendations also work to prevent dengue, which has so far caused over 10 million cases in the Americas, including the US territory of Puerto Rico. 

The CDC’s alert comes as a response to several travel-associated cases in the US and Europe, mostly from individuals returning from Cuba and Brazil. No local transmission has been reported in the US or Europe.  

Climate change, deforestation, mutations, possible culprits

Oropouche mosquito monitoring
PAHO staff explain mosquito sampling methodology to better understand the distribution of disease-carrying species.

The CDC report came just a few days prior to World Mosquito Day, in which the World Health Organization has called for member states to intensify their awareness of the dangers posed by mosquito-borne diseases. 

Climate change, deforestation, and unplanned urbanization are facilitating Oropouche’s march through Latin America and the Caribbean, PAHO noted in its analysis. As in many cases, these trends help facilitate the leap of vector-borne diseases that were previously prevalent mostly in remote rural areas to cities.

“Oropouche virus has infected people living in regions far from forested areas, thus indicating that an urban cycle can exist as well,” wrote the Lancet editorial team. The authors also speculate that genetic mutations could help explain the rapid increase in cases. Yet the virus’s spread follows a pattern similar to dengue, zika, and chikungunya – the mosquito-borne diseases that have smashed records this year. 

Like many neglected tropical diseases, the actual number of Oropouche cases may be much higher, said PAHO in a recent statement. 

And with Oropouche presenting symptoms similar to other arboviruses, PAHO is urging member states to strengthen epidemiological surveillance and laboratory diagnosis, particularly to identify fatal and severe cases and possible cases of vertical transmission. The organization also urges countries to “expand prevention campaigns and strengthen entomological surveillance and vector control actions to reduce mosquito and gnat populations.”

Image Credits: Earth.org, PAHO , PAHO/WHO.

Registered nurses Fatmata Bamorie Turay (left) and Elizabeth Tumoe, at the Princess Christian Maternity Hospital, in Freetown, Sierra Leone. Some ealthy countries are actively recruiting nurses from LMICs.

The International Council of Nurses (ICN) has called on the World Health Organization (WHO) to consider a “time-limited moratorium of active recruitment of nurses” from countries on the WHO Health Workforce Support and Safeguard List.

This follows a “dramatic surge” in the recruitment of nurses from low- and middle-income countries (LMICs) by wealthy countries, according to the ICN.

The Safeguard List identifies 55 countries that face the most pressing health workforce challenges related to achieving universal health coverage (UHC). Health workers shortages are one of the primary causes of countries’ inability to achieve UHC.

The ICN made this proposal in a recent report to the World Health Organization (WHO) on the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel.

It attributed the “dramatic surge in international nurse migration and recruitment” in large part to “attempts by some high-income countries to address their vast nursing shortages by actively recruiting from LMICs and easing the entry or professional recognition of internationally educated nurses (IENs)”.

The proportion of overseas-trained nurses employed in the Organisation for Economic Co-operation and Development (OECD) – made up of 38 developed countries – jumped from 5% in 2011 to nearly 9% in 2021.

The UK, USA, Canada, Australia, Germany and certain Gulf states are driving this recruitment 

UK takes nurses from ‘red list’ countries

In the UK, for example,  over 24,000 new international nurses were registered from September 2021 to September 2022, the highest in recorded history.

Some 19% of new overseas nurses in the UK between 2021-2023 came from countries facing “severe health workforce deficits”, according to the WHO Health Workforce Support and Safeguard List.

Over six months in 2022,  over 20% of new international nurses (more than 2,200) came from just two “red list” countries: Nigeria and Ghana. 

“Although active recruitment from these countries to the National Health Service (NHS) is prohibited in the UK, nurses can be first hired by for-profit recruitment firms to work in the private sector and later apply directly to the NHS as passive recruits,” according to the ICN.

International recruiters are also directly advertising to recruit scarce health care staff from low- and lower-middle-income countries in Africa, Asia, and the Caribbean, in breach of the code. 

The US reported that over 17,000 nurses applied for visas in 2022, a 44% increase from the previous year.

“Countries that have not been traditionally active in international nurse recruitment are also showing increased demand for overseas-trained nurses, including Finland as well as Scotland, where the government announced an allocation of £4.5 million to support active international recruitment of nurses as part of the overall plan for pandemic recovery and renewal,” notes the ICN.

Low-income countries face huge nurse shortages

Tonga and Fiji reported losing 20% to 30% of their nurses, primarily to Australia and New Zealand, at the 2024 World Health Assembly (WHA).

In Fiji, 800 nurses in resigned in 2022, over a fifth of the nursing population. At present, the country has 2,003 remaining nurses and around 1,650 nursing vacancies. Many hospitals have less than 40% of their established Registered Nurse positions 

Nursing representatives from Jamaica also reported at the WHA that around 20% of the country’s nurses have applied for certificates of current professional status, indicating that they are preparing to work abroad.

Over 1,700 registered nurses in Zimbabwe resigned in 2021, and some 900 left the country in 2022, with many moving to the UK. 

The Ghana Registered Nurses and Midwives Association recently reported that around 500 nurses are leaving that country every month, particularly experienced, specialist nurses.

The Philippines has a current shortage of 190,000 healthcare workers and is expected to face a shortage of 250,000 nurses by 2030 

Nurses’ right to migrate

“The ICN recognises and supports the right of individual nurses to migrate and pursue professional achievement through career mobility and to better the circumstances in which they live and work,” according to the report.

However, it is “gravely concerned” about the “large-scale nurse migration from the world’s most vulnerable countries, in large part driven by active nurse recruitment by a small number of high-income countries, including the United Kingdom, United States, Canada, Australia, and Germany, as well as certain Gulf States”. 

It “condemns the targeted recruitment of nurses from countries or areas within countries that are experiencing a chronic shortage of nurses and/or a temporary health crisis in which nurses are needed”.

“These trends are depleting already fragile health systems, preventing LMICs from rebuilding and responding to health challenges post-pandemic, and widening the significant gap in healthcare access and quality between high-income and low-income countries. 

“This situation jeopardises the global achievement of the UN Sustainable Development Goals, including universal health coverage, by 2030.”

Mitigating migration

Some wealthier countries are increasingly their own nurse training. In the UK, for example, the NHS Long Term Workforce Plan aims to educate over 60,000 nurses in England by 2029, a 54% increase from 2022/23.

Australia is developing its National Nursing Workforce Strategy to improve sustainability and self-sufficiency, while Germany’s 2024 Nursing Studies Strengthening Act aims to attract nursing students with monthly salaries to ease the workforce shortage.

The Filipino Department of Health has recently allocated funds to provide nurses with health insurance, housing, and other benefits in an attempt to stem the tide of nurse migration.

However, several LMICs are experiencing nursing shortages and are unable to provide employment or other measures to retain their nurses due to insufficient funding and other structural factors,

In Lesotho, in southern Africa, for example, almost a third of professional nurses and midwives are unemployed because of a lack of funding.

“LMICs require support to develop and strengthen their health and care workforce and systems so that they can meet their population’s needs,” the ICN stresses.

Aside from unemployment, nurses in LMICs often face poor working conditions, low compensation and safety issues.

“We have seen increased evidence of labour unrest and/or strike action in developing and lower-income countries in the past three years, including Uganda, Ghana, Fiji, and Tonga. 

“This must be recognized as symptomatic of the underlying issues feeding nurse migration and clearly demonstrates the need for efforts to strengthen LMIC health systems rather than deplete them by draining their workforce.”

Image Credits: World Bank/Flickr.

Indian doctors on strike nationally in protest against the rape and murder of a colleague while on duty.

Indian doctors held a 24-hour national strike over the weekend to protest the rape and murder of a young female doctor in a hospital in Kolkata, demanding better protection for health workers.

Around one million health workers were estimated to have supported the strike. Some junior doctors remain on strike, saying that they will not return to work until the authorities meet their safety demands.

The bloodied body of 31-year-old Dr Moumita Debnath was found in a seminar room in RG Kar Medical College and Hospital on 9 August. 

An inquest report confirmed sexual assault, and her family wrote in a court petition that they believed she had been gang raped. She had been on duty at the time of her murder.

Following protests by junior doctors and medical residents after the discovery of Debnath’s body, the Indian Medical Association (IMA) called for a 24-hour “nationwide withdrawal of services” and the suspension of all non-essential procedures over the weekend.

“We ask for the understanding and support of the nation in this struggle for justice for its doctors and daughters,” said IMA president  RV Asokan said in a statement ahead of the strike.

In a letter to India’s Prime Minister, Narendra Modi, the IMA called for a Central Act outlawing violence and damage to property at health facilities and for the security at health facilities to be as tight as airports.

“The 36-hour duty shift that the victim was in and the lack of safe spaces to rest… warrant a thorough overhaul of the working and living conditions of the resident doctors,” added the IMA in the letter.

According to the IMA, 60% of doctors and 85% of nurses in the country are female. An IMA study found that 75% of doctors have faced abuse, usually verbal, while at work, according to The Times of India.

the weekend protests took the form of marches, demonstrations and a 3km human chain of health workers in Kolkata, near the site of the attack. 

Despite its impact on patients, the action has had substantial public support. Supporters of the two biggest soccer clubs in West Bengal, the state where the attack took place, united in a march on Sunday evening to demand justice for Debnath and protection for doctors.

This Thursday, women in the state of West Bengal have called a “Reclaim the Night” march beginning at midnight, according to The Hindustan Times. The protest will coincide with the official start of India’s Independence Day.

The proliferation of untreated sewage and waste in wartime Gaza has led to the re-emergence of poliovirus.

The World Health Organization and UNICEF have appealed for ‘humanitarian pauses’ in the grinding Israel-Hamas war in the Gaza Strip in August and September to facilitate a massive polio booster campaign – as three suspected polio cases were being investigated by a Jordanian laboratory.

The appeal came as the entire region see-saws between the possibility of a regional war between Iran, the Lebanese Hizbullah and Israel, and an Israeli-Hamas ceasefire in Gaza. 

Israeli and Hamas negotiators are meeting in Doha today in a last ditch effort mediated by the United States, Egypt and Qatar, to find acceptable terms for a ceasefire that could help avert a wider war and lead to the release of some or all of the 116 Israeli hostages now held by the Islamic Hamas for over 10 months. 

But irregardless of that outcome, humanitarian pauses of at least seven days are needed to enable the mass administration of oral polio vaccine boosters to some 640,000 Gaza children, WHO and UNICEF said, in a joint statement on Friday. 

“WHO and UNICEF request all parties to the conflict to implement humanitarian pauses in the Gaza Strip for seven days to allow for two rounds of vaccination campaigns to take place. These pauses in fighting would allow children and families to safely reach health facilities and community outreach workers to get to children who cannot access health facilities for polio vaccination. Without the humanitarian pauses, the delivery of the campaign will not be possible.” 

Three children suspected of polio paralysis

Vaccine-derived poliovirus, which can spread through faeces and infect under-immunized children thus exposed, was detected in July 2024 in sewage samples in Khan Younis, in southern Gaza, as well as in Deir al-Balah, further north. More worrisome, three children presenting polio-related symptoms of suspected acute flaccid paralysis (AFP), were recently reported in the Gaza Strip, WHO revealed:

“Their stool samples have been sent for testing to the Jordan National Polio Laboratory.”

Over 1.6 million doses of the novel oral polio vaccine, nOPV2, which is used to stop vaccine derived poliovirus transmission (cVDPV2) in under-immunized populations, is due to be delivered to the Gaza Strip via Israel’s Ben Gurion Airport, WHO further revealed. 

Vaccine deliveries via Israel’s international airport

“The deliveries of the vaccines and the cold chain equipment are expected to transit through Ben Gurion Airport before arriving in the Gaza Strip by the end of August,” WHO and UNICEF stated, stressing that, “it is essential that the transport of the vaccines and cold chain is facilitated at every step of the journey to ensure their timely reception, clearance and ultimately delivery in time for the campaign.” 

“At least 95% vaccination coverage during each round of the campaign is needed to prevent the spread of polio and reduce the risk of its re-emergence, given the severely disrupted health, water and sanitation systems in the Gaza Strip,” the joint statement further said. 

“Other requirements for successful campaign delivery include sufficient cash, fuel and functional telecommunication networks to reach communities with information about the campaign,” it added. Currently, Israel and Hamas forces continue to battle across various parts of the 365 square kilometer enclave on the Mediterranean sea sandwiched between the Egyptian border and pre-1967 Israel.     

Polio is a sign of broader infectious disease crisis

The Gaza Strip has been polio-free for the last 25 years, WHO noted, with vaccine rates of 95% or more.  Israel withdrew from the enclave in 2005; two years later, Hamas seized power from the Palestinian Authority, which was violently ejected from Gaza. Israel re-occupied Gaza shortly after the Hamas invasion of Israeli communities along the enclave perimeter on the early morning of 7 October 2023, which led to the deaths of some 1200 men, women and children – as well as the capture of another 240 Israelis and foreign residents. 

Israel has been waging a bitter battle against the Islamic group ever since, cutting off access to Gaza from Egypt, but it has not succeeded in crushing the organization entirely.  Some 40,000 Gazans have since died during the fighting, while tens of thousands more people are wounded.  Amidst a sanitation catastrophe including the destruction of drinking water and waste management facilities, infectious diseases have run rampant in the enclave – exacerbated by heat, hunger and malnutrition. 

Polio’s re-emergence, “which the humanitarian community has warned about for the last ten months, represents yet another threat to the children in the Gaza Strip and neighbouring countries.  A ceasefire is the only way to ensure public health security in the Gaza Strip and the region,” said WHO and UNICEF.   

Image Credits: @WHOoPT.

Vials of the Bavarian Nordic mpox vaccine are now in ample supply, officials say. But deployment is another story.

Bavarian Nordic has no plans to sell or manufacture its vaccines directly to African countries, the company’s Vice President of Investor Relations told Health Policy Watch, saying that donations from rich countries will likely be the main source of supplies.  

WHO’s announcement of a global mpox health emergency may have sent a wake-up call to the world regarding the ‘perfect storm’ of mpox virus transmission brewing in the Democratic Republic of Congo (DRC) and a dozen other neighboring countries in central and southern Africa. 

And contrary to the situation in 2022-23 there is now ample production capacity to supply Africa with some two  million mpox doses by the end of this year, and another eight million doses by end 2025, Bavarian Nordic’s CEO Paul Chaplin, told Bloomberg News on Wednesday.   “What we are missing are the orders,” Chaplin said. 

Even so, the high costs of the vaccine, estimated at $100 a dose, as well as the huge challenges of deploying jabs in conflict-ridden DRC, the country at the epicenter of the crisis, create formidable challenges to actually matching supply with need – and getting jabs into arms, observers say. 

‘Vaccines to Africa will come from donations’  

Vaccines
A United States delivery of 655,200 COVID-19 vaccines to Ethiopia in 2021. Donations to Africa were too little, too late.

While Africa CDC officials talked about their aims to deploy millions of mpox vaccine doses, to counter the continental health emergency, declared on Tuesday, near-term procurement is likely to be far more limited, if it relies on third party donations – as was the case with COVID vaccines. 

And that seems to be the scenario unfolding so far.

Shortly after the WHO global health emergency was announced Wednesday, the United States offered to donate 50,000 doses of the BVN vaccine from its stockpiles, while the European Union announced a donation of  175,000 doses, to be combined with a pledge of 40,000 by Bavarian Nordic itself.   

“We have capacity ready to help. We have donated doses that Gavi [the Global Vaccine Alliance] has not yet used,” said another top Bavarian Nordic official, Rolf Sass Sørensen, in an email to Health Policy Watch.

But he dismissed a query as to whether the pharma firm might consider selling vaccines directly to the African nations at concessionary prices:

“It’s very unlikely that any African country will ever be responsible for buying vaccines,” said Sørensen, who is vice president of investor relations. “Vaccines to Africa will come from donations from organizations and countries. Pricing structure is always related to contract volumes and long term commitments,” he added.

Sørensen also ruled local African production of the Bavarian Nordic vaccine as technologically unfeasible. 

“We talk to producers around the world. We are not aware of any producers that can produce with our technology. So your scenario doesn’t seem realistic at all,” he said.

Ten times more vaccines are needed 

Mpox lesions – transmission can be through family and household contacts when lesions appear all over the body.

Donation offers made so far remain woefully inadequate to meet the needs, said Professor Piero Olliaro, a researcher at Oxford who studies mpox in the Central African Republic (CAR) as well as Europe.  

“It is disturbing that people will feel satisfied and portrayed as if they have provided a solutions, if they donated 100,000 doses,” he said. “You need enough doses so you can be guided by the needs and not the availability.” 

But with vaccine costs at around $100 per dose for the two jab series, deploying a more meaningful quantity – on the order of one or two million doses to at-risk people and communities in the 13 African countries where the outbreak is now spreading, would cost $100- $200 million to donors.

“Its taxpayers who will foot the bill,” Olliaro said, noting that the dilemma points, once more, to the need to shift more manufacturing to Africa.

DRC’s perfect storm of disease conditions 

DRC residents of eastern Congo have suffered years of displacement by violent militia groups – exacerbating hunger, poverty and disease.

Long before any vaccine deployment, WHO and its partners first need to come up with a strategy for mounting an effective immunization campaign – and engage political leadership in the Democratic Republic of Congo and its neighbours.   

The challenges to deployment are formidable – due both to the lack of knowledge about transmission as the conflict setting of the DRC, which is the epicenter for the most deadly variants that are circulating, Clades 1a and Clades 1b.  

“Vaccine is one thing,” said Olliaro.   “But it is not the ultimate answer. We know how difficult it is to vaccinate people and get acceptance to more vaccines, particularly in countries like the DRC that have been exposed to Ebola. 

“To deliver vaccines, you need to know who you are going to vaccinate. That should be made based on what you know about transmission and not upon how many doses are available,” he said. 

Clades 1a and Clades 1b now pose the real threat

Whereas the 2022-2023 global mpox emergency involved a milder form of mpox, transmitted mainly among men who have sex with men, the two variants circulating most widely in central Africa now include the more deadly Clade 1a and a novel Clade 1b, with a combined case fatality rate around 3%, according to the latest data from the Africa Centers for Disease Control.

Left untreated at the source, the potential for worldwide spread is growing, as the first Clade 1 case was reported outside of Africa, by Sweden’s public health agency, the BBC reported on Thursday.

Mpox in Africa – 2024

“Mpox is almost the archetype of these complex outbreaks that have not been dealt with properly and have the potential for spreading, creating more problems locally and nationally. But they are complex because of the context in which they occur. We need a much more systematic approach.” 

The eastern DRC Kivu region where the Clade 1b variant of the virus has emerged and is now spreading through community as well as heterosexual contact, has been wracked by a violent conflict with the M-23 militia forces – operating from and along the Rwanda border. 

This has led to the forced migration of tens of thousands of people within the region and across borders, exacerbating virus transmission due to malnutrition, unprotected sex and immune deficiencies from other untreated conditions like HIV/AIDS, Olliaro said.

Along with that, illegal mining operations deep in the Congo’s rainforest, add to the misery and exploitation of local communities, engaging women and child labourers in conditions where they are chronically exposed to heavy metal contamination.   

In that perfect storm of social conditions that exists in the DRC, as well as neighbouring countries such as CAR, malnutrition and immunodeficiencies from other untreated conditions like HIV – make people even more vulnerable to the virus.

“Any outbreak happening in that area has the potential for being very difficult to control,” said Olliaro. 

More deadly Clade 1a variant seeing longer transmission chains

Geographic distribution of reported mpox cases, the Democratic Republic of the Congo, 1 January to 26 May 2024 (7,851 cases). Since then infections rates have accelerated even more.

Meanwhile, the Equateur region of western DRC is  seeing longer transmission chains of the traditional and even more deadly, Clade 1a variant, which can be transmitted by close household contact, contact with infected items like linens, as well as sexual contact. 

Researchers are perplexed as to why Clade 1a transmission, which typically occurred from close contact with infected animals or bush meat but burned out rather quickly, now seems to be more persistent. 

“The classical Clade 1a that has been causing a big wave in the northwestern parts of DRC, Equateur province, is showing high morbidity and mortality in parts of that province well above 10%,” said Olliaro. 

“But the chains of transmission also seem to be much longer, the spread, and how far it can travel. This is also where you see more kids being infected. 

“As for how the infection is transmitted.  We don’t know enough about this. And that’s another foundation of a vaccine campaign,” he said, of the rapidly spreading variants of the orthopoxvirus, which belongs to the same family as smallpox.

Image Credits: CEPI , US State Department, Tessa Davis/Twitter , UNHCR, Africa CDC , WHO .