Mpox Breakdown: Cash, Strategy, and the Fight Ahead

Mpox cases in Africa have surged by over 160% this year, with 17,000 cases reported across 17 countries, including Burundi, Kenya, Rwanda, and Uganda reporting their first cases. This increase is significant compared to the 7,146 cases reported in 2022 and 14,957 cases in 2023. The Democratic Republic of the Congo (DRC) remains the most severely affected, accounting for 96% of cases and 517 out of 524 deaths.

In response, the Africa Centres for Disease Control and Prevention (Africa CDC) has declared the Mpox outbreak a Public Health Emergency of Continental Security (PHECS), marking its first such declaration since the agency's establishment in 2017. This decision highlights the scale of the current outbreak compared to the initial public health emergency declared in 2022. The rising number of cases and fatalities, particularly among those with high HIV prevalence, underscores the critical need for enhanced public health interventions. This has also led to the World Health Organization declaring it as public health emergency of international concern (PHEIC), highlighting the urgent need for coordinated global and regional responses.

Mpox is spreading rapidly to vulnerable groups, including children, who make up 60% of the cases in the DRC. One of the main risk factors for severe disease and death among persons with Mpox is immune suppression, especially among those with advanced HIV infection.

Given the surge in Mpox cases and the urgent public health declarations by both the Africa CDC and the WHO, a strategic and comprehensive response is essential. The scale of the outbreak and its impact on vulnerable populations highlight the need for coordinated efforts to mitigate the crisis and prevent further spread. Considering these challenges, the Africa CDC has identified nine crucial points that informed their decision-making and will guide their response efforts across the continent.

• Evidence and surveillance gaps: there is a significant limitation in the available evidence and epidemiological data on Mpox cases. The condition is often mild, leading to limited surveillance, inadequate contact tracing, and incomplete reporting. Consequently, the information that is available only partially reflects the true situation.
• Escalating burden in Africa: the burden of Mpox in Africa has significantly increased. The number of cases is now three times higher than when the WHO declared it a Public Health Incident of Concern (PHIC) in 2022. The current situation is markedly worse than it has been over the past two years.
• Rising case numbers: the number of reported cases is on the rise, and this upward trend is cause for serious concern.
• High case fatality rate: the case fatality rate (the proportion of diagnosed cases that result in death) is alarmingly high, ranging from 3-4%. This is higher than anticipated and exacerbated by the high prevalence of HIV in the region, which contributes to increased fatalities.
• Emergence of new cases and transmission: new countries are now reporting cases, with evidence suggesting significant human-to-human transmission rather than solely zoonotic spread. This raises concerns about cross-border contamination and the need for enhanced containment measures.
• Need for coordinated response: there is an urgent need for greater coordination in response to efforts to enhance the effectiveness of interventions.
• Limited vaccine access: vaccine access is currently limited, and the benefits of vaccination remain unclear due to its general use. A strategic approach is necessary, focusing on high-risk individuals such as healthcare workers and those with high exposure risk.
• Diagnostic challenges: there is insufficient diagnostic capability, as evidenced by the Democratic Republic of the Congo (DRC), where clinical cases are reported without corresponding lab results for over half of the cases. Improving diagnostic availability is crucial for effective public health measures, including case identification, contact tracing, and isolation.
• Response plan development: the Africa CDC is committed to developing a comprehensive response plan to address these challenges and improve the overall management of Mpox.

The ongoing rise in Mpox cases underscores the urgency for enhanced response measures and continued support for research and development. The Africa CDC’s key points highlight critical areas where increased efforts are needed, including improving surveillance, expanding diagnostic capabilities, and securing effective vaccines and treatments. Considering these needs, it is important to understand the financial landscape supporting Mpox R&D.

In its first year of recorded funding, Mpox R&D received a total of $79 million. Of this amount, $10.5 million (13%) was allocated to basic research, and $1.2 million (2%) went towards diagnostics. Nearly half of the total funding, $36 million (46%), was invested in drug R&D. The remainder of the funds was divided between vaccine development ($28m, 36%), basic research ($10m, 13%) and biologic development ($82k).

Over three-quarters of Mpox funding was provided by the US NIH ($55m, 84%), with almost all funding coming from the US government - US BARDA ($6.2m, 9%), US CDC ($0.5m, 1%), and other public funders in HICs, including the UK NHS ($3.5m, 5%) and the Canadian CIHR ($0.5m, 1%),

US NIH funding mostly went to vaccines ($27m, 49%) and drugs ($27m, 48%). Drug funding from the US NIH was focused on late-stage trials of tecovirimat - a repurposed smallpox drug, while majority of vaccine funding went towards Phase II trials evaluating alternative administration strategies for the JYNNEOS vaccine. The US NIH was the sole funder of Mpox diagnostics and biologics R&D in 2022.

In light of the ongoing efforts to combat Mpox, it’s important to understand the current treatment options available:

• JYNNEOS®, a third-generation vaccine based on the Modified Vaccinia Ankara virus, is approved for preventing smallpox and Mpox and has been the primary vaccine used in the US during the Mpox outbreak since 2022. Approved by the FDA in 2019 and recommended by the CDC's Advisory Committee on Immunization Practices (ACIP) for those at risk, JYNNEOS is favoured for its safety profile.
• In contrast, ACAM2000®, a second-generation vaccine based on live vaccinia virus, is also approved for smallpox but is not used for Mpox due to its risks for immunocompromised individuals. This underscores the need for safer alternatives, with newer vaccines still in development.

Both JYNNEOS and ACAM2000 are recommended by WHO’s Strategic Advisory Group of Experts on Immunization and have Emergency Use Authorization in countries like Nigeria and the DRC. The WHO is facilitating Emergency Use Listing to allow access in lower-income countries and support procurement by Gavi and UNICEF.

Repurposed smallpox treatments such as tecovirimat and brincidofovir are being investigated for Mpox, though large-scale efficacy trials are still needed. As Mpox cases escalate, the combined focus on funding, strategic response, and ongoing research will be key to navigating this complex challenge. Addressing these critical areas effectively will be essential for advancing our fight against Mpox and safeguarding global health.

To explore funding for Mpox R&D, visit our G-FINDER data portal here.

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