Less than a drop in the ocean: why donations will do little to control mpox I Medicines for Africa

What does it take to stop a disease outbreak of international concern like mpox? It takes sustained coordinated effort to implement public health measures alongside vaccination to bring the outbreak under control.

What does it take to stop a disease outbreak of international concern like mpox? It takes sustained coordinated effort to implement public health measures alongside vaccination to bring outbreaks of this nature under control. The WHO declared the ongoing mpox outbreak in Africa a “public health emergency of international concern.” The DRC accounts for the bulk of reported figures. According to WHO estimates, this year alone, the number of mpox cases in some parts of the Africa region have cumulatively increased by more than 160% compared to 2023. Children are disproportionately affected with nearly 70% of the cases and 85% of deaths occurring among children under 15. The arrival of the 100,000 vaccine doses in the DRC capital, Kinshasa, marks the second time a country in Africa has received mpox vaccines. Nigeria received 10’000 doses from the US government last week.

It therefore an important development that the DRC being the epicentre of this outbreak also just received a donation of 100,000 doses of mpox vaccines from the European Union (EU), enough to vaccinate 50’000 people. US government donation of 10’000 doses to Nigeria donation was enough to also vaccinate 5’000 people. These donations are a generous gift that highlight efforts by the US and the EU to provide a critical lifeline for affected communities. They will protect a lucky few. The vaccination program, is set to roll out in October. It will initially focus on vaccinating contacts of suspected cases and healthcare workers in the worst-affected areas. Training for healthcare personnel and vulnerable groups with public awareness campaigns forming a crucial part of the effort. African countries have decades of experience running effective vaccination campaigns. They have experience with the appropriate storage and administration of vaccines during campaigns.

However, can quantities this small protect enough people to have significant impact on limiting mpox spread when it is already occurring at an alarming rate? Trying to bring a serious disease outbreak like mpox with the occasional donation of token quantities of vaccine enough to vaccinate a few thousand people between intervals of weeks and months just isn’t going to get the job done. We know this from the Covid-19 experience. For many months, the country at the epicentre of the outbreak has not received a single dose of vaccine. Even Nigeria, a country affected to a lesser extent received vaccine before the DRC. In both cases however, the donated vaccines are too little compared to the 10’ million that the Africa CDC estimates is needed.

Much has been said about the significance of this moment. The fact that a second donation of 100’000 doses of vaccines has occurred. We need to be clear about what this moment is and is not. Amongst other things, this moment is a sad indictment of the state of an international cooperation which touts global solidarity as the best tool against health security threats of this nature. What use is having a system that in moments of peril from disease outbreaks, all the infection and prevention control tools that are needed to effectively stop the spread of a deadly disease are always concentrated in countries where the disease is not whilst those that have it go without? And so this moment is not a significant step in addressing the mpox outbreak. After all, this outbreak has been going on for quite some time. After months of nothing, two donations of token quantities of vaccine that are more a face-saving gesture than a moment of genuine impact are being celebrated as a significant milestone in outbreak control is not a credible mark of progress. Vaccines took much too long to come. And when they have come, the quantities are too insignificant to make real impact.

It would not be hyperbole to say that this moment is a case of too little too late. Regional organisations like the Africa Centre for Disease Control (CDC) whose mandate it is to prepare for moments like this appear to have been caught unprepared by an outbreak that has been unfolding over months before escalating into a an international crisis. International agencies like the WHO have been criticised for waiting until August to initiate the process that would make vaccines available to African countries. People in affected communities have been let down by everyone - their government, reginal organisations like the Africa CDC, international organisations like the WHO and UNICEF and everyone else who preaches global solidarity as an answer to global health security threats.

Bavarian Nordic, the company making the only vaccine available has announced that it would not sell its vaccine directly to African nations. It appears that it has not been selling vaccines directly to African countries for some time. According to reports, the DRC requested to vaccines to buy two years ago from Bavarian turned it down even though stock was available at the time. It is not clear why. Recently the company has announced a contract to manufacture almost half a million doses for an undisclosed European country and will produce $156.8 million worth of vaccines for the US government which will be manufactured and invoiced in 2024.What is clear is that if an African country wanted to buy mpox vaccines today they would not be able to. Besides, Bavarian has put vaccines further out of reach of African nations by setting a unit price of USD100-$141 per dose, a significant barrier to access for a region facing multiple crisis of cholera, measles, malaria and HIV. Whatever the justification, choosing not to sell vaccines to affected countries disregards the death and suffering that Bavarian’s vaccine could help alleviate.

Why not at least leave the possibility of countries buying vaccine open should they chose to? It is well understood that this is a commercial enterprise and businesses are in the business of making money. It costs money to produce vaccines or any other infection prevention control tool and therefore it would be unreasonable to expect such products to be given away for free. Nevertheless, human lives are at stake. At a minimum, the company should be open to negotiating commercial deals with affected countries or the Africa CDC to find mutually acceptable ways of making vaccine available to affected communities. The company has indicated economies of scale are important. The Africa CDC can provide that. In a moment of crisis like this one, the company should set a price that is reasonable to make it possible for African countries to buy a life-saving vaccine.

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It is an unreasonable stance for the company to say that vaccines will only be available to African countries though donors. The problem with the donations made so far is just how few they are – only two and how small they are 110’000 doses. It is questionable whether such quantities can have a meaningful impact on outbreak control. Vaccination is a powerful tool for limiting the spread of infectious diseases. But only when it is done at a scale sufficient enough to achieve herd immunity and stop community transmission. Whilst the WHO is currently not recommending mass vaccination, targeted vaccination of the most vulnerable populations remains a necessity. While doses donated so far represent progress of sorts, they remain a tiny fraction of what is needed. Africa CDC estimates that at least 10 million doses will be required to bring the outbreak under control. Western partners, including the EU and the U.S. have pledged a total of up to a million doses of which 110’000 doses has been received by Nigeria and the DRC. This slow trickle of vaccines through third parties like donors is both unhelpful and counterproductive. The resulting delays create opportunity for the virus to mutate and possibly become more virulent and more transmissible. Experts argue that Bavarian Nordic should lower the price or allow generic manufacturing to increase vaccine availability. They are right. ?

Suffices to say that the escalating outbreak in the DRC and other parts of Africa is not just a regional issue. It also has global implications. The potential for mpox to spread globally remains a serious concern. The African continent has porous borders with frequent movement of people, good and services which creates ideal conditions for viral spread beyond the continent. A truck driver who had traveled through several countries was recently diagnosed with mpox by Kenyan authorities. This highlights the ease with which the virus can cross international borders. In 2022, an mpox outbreak spread from Europe to other parts of the world. That outbreak in Europe was brought under control through mass vaccination coupled to public health measures like heightened surveillance and contact tracing. Public health measures alone are insufficient to bring the current outbreak in Africa under control. Vaccination is needed. Making vaccines available in meaningful quantities to affected African countries is not optional. It is essential to containing the mpox outbreak under control. Containing the mpox outbreak in Africa also requires coordinated international action. Vaccine donations at the scale so far witnessed are nowhere near enough. It’s a drop in the ocean.

What will stop this outbreak are sustained efforts to provide sufficient infection prevention and control tools including vaccines, treatments, and diagnostics. That means African governments must step up to commit more than $600 million in funding that the Africa CDC has called for over the next six months. The Africa CDC has indicated that it has 10% of the $245 million in funding that it needs to execute its outbreak control strategy, according to the Africa CDC’s chief of staff, Ngashi Ngongo. What is currently available is $20 million – $10 million from the DRC government and $10.4 million from the AU. The three million doses that the Africa CDC says could be available by the end of the year will cost more than the funding currently available. Without adequate support by governments and international partners, mpox will continue to devastate African nations, particularly children. Vaccination, public health campaigns, and enhanced surveillance will continue to be the primary components of the African response. But only global commitment to fair access to resources will bring this outbreak under control, both for Africa’s sake and for the sake of the world

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