A COVID-19 encore with monkeypox

In the midst of the COVID-19 pandemic, we have another disease, monkeypox, which the World Health Organization (WHO) has declared a Public Health Emergency of International Concern (PHEIC). That was towards the end of July.

The panic was triggered in early May, when the United States and countries in Europe, where the disease is not endemic, started reporting outbreaks of monkeypox along with several endemic countries in West and Central Africa.

This is why the disease became a matter of global concern. Otherwise, would cases in the Democratic Republic of the Congo or say, in Nigeria, have occasioned such alarm?

But with monkeypox cases and clusters erupting in both non-endemic and endemic countries, the disease is belatedly coming into WHO’s focus, after its advisory committee decide twice earlier against labelling monkeypox a PHEIC.

Monkeypox is a viral infection that has been endemic in about a dozen countries in Africa for several years now. There has been an epidemic in Nigeria since 2017, with more than 200 confirmed and over 500 suspected cases, according to media reports.

In 2018, Nigerian scientists had warned that the virus had changed its behaviour and was spreading not from animals but from humans to humans.

No one took serious note of this and, for lack of funds for research, there was no follow-up on the findings of the scientists.

The crux of the problem, in the view of some public health experts, has been the lack of engagement by WHO in ensuring vaccinations in the endemic regions of Africa, even though scientists and public health officials have been warning for years now that the virus could spread more widely and rapidly.

Reports say that over 31 million doses of the smallpox vaccine, which also provides protection against monkeypox, had earlier been pledged to Africa. But these vaccines were never deployed against monkeypox to African countries. Why has WHO been so lax in responding to the African epidemic which, unlike COVID-19, did not arrive without warning?

Now, of course, there is a scramble for vaccines that are in acutely short supply and, tragically, this is a replay of the COVID-19 scenario where rich nations grabbed the bulk of the available doses.

The likelihood of any vaccine equity this time around is much bleaker, primarily because the world is depending on a single company to get monkeypox under control. Bavarian Nordic, a Danish company, holds the patent for Jynneos, the only vaccine approved by the US Food and Drug Administration and the European Medicines Agency for monkeypox.

There is more bad news. Bavarian Nordic’s European vaccine production line has been closed since spring and will not reopen until later this year, according to a company investor filing in May.

Nearly 90 per cent of the stock of roughly 16 million doses of the vaccine that are reported to be available is in bulk form, according to WHO. Of the remainder, the biggest chunk of 1-1.4 million doses has been taken by the US, which has financed the development of the vaccine, according to global health analytics firm Airfinity.

Germany and the United Kingdom are said to have secured between 40,000 and 54,000 doses each. Desperation is in the air with Europe and the US deciding to space out a vaccine dose over five jabs, although research is sketchy on how effective this will be.

Bavarian Nordic says it is doing everything to push up production and is in talks to license its technology to contract manufacturers in Europe, but there is no firm agreement as yet. Could India provide a possible solution with rapid escalation of production through its established vaccine facilities?

Contract manufacturing apart, the Indian Council of Medical Research appears keen on developing technology within the country and has sought expression of interest from companies willing to develop vaccines and diagnostic kits to fight monkeypox. Nearly three dozen companies have responded, but it is likely to be a long haul before results show.

WHO, on its part, is falling back on appealing for donations just as it did for COVID-19. Its partner GAVI, the Vaccine Alliance, is urging countries with stockpiles —or supplies on order — “to be generous and flexible in releasing doses to countries with cases that do not have access to ensure equality”.

Donations are critical to fighting the virus, but where are the spare vaccines? The big hope is the US, which was the highest donor of COVID-19 vaccines. But since the country is rationing its own monkeypox doses, there is little chance of securing substantial supplies from Washington.

Almost three years into the pandemic and after a sustained global campaign for vaccine equity, we do not seem to be any better prepared for the latest emergency. Monkeypox is spreading rapidly and at the last count there were 39,000 reported cases in 95 countries.

There are doubts if this is the true figure since the disease has been heavily stigmatised — it is more prevalent among men who have sex with men—and many people are unlikely to go for testing or even report infection. Africa has to be the priority if the monkeypox emergency is to be tackled with some measure of success globally.

Africa is where the highest fatalities have been recorded this year, with 76 reported deaths since January. But no strategy appears to have been put in place to tackle the crisis on the continent.

Simultaneously, COVID-19 continues to cull more victims, with a 35 per cent increase in fatalities in the past month. The WHO chief told a press briefing in the middle of August that the death toll of 15,000 people in just one week was unacceptable “when we have all the tools to prevent infections and save lives”.

How true is this? The manufacturing of therapies and diagnostics to detect COVID-19 is still hampered by the patent protection rules of the World Trade Organization, which curb the use of critical technology needed to make such products.

Vaccines may have been allowed to override patent protection at the ministerial conference in June, but there are no signs of new vaccine units coming up because other hurdles remain in place.

The stark inequities in the global health system that the COVID-19 pandemic highlighted are being thrown into sharp relief once again by monkeypox.