There has been a concerning number of mpox cases in Africa due to a new mutation. The virus has a high fatality rate in Africa, and it is crucial that they receive access to resources to help manage and contain the outbreak to save lives in Africa and to prevent it from impacting more countries.
On August 14th, 2024, the World Health Organization (WHO) declared mpox, formerly known as monkeypox, a Public Health Emergency (PHE) of International Concern. This marks the second time in two years that mpox has led to a PHE, but this instance is due to a different version of mpox compared to the 2022 outbreak. This PHE declaration is critical to making sure Africa has access to resources, including vaccines, to help contain and control this outbreak. At this time the risk to people in other countries remains low.
What is mpox, and why has it been in the news so much these last few years?
Mpox is a virus with two distinct types, known as clade 1 and clade 2. Both clade 1 and clade 2 have been endemic to the Democratic Republic of Congo (DRC) for years but clade 1 is more severe, with a fatality rate of 3-10%. Clade 2 is less severe, with a fatality rate of about 1%.
In 2022, public health agencies noted a global increase in mpox cases due to clade 2, primarily affecting men who have sex with men, transgender, and non-binary individuals. While clade 2 cases continue to circulate globally, the PHE for this strain ended in 2023. People in these at-risk categories are still recommended to get two doses of mpox vaccine, 28 days apart, due to ongoing global circulation.
The current PHE is different. Africa has seen a dramatic increase in mpox cases due to a mutation within clade 1, called clade 1b. This surge led to the PHE being declared on August 14th, 2024.
What is the situation in Africa?
Africa is experiencing the highest number of clade 1 cases ever recorded, likely due to new mutations in clade 1b that make it more capable of spreading human-to-human. Africa has reported more than 15,600 cases and around 537 deaths. The DRC accounts for 96% of cases and 97% of deaths in Africa, but the outbreak has also spread to 13 African countries, including Burundi, Kenya, Rwanda, and Uganda, which have never previously reported mpox cases.
In the DRC, children under 15 account for 68% of cases and 75% of deaths. Most cases are impacting males.
This number of cases is 160% higher than in previous years. Due to the increasing numbers of cases, deaths, and spread, the WHO has declared a Public Health Emergency of International Concern. This PHE designation will help allocate resources, including vaccines, to these countries.
Is clade 1b in other countries yet?
On August 15th, 2024, Sweden reported the first case of mpox due to Clade 1b outside of Africa. The individual had traveled to a region in Africa where the outbreak is occurring. As of now, no other cases have been reported, but more cases may emerge as surveillance and awareness increase.
Because we are still seeing cases of clade 2 globally it will be important for countries to begin to report if cases are due to clade 2 or clade 1b.
How is mpox spreading, and what are the symptoms?
In this outbreak, most cases have been linked to sexual networks or direct contact with an infected human, animal, or their secretions. Some research suggests that mpox may be able to spread through respiratory droplets, but this does not appear to be a primary driver in this outbreak, and more research is needed on modes of transmission.
Symptoms of mpox vary from person to person. They usually begin 3-17 days after exposure, and the illness lasts 2-4 weeks. Early symptoms include fever, headache, muscle aches, backache, swollen lymph nodes, chills, and exhaustion. Respiratory symptoms can also occur, but not all patients experience these early symptoms.
Eventually, patients develop painful lesions. These lesions can be localized to one area of the body, such as the mouth or genital area, or they can be spread across multiple body areas. The lesions change appearance throughout the infection before eventually scabbing over and falling off. People are thought to be contagious from the time the first symptoms appear until the lesions scab over and fall off.
During the 2022 outbreak, there were very few deaths in the US, and all were in people with compromised immune systems. It is unclear if fatality rates for clade 1b would be as high in countries with better access to healthcare since medical care is limited in these African countries.
Are there treatments and prevention methods for mpox?
Mpox is closely related to the eradicated smallpox virus. Due to concerns about a potential resurgence of smallpox from bioterrorism, vaccines have been developed that are likely to also protect against both clade 1 and clade 2 mpox. Three vaccines are currently used in different parts of the world: ACAM2000, MVA-BN (also known as JYNNEOS), and LC-16.
Treatments also exist due to the similarity between mpox and smallpox. TPOXX has been stockpiled in case of a smallpox outbreak but was successfully used to treat those with mpox. Tpoxx continues to be widely available for those who are at increased risk of severe disease from mpox.
African countries have not had access to these vaccines or treatments. The PHE declaration will hopefully help change that.
Am I currently at risk?
At present, the risk of clade 1b outside the affected African countries is very low. This could change if cases increase globally, but for now, you are unlikely to be exposed. However, if cases do rise in your area, following infectious disease protocols such as masking, handwashing, avoiding sick individuals, and disinfecting surfaces can reduce your risk of mpox.
Can I get a mpox vaccine just in case?
Currently, in the USA, access to the mpox vaccine is limited to individuals who meet certain criteria outlined below:
- Men who have sex with men, transgender, gender non-binary, and gender-diverse individuals who also meet one of the following conditions:
- Have had one or more STIs
- Have had more than one sexual partner
- Have had anonymous sexual encounters or encounters at commercial sex venues
- Have had sex at large public events in areas with mpox transmission
You are also eligible if you have sex with anyone who may fit into the above criteria or were possibly exposed to someone with mpox.
If you meet this criteria, it is worth getting the mpox vaccine due to the continued global circulation of clade 2. In the USA, the most common vaccine used is JYNNEOS, which is a two-dose vaccine with the second dose given four weeks after the first.
What else should we do?
Clade 1 mpox has been endemic in the DRC for years, but they have not had access to vaccines or the public health infrastructure to help control it. Now that cases are increasing and other countries are concerned about the impact, there is more discussion about vaccine access in these areas. Global vaccine equity is something we all should be concerned about before increases like this make it more likely we will also be impacted. Pathogens do not respect geographic borders. Organizations such as GAVI, a global vaccine alliance, and the Coalition for Epidemic Preparedness, are working hard on this issue.
