Co-authors: Lior Miller, Megan Coffee, Tamara Chikhradze, and Mesfin Teklu Tessema
Since the Africa Centres for Disease Control and Prevention (Africa CDC) and the World Health Organization (WHO) respectively declared mpox a Public Health Emergency of Continental Security and a Public Health Emergency of International Concern (PHEIC) in August, the international community has mobilized to call for comprehensive surveillance, increased access to diagnostics and treatment, and accelerated access to vaccines in the affected countries. This marks the first time that the Africa CDC has used its expanded powers to declare a public health emergency, representing an important milestone for continental leadership.
The epicenter of the outbreak is the Democratic Republic of Congo (DRC), which is currently experiencing the world's largest mpox outbreak with over 34,000 suspected cases involving two distinct strains: clade Ia, which is predominantly affecting children in western DRC, and clade Ib, a new variant which is spreading rapidly in the eastern region. The outbreak has spread to countries that previously had no cases, including Burundi, Kenya, Rwanda, and Uganda. There is also evidence of intercontinental spread to Sweden, India, and Thailand.
While mpox is endemic to the DRC, the new form, clade Ib, is of particular concern because it appears to spread more easily from person to person. Cases are surging in eastern DRC, where a humanitarian crisis has left nearly 5.5 million internally displaced people without basic necessities such as safe water, sanitation, hygiene, and healthcare services. The outbreak is concentrated in communities that have experienced successive infectious disease epidemics, including Ebola, cholera, and COVID-19 alongside armed conflict, displacement, social unrest, and the impacts of climate change. This is creating tinderbox-like conditions conducive to the resurgence of mpox and other neglected infectious diseases. These factors have further eroded trust in authorities and health systems.
Available data from affected countries suggest that familiarity with mpox is low and that misinformation, conspiracy theories, and rumors about how it is spread are common, contributing to lower vaccine acceptance attitudes and increased hesitancy about seeking health care.
Understanding the mpox epidemic as a polycrisis, exacerbated by climate change, conflict, concurrent humanitarian crises, and displacement, is therefore essential for not repeating the mistakes of past epidemic responses. Focusing solely on technocratic solutions like diagnostics, vaccines, and treatments will not be sufficient. While equitable access to vaccines is essential, vaccination, which requires community trust, acceptance, and demand, is what saves lives. Our responses need to be designed around the beliefs, attitudes, and needs expressed by affected families and communities. The following recommendations, aligned with the Africa CDC and World Health Organization’s joint Mpox Continental Preparedness and Response Plan for Africa will help address key drivers of the outbreak, and contribute to future preparedness and resiliency. These recommendations emanate from underlying issues that the International Rescue Committee (IRC), countries, and the global health community have repeatedly faced in responding to past and ongoing outbreaks, and the solutions that we have on hand that we know from experience are needed and will work.
Strengthen community engagement and trust, including through empowering and protecting community health workers (CHWs) and other frontline health care workers as the first line of detection, risk communication and community engagement strategies, and service delivery.
CHWs and other frontline health care workers, known and trusted by their communities, play key roles in responding to pandemics such as mpox including through community education and raising community awareness, addressing stigma, case detection, contact tracing, providing essential health services and referring clients for additional facility-based health care services. CHWs are also cost-effective, with an estimated 10:1 return on investment for every dollar invested in them.
The IRC supports over 16,000 CHWs across 33 community health worker programs in 24 countries. We train and support CHWs to prevent and respond to pandemics and epidemics. CHWs help bring essential services closer to communities in hard-to-reach areas. For example, trained CHWs are using risk communication and community engagement techniques to raise awareness about mpox and address rumors and misinformation in IDP camps in the DRC, with support from the IRC.
However, there is a global shortage of CHWs and other human resources of health, and the majority of CHWs are unpaid volunteers who are not integrated into the formal health sector. The seminal Monrovia Call to Action is galvanizing momentum to invest in community health programs and ultimately ensuring that everyone has equitable access to health services. The IRC is leading efforts in researching user-centered models for CHW recruitment, remuneration and support. We are developing a CHW policy that will ensure evidence-based, standardized and sustained efforts to strengthen CHW-led PHC programs that are integrated within national health ecosystems.
Institute innovative vaccination approaches and partnerships to reach displaced people in humanitarian settings.
To reach underserved communities in humanitarian settings affected by conflict and climate change, the IRC-led Reaching Every Child in Humanitarian Settings (REACH) Consortium, the first time Gavi has directly funded and supplied humanitarian partners, is employing innovative approaches to reach children under five with routine vaccination services for common, but serious diseases in the Horn of Africa including in Ethiopia, Somalia, South Sudan, and Sudan with expansion to Chad underway. REACH’s unique partnership model with civil society, local, and humanitarian partners is effectively reaching children that are beyond the reach of government systems with vaccination services. By engaging the full range of delivery partners in conflict-affected communities, including NGOs, is helping to deliver vaccinations in missed communities.
REACH has successfully negotiated humanitarian access and forged local partnerships to reach communities that were previously inaccessible, a key milestone for equitable vaccination. Using conflict-sensitive programming has helped to understand evolving community norms, preferences, and barriers and to strengthen community trust, decrease vaccine hesitancy, and increase acceptance. Geo-spatial mapping helped to understand pockets of need and displacement and to use these data to respond with agility and flexibility. The project has instituted cross-border operations, underscoring the need for a regional approach to planning vaccine delivery and rollout.
After two years, the REACH Consortium has successfully reached communities previously not covered by routine immunization, delivering over 2.1 million key vaccination doses in conflict-affected settings and placing over 650,000 children on the path to full immunization.
The REACH project can serve as a model for delivering vaccinations and other preventive services in fragile and humanitarian contexts where mpox cases are surging and during other disease outbreaks.
Strengthen infection, prevention, and control capacity at the primary care level.
Health systems, particularly those at the primary health care level, need to be adequately prepared and resourced to prevent and control infectious disease outbreaks, reduce health care-associated infections, and combat antimicrobial resistance. Infection, prevention, and control (IPC), a package of practical, evidence-based, and cost-effective solutions to prevent or stop the spread of infection, is not only a proxy for the overall quality of health programs but is a core component of achieving global health security. Indeed, mpox and public health emergencies before it, including COVID-19 and Ebola, spread partly because of weakened primary health care systems. Comprehensive IPC within health facilities protects patients and health care workers, yet only 15.2% of health care facilities globally meet IPC minimum requirements. IRC has an ambition to ensure that by 2027, 80% of supported facilities meet IPC minimum standards. We are already seeing progress; since 2020, 20% more of IRC-supported health facilities are meeting these standards.
Alongside IPC in facilities, community-based interventions to increase access to clean water, adequate and reliable sanitation, and to boost basic hygiene practices such as handwashing can reduce disease exposure and transmission in vulnerable households and communities. This is particularly vital for IDPs and refugees, as people living in displacement settings often grapple with overcrowding and challenging environments that make it hard to implement and practice preventive actions. As part of IRC’s emergency response to mpox in the DRC, IRC and its partners have strengthened community hygiene in IDP sites through the delivery of hygiene kits and other IPC measures.
Commit to a stronger global health security architecture.
Pandemics such as mpox are ultimately political, and as such, effective preparedness and response requires good governance, binding accountability mechanisms, and significant, predictable, and sustainable financial resources. We also know that the quality of governance and the resources available to governments and global health institutions are pivotal in determining how harmful public health crises like pandemics can become and how effectively they can respond in a coordinated and effective way.
Donors and governments have collectively pledged $1 billion for mpox response in Africa, which is a robust and promising start. However, only slightly over half of the estimated 10 million vaccine doses needed have been pledged, and only a limited fraction of those have been delivered. There needs to be greater equity in sharing of global public goods such as vaccines and reliable diagnostics, including expanded capacity for local manufacturing to reduce reliance on stockpiles in donor countries. The Pandemic Fund, established in 2022 to provide dedicated, long-term financing for pandemic prevention, preparedness, and response in low- and middle- income countries, fast-tracked US$128.89 million to 10 countries impacted by mpox in Africa; a step in the right direction for increasing capacity for strengthening disease surveillance, laboratory capacity, workforce preparedness, and coordination.
This summer, a landmark package of amendments to strengthen the International Health Regulations was agreed upon by the World Health Assembly; there now needs to be continuous oversight and accountability to ensure their implementation. Negotiations for a Pandemic Accord, focused on equitable pandemic preparedness and response, continue and should be adopted before 2024 comes to a close, following the recommendations of the Independent Panel for Pandemic Preparedness and Response.
With climate change, we can expect to see the introductions or spillovers of zoonotic infections as animals and people come into more frequent contact, particularly in fragile and conflict-affected settings that are already under-resourced. This latest outbreak presents an opportunity to learn from effective community-driven responses in humanitarian settings, such as the REACH project, in order to build trust in vaccination and other services, access hardest-to-reach communities, and through a strengthened global health security architecture, enhance resilience and preparedness for future outbreaks.