Tag: mpox

SA’s HIV Burden a Concern as New Mpox Strain Spreads in DRC – but Much Still Unknown

Mpox (monkeypox) virus. Source: NIH

The African Centre for Disease Control and World Health Organization have raised the alarm following a drastic uptick in mpox cases. This surge is being driven by a new strain of the virus. Elri Voigt reports about what we know so far and potential implications for South Africa.

Mpox, a viral illness first identified in Africa in 1970, made headlines in 2022 when it spread across the globe for the first time. Since then, the outbreak has evolved, with multiple strains of the virus circulating in different countries. A new strain, known as clade Ib, first discovered in the Democratic of the Republic of Congo (DRC), is responsible for much of the most recent surge in mpox cases.

These recent developments are complex, and the situation is likely to change. This was the common theme of a special session on the mpox outbreak during the World Health Organization (WHO) Regional Committee for Africa meeting at the end of August. This session took place two weeks after the WHO declared the outbreak to be a Public Health Emergency of International Concern.

“We don’t have one outbreak. We have multiple outbreaks in one,” Dr Jean Kaseya, the Director General of the African Centre for Disease Control (CDC) remarked.

These outbreaks are caused by different clades of the mpox virus. Clades are a classification system based on the genetic similarities between different strains of a virus, explained Professor Tulio de Oliveira, Director of the Centre for Epidemic Response and Innovation (CERI) at Stellenbosch University (SU). “So, what it means is that when we see a genetic change [in a virus] that’s really visible and that may have impacted it, normally we call it a different clade or genotype or variant,” he said.

This is similar to classifying different strains of SARS-CoV-2 as variants, Dr Duduzile Ndwandwe, a molecular biologist working for Cochrane South Africa, an intramural research unit within the South African Medical Research Council, told Spotlight.

She explained that the different mpox clades and sub-clades have mutated so they have genetic differences but still fall under the umbrella of mpox.

“In a nutshell…it’s just talking about the differences in the genome sequence of the virus, how many mutations [it has] or how big the mutations are in that virus’s strain of mpox,” she said.

‘Jump in evolution’

Dr Aida Sivro, senior scientist at the Centre for the AIDS programme of Research in South Africa (CAPRISA), in 2022 told Spotlight that there are two clades of the mpox virus, which were then referred to as the Central African Clade (clade I) and the West African Clade (clade II).

Since then, clade I went through a big jump in evolution and a sub-clade emerged in the DRC, now called clade Ib, De Oliveira told Spotlight. The previous outbreak in 2022 was mostly driven by another sub-clade called clade IIb.

To further complicate matters, there’s a third strain of the virus also circulating – clade Ia.

At the moment, the DRC accounts for about 90% of mpox cases in the African Region, according to Dr Fiona Braka, the Emergency Response Manager for WHO’s AFRO region. She explained that right now the situation is not fully understood because a lack of diagnostics and testing capabilities is limiting understanding of the true burden of disease.

What we do know, she said, is that there are two distinct outbreaks in the DRC. Based on the information currently available, clade Ia is circulating in regions in the country where mpox is considered endemic and affecting mostly children. While clade Ib is spreading mostly among adults in the eastern provinces of South Kivu and North Kivu.

The clade Ib strain has since spread from the DRC to neighbouring countries Burundi, Rwanda, Uganda and Kenya, according to Braka. Sweden and Thailand have also identified one case each.

As of 1 September, the WHO reported that there have been 3 751 confirmed cases of mpox and 32 deaths across 14 countries in African in 2024 alone. But there are many more suspected cases of mpox that have not been tested.

Implications for South Africa

De Oliveira said at this point, South Africa shouldn’t be overly concerned about mpox, but it should be alert. The best way to do this is to make sure the public know what the symptoms are so they can present for diagnosis and treatment if they suspect they have the virus.

In a similar vein, Ndwandwe said the public shouldn’t panic, but we as a country need to remain vigilant. She added that because clade Ib is spreading on the African continent, there is a risk of it spreading to South Africa through cross-border travel, making it a public health concern.

This year, 24 cases of mpox have been reported in South Africa. Three people have died, while 19 have recovered. Two people are still considered to have active disease, with the most recent case identified in early August.

But this doesn’t necessarily mean there aren’t more cases of mpox in the country. “What we do suspect is that we may have milder cases that are actually not reported,” Nevashan Govender, the operation manager of the Emergency Operations Center at the National Institute for Communicable Diseases (NICD) told Spotlight.

He said so far, all the cases in the country have been caused by clade IIb and no cases of clade Ib have been identified.

A polymerase-chain-reaction (PCR) test is the gold standard test used to determine whether someone has mpox. But genome sequencing would need to be done to identify what clade they have.

Lots of unknowns around new strain

At the moment, there are a lot of unknowns around clade Ib.

What is of concern, according to Braka is the severity of disease seen especially in people who are immunocompromised and in pregnant women and children. Ndwandwe added to this and said there is a concern that clade Ib has higher fatality rates than clade IIb.

De Oliveira cautioned against jumping to conclusions about the severity of this new clade without sufficient data. He said we don’t know for sure yet if clade Ib is causing more severe disease than IIb. What we do know from mpox in general, he said, is that when someone is immunocompromised in some way, they tend to develop more severe symptoms.

Govender echoed De Oliveira’s caution that we don’t yet know enough about clade Ib to say definitively if it is for example more transmissible than other clades

“It’s not to say that it isn’t [more transmissible], but there is just not a lot of evidence stating that it is absolutely true…There’s a lot of knowledge and information gaps,” he said.

The NICD in a recent update also stressed that there are a lot of unknowns about this new strain. It added: “South Africa continues to prioritise enhanced surveillance and raising awareness for mpox.”

The state of vaccines and treatment for mpox

Spotlight reported previously that the smallpox vaccine, which hasn’t been routinely administered in South Africa since the 1980s when smallpox was eradicated, is thought to offer some degree of protection against mpox. However, it’s difficult to predict just how much protection the smallpox vaccine would provide, Sirvo told Spotlight for that previous article.

There are currently three vaccines against mpox that have been approved in some countries, a spokesperson from the vaccine alliance Gavi told Spotlight. These are LC16m8, JYNNEOS and ACAM2000.

LC16m8 is a third-generation small pox vaccine manufactured by KM Biologics. According to WHO, from 2022 it had mainly been used in Japan.

The JYNNEOS vaccine is a third-generation smallpox vaccine, manufactured by Bavarian Nordic, Ndwandwe said, and it was used during the outbreak in 2022. She added that this vaccine is considered the preferred option due to its safety profile and targeted protection against mpox.

ACAM2000 is a second-generation vaccine for smallpox and manufactured by Emergent BioSolutions. But it was only approved by the FDA for use in those at high risk for mpox at the end of August this year. It was not widely used during the 2022 outbreak but was available in some places under a compassionate use protocol (a means of providing medicines or vaccines that have not yet been registered).

In 2022, the Centre for Disease Control (CDC) recommended that JYNNEOS be used as the primary vaccine against mpox because it was associated with fewer side effects than ACAM2000.

While these vaccines exist, it doesn’t mean everyone can access them easily. Countries on the African continent have so far relied on vaccine donations facilitated by the WHO, with an initial 10 000 doses expected to arrive in Africa sometime this month.

Vaccine manufacturers KM Biologics and Bavarian Nordic have submitted proposals to the WHO for emergency use listing (EUL), according to WHO Director-General Dr Tedros Adhanom Ghebreyesus. He added this will allow UNICEF and the vaccine alliance GAVI to buy the vaccines to supply to countries that haven’t issued their own national regulatory approval yet.

The treatment options for mpox are also limited. According to this WHO factsheet on mpox, some antivirals have received emergency use authorisation in some countries and are being evaluated in clinical trials. However, so far there is no proven effective antiviral treatment for mpox.

Tecovirimat, which was approved to treat smallpox, is one of these antivirals being evaluated. According to the CDC, studies in animals have shown the antiviral might help treat mpox but it is still considered an investigational drug for mpox. The drug has been used in some cases of severe mpox.

When asked about this, Ndwandwe agreed more research needs to be conducted to fully understand the evidence around using Tecovirimat. “But what we know now is that the fact that it was authorised for compassionate use, there is some benefit to using that treatment, given that there isn’t any other [treatment,” she said.

Mpox vaccine and treatment availability in South Africa

According to De Oliveira, a small batch of vaccines against mpox and an antiviral drug were made available to South Africa through donations during the outbreak earlier this year.

But the country would need more vaccines if cases increase to protect those at risk for severe disease.

At the moment, South Africa does not have access to any mpox vaccines and has asked for a donation of 40 000 vaccine doses, Foster Mohale, spokesperson for the health department told Spotlight. The country has requested the JYNNEOS vaccine, based on the recommendation by the National Advisory Group on Immunisation.

He added that South Africa’s request to its international partners and the WHO is ongoing support with access to tecovirimat should the need increase. He also requested the WHO’s assistance in procuring the 40 000 vaccine doses to vaccinate high-risk groups if mpox cases increase.

When asked if the department will be entirely reliant on donations of mpox vaccines or would seek to procure its own if cases increase, Mohale said it depends. “South Africa has been in communication with the vaccine manufacturer, Bavarian Nordic, and will consider procurement if needed,” he added.

Because there is a shortage of mpox vaccines and treatment and uncertainty about the sustainability of donated supplies, Ndwandwe said: “Our best defence at this point in time is to prevent [the spread of mpox cases] as much as possible and detect the cases as they start, early on.”

Symptoms of mpox

Govender said the NICD is urging people not to panic but to stay informed on the signs and symptoms of mpox using some of the accurate information available from either the National Department of Health or the NICD.

“The first line of defence for any public health emergency and outbreak comes from when people take initiative to protect themselves,” he said.

Mpox, which is spread by close contact, either household or sexual contact, with someone who has the virus, could initially manifest in flu-like symptoms or the characteristic mpox rash. These include a fever, sore throat, muscle aches, headaches and swollen lymph nodes, according to the WHO factsheet on mpox. The rash starts flat and then becomes a blister filled with fluid, which eventually dries and falls off. The rash can occur on someone’s palms or soles of their feet, face, mouth and throat and sometimes the genital areas.

Children, pregnant women and those who are immunocompromised are most at risk for developing severe disease or dying, the factsheet stated. This includes people living with HIV whose viral load is not well controlled.

Mpox is a virus and as with all viral infections it’s the immune system that fights it off, Ndwandwe explained. However, if someone is immunocompromised, so has a weakened immune system, there is a greater chance that the mpox virus will overtake their immune system and cause severe disease.

This is one of the reasons why we would be concerned about the disease in South Africa, Professor Helen Rees, the Co-Chair of the Incident Management Team (IMT) on mpox, previously told eNCA.

“We have many people living with HIV in the country, many of whom are on antiretroviral therapy, their immune system is good. But we have many others, who don’t know what their status is and might be vulnerable to severe mpox,” she said.

Republished from Spotlight under a Creative Commons licence.

Read the original article

WHO Declares International Public Health Emergency over Mpox Outbreak

Mpox (monkeypox) virus. Source: NIH

WHO Director-General Dr Tedros Adhanom Ghebreyesus has determined that the upsurge of mpox in the Democratic Republic of the Congo (DRC) and a growing number of countries in Africa constitutes a public health emergency of international concern (PHEIC) under the International Health Regulations (2005) (IHR).

Dr Tedros’s declaration came on the advice of an IHR Emergency Committee of independent experts who met earlier in the day to review data presented by experts from WHO and affected countries. The Committee informed the Director-General that it considers the upsurge of mpox to be a PHEIC, with potential to spread further across countries in Africa and possibly outside the continent.

The Director-General will share the report of the Committee’s meeting and, based on the advice of the Committee, issue temporary recommendations to countries.

In declaring the PHEIC, Dr Tedros said, “The emergence of a new clade of mpox, its rapid spread in eastern DRC, and the reporting of cases in several neighbouring countries are very worrying. On top of outbreaks of other mpox clades in DRC and other countries in Africa, it’s clear that a coordinated international response is needed to stop these outbreaks and save lives.”

WHO Regional Director for Africa Dr Matshidiso Moeti said, “Significant efforts are already underway in close collaboration with communities and governments, with our country teams working on the frontlines to help reinforce measures to curb mpox. With the growing spread of the virus, we’re scaling up further through coordinated international action to support countries bring the outbreaks to an end.”

Committee Chair Professor Dimie Ogoina said, “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. 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.”

This PHEIC determination is the second in two years relating to mpox. Caused by an Orthopoxvirus, mpox was first detected in humans in 1970, in the DRC. The disease is considered endemic to countries in central and west Africa.

In July 2022, the multi-country outbreak of mpox was declared a PHEIC as it spread rapidly via sexual contact across a range of countries where the virus had not been seen before. That PHEIC was declared over in May 2023 after there had been a sustained decline in global cases.

Mpox has been reported in the DRC for more than a decade, and the number of cases reported each year has increased steadily over that period. Last year, reported cases increased significantly, and already the number of cases reported so far this year has exceeded last year’s total, with more than 15 600 cases and 537 deaths.

The emergence last year and rapid spread of a new virus strain in DRC, clade 1b, which appears to be spreading mainly through sexual networks, and its detection in countries neighbouring the DRC is especially concerning, and one of the main reasons for the declaration of the PHEIC.

In the past month, over 100 laboratory-confirmed cases of clade 1b have been reported in four countries neighbouring the DRC that have not reported mpox before: Burundi, Kenya, Rwanda and Uganda. Experts believe the true number of cases to be higher as a large proportion of clinically compatible cases have not been tested.

Several outbreaks of different clades of mpox have occurred in different countries, with different modes of transmission and different levels of risk.

The two vaccines currently in use for mpox are recommended by WHO’s Strategic Advisory Group of Experts on Immunization, and are also approved by WHO-listed national regulatory authorities, as well as by individual countries including Nigeria and the DRC.

Last week, the Director-General triggered the process for Emergency Use Listing for mpox vaccines, which will accelerate vaccine access for lower-income countries which have not yet issued their own national regulatory approval. Emergency Use Listing also enables partners including Gavi and UNICEF to procure vaccines for distribution.

WHO is working with countries and vaccine manufacturers on potential vaccine donations, and coordinating with partners through the interim Medical Countermeasures Network to facilitate equitable access to vaccines, therapeutics, diagnostics and other tools.

WHO anticipates an immediate funding requirement of an initial US$ 15 million to support surveillance, preparedness and response activities. A needs assessment is being undertaken across the three levels of the Organization.

To allow for an immediate scale up, WHO has released US$ 1.45 million from the WHO Contingency Fund for Emergencies and may need to release more in the coming days. The Organization appeals to donors to fund the full extent of needs of the mpox response.

Source: WHO

Debunking Myths About Mpox

Mpox (monkeypox) virus. Source: NIH

Myths are widely held beliefs about various issues, including illness and disease. They come about through frequent storytelling and retelling. Dr Themba Hadebe, Clinical Executive at Bonitas Medical Fund, helps debunks myths about monkeypox (mpox).

Myth 1: Mpox (formerly monkeypox) is a new disease created in a lab

Fact: The mpox virus was discovered in Denmark (1958) in a colony of monkeys at a laboratory kept for research.  The first reported human case was in 1970 in the DRC. Mpox is a zoonotic disease, meaning it can be spread between animals and people. It is found regularly in parts of Central and West Africa and can spread from person to person or occasionally from animals to people.  

Myth 2: Mpox comes from monkeys

Fact: Despite its name, monkeypox does not come from monkeys. The disease earned the name when the ‘pox like’ outbreaks happened in the research monkeys. While monkeys can get mpox, they are not the reservoir (where a disease typically grows and multiplies). The reservoir appears to be rodents.

Myth 3:  Only a handful of people have contracted mpox

Fact: Globally, more than 97 000 cases and 186 deaths were reported across 117 countries in the first four months of 2024. South Africa is among the countries currently experiencing an outbreak.  On the 5 July, it was reported that the number of mpox cases in the country has risen to 20. This after four more cases have been confirmed in Gauteng and KwaZulu-Natal in the last few days.

15 patients have, however been given a clean bill of health.

Myth 4:  It is easy to diagnose mpox

Fact: It is easy to mistake mpox for something else. While the rash can be mistaken for chickenpox, shingles or herpes, there are differences between these rashes. Symptoms of mpox include fever, sore throat, headache, muscle aches, back pain, low energy and swollen lymph nodes. Fever, muscle aches and a sore throat appear first. The rash begins on the face and spreads over the body, extending to the palms of the hands and soles of the feet and develops over 2-4 weeks in stages. The ‘pox’ dip in the centre before crusting over.

Laboratory confirmation is required. A sample of one of the sores is diagnosed by a PCR test for the virus (MPXV).

Myth 5: Mpox is easily treated

Fact: ‘Currently,’ says the National Institute for Communicable Diseases (NICD), ‘there is no registered treatment for mpox in South Africa. However, the World Health Organization (WHO) recommends the use of TPOXX for treatment of severe cases, in immunocompromised people’. However, the Department of Health (DoH) has only obtained this treatment, with approval on a compassionate use basis, for the five known patients with severe disease.

There is no mpox vaccine currently available in South Africa.

Myth 6: You can get mpox from being in a crowd or from a public toilet seat

Fact: Mpox is not like Covid-19 which is highly contagious. It spreads through direct contact via blood, bodily fluid, skin or mucous lesions or respiratory droplets.

It can also spread though bites and scratches. Studies have shown that the virus can stay on surfaces but it is not spreading in that way or in a public setting. The risk of airborne transmission appears low.

Myth 7: Mpox is deadly

Fact: While mpox lesions can look similar to smallpox lesions, mpox infections are much milder and are rarely fatal. That said, symptoms can be severe in some patients, needing hospitalisation and, in rare cases, result in death. It is, however, painful and very unpleasant. So, it is important to avoid infection.

Myth 8: Mpox is sexually transmitted

Fact: You can become infected though close, direct contact with the lesions, rash, scabs or certain bodily fluids of someone who has mpox. Even though this could imply transmission though sexual activity, it is not limited to that.  You can also be exposed if you are in close physical proximity to infected people, such as spouses or young children who sleep in the same bed.

Myth 9: I can’t protect myself from getting Mpox

Fact:  You can take precautions: Avoid handling clothes, sheets, blankets or other materials that have been in contact with an infected animal or person. Wash your hands well with soap and water after any contact with an infected person or animal and clean and disinfect surfaces. Practice safe sex and use personal protective equipment (PPE) when caring for someone infected with the virus.

Myth 10:  You can’t stop other people being infected by you

Fact: You may not protect them by 100% but you can isolate. Also, alert people who have had recent contact with you.  Wash your hands regularly with soap and water or use hand sanitiser, especially before or after touching sore and disinfected shared spaces.  Cover lesions when around other people, keep skin dry and uncovered (unless in a room with someone else).

Mpox is a notifiable medical condition but is treatable, if you are concerned, call the DoH toll free number of 0800 029 999 but remember, your GP is your first port of call for all your healthcare needs.

More Monkeypox Antibodies with Childhood Smallpox Vaccination

Mpox (monkeypox) virus. Source: NIH

In a study published in Cell Host & Microbe, scientists studied the sensitivity of MPXV, the virus that causes mpox (formerly monkeypox) to neutralising antibodies (NAbs) generated after infection with the virus and/or vaccination with IMVANEX. They found that those who had been born before 1980 had more antibodies in response to either IMVANEX vaccination or mpox infection, highlighting the lasting protection of smallpox vaccination.

The IMVANEX vaccine has been used as pre- and post-exposure prophylaxis in high-risk populations, but its effectiveness is not yet well characterised. To analyse the sensitivity of the virus, a team of scientists led by Pasteur Institut developed two cellular tests to quantify neutralising antibodies, using either the attenuated virus as a vaccine (MVA) or an MPXV strain isolated in a recently infected individual.

In 2022-2023, an unprecedented epidemic of 87 000 cases of mpox occurred in non-endemic areas, affecting people with no direct link to travel in Central or West Africa, where the virus has historically been present. MPXV is mainly transmitted to humans by rodents, with human-to-human transmission occurring via respiratory droplets or close contact. Symptoms are less severe than those of smallpox, and the case-fatality rate is lower. MPXV is still circulating at very low levels in non-endemic areas, which is why it is important to improve characterisation and analyse the immune response of people infected with the virus or vaccinated with IMVANEX, the third-generation vaccine currently available, initially developed for smallpox.

The large number of sera analysed provided good statistical power, meaning that the analysis could be narrowed to subgroups of patients based on various criteria such as age.

The study demonstrated the role of complement, already known for other poxviruses, and the neutralising activity of the antibodies generated by infection or vaccination. Robust levels of anti-MVA antibodies were detected after infection, vaccination with the historic smallpox vaccine, or administration of IMVANEX or another MVA-based vaccine candidate. MPXV was minimally sensitive to neutralisation in the absence of complement. The addition of complement from sera enhanced detection of individuals with antibodies and increased their level of anti-MPXV antibodies. Four weeks after infection, anti-MVA and -MPXV NAbs were observed in 94% and 82% of individuals, respectively. Two doses of IMVANEX generated anti-MVA and -MPXV NAbs that were detectable in 92% and 56% of vaccinees, respectively.

The highest level of antibodies was found in individuals born before 1980 (who had therefore been vaccinated for smallpox), whether after infection or after administration of IMVANEX, highlighting the impact of historic smallpox vaccination on immune responses to infection or administration of IMVANEX. This suggests that a sort of hybrid immunity was generated in infected individuals who were vaccinated in childhood.

The number of MPXV infections has been constantly on the rise since mass vaccination for smallpox was discontinued in the 1980s. “The neutralisation assays developed in connection with this research may help define correlates of protection against infection or disease severity. The assays can also be used to conduct epidemiological surveys, assess the duration of protection conferred by previous infection or by authorised and candidate vaccines, and analyse the use of immunotherapeutic intervention. The assays represent useful tools to understand the mechanisms of multiplication of MPXV and its effects on public health, and to optimsze patient treatment,” commented Olivier Schwartz, Head of the Institut Pasteur’s Virus and Immunity Unit and last author of the study.

Source: Institut Pasteur