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Dimie Ogoina: Everyone is at risk of mpox infection

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Saturday, September 14, 2024

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Professor Dimie Ogoina

On 14 August, the World Health Organization (WHO) declared a public health emergency of international concern (PHEIC), due to its potential for wider transmission of mpox (monkeypox). Since mpox – an infectious disease caused by the monkeypox virus – can be particularly severe in children and pregnant women, United Nations International Children's Emergency Fund (UNICEF) agreed with WHO: on 31 August UNICEF issued emergency tender to secure mpox vaccines for crisis-hit countries.

The decision to apply the WHO’s highest-level alert was based on an opinion of a special panel of experts, known as the Emergency Committee regarding the upsurge of mpox.[1] Professor Dr. Dimie Ogoina, the chairperson of the WHO Emergency Committee, agreed to answer five queries from Wikinews reporter professor Dr. Roman Balabin.

Professor Ogoina is the president of the Nigerian Infectious Diseases Society. He is also a professor of medicine at the Niger Delta University (NDU) and a chief medical director at NDU Teaching Hospital. In 2023, Professor Ogoina was included in the Time 100 list of the most influential people of the year by the US magazine Time.

1. Justification of Concerns About Mpox Neglect:

Roman Balabin: You were among the very first to raise the alarm as mpox (monkeypox) spread through Nigeria’s cities in 2017.[2] In September 2022 you wrote an article “A brief history of monkeypox in Nigeria” for the Infectious Diseases Society of America (IDSA) where you forewarned that “it seems monkeypox, like HIV, will again be forgotten as a disease for Africa and other minorities”.[3] Two years later, do you think that your concerns were fully justified?

Dimie Ogoina: Mpox, previously known as monkeypox, was neglected for over 50 years until the 2022 global outbreak affected mostly developed countries outside Africa, including Europe and America. This outbreak led to the rapid development and deployment of mpox vaccines and therapeutics in these affected countries. However, after the Public Health Emergency of International Concern (PHEIC) was declared over in May 2023, mpox cases continued to rise in Africa, where no country had access to these medical countermeasures.

The cycle of neglect persisted – WHO openly stated that outside of contingency funds used during the 2022 outbreak, no donations were received for the mpox response in Africa. As a result, Africa had to confront the rising cases with limited resources, leading to new challenges, such as the first reports of sexual transmission of clade I, the emergence of a new Ib strain, and its spread to new countries within the continent.

So yes, my concerns were fully justified – mpox has indeed been largely forgotten as a disease for Africa. Whether the second declaration of PHEIC will lead to sustainable investments in Africa remains to be seen.

2. Consensus Among WHO Emergency Committee Members:

Roman Balabin: In August 2024 WHO director-general Dr. Tedros Adhanom Ghebreyesus declared mpox a public health emergency of international concern (PHEIC). This is the WHO’s highest-level alert. The Emergency Committee unanimously advised WHO to declare this second global emergency. Were there still any differences of opinion among 16 committee members? Are there disagreements between different experts on some of the details of our current situation?

Dimie Ogoina: As presented during the press briefing following the Emergency Committee meeting, all 15 members who attended were unanimous in advising the WHO Director-General that the upsurge of mpox constituted a public health emergency of international concern. The committee, as noted in the WHO meeting report, observed low testing rates, particularly in the DRC, and challenges in accurately estimating case fatality rates due to diagnostic issues and poor data quality.

Additionally, while clade I was historically known to be more transmissible and severe than clade II, which caused the global outbreak, more information is needed to assess the transmissibility and clinical severity of the new clade Ib strain.

3. Containment of Mpox and Pandemic Potential:

Roman Balabin: For half a century mpox was restricted to a dozen countries in sub-Saharan Africa. The August 15 report of a case in Sweden – followed by the first case in Thailand – underscores the pandemic potential of mpox. Do we have a chance to contain mpox close to the areas where the virus is considered endemic? Or is another global pandemic inevitable?

Dimie Ogoina: The declaration of a PHEIC gives us a second chance to address this outbreak and prevent history from repeating itself. There is a lot of activity and attention focused on the mpox upsurge in Africa, with media coverage highlighting the neglect and suffering in the continent. Some countries outside Africa have made pledges to donate mpox vaccines and offer support. African leaders are speaking out and making commitments to address the outbreak.

However, the true test of these commitments will be evident in about six months – will the media still be interested? Will the global north and its partners invest sustainably in the response? Will African leaders remain committed despite competing challenges? Only time will tell if mpox can result in another global outbreak or a pandemic.

The clade II outbreak in Nigeria in 2017 was ignored, yet five years later, it led to a global outbreak in 2022. Now, with clade Ib spreading mostly in Africa but also appearing outside the continent, another global outbreak is possible if we remain complacent. It’s only a matter of time.

Child during mpox outbreak (DRC, 1997)

4. Effectiveness of Smallpox Vaccines Against Mpox:

Roman Balabin: Mpox is a member of the Poxviridae family of viruses called Orthopoxvirus, which also includes classical smallpox (variola vera). Even when WHO advised countries to stop routine immunization programs against smallpox – an ancient scourge that killed up to 30% of those infected – some countries continued to vaccinate against it until the 1980s. Are these vaccines still effective? Should people who were vaccinated against classical smallpox 40-50 years ago consider themselves protected?

Dimie Ogoina: It has been well-established that prior smallpox vaccination provides cross-protective benefits against mpox, with vaccinated individuals being less likely to get infected or develop severe disease compared to the unvaccinated. However, the full protection offered by smallpox vaccination is uncertain today due to several factors.

First, immunity from smallpox vaccination may have waned over time, leaving many previously vaccinated individuals less protected. Second, with the emergence of new mpox strains and new transmission routes, particularly sexual transmission, the extent of protection from a prior smallpox vaccine remains unclear.

Third, HIV has now emerged as a risk factor for mpox, potentially negating the protective benefits even in previously vaccinated persons. As a result, we cannot confidently say that any specific age group is fully protected against mpox – everyone is at risk of infection and spreading the virus. Preventive strategies should focus on vulnerable groups while also aiming to prevent exposure and infection in the general population.

Colorized transmission electron micrograph of mpox particles (pink) found within an infected cell (green), cultured in the laboratory (2022)

5. Potential Need for a Renewed Global Vaccination Campaign:

Roman Balabin: Karl Simpson and his colleagues estimated in 2020 that over 70% of the world’s population was no longer protected against smallpox and similar viruses.[4] What are the chances that WHO will need to renew its global vaccination campaign that eradicated smallpox in 1977? Will we need additional scientific studies to ensure that modern vaccines are efficient against mpox?

Dimie Ogoina: Unlike smallpox, which had no established animal reservoir, mpox does have an animal reservoir, though this has not been definitively identified even after 54 years – a sign of the ongoing neglect. This makes the eradication of mpox more complicated.

At this point, mass vaccination is not recommended, primarily due to limited evidence about the long-term benefits of current mpox vaccines and the belief that mpox is currently limited to vulnerable groups rather than the general population. Ultimately, we need new, effective, and safe vaccines that protect the general population, as mpox is gradually shifting from restricted populations to the general population.

With over 70% of the world’s population at risk and recurring neglect of the disease, everyone could be at risk in the near future. Africa should invest in itself and stop waiting for handouts – if we rely on the global north to develop new vaccines and therapeutics, we will likely be the last to receive them, if at all.

References

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  1. ↑  «The IHR Emergency Committee regarding the upsurge of mpox 2024». World Health Organization, 4 сентября 2024 года. (архив)
  2. ↑ Jon Cohen, Abdullahi Tsanni «Pulling Back the Curtain. The untold story of how Nigeria’s mpox outbreak sparked a worldwide epidemic». Science, 16 августа 2024 года. (архив)
  3. ↑ Dimie Ogoina «A brief history of monkeypox in Nigeria». Infectious Diseases Society of America, 20 сентября 2022 года. (архив)
  4. ↑ Karl Simpson «Human monkeypox – After 40 years, an unintended consequence of smallpox eradication». Vaccine, 14 июля 2020 года. (архив)

Sources

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