In response to the mpox outbreak, declared a PHEIC by WHO and a PHECS by Africa CDC, the two organisations announced that they are co-leading a “coordinated, continent-wide response”. The Mpox Continental Preparedness and Response Plan for Africa describes “essential priorities” to control the current outbreak, focusing on ten pillars. The plan categorises Member States into four risk-based groups to ensure efforts and resource allocation are targeted. The estimated budget for September 2024 to February 2025, excluding the cost of vaccines, is US$599,153,498
Collective commitment
In the foreword by Africa CDC Director General Dr Jean Kaseya and WHO Africa Regional Director Dr Matshidiso Moeti, the declaration of mpox as a PHECS is described as a “bold move”. This was followed by WHO’s declaration, reflecting “alignment” and “collective commitment to raising awareness, mobilising resources, and galvanising action at all levels”. Drs Kaseya and Moeti state that current “battle” against mpox has been shaped by “hard-earned lessons” from the COVID-19 pandemic.
“The experience of COVID-19 exposed vulnerabilities in our health systems, showed Africa’s inequity and unfair treatment in terms of access to medical countermeasures, highlighted the urgent need for enhanced preparedness, and underscored the importance of swift, coordinated action in the face of emerging health threats.”
The “foundation” of the mpox response is built on lessons of “solidarity, resilience, and collaboration”.
4-ONE
A new approach is outlined: a “4-ONE APPROACH”:
- ONE coordination mechanism
- ONE continental response plan
- ONE budget
- ONE monitoring and evaluation mechanism
Africa CDC and WHO will lead efforts to implement the “unified approach” with global and continental stakeholders. The plan is a “roadmap” to facilitate a “coordinated, comprehensive, and evidence-based response” that puts the principles of “equity, inclusivity, and accountability” at the centre.
“As we move forward, we are guided by our strong commitment to protecting the health of all Africans, enhancing our collective resilience, and securing a healthier future for our continent. Together, we will overcome this challenge and build a stronger and resilient Africa.”
Mpox: then and now
Mpox was first described in the Democratic Republic of Congo (DRC) in 1970. It is a viral zoonotic illness that has caused “numerous outbreaks” since its identification. Although early outbreaks tended to be associated with zoonotic transmission from wildlife to humans, recent cases in urban settings have suggested changes in transmission dynamics.
“The emergence of zoonotic diseases is driven by complex ecological, climatic, political, economic, security, and social factors, some of which are becoming further exacerbated on the continent.”
However, the “warning signs” of local outbreaks are often “neglected” with “limited investigation, surveillance, diagnosis, and response”. Despite improvements in surveillance and reporting systems to enhance the understanding of mpox’s epidemiological patterns, “significant gaps” remain. Mpox virus has two variants: clade I and clade II. Clade I is geographically concentrated around the Central and Eastern Africa region and is considered “more virulent”; Clade II is found in Western Africa and other regions.
In the global outbreak of 2022-2023, the disease spread drew “renewed focus” on medical countermeasures. While many countries outside Africa were “quick to respond”, Africa faced “significant challenges in accessing these crucial tools”. Despite the high burden of mpox in several countries in Africa, access to vaccines and other medical countermeasures was inequitable.
“This lack of access was due to multiple factors, including limited global production capacity, unequal distribution agreements, and a lack of investment in public health infrastructure in Africa.”
Vaccines like JYNNEOS (MVA-BN) and ACAM2000 were widely authorised for emergency use but were “largely unavailable to African countries”. The authors of the plan attribute this to pre-existing contracts between manufacturers and high-income countries. Furthermore, logistical challenges exacerbated the disparity; “inadequate” cold chain storage facilities and distribution networks” created obstacles to the delivery of countermeasures.
“This inequity underscored the urgent need for Africa to develop self-reliance in manufacturing and distributing medical countermeasures to avoid similar scenarios.”
The current situation is concerning; reported cases are increasing in number across the continent. In comparison with 2022, there was a 79% increase in reported cases in 2023. By 3rd September 2024, confirmed cases have exceeded the number reported in 2023 by over 3,700. Furthermore, the recent outbreak has “dramatically” affect children under 15 years (60%). In 2024, 13 countries have reported cases, with a new subvariant of mpox clade I (clade Ib) identified since September 2023. This has been ‘widely circulating” among commercial sex workers and their sexual contacts.
While the increasing cases are worrying, the “true burden” is uncertain. Thus, the authors demand enhanced surveillance and detection. They also highlight the need for vaccination of both targeted and expanded priority population groups, particularly in the context of Africa’s “weaker surveillance systems and limited diagnostic capacity”.
“The Mpox Continental Preparedness and Response Plan for Africa (MCPRPA) seeks to build a stronger foundation for health security in Africa through a country-driven unified approach, prioritising prevention, enhancing immunity at community level, and promoting the continent’s self-reliance.”
Risk categories
The plan classifies African Union Member States according to their mpox status and risk level. The risk level is for “planning and resource optimisation”.
- Experiencing sustained human-to-human transmission: DRC, Burundi, Nigeria, South Africa, Côte d’Ivoire, Central Africa Republic
- Not already falling into category 1 but experiencing sporadic human cases since 1st January 2022 and/or countries that are assessed as having endemic zoonotic reservoirs for mpox: Rwanda, Kenya, Uganda, Sierra Leone, Libera, Ghana, Cameroon, Gabon, Republic of Congo, Morocco, Egypt, Benin, Mozambique, Sudan
- Not already falling into the first two categories that are assessed as requiring readiness including due to proximity to category 1 countries by land, air, or sea: Angola, Zambia, Eswatini, Lesotho, Ethiopia, South Sudan, Tanzania, Malawi, Republic of Guinea
- All other countries
Guiding principles
The plan relies on guiding principles from lessons learnt during the COVID-19 pandemic; the align with the 2023 Lusaka Agenda, which emphasises “strengthening joint approaches for achieving equity in health outcomes, operational coherence, and a coordinate approach to product development and research”.
- Country-driven: The plan focuses on mpox preparedness and response interventions based on priorities identified by affected countries to ensure that the response is tailored to the needs of each country.
- Science-driven: The strategic approaches and key interventions are grounded in the best available scientific evidence, ensuring that the response is effective and adaptive to the evolving understanding of the virus and its transmission.
- Equity and solidarity: Prioritisation of issues and resource allocation should be sensitive to the needs of the most affected regions/provinces, vulnerable groups, and countries most in need. This is supported by global solidarity, ensuring that medical countermeasures are made available to African Member States equitably.
- Unified: Align all partners around a single cohesive plan, ensuring that all stakeholders work toward common objectives, minimising duplication and maximising impact.
- Single collaboration mechanisms: Streamline efforts through coordinated leadership.
- Sustainability: Focus on developing sustainable, long-term solutions that can be scaled and maintained over time, ensuring that countries are better prepared for future outbreaks and that response efforts have a lasting impact.
10 pillars
The plan has 10 pillars, each with a strategic objective and actions.
- Coordination and leadership
- Strategic objective – establish one functional coordination mechanism with one team, one plan, one budget, and one monitoring and evaluation (M&E) framework at continental, national, and subnational levels.
- Actions – enhance harmonised coordination and collaboration between relevant stakeholders including resource mobilisation.
- Risk communication and community engagement (RCCE)
- Strategic objective – support and engage communities, particularly the most vulnerable members, so that they practice key public health recommendations and access the needed services to reduce transmission, morbidity, mortality, and secondary impacts.
- Actions – engage communities in public health response and ensure their perspective and realities drive the mpox response interventions.
- Surveillance
- Strategic objective – establish/enhance functional event-, community-based-, and cross-border mpox surveillance systems at continental, national, subnational levels.
- Actions – strengthen mpox surveillance through event/community-based surveillance, contact tracing, point of entry, and cross-border information sharing.
- Laboratory capacity
- Strategic objective – strengthen mpox laboratory testing and sequencing capacity to confirm at least 80% of suspected mpox cases and sequence at least 5% of epidemiologic and geographic representative confirmed mpox cases.
- Actions – strengthen laboratory testing for diagnostic and sequencing through training and provision of equipment and reagents.
- Case management
- Strategic objective – support comprehensive case management for mpox, including medical, nutritional, and psychosocial care, to reduce the case fatality rate to below 1% (0.5%).
- Actions – strengthen case management for mpox.
- Infection prevention and control
- Strategic objective – strengthen infection prevention and control measures at 80% of health facilities and schools in hotspots of mpox-affected and at-risk Member States to minimise the risk of mpox transmission.
- Actions – strengthen infection and prevention control measures at households, schools, health facilities, and communities.
- Vaccination
- Strategic objective – support the administration of mpox vaccination to 80% of the targeted population.
- Actions – vaccination of targeted and expanded high-risk population groups is a proactive measure to address the delayed responses that can occur due to weaker health systems, weaker surveillance systems, and limited diagnostic capacity. This would build population resilience, reduce the public health impact of mpox, and prevent healthcare systems from becoming overwhelmed. Mpox vaccination will be implemented in two phases. In the first phase, vaccines will be administered to the exposed group of contacts and the contacts of contacts and the expanded group of those at risk. In the second phase, consideration could be given for affected communities, depending on progress in epidemiology and vaccine availability.
- Research and innovation
- Strategic objective – coordinate and conduct mpox operational and clinical research across the continent to address critical knowledge gaps and support response efforts, and coordinate and enhance research and development (R&D) for the manufacturing of countermeasures to ensure rapid deployment during outbreaks.
- Operations support and logistics
- Strategic objective – provide robust operational support, ensuring the safety and security of response staff, maintaining key infrastructure and ensuring the efficient procurement and distribution of essential supplies.
- Actions – ensure robust support by developing standards for mpox supplies, coordinating demand forecasts, enhancing supply transparency and implementing fair allocation, strengthening logistics, and maintaining supply chain integrity for equitable distribution.
- Continuity of essential services
- Strategic objective – advocate for and support Member States to monitor the implementation of basic services ensuring continuity to avert loss of gains.
Budget
The plan also details “key resource requirements” for the first six months of operations. The estimates assume an initial case load of 2,000 cases per week, which increases to 4,000 cases per week in the first two months of operations. This is expected to continue through the fourth month, after which cases might decrease. The total estimated number of suspected cases is 92,000 over the first six months. Vaccine procurement costs are excluded from budget estimates as these depend on the outcome of “ongoing negotiations” with manufacturers.
The overall estimated budget for the six-month plan is US$599,153,498. Of this, 53% (US$315,311,463) are assigned to mpox outbreak response effort in the 13 affected Member States. 2% (US$14,000,000) will support the 15 high risk, non-affect Member States with emergency preparedness and 45% (US$269,842,035) will go toward partners’ operational and technical support.
Monitoring and evaluation
The monitoring and evaluation of the plan are centred on a results-based management approach, ensuring capture and analysis of key performance results information and dissemination for management decision-making, reporting, and stakeholder use.
- Input and output monitoring will be ensured through reporting tools developed by the incident management system (IMS). Periodic and ad-hoc joint support supervision visits will take place and internal review mechanisms will be used to ensure the correctness, completeness, and timeliness of monitoring data.
- The Continental incident management team (IMT) will conduct periodic evaluations of the plan.
- Data collection will be shared with the Continental IMT, which has the primary mandate for its monitoring.
Will this approach be sufficient to control the outbreak and establish mechanisms for future health threats on the continent? For expert insights into equitable vaccine development and deployment, get your tickets to join us at the Congress in Barcelona this October, and don’t forget to subscribe to our weekly newsletters here.
