加布里埃爾·伊曼紐爾 / 2024 年 10 月 8 日 / 不斷變化的世界中的生活故事/ 山羊和蘇打水（註）
天花和mpox是相關疾病－消滅前者無意中為後者創造了機會。左圖：1884 年的一幅插圖描繪了一
名婦女臉上和手上的天花膿皰。右圖：一張 1997 年的照片顯示了一名婦女的手掌，她在剛果民主
共和國爆發mpox 期間感染了mpox。 CDC/Image Point FR/BSIP/Universal Images Group（來自
Getty Images）
這一切都始於 1970 年一次去奶奶家的平淡無奇之旅。9個月大的孫子生病了。首先是發燒。然後，
出現令人討厭的皮疹。驚慌失措的醫生懷疑是天花，但他們很快就發現了更令人困惑的事情：第一
個已知的人類猴痘病例，現在稱為mpox。這個孩子是零號病人。
今天，距離剛果民主共和國偏遠角落發生的那起病例已經過去 50 多年了，同樣的病毒正讓公共衛生
專家們手忙腳亂。今年迄今，15 個非洲國家已出現 3 萬多例疑似 MPOX 病例，使往年總數相形見絀
。這種激增促使一些人重新審視 MPOX 的歷史。
「猴痘於 1970 年被發現，現在到了 2024 年，它的發病率急劇上升，一路上發生了什麼」？八月，烏
干達衛生部長簡‧魯思‧阿森 (Jane Ruth Aceng) 在剛果共和國布拉柴維爾舉行的世界衛生組織區域會
議上問道。
回顧過去，研究人員現在發現，mpox 的起源與對抗天花有著千絲萬縷的關係。
「我們接種了天花疫苗並消滅了它。但你看，隨之而來的是：mpox」。Aceng說道。
天花和mpox 密切相關，對其中一種病毒的免疫力有助於抵抗另一種病毒。當天花疫苗接種終止時，
世界對天花的免疫力消失了，對抗痘病毒所需的醫療訓練也開始消失。
這是一個關於意想不到後果的故事，以及如何戰勝天花意外地為mpox創造了機會。專家表示，研究
mpox的歷史可以為我們提供寶貴的經驗教訓，讓我們了解病毒是如何變化的，我們的醫療工具箱是
如何變化的，以及人們可以採取哪些措施來重新戰勝病毒。
根除天花如何為mpox鋪路
醫生不知道在前往祖母家的那次不幸的旅行中孫子是如何感染上mpox的。儘管他的祖母住在距離剛
果民主共和國首都大約一周路程的地方，但男孩的醫生確保將小男孩的瘡痂送到莫斯科進行分析。
這就是MPOX診斷的地方；這種病毒自 1958 年以來就已為人所知，但此前人們認為僅會感染猴子。
孫子的皮疹引起了全球的關注，因為當時人類正接近一項重大成就：消滅天花，該病毒僅在 20 世紀
就奪走了數億人的生命。
1968 年，貝南康托努，全球消滅天花工作人員正在為一群當地居民接種疫苗。
（史密斯收藏/加多/蓋蒂圖片社拍攝 / 檔案照片）
「這是人類最偉大的勝利之一」，約翰霍普金斯大學彭博公共衛生學院的流行病學家和國際衛生專家
威廉·莫斯博士說。
為了證明天花真的消失了，科學家需要調查每一個看起來像天花的皮疹。
莫斯說，正是由於對天花進行了「非常密集的監測」，男孩的mpox病例才被確診。其他很快就開始蔓
延的mpox病例也是如此。
當時，病毒的確切來源讓科學家感到困惑：是否是與猴子接觸？或者也許是另一種森林動物？科學
家確實知道的是，mpox 在生物學上與天花有關。它們屬於同一病毒家族。
研究可疑皮疹的病例調查人員很快就意識到，感染mpox的人沒有接種天花疫苗。例如，9個月大的
孩子是家中唯一沒有接種天花疫苗的孩子，也是唯一感染mpox的孩子。一年前，當一支流動天花疫
苗接種小組駛過小鎮時，他還沒出生。
公共衛生專家很快就意識到，在沒有天花感染和疫苗接種的世界中，沒有人會對mpox產生免疫力。
在停止接種天花疫苗之前，他們權衡了這種風險。
「總體建議是，不需要 [天花] 疫苗接種 [來預防MPOX]」，加州大學洛杉磯分校菲爾丁公共衛生學院流
行病學教授、MPOX 首席研究員 Anne Rimoin 說。
一方面，他們沒有看到mpox這是一個很大的威脅。 「人與人之間傳播的可能性很低，」里莫安說。
研究人員推測，mpox 來自與森林動物的接觸，「當時的總體前景是，隨著城市化，接觸野生動物的
機會會降低」，她說。
此外，天花疫苗的效果也遠非理想。莫斯說：「人們可能會死於天花疫苗。」他指出，它含有活病
毒，不適合免疫系統較弱的人。
在 1978 年的一份病例報告中，世界衛生組織得出結論：「有證據顯示，這種 [mpox] 罕見且散發的疾
病傳播性不強，似乎不是一個公共衛生問題」。
因此，天花疫苗接種被停止。在剛果民主共和國，這種情況在 20 世紀 80 年代初期結束。一代容易
感染mpox的兒童來到了這個世界。
天花的關聯
很快進到 2022 年，然後又到 2024 年，世界衛生組織宣布 MPOX 為「國際關注的突發公共衛生事件
」，這是其最高警報級別。
「善行難免受到懲罰，對吧？」，里莫安說。
2010 年，她在《美國國家科學院院刊》上發表了一項研究，記錄了隨著天花免疫力的減弱，mpox病
例如何「急劇增加」。許多專家認為，缺乏天花免疫力是當前疫情中大多數病例和死亡都是因為年
齡太小而沒有天花免疫力的兒童的原因之一。
TOPSHOT – 2024 年 8 月 17 日，戈馬北部尼拉貢戈綜合轉診醫院之mpox 治療中心的診室外，病
人正在聽取醫生的診治。自今年年初以來，剛果民主共和國已報告約 16,000 例病例，是疫情的焦
點和中心，世界衛生組織 (WHO) 於週三啟動了國際最高級別的警報。南基伍省衛生部門流行病學
家 Justin Bengehya 博士表示，南基伍省每週記錄約 350 例新病例。北基伍省首府戈馬則幾乎被
武裝叛亂包圍，數十萬流離失所者擠在臨時營地中，人們擔心混亂會導致疫情大規模蔓延。（照片
由 GUERCHOM NDEBO/法新社透過 Getty Images 拍攝）
然而，里莫安認為停止接種天花疫苗的法令「絕對」是正確的選擇。 「你可以將這些資源用於其他
疫苗、其他健康問題。把 [天花] 從你的清單上劃掉，轉向其他事情」，她說道。
其他人也同意。 「這絕對是正確的決定」，美國疾病管制與預防中心前首席醫療官米奇·沃爾夫博士
說。
但是，里莫安承認，世界現在正在為這項決定付出代價。
mpox 發生了怎樣的變化？
除了全球免疫力的喪失之外，自從MPOX被發現以來，MPOX的情況還發生了三個重大變化——但基
本上被忽視了。
首先，病毒本身發生了變化。
世界衛生組織 1978 年關於 MPOX 是一種「傳染性不高的罕見且散發的疾病」的評估中的幾乎所有內
容都已不再正確。
傳統上，一個人在接觸受感染的野生動物（通常是小囓齒動物）後會感染mpox。如今，它很容易從
一個人傳播到另一個人，通常是透過密切接觸——例如在家庭中共用床單——或透過性接觸。這意
味著病毒可以比以前傳播得更遠、更快。
城市化會減少野生動物之間的互動從而消滅這種病毒的想法現在被證明是荒謬的。相反，剛果民主
共和國衛生部報告首都金薩沙已有 500 多例病例。 「這是我們非常擔心的事情，」非洲疾病管制與
預防中心主任 Ngashi Ngongo 博士說，他指出金薩沙是一個大城市，而且人滿為患。「這使得它非常
容易快速擴張」。
第二個大變化？關鍵的醫療技能已經喪失。
當消滅天花運動如火如荼地進行時，不僅疫苗到達了世界上最偏遠的角落，而且全球各地的工作人
員都接受了注射疫苗、檢測皮疹和收集樣本進行分析的培訓。現在，這些技能已經減弱。
每次關於MPOX的討論，專家都會對缺乏高品質數據表示遺憾。還記得從剛果民主共和國雨林深處送
到莫斯科進行檢測的9個月大嬰兒的痂嗎？現在證明這種類型的機動非常具有挑戰性。
「大多數收集這些標本的人都沒有接受過培訓，不了解什麼是優質標本，」非洲疾病預防控制中心
總幹事讓·卡塞亞 (Jean Kaseya) 博士說。他說，事實證明，運輸過程中的標本收集和正確儲存是主要
挑戰。
同樣，疫苗接種技能也已喪失。許多mpox疫苗最初是針對天花開發的。大多數天花疫苗都接種了一
種用特殊的針刮擦皮膚，在上臂留下著名的疤痕的方法。這與日本 MPOX 疫苗使用的技術相同，這
是目前剛果民主共和國批准用於兒童的唯一疫苗。在剛果民主共和國推廣該疫苗的障礙之一是需要
大量的培訓工作。
「這是一項相當熟練的技術，[教授這項技能] 需要時間。幾十年來，[它]一直沒有被用於疫苗接種計
畫」，負責世衛組織突發衛生事件計畫的邁克·瑞安博士說。
而且，事情發生的最後一個變化是：世界合作的胃口已經萎縮。
約翰霍普金斯大學的莫斯表示，「目前幾乎難以想像」根除天花運動期間所進行的國際合作。這需
要跨越戰區和政治分歧的協調。
儘管目前非洲的MPOX疫情已經獲得了美國、歐洲和日本的大量捐款，但許多人認為，缺乏合作至少
是導致當前疫情爆發的部分原因。
非洲疾病預防控制中心的卡塞亞說：「我們正在與我們的合作夥伴、來自西方國家的同事進行交談，
我們告訴他們，他們也應對非洲發生的情況負責」。
他說，2022年mpox爆發期間，世界只關心在歐洲和美國傳播的mpox病毒株，而對於中部非洲的
mpox病毒株，「他們沒有進行研究。他們沒有進行研究……（關於當前疫情的）百分之八十的未知
數是因為我們的同事和合作夥伴不想看到正在發生的現實」，他說。
「我們並不是責怪他們，而是告訴他們真相，」卡塞亞說。
是時候復興天花疫苗了嗎？
自從做出停止接種天花疫苗（甚至MPOX）的重大決定以來，發生了許多變化。里克·布萊特認為現
在是重新考慮這項決定的好時機。
曾領導美國生物醫學高級研究與發展中心的布萊特表示，他希望看到一場關於是否「再次開始為民
眾、全球民眾接種疫苗，以確保我們都受到保護，免受MPOX和天花以及我們可能看到的其他衍生物
的侵害」。
布萊特指出，在過去的幾十年裡，天花和mpox疫苗變得更加安全。 mpox 病毒無疑已經證明了其進
化和廣泛傳播的能力。
然而，他很快承認，任何大規模疫苗接種工作都不會立即發生。目前，沒有足夠的MPOX疫苗劑量來
應對當前的MPOX疫情，更不用說將其添加到常規疫苗接種清單中了。
約翰霍普金斯大學的莫斯不太確定大規模疫苗接種是否可行，因為MPOX尚未在一般人群中廣泛傳播
。 「我仍然認為它更具針對性，無論是高風險人群還是空間上」，他說。這就是剛果民主共和國採
取的方法，重點關注熱點地區以及高風險族群，如兒童、醫護人員和性工作者。
他們一致認為，需要大幅增加疫苗的生產和供應，並就需要採取哪些措施來預防痘病毒進行更廣泛
的討論。
註：Goats and Soda NPR：全國公共廣播電台（英語：National Public Radio，縮寫：NPR）是
美國一家獲公眾贊助及部分政府資助、但獨立運作的非商業性媒體機構，成立於1970年2月24日，
開播於1971年4月。 它的總部位於華盛頓哥倫比亞特區，西部總部位於卡爾弗城。而山羊和蘇打水
(Goats and Soda) 是 NPR 的全球健康與發展部落格。部落格講述在不斷變化的世界中的生活故事
，重點關注低收入和中等收入國家（也稱為全球南方國家）。並且牢記，我們都是這個地球村的鄰
居。
The end of smallpox was … the beginning for mpox
Gabrielle Emanuel / October 8, 2024 / STORIES OF LIFE IN A CHANGING WORLD/ Goats and Soda
Smallpox and mpox are related diseases — and the eradication of the former inadvertently creating an opening for the latter. At left: An illustration from 1884 depicts smallpox pustules on the face and hand of a woman. At right: A 1997 photograph shows the palms of a woman who contracted mpox during an outbreak in the Democratic Republic of Congo. Smith Collection/Gado/Getty Images; CDC/Image Point FR/BSIP/Universal Images Group via Getty Images
It all started with an unremarkable trip to grandma’s house in 1970. But two days into the visit, something went terribly wrong.
The 9-month-old grandson fell ill. First, a fever. Then, a nasty rash. Alarmed doctors suspected smallpox but, instead, they soon discovered something even more bewildering: The first-known human case of monkeypox, now called mpox. The child was patient zero.
Today, more than 50 years after that case in a remote corner of the Democratic Republic of Congo, that same virus is sending public health experts scrambling. So far this year, there have been more than 30,000 suspected mpox cases in 15 African countries — dwarfing previous yearly totals. The surge is prompting some to revisit mpox’s history.
“Monkeypox was detected in 1970 and now it is blowing out of proportion in 2024, what happened along the way?” asked Ugandan health minister Jane Ruth Aceng at a regional World Health Organization meeting in Brazzaville in the Republic of Congo in August.
Looking back, researchers now see that the origins of mpox are inextricably intertwined with the fight against smallpox.
“We vaccinated for smallpox and eradicated it. But look, something came out of that: monkeypox,” said Aceng.
Smallpox and mpox are so closely related that immunity to one helps fight off the other. When smallpox vaccinations were terminated, the world’s immunity to mpox evaporated, and the medical training needed to combat a pox virus started to dissipate too.
This is a story about unintended consequences, and how triumphing over smallpox accidentally created an opening for mpox. Experts say examining the history of mpox carries valuable lessons about how the virus has changed, how our medical toolbox has changed — and what people might do to regain the upper hand over the virus.
How eradicating smallpox paved the way
Doctors don’t know how the grandson contracted mpox on that ill-fated trip to his grandma’s house. And even though his grandma lived about a week’s journey from the DRC’s capital, the boy’s doctors made sure crusts from the little boy’s sores were sent to Moscow for analysis. That’s where the mpox diagnosis was made; the virus has been known since 1958 but had previously only been thought to infect monkeys.
Sponsor Message
The grandson’s rash attracted global attention because, at that moment in time humanity was closing in on a major accomplishment: The eradication of smallpox, a virus that had killed hundreds of millions in the 20th century alone.
Global Smallpox Eradication worker vaccinating a group of local residents, Contonou, Benin, 1968. Image courtesy Centers for Disease Control (CDC). (Photo by Smith Collection/Gado/Getty Images)
Smith Collection/Gado/Getty Images/Archive Photos
“It’s one of humanity’s greatest triumphs,” says Dr. William Moss, an epidemiologist and international health expert at the Johns Hopkins Bloomberg School of Public Health.
In order to prove that smallpox was really, truly gone, scientists needed to investigate every rash that looked like smallpox.
Moss says it was only because of this “very intensive surveillance” for smallpox that the boy’s case of mpox was identified. The same was true for the other cases of mpox that soon started to trickle in. By 1978, there were a total of 36 documented monkeypox cases in humans.
At the time, the exact source of the virus stumped scientists: Was it from contact with monkeys? Or perhaps another forest animal? What scientists did know was that mpox is biologically related to smallpox; they’re in the same family of viruses.
Case investigators studying the suspicious rashes quickly realized that those who got mpox had not been vaccinated against smallpox. For example, the 9-month-old was the only one in his family not vaccinated against smallpox and the only one to get monkeypox. He hadn’t been born yet when a mobile smallpox vaccination team rolled through town a year earlier.
Public health experts soon realized that in a world without smallpox infections and vaccinations, nobody would have immunity against mpox. Before stopping smallpox vaccinations, they weighed this risk.
“The overall recommendation was that [smallpox] vaccination was not needed [to protect against mpox],” says Anne Rimoin, a professor of epidemiology at the UCLA Fielding School of Public Health and a leading mpox researcher.
For one thing, they didn’t see mpox as a big threat. “The potential for human-to-human transmission was low,” says Rimoin. Researchers surmised that mpox came from contact with forest animals “and the overall outlook – in those days – was that with urbanization the chances of exposure to wild animals would be lower,” she says.
Sponsor Message
In addition, the smallpox vaccine was far from ideal. “People could die from the smallpox vaccine,” says Moss, noting that it contained a live virus and wasn’t suitable for those with weakened immune systems.
In a case report from 1978, the WHO concluded: “Evidence is that this [mpox] rare and sporadic disease is not highly transmissible and does not appear to be a public health problem.”
And so, smallpox vaccinations were stopped. In the DRC, they ended in the early 1980s. And a generation of children vulnerable to mpox came into the world.
The smallpox connection
Fast forward to 2022, and then again to 2024, and the WHO declared mpox a “public health emergency of international concern,” its highest level of alarm.
“No good deed goes unpunished, right?” says Rimoin.
She published a study in PNAS in 2010 documenting how mpox cases have “dramatically increased” as immunity from smallpox has waned. And many experts believe the lack of smallpox immunity is one reason that the majority of cases — and deaths — in the current outbreak are in children who were too young to have smallpox immunity.
TOPSHOT – Patients listen to a doctor outside the consultation room of the Mpox treatment centre at Nyiragongo General Referral Hospital, north of Goma on August 17, 2024. With around 16,000 cases recorded since the beginning of the year, the DRC is the focus and epicentre of the epidemic that led the World Health Organisation (WHO) to trigger its highest level of alert at the international level on Wednesday. The province of South Kivu records around 350 new cases per week, according to Dr Justin Bengehya, epidemiologist at the provincial health division of South Kivu. Goma, capital of the province of North Kivu, almost surrounded by an armed rebellion and where hundreds of thousands of displaced people are crammed into makeshift camps, fears a large-scale spread due to promiscuity. (Photo by GUERCHOM NDEBO / AFP) (Photo by GUERCHOM NDEBO/AFP via Getty Images)
Guerchom Ndebo/AFP via Getty Images/AFP
Yet, Rimoin thinks the edict to stop smallpox vaccinations was “absolutely” the right choice. “You can put those resources towards other vaccines, other health problems. Cross [smallpox] off your list, move on to something else,” she says.
Others agree. “It was definitely the right decision,” says Dr. Mitch Wolfe, former chief medical officer of the U.S. Centers for Disease Control and Prevention.
But, Rimoin acknowledges, the world is now paying the consequences for that decision.
How mpox has changed
In addition to the global loss of immunity, there are three big ways the mpox landscape has shifted since the time mpox was discovered — and largely dismissed.
First, the virus itself has changed.
Just about every piece of the WHO’s 1978 assessment that mpox is a “rare and sporadic disease [that] is not highly transmissible” is no longer true.
Sponsor Message
Traditionally, a person got mpox after handling infected wild animals, often little rodents. Today, it spreads readily from one person to the next, often through close contact — like, say, sharing linens within a family — or through sexual contact. This means the virus can spread much further and faster than before.
The idea that urbanization would reduce wildlife interactions and therefore squash this virus is now proven preposterous. To the contrary, the DRC’s Ministry of Health has reported more than 500 cases in the capital of Kinshasa. “That is something that worries us very much,” says Dr. Ngashi Ngongo, chief of staff at the Africa Centers for Disease Control and Prevention, pointing out that Kinshasa is a big and overcrowded city. “That makes it very prone for rapid expansion.”
The second big change? Key medical skills have been lost.
When the smallpox eradication campaign was in full swing, not only were vaccines reaching the most remote corners of the world but staff all over the globe were trained to give the vaccines, detect the rash and collect samples for analysis. Now, those skills have waned.
Barely an mpox discussion goes by without experts lamenting the lack of high-quality data. Remember the 9-month-old’s scabs that were sent from deep in the DRC rainforest to Moscow for testing? That type of maneuver is now proving very challenging.
“Most of the people that collected these specimens have not been trained to understand what is a quality specimen,” says Dr. Jean Kaseya, the director general of Africa CDC. He says specimen collection and correct storage during transportation are proving to be major challenges.
Similarly, vaccination skills have been lost. Many of the mpox vaccines were first developed for smallpox. And most smallpox vaccinations were done with a special needle that scrapes the skin, leaving that famous scar on the upper arm. That’s the same technique used for the Japanese mpox vaccine, which is the only vaccine currently approved for kids in the DRC. One of the hurdles to rolling out that vaccine in the DRC is that it will require a major training effort.
Sponsor Message
“That’s quite a skilled technique, and [teaching that skill] will take time. [It] hasn’t been used in vaccination programs for decades now,” says Dr. Mike Ryan, who runs WHO’s Health Emergencies Program.
And, a final way things have changed: The world’s appetite for cooperation has shrunk.
The international collaboration that was present during the smallpox eradication campaign is “almost unimaginable right now,” says Moss of Johns Hopkins. It took coordination across war zones and political differences.
While the current mpox outbreak in Africa has garnered major donations from the U.S. to Europe to Japan, many argue that a lack of collaboration is, at least partly, to blame for setting the current outbreak in motion.
“We are talking with our partners, with our colleagues from Western countries, and we are telling them, they are also responsible for the situation that’s happening in Africa,” says Africa CDC’s Kaseya.
He says during the 2022 mpox outbreak, the world was only concerned with the strain of mpox circulating in Europe and the U.S. When it came to the strain in Central Africa, “they didn’t conduct studies. They didn’t conduct research…Eighty percent of the unknowns [about the current outbreak] are because our colleagues and partners didn’t want to see the reality that was going on,” he says.
“We are not blaming them, but we are telling them the truth,” Kaseya says.
Is it time to revive the smallpox vaccine?
A lot has changed since the fateful decision to stop vaccinating for smallpox — and by extension mpox. Rick Bright believes it is a good time to reconsider that decision.
Bright, who used to lead the U.S. Center for the Biomedical Advanced Research and Development Authority, says he’d like to see a discussion about whether to “begin, once again, vaccinating the population, the global population, with the vaccine to make sure that we are all protected from mpox and smallpox and other derivatives that we might see.”
Bright points out that, in the intervening decades, the smallpox and mpox vaccines have become a lot safer. And the mpox virus has certainly proven its ability to evolve and spread widely.
However, he’s quick to admit, any mass vaccination effort would not happen immediately. Right now, there aren’t enough mpox vaccine doses to address the current mpox outbreak, let alone add it to the routine vaccination list.
Moss, of Johns Hopkins, isn’t so sure mass vaccination is the way to go since mpox has not spread widely in the general population. “I still see it as more targeted, whether it’s a high risk population or spatially,” he says. That’s the approach the DRC has taken, focusing on hotspots as well as populations that are most at risk, like children, health care workers and sex workers.
What they agree on is that there needs to significantly more vaccine production and availability — and a broader discussion about what protection from pox viruses is needed.