Another Pandemic Looms. Guess What? We’re Still Not Ready

Lawrence Gostin, S Halabi, A Finch

Just one day after the World Health Organization declared the deadly mpox outbreak in Africa a global health emergency, Sweden reported its first case of a dangerous strain of the disease (and there may be more cases). The threat of a pandemic of mpox is here yet again. To curb this crisis, the affected countries in Africa need tests, vaccines and people to respond. Now.

Cases of mpox (formerly known as monkeypox), a viral illness spread primarily through close physical contact, are up 160 percent in Africa compared to the first seven months of 2023. So far this year, over 15,600 cases have been reported and 537 people have died, a majority of them children.

The bulk of the spread, which is fueled by a subtype of mpox believed to cause more severe illness and death, is happening in the Democratic Republic of Congo and a dozen other African countries. This includes countries that hadn’t reported mpox cases previously, such as Burundi, Kenya, Rwanda and Uganda. The Africa Centers for Disease Control and Prevention says the reported cases are most likely just the “tip of the iceberg.” Thousands of cases may remain undetected because of cavernous gaps in surveillance, testing and contact tracing.

Sweden’s case is the first of this kind of mpox outside Africa. The person had traveled to an area affected by the disease. While the European Center for Disease Prevention and Control says that the risk of severe disease among the general public remains low, it’s highly likely there could be more imported cases.

We shouldn’t discount the pandemic potential of mpox. If mpox cases were to seed in Europe, there could be rapid and sustained spread. Routine smallpox vaccinations were discontinued after the W.H.O. declared the disease eradicated in 1980. (The United States stopped routine vaccinations in 1972.) This means the world’s population, including in the United States, is relatively naïve to orthopoxviruses — the group of viruses that include mpox and smallpox. Given how effectively mpox can spread through sex and other kinds of close contact, for instance, in homes and hospitals where there’s insufficient protective gear, mpox could become a major threat.

This is the second time the W.H.O. has declared mpox a public health emergency of international concern. The last time was in 2022, when there was an outbreak of a different type of mpox centered on Europe and the United States, especially among men who have sex with men. It affected nearly 100,000 people and was largely quelled thanks to vaccines and behavior changes.

This dangerous subtype of mpox in countries that haven’t dealt with it before is cause for grave alarm. That is not only because of the risk to people’s health, but also because of what could happen to the world’s limited supply of vaccines.

A case in Sweden means there could be a temptation for rich countries to start hoarding mpox vaccine stocks for their own populations. This must be avoided at all costs. Africa C.D.C. has estimated that it needs 10 million doses to stop the current outbreak. But as was the case with the Covid vaccines, mpox vaccines are in the hands of the world’s richest countries and companies. Denmark’s Bavarian Nordic is one of a few companies in the world with an approved mpox vaccine. An agreement between Africa C.D.C., the European Union and Bavarian Nordic has already been reached for the procurement and rapid distribution of about 200,000 doses, but many more are needed. The United States has said it will donate 50,000 doses to Congo from its stockpile. But this still leaves Africa nowhere near the 10 million doses needed.

Bavarian Nordic says that by the end of this year it could manufacture two million more doses, and then eight million doses next year, if purchase orders are made. But there is no clear commitment to make these doses affordable for African countries.

After the deeply inequitable global response to Covid-19, in June the W.H.O. adopted fundamental revisions to its International Health Regulations (which define countries’ legal obligations to prevent and control the international spread of disease). It also extended the deadline to complete a new comprehensive Pandemic Agreement until next May at the latest. These international legal measures are supposed to deliver the kind of emergency response the world failed to provide for Covid-19 — equity between rich and poor states and populations, rapid deployment of vaccines and true cooperation among countries facing a common threat.

Organizations of wealthy countries including the Group of 7 and the Organization for Economic Cooperation and Development should immediately convene with international development partners such as the World Bank, the Inter-American Development Bank and the Asian Development Bank to support financing for vaccines, as well as tests and laboratory support. Groups including Gavi, the global vaccine alliance, and UNICEF should draw on available financing mechanisms to procure and distribute vaccines to affected areas and provide operational help. Data about the outbreak must also be shared instantly.

The threat of mpox needs to be communicated to communities without stigmatization. This includes clear messages about protecting against transmission within people’s homes, delivered by trusted community members as messengers. Criminalization of same-sex sexual activity in some African countries could make access to vaccination or treatment more difficult.

Urgent, coordinated action is needed now  especially the equitable sharing of vaccines. Covid-19 and too many health emergencies before that have taught us that complacency and delayed action pose a threat to all of us.

The authors are experts at the O’Neill Institute for National and Global Health Law at Georgetown University