World Health Organization (WHO) director general Tedros Adhanom Ghebreyesus has now officially declared monkeypox a public health emergency of international concern (PHEIC). The decision comes after the global health body’s International Health Regulations Emergency Committee on the disease failed to reach a consensus on the declaration at the end of its second meeting in less than a month. Between the meetings, the number of confirmed cases worldwide rose from 3,040 across 47 countries to more than 16,000 in 75 countries and territories, and the number of deaths rose from one to five, according to the WHO.

Before a PHEIC was declared, Matshidiso Moeti, WHO regional director for Africa, told Scientific American that earlier action would have drawn additional attention to the disease and spurred countries to assess the risks and be better prepared. She added that it would also have made more funding and resources available to African countries—where monkeypox has been endemic for decades—to respond to the disease.

An earlier declaration had the potential to “trigger additional attention from all countries, and possibly then trigger the availability and the allocation of additional resources at the global level that might be available to African countries,” Moeti said. “It places an obligation on some of the entities that control some of the tools available to provide support.”

Tedros thinks it isn’t too late, however. In his PHEIC declaration, he said that “with the tools we have right now, we can stop transmission and bring this outbreak under control.”

In the Democratic Republic of the Congo (DRC), additional resources could have helped expand response efforts to many provinces that had suspected cases but were not being supported by current partners, according to Justin Masumu, dean of the faculty of veterinary medicine at DRC’s National Pedagogical University.

Moeti noted to Scientific American that the WHO is working with African countries and has been providing all available support. But Christian Happi, director of African Center of Excellence for Genomics of Infectious Diseases, disagrees with some aspects of the WHO’s handling of the monkeypox outbreak, describing them as shameful. According to him, there was no talk of using the world’s stockpile of smallpox vaccine for monkeypox when cases were only being reported in African countries.

“But today, [now] that they have [monkeypox] in the Global North, they’re now mobilizing stuff, and it’s a shame [for] the WHO to do that,” he says.

According to a spokesperson for the WHO, the organization “continues to work closely with the ministries of health and the laboratory networks in the African region, and supports the countries that have been reporting cases of monkeypox in the last few years such as Nigeria, Democratic Republic of the Congo, Central African Republic and Cameroon.”

Stretched, Finite Resources

In Nigeria, monkeypox reemerged in 2017 after nearly 40 years of no confirmed cases. While the number of confirmed cases in the country dropped from a previous peak of 88 in 2017 to just eight in 2020, as of July 17, 2022, the case count has reached 117, according to the Nigeria Center for Disease Control (NCDC).

NCDC’s director general Ifedayo Adetifa says the Nigerian government has initiated an emergency response to the current monkeypox outbreak and has had surveillance in place since 2017. But he admits that limited resources pose a challenge to the country’s ability to simultaneously respond to multiple disease outbreaks. “We have limited, finite resources that are all being competed for by varying priorities,” Adetifa says. “We continue to deal with everything—Lassa fever, cholera, measles, yellow fever, monkeypox [and] COVID—as the case requires, regardless of what the headlines are focused on,” he says.

Testing Gaps

Several African countries continue to provide daily updates on the state of the COVID pandemic. But such updates are not available for monkeypox, and a major reason for this is the gap between the number of suspected and confirmed cases. From January 1 to July 8, there were a total of 2,087 suspected monkeypox cases on the continent, of which only 203 were confirmed. This wide gap has been attributed to the paucity of testing kits and ingredients such as reagents.

“While all African countries have the polymerase chain reaction machines needed to test for monkeypox, thanks to reinforced laboratory capacity in the wake of COVID-19, many lack reagents and, in some cases, training in specimen collection, handling and testing,” Moeti told Scientific American. She said the WHO is working to secure 60,000 tests for Africa, of which about 2,000 tests and reagents will be shipped to high-risk countries—such as the DRC—that account for about 80 percent of suspected cases on the continent.

Masumu notes that because of inadequate testing, the true magnitude of the monkeypox outbreak in the DRC is not yet known. “What is true is that what we know is not the reality,” he says. “We don’t analyze all the suspected samples. We should have many more cases in the field that are not recorded.”

Vaccine Inequity

Critics have highlighted inequity in the distribution of COVID vaccines as one of the reasons for their low uptake in Africa. A similar trend is already occurring with the distribution of smallpox vaccines, which also protect against monkeypox, according to the Africa Centers for Disease Control and Prevention (Africa CDC).

Had a PHEIC been declared sooner, Moeti noted, African countries could have had access to additional tools, including unapproved vaccines for the disease. But Ahmed Ogwell Ouma, acting director of the Africa CDC, revealed in a press briefing on July 21 that there are no smallpox vaccine doses on the continent.

In sharp contrast, the U.S. government has already distributed more than 191,000 doses of vaccines in response to monkeypox. On July 15 it added 131,000 doses of Bavarian Nordic’s JYNNEOS monkeypox vaccine to its stockpile, and 786,000 more doses are expected by the end of the month. The country also has about 100 million doses of ACAM2000, a Food and Drug Administration–licensed vaccine for smallpox that also works against monkeypox but has side effects and should not be used in immunocompromised people. (The U.S. response to monkeypox has not been perfect, however.)

A similar vaccination rollout is also underway in the U.K., which has recently acquired an additional 100,000 vaccine doses to continue its selective vaccine strategy—an approach that aims to interrupt “transmission in the subset of individuals at increased risk,” according to the U.K. Health Security Agency. This includes gay, bisexual or other men who have sex with men.

Happi argues that while a prompt emergency declaration backed with a holistic approach to tackle the disease everywhere would have been a sound public health strategy, the current inequity will further put global health at risk.

“Our lives are not the same; their lives are worth more than ours,” Happi says, referring to people in African nations versus those in wealthy Western countries. “But unfortunately for them, because you think you’re [only] neglecting some other people, you will keep having the disease in your backyard, you will keep struggling with it. Any outbreak anywhere should concern the whole world, [which is] not how they are dealing with it now.”

The Bigger Picture

Happi believes that the current impasse should drive Africa to rally behind the Africa CDC to meet the continent’s public health emergency response needs. “The reason why people are reckoning with Africa CDC is because [the agency is] very pragmatic. [It’s] very impactful,” he says.

The Executive Council of the African Union agrees. At a recent meeting, it adopted an amended statute of the Africa CDC that empowers the health agency to declare public health emergencies of continental security concern even when the WHO doesn’t declare a PHEIC. The WHO initially pushed back against this amendment because of its concern that such a declaration could potentially result in travel restrictions similar to the travel bans that were announced when South Africa’s genomic surveillance network first reported the Omicron variant of SARS-CoV-2, the virus responsible for COVID-19.

Similarly, Karim Tounkara, regional representative for Africa at the World Organization for Animal Health, says that in order to have a better response to monkeypox and other zoonotic diseases, African countries need to prioritize prevention. And this can be done by countries better appropriating the “One Health” approach that treats human, animal and environmental health as interconnected and paying more attention to wildlife monitoring to prevent future outbreaks.

“We encourage all countries to do everything possible to strengthen the capacity for early detection and early response,” Tounkara says. In addition to improving testing among the population, he says, attention should be given to strengthening the capacity of veterinary diagnostic laboratories because “it will always be better to tackle the disease from the animal sources.”