Mpox is nothing new to Africa yet there is no vaccine available on the continent, exposing rank inequity in global distribution as tens of richer nations inoculate people facing far less risk.
Experts say that inequality - alongside competing health problems and slow regulation - is putting millions of Africans in jeopardy, after scientists found the virus was now mutating fast, leaping from person to person and stealing over borders.
"The lack in the distribution of mpox vaccines in Africa is due to challenges in supply, funding, and infrastructure, and because the disease is less prevalent compared to other health priorities," Duduzile Ndwandwe, a scientist at the South African Medical Research Council (SAMARA), said in emailed comments.
Mpox had been circulating in the Democratic Republic of Congo since January last year but only became a grave concern this January when scientists spotted the worrying, new mutation.
Two mpox vaccines made by Denmark's Bavarian Nordic and Japan's KM Biologics used to combat a 2022 outbreak have been widely available in at least 70 countries outside Africa - even administered for free in some US and European clinics.
But before Nigeria received 10,000 doses from the United States this week, no mpox vaccine was available - in any country - in Africa, and the variant now circling vulnerable, displaced populations in DRC is even more virulent than previous strains.
'A SERIOUS EPIDEMIC'
Mpox, formerly known as monkey pox, has been a public health problem in parts of Africa since 1970, but received little global attention until an international outbreak in 2022.
It typically causes flu-like symptoms, pus-filled lesions and can kill. Protection costs about $100 a person.
Jimmy Whitworth, professor of epidemiology at the London School of Hygiene and Tropical Medicine, described the new variant, clade 1b pox, as "fairly lethal".
"This appears to be from sexual contact that it's spreading, and this time it is going from person to person," Whitworth said. "There's now a need to raise it to the priority list because this is a serious epidemic."
Since January 2023, there have been more than 27,000 suspected cases and 1,100 deaths in Congo, according to government figures, mainly among children.
The viral infection has spread from DRC to 12 neighboring countries, leading the World Health Organization (WHO) to designate the outbreak a public health emergency.
Many African nations are struggling to meet the challenge.
Whitworth said the $100 needed to distribute a dose of the vaccine is prohibitive for governments who must quash multiple threats - measles, malaria, cholera - with limited budgets.
"It is a huge expense to vaccinate just DRC. If you asked people in DRC last year what the higher priority was, 'was it the measles or mpox vaccine?' They would have said 'measles vaccine'. And so would anybody else in public health because that was a bigger threat then," the epidemiologist said.
National regulations are also a problem.
Despite the severity of the mpox crisis and the risk of it spreading across DRC's borders, local regulators only approved a vaccine in June with no date yet set for distribution.
WHY THE DELAY?
In 2022, two mpox vaccines, along with public health campaigns against risky behavior, effectively controlled an outbreak that had hit 100 countries globally.
But African countries have so far remained underserved, with efforts only now ramping up to bolster their protection.
Africa Centers for Disease Control and Prevention (Africa CDC) said it had been granted 9.34 million euros ($10.43 million) in emergency funding from the Africa Union for its mpox response and it said it would need 10 million doses of vaccines.
Bavarian Nordic said it can make 10 million doses of its vaccine by end-2025 and offered 2 million doses this year.
The WHO gave its partner agencies, including global vaccine organization Gavi and UNICEF, the go-ahead to buy mpox vaccines pre-approval to speed their delivery to Africa.
DRC had expected to receive its first vaccines in the week of Aug. 26 after the United States and Japan both promised deliveries, but has since said it would take longer.
European Union countries have also pledged donations to help Africa fight the current outbreak.
Whitworth said regulators in Rwanda, Burundi, Uganda and Kenya, all countries where cases have been detected, should approve vaccines urgently without waiting for a full outbreak.
"The vaccine isn't even licensed in those countries," said Whitworth. "Those countries ... need to speed up the process."
WEAK HEALTH SYSTEMS
Even pre-mpox, Congo's health system was at breaking point - weighed down by epidemics of measles and Ebola and years of conflict - and campaigners say short-term fixes won't work.
Katharina Schroeder from Save the Children said long-term investment in social welfare and healthcare infrastructure were vital to prevent future outbreaks, with many remote health centers lacking basic testing kits or trained staff.
"The health centers outside the city need to be equipped to triage patients ... because often they're looking for things like gloves and masks," Schroeder said.
Save the Children has been training staff on the disease, but even when diagnoses are successfully sped through, few sick patients can then afford to isolate for the mandated four weeks.
"They understand this is mpox, they understand this is dangerous for their family. But they still don't go into isolation because they live day by day. They don't have enough to eat," Schroeder said.
