The World Health Organization on August 14 declared that the upsurge of mpox in the Democratic Republic of the Congo and nearby countries is a public health emergency of international concern. Advocates say the burgeoning outbreak is worsened by neglect from wealthy countries and inequitable access to mpox vaccines.
This is the second time the global health organization has declared an mpox emergency. It also did so in 2022 during a global outbreak that included cases in the U.S. and elsewhere. While cases outside of Africa still occur, though at a much lower level, the number of infections, particularly in the DRC, led the WHO to make its second declaration.
The current outbreaks in the DRC involve Clade I mpox, a strain of the virus that has historically had a higher mortality rate than Clade II, which was responsible for the global outbreak in 2022. Clade I has not yet been detected in the United States — so far, Sweden is the only country outside Africa to report a confirmed case — but health officials are concerned about international spread.
"The detection and rapid spread of a new clade of mpox in eastern DRC, its detection in neighboring countries that had not previously reported mpox, and the potential for further spread within Africa and beyond is very worrying," WHO Director-General Dr. Tedros Adhanom Ghebreyesus said at a news briefing. "It's clear that a coordinated international response is essential to stop these outbreaks and save lives."
Meanwhile, Clade II mpox continues to circulate at a low level in the U.S., primarily among men who have sex with men. As of early March, the Centers for Disease Control and Prevention had tallied more than 32,000 total cases, resulting in 58 deaths. In San Francisco, 21 cases have been reported so far this year, according to the SF Department of Public Health.
"At this time, mpox cases in San Francisco remain very low. The current seven-day average for mpox cases is currently zero. At this time, mpox detections in San Francisco's wastewater are significantly below levels seen during the 2022 outbreak," according to a DPH statement sent to the Bay Area Reporter. "SF DPH continues to monitor developments regarding Clade I mpox along with our federal and state partners. We will continue to update the community if further actions are needed to protect health."
Mpox in the DRC
Prior to the 2022 global outbreak, mpox was known as an uncommon disease in western and central Africa, where it largely affected children. According to an August 12 WHO situation report, there are concurrent ongoing outbreaks in the DRC. More than 15,000 cases and over 500 deaths have been reported so far this year. But due to inadequate health infrastructure and civil conflict, mpox testing has been limited, and there are wide discrepancies between suspected and laboratory-confirmed cases.
In areas of the DRC where mpox is endemic, the traditional picture still holds. Clade Ia mpox is transmitted through multiple routes, primarily close physical contact and contact with wild animals. Children have accounted for a majority of cases and deaths.
At the same time, an outbreak in eastern DRC caused by the newly identified Clade Ib mpox appears to be spreading mainly through sexual contact. Unlike the 2022 Clade II outbreak, however, cases have included similar numbers of men and women, many of whom are sex workers and their clients. Beyond the DRC, Clade Ib mpox has been reported recently in nearby Burundi, Kenya, Rwanda, and Uganda.
Clade I mpox is considered more deadly than Clade II. During the 2022 Clade II outbreak, the overall fatality rate was low, at around 0.2%. But mpox can be more severe in people with advanced HIV, and most people who died in the U.S. were Black gay men with AIDS. Historically, fatality estimates in African countries have ranged up to 10%, but mortality depends on the availability of medical care, so it's hard to compare wealthy and low-income countries.
"The current upsurge of mpox in parts of Africa, along with the spread of a new sexually transmissible strain of the monkeypox virus, is an emergency, not only for Africa, but for the entire globe," said Dr. Dimie Ogoina, who chaired the emergency committee that recommended the WHO declaration. "Mpox, originating in Africa, was neglected there, and later caused a global outbreak in 2022. It is time to act decisively to prevent history from repeating itself."
Mpox vaccination
Mpox is mainly transmitted through skin-to-skin contact, including sex, hands-on caregiving, and contact between members of a household. It can also spread through saliva, respiratory droplets at close range, and contact with materials such as clothes or bedding used by people with mpox lesions. Airborne transmission without close contact appears to be rare.
At this time, the CDC assesses the risk posed by the DRC outbreak as "very low" for the U.S. general population and "low to moderate" for gay and bisexual men and those in their sexual networks. Experts "do not believe that a similar scenario of transmission is likely in the United States" due to limited travel from the DRC, smaller and less crowded households, better access to improved sanitation and health care, and the lack of animal reservoirs.
Nonetheless, federal and local health officials urge people at higher risk to get vaccinated regardless of whether a local outbreak is underway. These include gay and bisexual men, transgender and gender-diverse individuals, people living with HIV, those on PrEP, sex workers, and others in their sexual networks. There is currently no vaccine shortage, and San Francisco's health department offers it to anyone who wants protection from mpox.
Two doses of the Jynneos vaccine should be given at least four weeks apart, but people who received only a single dose in 2022 can get the second dose at any time and do not need to restart the series.
"The two-dose mpox vaccine provides the best protection against mpox, including Clade I," according to the DPH statement. "Booster doses are not recommended at this time for those who have completed the two-dose series. In addition, mpox vaccination is not recommended at this time for those who have previously been infected."
The antiviral drug TPOXX (tecovirimat) is recommended for mpox treatment. The medication is effective against Clade II mpox, but data released last week suggest that it may not work as well against Clade I. The study did show, however, that adults and children in the DRC who received good supportive care had a lower risk of death.
While mpox testing, vaccines, and treatment are now readily available in the U.S., this is not the case in the DRC and other affected countries in Africa.
WHO is working with national health officials and partner organizations to increase access, but cost, stigma, transportation and distribution logistics, overstretched health facilities, and displacement of refugees present barriers to mpox prevention and care.
The Treatment Action Group, a U.S.-based HIV/AIDS advocacy organization, supports WHO's mpox emergency declaration but was critical of the global health system in general.
"The limited access to vaccines, tecovirimat, and other essential health commodities this far into the current outbreak is yet another demonstration that the existing global health system cannot guarantee the human rights to health and scientific progress for all. Major reforms and a reallocation of resources are necessary," TAG said in a statement. "Effectively reaching populations at risk for sexual transmission is an essential element of the response to mpox, and in this context right-wing forces globally promoting criminalization of sexual and gender minorities — which include prominent American organizations — are not only viciously bigoted and morally reprehensible but an international threat to public health.
"In TAG's view, the present situation is at least partially the consequence of lingering inequalities from responses to the 2022 mpox outbreak, which saw vaccines and other resources concentrate in the global north with relatively little attention devoted to addressing the drivers of mpox in the DRC and other endemic areas," the TAG statement added.
For more information about mpox vaccines in San Francisco, click here.
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