Honorables / Excellencies Ministers of Health All African Union Member States
Subject: Update on the Mpox outbreak in Africa
Excellencies and colleagues,
I bring you warmest greetings from Africa Centres for Disease Control and Prevention, the specialized agency of the Africa Union established to strengthens the capacity and capability of Africa’s public health institutions as well as partnerships to detect and respond quickly and effectively to disease threats and outbreaks, based on data-driven interventions and programmes.
In fulfilment of the mandate given to Africa CDC to provide health security of the Continent, a couple of decision actions have been taken and below I outline the critical decision pathways and the needed actions on the current situation of Mpox.
BACKGROUND
From 2023 to date, the Mpox viral zoonotic disease has been reported in 16 African Union Member States in all 5 AU regions, with a high case fatality rate above 3.9%.
From January to 10 th August 2024, 17,541 cases and 517 deaths have been recorded, which represents a 160% increase compared to 2023.
Given the clear and present danger that the onslaught of Mpox was posing to the continent, Africa CDC consider the possibility of invoking its Statues of Article 3 (e) to declare a Public Health Emergency of Continental Security. But this would be the first time and thus needed a consensus across different critical stakeholders. Hence, Africa CDC called for a meeting of an independent high level technical body called Emergency Consultative Group (ECG) to critically review all available data and make recommendations to the Director General Africa CDC on the way to move forward.
This ECG comprises by 20 senior and high-level scientific experts from Africa supported by other respected international scientific experts. This august body thoroughly reviewed the below epidemiology situation:
Limitations of the epidemiology : The cases and deaths seen are just the tip of the iceberg given that Mpox is mostly a mild condition, limited surveillance, testing, contact tracing and reporting
High burden of cases: The cases in Africa have more than tripled in relation to a comparable period when Mpox was declared a PHEIC in 2022.
Cases are increasing: There has been an rapid increase in cases recently in the midst of an overall upward trend.
High case fatality rate: The CFR is between 3% and 4% and the link with HIV is particularly concerning for Africa.
Cases are spreading to new countries: Several countries without previous cases have recently reported imported cases of their first Mpox cases for 2024. Given this trend, there is a high risk that it could spread beyond Africa as well.
Greater co-ordination of the response: Disparate attempts are being made to address Mpox but co-ordination needs to improve
The complexities around the Vaccines: While vaccine access is limited, the benefits of an expensive vaccine with limited clinical efficacy data need to be carefully assessed and a plan needs to be developed to ensure that vaccines are appropriately deployed to maximise benefit.
Limited Diagnostics: Access to diagnostics is too limited
Response plan: The Africa CDC and Member States supported by other partners need to develop an integrated response plan for the continent.
Based on this analysis, the ECG recommended to the DG Africa CDC to declare the status of Public Health Emergency of Continental Security (PHECS).
The DG of Africa CDC further extensively consulted the Pandemic Prevention and Preparedness Response (PPPR) Commission, the Advisory Technical Council (ATC) and the Governing Board (GB). All of these continental bodies overwhelmingly supported this decision.
On 13 Aug 2024, thanks to the prerogative and power given to the DG Africa CDC under Article 3 (e) of the Statutes, the Director General Africa CDC declared Mpox as PHECS.
On 14 Aug 2024, WHO Director General declared Mpox as Public Health Emergency of International Concern (PHEIC) following the same criteria used by Africa CDC.
EPIDEMIOLOGICAL SITUATION
From 1 st January 2024 to 23 Aug 2024, a total of 21,466 cases (3,350 confirmed; 18,116 suspected) and 591 deaths [case fatality rate (CFR): 2.9%] of Mpox have been reported from 13 Africa Union (AU) Member States (MS): Burundi, Cameroon, Central Africa Republic, Congo, Côte d’Ivoire, Democratic Republic of Congo, Gabon, Liberia, Kenya, Nigeria, Rwanda, South Africa and Uganda.
Even as I wrote this letter, Gabon has confirmed its first case, while Sierra Leone and Malawi are now testing their suspected cases.
I would like to draw Your Excellencies’ attention to the fact that a negative test result in the laboratory does not mean there is no Mpox epidemic. I provide more explanations on this in point 4 of this letter
AFRICA CDC RESPONSE SO FAR
Coordination
Before declaration, the Director General consulted various personalities and bodies:
H.E. President Ghazouani Chair of the Committee of Heads of State and Government of Africa CDC (CHSG);
H.E. Cyril Ramaphosa, President of South Africa and AU PPPR Champion
H.E. President Moussa Faki, Chairperson of African Union Commission
Affected Member States and even some high-risk countries
National Public Health Institutes of affected Member States,
PRC and Joint sitting of PRC Sub-Committee on general supervision and coordination on budgetary, financial and administrative matters that approved the disbursement of from the COVID-19 Fund of US$10.4 million to respond to Mpox
Governing Board of Africa CDC comprised by Ministers of Health, Commissioner HHS AUC and some key partners;
Advisory and Technical Council of Africa CDC
Emergency Consultancy Group (ECG)
Pandemic Prevention, Preparedness and Response (PPPR) Commission
JEAP Principals meeting (Africa CDC, WHO AFRO, WHO EMRO, WHO HQ, UNICEF ESARO, UNICEF WCARO, UNICEF HQ),
Various partners from philanthropies, private sector, bi and multilateral cooperation
After the declaration, Africa CDC is using its mandate as stated under Article 3 (f) of its Statute to coordinate and support AU Member States in health emergencies response particularly those which have been declared PHECS or PHEIC emergencies as well as health promotion and diseases prevention through health systems strengthening, by addressing communicable and non-communicable diseases, environmental health and Neglected Tropical Diseases (NTDs).
Working closely with the AU Member States, WHO, and various partners, Africa CDC is supporting Member States in their preparedness and response activities. Africa CDC is leveraging the AU political, policy, and advocacy capacities to response to the Mpox.
Africa CDC activated its Emergency Operations Centre to support the preparedness and response efforts with the aim to enhance coordination and provide technical support to AU Member States.
The Director General appointed an Incident Manager and Deputy Incident Manager.
A continental strategy for Mpox was developed which is used to mobilise resources to coordinate the outbreak response.
One Incident management team was established under the leadership of Africa CDC and comprised all partners intervening in the response
In addition to the Emergency Consultative Group, the Director General created, two other bodies to help him to manage this outbreak: African global health Ambassadors (AGHA) and Senior Strategic Advisory Team (SSAT)
Consultation and Support to Member States
Africa CDC led consultation meetings with various countries to sensitize on the importance of domestic resources and awareness of the disease. The DG met with Heads of State and Government of these countries: Angola, Botswana, Congo Brazza, Democratic Republic of Congo, Eswatini, Lesotho, Madagascar, Malawi, Mauritania, Mauritius, Mozambique, Namibia, Seychelles, South Africa, United Republic of Tanzania, Zambia and Zimbabwe.
Partnerships for supply of Vaccines in Africa: Africa CDC established a partnership with the European Commission’s Health Emergency Preparedness and Response Authority (HERA) to provide 215,000 doses of the vaccines from Bavarian Nordic (BN) to ensuring equitable distribution based on local needs. Africa CDC is concluding other partnerships that will be announced very soon.
Africa CDC conducted with success a large consultation with a number of partners to adhere and support the incident management team in place under the leadership of Africa CDC. These partners include WHO, UNICEF, Gavi, World Bank, AfreximBank, BAD, USA, Canada, European Union, …
Africa CDC deployed 24 staff members from its headquarters and RCCs including from the African Volunteers Health Corps (AVoHC) roster to support the response in the Democratic Republic of Congo (DRC) and other affected Member States.
Africa CDC is deploying around 200 epidemiologists and logisticians in all other affected countries.
Enhanced Surveillance and Detection: Africa CDC is improving case detection and surveillance capabilities throughout Africa. This includes upgrading diagnostic facilities in national and regional laboratories and implementing rapid notification systems for suspected cases.
Training Health Personnel: Intensive training programs for healthcare workers are being conducted to equip them with the skills needed to identify, isolate, and treat Mpox cases. Training also extends to epidemiologists and public health experts.
Information Sharing and Coordination: The agency is facilitating the exchange of critical information among AU Member States to ensure a coordinated response. Regular meetings including media briefings by the Director General and communication platforms are established to share data and strategies.
Public Awareness Campaigns: Africa CDC is running awareness campaigns to educate the public on Mpox prevention. Collaborations with ministries of health, media, and community organizations help disseminate clear and accessible information.
Medical Supplies and Research Support: The organization is working with regional and international partners to ensure the availability of essential medical supplies, including vaccines and diagnostic kits. Additionally, Africa CDC supports research initiatives for vaccine development and clinical trials tailored to the African context.
Community Engagement: Africa CDC is promoting community networks trained to raise awareness and distribute informational materials on Mpox prevention, encouraging preventive behaviors at the household level.
Establishment of the Africa Taskforce for Mpox Coordination: This taskforce aims to enhance preparedness and response capacities, facilitate rapid epidemic response, and prioritize scientific research to better understand Mpox dynamics.
CONFIRMATION OF Mpox CASES
Some of you are reaching out to us especially in the context where lab is negative for Mpox. To better advise you, Africa CDC have also consulted I consulted our African best epidemiologist and lab experts but also international experts and appropriate bodies like US CDC, China CDC, Europe CDC and WHO.
The conclusion is that relying solely on laboratory test results for diagnosing Mpox is not advisable . We need a holistic approach that integrates laboratory testing with clinical assessment and epidemiological data that is essential for accurately diagnosing and managing Mpox. The diagnosis and management of Mpox should involve a comprehensive approach that considers multiple factors:
Clinical Presentation : The signs and symptoms of Mpox, such as fever, rash, swollen lymph nodes, and lesions, are critical in diagnosing the disease. A thorough clinical examination is essential, especially when laboratory results are inconclusive or negative.
Epidemiological Context : Understanding the patient’s exposure history, such as contact with known cases or travel to areas with ongoing Mpox outbreaks, is crucial. This context can provide strong evidence for a probable case, even in the absence of positive lab results.
History and Risk Factors : Reviewing the patient’s medical history, including any recent exposure to animals or contaminated materials, can offer additional clues for diagnosis.
Laboratory Testing : While important, lab tests should be interpreted in conjunction with clinical and epidemiological data. False negatives are possible, and a negative test does not entirely rule out Mpox, especially if there is strong clinical suspicion. For all Mpox cases, countries have to perform HIV and STI tests.
Follow-up and Monitoring : Continuous monitoring of the patient’s symptoms and possibly repeating tests can help in making a definitive diagnosis. If Mpox is suspected but initial tests are negative, clinicians may decide to repeat the tests or use different types of samples.
Differential Diagnosis : Other conditions with similar symptoms (like chickenpox, measles, or bacterial skin infections) should be considered and ruled out.
Regarding the Mpox testing, it can sometimes yield a negative result in the laboratory even when the disease is present due to several factors:
Timing of Sample Collection : The accuracy of Mpox testing depends significantly on when the sample is collected. If the sample is taken too early or too late in the course of the infection, the viral load might be too low to be detected.
Type of Sample Collected : The type of sample collected (e.g., from a lesion, blood, or other bodily fluids) can affect the test results. Lesion swabs are typically the most reliable, but if a different type of sample is used, it may not contain enough viral material for detection.
Quality of the Sample : Poor sample collection techniques can lead to inadequate samples, resulting in a false negative. This might include improper handling, storage, or contamination of the sample.
Test Sensitivity and Specificity : No test is perfect, and some Mpox tests may have lower sensitivity, meaning they might not detect very low levels of the virus. This can result in a false negative if the viral load in the sample is below the test’s detection threshold.
Viral Variability : Different strains or mutations of the Mpox virus might not be as easily detected by certain tests, especially if the tests were designed for a specific strain.
Host Immune Response : In some cases, an individual’s immune system might clear the virus or suppress its replication to levels undetectable by laboratory tests, even though the disease was present.
CHALLENGES
There are still some challenges identified like:
Low level of domestic resources from Member States,
Only 3 African countries already approved the utilization of the Mpox vaccines (Nigeria, South Africa and DRC). It is critical for other countries to approve the introduction of the vaccines
Suboptimal communication activities to raise awareness of population and sensitize them for the use of vaccines
The tension of the increasing demand of the vaccines by western nation and the monopoly in the manufacturing of vaccines (BN is the only one currently manufacturing this vaccine), puts Africa at a disadvantage in securing the vaccines given the limited market demand by African leaders.
There is a serious risk that Africa will not be consider in the distribution of the vaccines and other medical countermeasures if African leaders don’t come strongly together to make their voice on the fight against this disease
There is a significant continuous threats cross-border circulation of the virus affecting countries that were previously non-endemic
Lack of diagnostic capabilities leading for a testing rate around 18% in some countries
Inadequate surveillance system leading for under detection and notification of cases
Risk now openly mentioned in some Western countries to impose travel restrictions to Africa if our leaders and communities don’t take this outbreak seriously
NEXT STEPS
The African Incident Management Team (Africa CDC, WHO, UNICEF, MSF, CEPI, Wellcome trust, Gavi…) will work with all countries to ensure that each affected country
and countries that are at risk of Mpox have an updated response plan and a preparedness plan respectively.
Support will be provided for affected countries with the donation of vaccines already secured. We need to ensure that (1) regulatory authorities agreed to use the vaccine, (2) the supply chain logistics is in place, and (3) communication activities are ongoing to ensure acceptance of the vaccines by the targeted population
While your respective NPHIs are meeting with the incident management team every week, we will initiate a meeting every 2 weeks with all Ministers for strategic discussions and guidance
We are working with our Heads of State for a meeting that will involve most of them and partners at the highest level. We will keep you posted on that very soon.
The Africa CDC will remain at your disposal for any request that can help to address this health issue in our continent. I than you.
Yours Sincerely,
H.E. Dr Jean Kaseya
Director General, Africa CDC