Mpox: Coordination, Collaboration, Planning And Finance For Equity Required

30th August 2024

A statement from the Right Honourable Helen Clark and the active former members of The Independent Panel for Pandemic Preparedness and Response:

Given the mpox emergency, stakeholders including the World Health Organization headquarters and regional offices, the Africa Centres for Disease Control and Prevention, international and regional health actors and those who can finance the response must ensure a co-ordinated and transparent plan to protect people’s lives and stop the spread of mpox.

The Independent Panel will be monitoring the ongoing response to the mpox outbreak carefully, to draw lessons and provide constructive inputs. Our bottom-line interest is in the health and welfare of people everywhere. 

People can be protected and the spread of mpox stopped if health organizations, countries and wider stakeholders work in solidarity, with equity at the heart of the response. We recognize the complexities of these outbreaks which involve different virus clades, affected populations, and countries experiencing humanitarian crises. 

We recommend a systematic approach to the response, grounded in lessons from the inequitable Ebola, COVID-19 and 2022-2023 mpox experiences. The list below is not exhaustive, but rather highlights the areas that must be of priority in order not to repeat the mistakes that have led to preventable suffering and death from previous public health emergencies of international concern.

We insist this is not a time to learn more lessons, but instead to apply them. We call for:

1. An inclusive coordination mechanism with clear roles and responsibilities that are transparently communicated. The political and strategic health response must be well coordinated between the World Health Organization (WHO), its regional offices and the Africa Centres for Disease Control and Prevention (Africa CDC). Given the lack of a reformed coordination mechanism since the COVID-19 emergency, the existing “ACT-A” may be what is available from which to build. The role of each stakeholder including the ‘i-MCM-net’ should be made very clear.

Coordination for the mpox response must incorporate lessons from the ACT-A review, and the partnership must expand to include members who represent the interests of the people most affected by the mpox outbreak, through a whole-of-government and whole-of-society approach. This can include, for example, mpox experts, health equity experts, and civil society organisations that work in affected countries, including on issues of maternal and child health, with gay, bisexual and other men who have sex with men, are involved in the HIV response or deliver humanitarian aid in the region.

Financial institutions including the African Development Bank, IMF and World Bank should be at the table, but equity must remain the driver.

Communication must be transparent, published regularly, aligned across stakeholders and clearly state challenges and needs.

2. WHO and the Africa CDC, with partners, must ensure an agile, evidence-based, integrated, costed global and regional health response plan that includes clear global, regional and country level costing and provisions for rapid adaptation to changing outbreak dynamics. The plan must, inter alia, account for the funding and technical assistance required to implement primary public health measures in partnership with communities, equitably access required medical countermeasures and their delivery, support the considerable research required to understand the dynamics of the different mpox clades, and ensure equitable access to point of care diagnostic tools and effective vaccines and treatments.

3. Donors must step up together with affected countries and fund the plan; and all potential funding avenues should be fully explored. Given that the 2014 - 2016 Ebola outbreak had a $53 billion economic and social cost, the required investment in the mpox response will likely pale in contrast to the potential costs of mpox spread throughout Africa and to other continents.[i]

The funds most recently pledged are a far cry from the needs, including the $135 million WHO has published is required for international support for the next six months and the eventual Africa continental plan to ensure country needs are met.[ii]

Gavi and the relevant donors must also examine the extent to which it can use the reportedly $1.8 billion COVAX AMC funding that remains to contribute to the overall mpox response- a significant sum that was intended to be used for the COVID-19 response.[iii] The African Development Bank, IMF, World Bank and other international financial institutions must urgently explore options.

This current scramble for funds is a major reason why The Independent Panel recommended the establishment of an emergency surge finance mechanism – a recommendation which is highly relevant right now.

While the potential role for vaccines in the response is currently severely limited by lack of availability and transparency, Gavi has indicated that it can deploy its new US$500 million First Response Fund towards vaccine-related investments and purchases. CEPI has ongoing investments in mpox vaccine research of around $100 million.[iv][v][vi]

4. The most urgent focus and investment on the ground must be on rolling out and intensifying basic public health measures. It is clear that existing diagnostics cannot be immediately scaled, the vaccines available are insufficient in number and will take time to deploy, and there currently is no proven treatment.

The spread and harm of mpox can and must be reduced by public health measures that are tailored to the affected communities and to the transmission patterns of the local outbreak. This includes support to health facilities and health workers, and investment in community risk communication and engagement to ensure people understand the risks of both zoonotic infection and human-to-human transmission, are encouraged to adjust behaviours sustainably, and feel supported to be tested, receive care and participate in possible pre- or post-exposure vaccination trials. Focus on reduction of stigma and discrimination is essential. Trusted civil society organizations and patient organizations, including those working on HIV, must be identified and engaged. In addition, laboratory capacity for PCR testing and surveillance must continue to be increased. As it is known that uncontrolled HIV is a significant risk factor for poor outcomes of mpox, efforts to diagnose and provide access to HIV treatment should be intensified.

5. Vaccines, a global common good during a public health emergency, are an essential tool to help stop these outbreaks. WHO’s Strategic Advisory Group of Experts on Immunization has reviewed and made recommendations on three mpox vaccines.[vii] Vaccines were effective in helping to contain the 2022-2023 mpox outbreaks in wealthy countries. However, mpox vaccines have remained unavailable in the most-affected countries in Africa. In order to start rolling out effective vaccination, transparency in vaccine availability and the equitable distribution of existing and future vaccines are urgently needed.

Vaccination plans must be evidence-based and designed according to public health needs. Early estimates by the Africa CDC indicate the African continent alone will require at least ten million doses. It will require far more if mpox spreads continent-wide. To date about one-tenth of that amount has been publicly pledged by different countries and manufacturers, and reports say Japan is prepared to provide a significant 2-3 or more million doses.[viii] We commend Spain’s initiative of donating 500,000 doses, or 20% of its stockpile.[ix] We urge that pledges are readily translated into vaccines delivered to countries. 

In the spirit of equity and solidarity, countries with stockpiles or purchase options must immediately donate doses for deployment where they are most needed. While donations are not sustainable and are not a substitute for local vaccine manufacturing capacity, they are required today to kickstart the emergency mpox response.

Ensure fair and transparent vaccine prices. While prices paid by different purchasers remain shrouded in secrecy, the published price per vaccine dose ranges from $50 - $100.[x][xi] This is expensive according to any standard, and unaffordable for the most- affected countries in Africa. There is no room for health emergency profiteering and all producers should offer fair and transparent prices. Given the Bavarian Nordic vaccine was developed with over US$500 million in US-government support, the company should lower the price to near product costs in the context of the international health emergency response.[xii][xiii][xiv]

Accelerate WHO emergency use listing (EUL). WHO could have opened the EUL process for mpox countermeasures much earlier, but now that it is underway, we call on all responsible to make the process as smooth and rapid as possible. Regulatory processes and requirements must be streamlined for speed and simplicity, including to ensure Gavi and UNICEF can readily purchase products that have been approved by a WHO-listed Authority operating at maturity level 3 or above.

Transfer the technology to increase the number of producers and doses available globally. Bavarian Nordic has stated it is working to expand manufacturing in Africa. We urge full transparency in plans and timing, and full technology transfer to ensure self-sufficiency and resilience, including for other mpox vaccines and in other regions. If needed, countries should also immediately consider compulsory licenses. Gavi must explore how its Africa Vaccine Manufacturing Accelerator can help to finance African mpox vaccine production. 

6. Significant investments in research and development are essential to understand mpox, as well as vaccine effectiveness, including to design evidence-based vaccination strategies. There are major gaps in knowledge about mpox, the virus and its clades, its genetic diversity and evolution, and its transmission routes and dynamics. Similarly, research is needed to better understand vaccine safety and effectiveness in different target groups including children, pregnant women and immunocompromised individuals, and in different epidemiological contexts. New treatments and point-of-care diagnostics must be developed, and as needed better vaccines, and all must be developed with affordable and equitable access in mind from the start. Significant investments are required, and we encourage research funding to be prioritised for Africa-based researchers. 

7. All countries must ensure their own preparedness and response to mpox and follow the WHO guidance including on travel and trade. Countries must be ready to detect cases and care for those people, while carefully communicating about the evidence and risks to the general population. At-risk including vulnerable groups must have access to the information and protective tools they need. People will be prone to misinformation, and stigma and discrimination could badly affect the response. All people must have the information they require to take appropriate measures, and to support fellow citizens who are most at risk.[xv]

Notes:

[i] Caroline Huber, Lyn Finelli, and Warren Stevens, “The Economic and Social Burden of the 2014 Ebola Outbreak in West Africa,” The Journal of Infectious Diseases 218, no. suppl_5 (November 22, 2018): S698–704, https://doi.org/10.1093/infdis/jiy213.

[ii] “Mpox Global Strategic Preparedness and Response Plan,” accessed August 29, 2024, https://www.who.int/publications/m/item/mpox-global-strategic-preparedness-and-response-plan.

[iii] “Gavi Board Meeting, 6-7 June 2024,” June 17, 2024, https://www.gavi.org/governance/gavi-board/minutes/6-7-june-2024.

[iv] “BioNTech and CEPI Announce Partnership to Advance mRNA Mpox Vaccine Development and Support CEPI’s 100 Days Mission | CEPI,” accessed August 19, 2024, https://cepi.net//biontech-and-cepi-announce-partnership-advance-mrna-mpox-vaccine-development-and-support-cepis-100.

[v] “Bavarian Nordic and CEPI Partner to Advance Mpox Vaccination in Africa | CEPI,” accessed August 19, 2024, https://cepi.net//bavarian-nordic-and-cepi-partner-advance-mpox-vaccination-africa.

[vi] “New Clinical Trial Will Assess If Mpox Vaccination Works after Virus Exposure | CEPI,” accessed August 19, 2024, https://cepi.net//new-clinical-trial-will-assess-if-mpox-vaccination-works-after-virus-exposure.

[vii] “Vaccines and Immunization for Monkeypox: Interim Guidance, 16 November 2022,” accessed August 19, 2024, https://www.who.int/publications/i/item/WHO-MPX-Immunization.

[viii] “Mpox Vaccine Tracker: Millions Pledged, Millions Still to Be Delivered | Think Global Health,” Council on Foreign Relations, August 27, 2024, https://www.thinkglobalhealth.org/article/mpox-vaccine-tracker-millions-pledged-millions-still-be-delivered.

[ix] “España Aportará 100.000 Viales de La Vacuna de Mpox a África Con Dosis Para 500.000 Personas,” accessed August 29, 2024, https://www.sanidad.gob.es/gabinete/notasPrensa.do?id=6503.

[x] “WHO Emergency Listing Urgent for DRC Mpox Outbreak,” SciDev.Net (blog), accessed August 29, 2024, https://www.scidev.net/global/opinions/who-emergency-listing-urgent-for-drc-mpox-outbreak/.

[xi] “Mpox Global Strategic Preparedness and Response Plan.”

[xii] “WHO Emergency Listing Urgent for DRC Mpox Outbreak,” SciDev.Net (blog), accessed August 29, 2024, https://www.scidev.net/global/opinions/who-emergency-listing-urgent-for-drc-mpox-outbreak/.

[xiii] “News | Bavarian Nordic,” accessed August 19, 2024, https://www.bavarian-nordic.com/investor/news/news.aspx?news=5560.

[xiv] “News | Bavarian Nordic,” accessed August 19, 2024, https://www.bavarian-nordic.com/investor/news/news.aspx?news=6584.

[xv] “First Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Upsurge of Mpox 2024,” accessed August 25, 2024, https://www.who.int/news/item/19-08-2024-first-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-upsurge-of-mpox-2024.

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