
==== Front
New Microbes New Infect
New Microbes New Infect
New Microbes and New Infections
2052-2975
Elsevier

S2052-2975(24)00249-X
10.1016/j.nmni.2024.101465
101465
Editorial
Mpox Clade I outbreak and the first European case ex Africa, in Sweden – A call for global health equity
Askling Helena H. helena.hervius.askling@ki.se
⁎
Center for Health Crises, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
Academic Specialist Centre, Stockholm Health Services, Region Stockholm, Sweden
Gisslén Magnus
Public Health Agency of Sweden, Solna, Sweden
Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Department of Infectious Diseases, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
von Schreeb Johan
Center for Health Crises, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
⁎ Corresponding author. helena.hervius.askling@ki.se
19 8 2024
12 2024
19 8 2024
62 101465© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcMpox belongs to the genus Orthopoxvirus. It is a zoonotic DNA-virus that was first described in monkeys in the 1950s, and in man 1970, and closely related to the now eradicated and strictly human smallpox-virus. Mpox is divided into two main Clades, I and II, based on genetic differences. Before this millennium, disease caused by mpox was mainly sporadic in humans in Central and West Africa, transmitted through rare contact with infected rodents. In West Africa, both Clade IIa and IIb have circulated for years, with mpox cases steadily rising, likely due to the virus's genetic adaptation for human transmission and the waning immunity from smallpox vaccination, which ended in Congo 1980, with some sporadic vaccinations until 1984 [1].

The World Health Organization (WHO) declared a Public Health Emergency of International Concern, PHEIC, in 2022 in response to the fast spreading of mpox Clade IIb outside the African continent. Resources were allocated, and efforts were made to curb the outbreak, including disseminating information, encouraging behavioural changes, and vaccinating at-risk groups. As a result, the spread of the disease decreased significantly, leading to the PHEIC being declared over in 2023. A PHEIC has now been declared once again, this time due to mpox caused by Clade I. Clade Ia has been endemic in Central Africa for long, while the new Clade Ib was first detected in the eastern parts of the Democratic Republic of Congo (DRC) in September 2023. Since late 2023, both these Clades have dramatically increased in the DRC, with Clade Ib recently spreading to neighbouring countries. By August 13, 2024 the Africa CDC declared a Public Health Emergency of Continental Security (PHECS), followed by a PHEIC declared by the WHO on August 14. The disease caused by Clade I appears to be more adapted to humans, suggesting that it may be more transmissible, although this has not yet been definitively confirmed. Unlike Clade I, which may also spread through close household contacts, Clade II, in the recent outbreak outside Africa, spread primarily through sexual contact. A disproportionately high number of children have been affected in the Clade I outbreak, with over 500 reported deaths so far. However, due to the unknown number of unreported cases and deaths, it is difficult to accurately determine the Case Fatality Rate.

The first confirmed case of mpox Clade Ib outside Africa was reported in Stockholm, Sweden, on August 15. The individual had recently travelled to an affected area in Africa and, while not severely ill, is being managed under strict disease prevention protocols, including contact tracing, which were implemented very early by healthcare and national authorities – a crucial measure in preventing further spread. No secondary case has been detected so far. The PHEIC declaration, along with the first reported Clade I case outside Africa, generated significant media attention in Sweden and internationally. While this publicity can help raise awareness, secure funds, and drive positive change, the global community might benefit from some self-reflection on why, despite a previous PHEIC and the increase in Clade I cases nearly a year ago, the urgent need to focus resources in the DRC is only now being emphasized. Earlier attention might have been beneficial. When the previous PHEIC was declared over in 2023, many questions about the evolution of the virus remained unanswered, and there has been an ongoing debate whether the PHEIC was an effective way to manage the outbreak [2]. This situation also underscores the critical need for continuous preventive efforts to strengthen public health and health care systems in low-income countries, where basic health problems often overwhelm health facilities. In the DRC, it is estimated that annually 290,000 children under the age of 5 die each year from treatable conditions such as diarrhea, malaria and measles. Health expenditure per capita in the DRC is just 0.3 % of that in Sweden ($22 versus $6.900 in 2021, according to the World Bank). Additionally, in the DRC, approximately 20 % of children receive none of the basic recommended vaccines, with even higher rates in some areas. Healthcare staff are frequently unpaid and work with very limited resources [3]. The WHO's prioritization of resources to the area is a crucial and commendable effort to help affected countries manage the epidemic, which is the most effective measure to reduce the risk for the rest of the world. However, the recent surge in media attention, as a consequence of a single case outside Africa, raises important ethical considerations regarding the balance of attention and resource allocation. Numerous reports, high-level meetings and conferences have emphasized the critical importance of health and vaccine equity to prevent spread of diseases and, ultimately, future pandemics. Factors such as deforestation, climate change, poverty and the displacement of people into large camps due to conflicts are increasingly bringing humans and wild animals into closer contact, exposing both to new pathogens. The lessoned learned from the Ebola outbreak and the COVID-19 pandemic underscore the importance of health equity and the need for robust epidemiological surveillance, accessible diagnostics, vaccine manufacturing and logistics in resource-limited settings. The WHO's statement that “We are not safe until all are safe” remains as relevant as ever.

Now is the time for the global community to show that it has learned from recent outbreaks by providing the resources needed to control the current situation, including rapid access to sufficient vaccine doses in the most affected areas, building more resilient health systems and allocating enough resources to ensure that children do not die from preventable diseases due to poverty. The declared PHEIC has successfully increased global awareness, which is a positive step; however, it is crucial that we continue these efforts even after media attention fades and the PHEIC is over. Sustained funding and political commitment are essential to maintaining basic healthcare, routine immunizations, maternal health, virological and epidemiological research, clinical vaccine trials and ongoing surveillance of infectious diseases. As Swedish physicians we remain privileged and trust that our health system will manage to contain mpox and remain resilient. However, we insist that much more efforts and resources must be invested in low-income health-care systems to avoid the death of children, in Congo and elsewhere where needed, and to prevent new contagious pathogens to spread. Let's not wait, let's make global health equity happen!
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