www.thelancet.com/infection Vol 24 November 2024 / 2024 年 9 月 10 日線上發表 https://doi.org/10.1016/ S1473-3099(24)00577-2
非洲MPOX發生率不斷上升，導致非洲疾病管制與預防中心宣布針該大陸安全之首次公共衛生緊急事件，並促使世衛組織發布全球最高衛生警報——國際關注的公共衛生緊急事件（PHEIC） 。 這凸顯了疫情的特殊性、對其他國家的公共衛生風險以及應採取協調一致的國際應對措施的迫切需求。
2022 年，當世界衛生組織在全球爆發MPOX 後宣布其為國際關注的公共衛生緊急事件（PHEIC）時，非洲國家報告了來自13 個國家的不到1,300 例確診病例，其中剛果民主共和國和奈及利亞報告了非洲大陸實驗室確診病例數最多的情況。隨著全球病例數隨著時間的推移大幅下降，特別是在北半球國家，PHEIC 於 2023 年 5 月解除。相較之下，非洲國家由於實驗室確認能力低下，疑似病例數增加了78·5%，從2022年的約8,000例增加到2023年的約15,000例。截至 2024 年 8 月，非洲大陸已報告超過18,000例疑似病例（其中確診病例5,000餘例），死亡病例600餘例，較2023年同期增加160%。
剛果民主共和國仍然是疾病的流行中心，佔新病例和死亡人數的 96% 以上。該病毒已在 26 個省份中的 22 個省份傳播，大多數確診病例為 10 歲以下兒童。 2023 年 3 月，剛果民主共和國報告了首例在同性戀、雙性戀和其他男男性行為者中出現的 I 型 MPOX 病例，在2023 年9 月至2024 年8 月期間，據報道，北基伍省和南基伍省的成年異性戀者和女性性工作者的性網絡中出現了持續的MPOX 人際傳播鏈，這是由新描述的I 進化枝變體引起的病毐株，現在稱為進化枝 Ib。
2024年7月初，由於剛果民主共和國東部人口流動，Ib型mpox分支跨越邊境，導致蒲隆地、肯亞、盧安達和烏干達等從未報告過一例mpox病例的國家出現300多例mpox病例。 自2024 年初以來， IIb 分支mpox 也在南非重新出現，已有24 例確診病例和3 例死亡，在晚期HIV 疾病人群中發病率和死亡率較高。2024 年，其他非洲國家報告了 100 多例確診的 MPOX 病例，包括象牙海岸、奈及利亞、中非共和國和剛果共和國等。然而，與剛果民主共和國一樣，由於報告不足和確診不足的挑戰，這些病例數被認為是嚴重低估的。
需要迫切了解非洲MPOX的激增、從人畜共通相關疾病朝向性傳播和社區傳播轉變的傳播動態、向新國家的跨境傳播、以及隨之而來的兒童和愛滋病毒感染者的發病率和死亡率，需要在受影響最嚴重的國家與全球夥伴關係中進行緊急理解和採取跨領域介入措施。
檢測率低（特別是在剛果民主共和國），以及非洲普遍存在的病例漏報現象，要求實施加強和主動的監測活動，包括針對正式和非正式醫療機構之城市和偏遠農村地區人口，根據尋求醫療保健的行為、性交易熱點地區以及性傳播感染 (STI) 診所（如果有的話）積極地發現病例。入境口岸的監測和健康教育對於預防、發現和遏制進一步跨境傳播至關重要，但不應實施旅行限製或煽動污名。實驗室能力需要加強和大量投資，以提高診斷的 PCR 檢測率，特別是在剛果民主共和國，並能夠開發和部署具有成本效益的治療現場檢測和移動實驗室，以便於偏遠地區和衝突地區的 MPOX 診斷。
自 1970 年剛果民主共和國報告第一例人類 MPOX 病例以來，54 年後，人們對非洲 MPOX 的自然史、傳播動態和風險因素的了解仍然存在差距。迫切需要進行多國合作研究來解決這些知識差距，包括非洲第一分支型和第二分支型之mpox的性傳播程度以及它與傳統mpox的不同之處，人畜共通和人際傳播之間的相互作用， HIV和其他性傳播感染、水痘帶狀皰疹病毒感染、麻疹和瘧疾等合併感染的發生率、自然感染後的保護期、MPOX的長期後遺症等。
所有受影響的非洲國家仍缺乏與 mpox 相關的醫療對策，例如疫苗和治療方法，估計需要超過 1000 萬劑，而非洲大陸僅提供 260–360 萬劑，主要透過來自全球合作夥伴捐贈。最近世界衛生組織緊急使用mpox疫苗清單以及奈及利亞和剛果民主共和國對mpox疫苗的監管批准，有望有助於促進非洲國家疫苗的取得和使用。然而，要實現 2025 年生產 1,000 萬劑的目標，需要更多的財政資源和疫苗製造商的承諾。非洲領導人必須將當地資源投入這項努力中，並努力擴大區域製造能力，同時利用全球合作夥伴提供所需的支援。疫苗接種計畫應針對最脆弱的人群，並應納入社區參與，並就疫苗保護期限的不確定性進行明確溝通，以及其他促進人群可持續接受疫苗的宣傳等相關介入措施。非洲疫苗的推廣必須包括對該大陸的疫苗有效性和功效試驗，以揭示特定情況下的疫苗接種結果（如果有的話）。
在剛果民主共和國的第I 型mpox 進化枝個體中，與標準照護相比，替考維馬 (tecovirimat)在縮短MPOX 皮損消退時間方面總體上缺乏臨床益處，因此需要對非洲的IIb 進化枝進行類似的療效試驗，以及開發和測試治療該疾病的新藥。 PALM（Pamoja Tulinde Maisha：一起拯救生命）007 試驗顯示，接受高品質支持性照護的住院治療可將參與者的死亡率大幅降低至1·7%，而剛果民主共和國目前報告的死亡率為3· 6%。該研究強調了對基本藥物（如止痛藥、退燒藥、抗菌藥物、皮膚損傷照護用品和靜脈輸液）的可用性和可及性的迫切需求，以確保高品質的臨床照護。這些藥物對於控制 MPOX 患者的症狀、減少併發症和降低死亡率至關重要。
客製化的社區外展活動以進行疾病預防和控制教育，需依賴疾病傳播動態的準確資訊。與 2022 年流行病相比，實驗室和分子流行病學可能有助於準確了解不同的傳播模式、臨床表現和受影響人群。公共衛生工作必須適應當地情況，以解決不信任、文化差異和錯誤訊息。社區領袖、高危險群和倖存者的參與至關重要。隨著疫苗接種活動的開展，社區參與將是確保接種疫苗和控制 MPOX 傳播的關鍵。優先考慮這種方法可以促進合作、減少恥辱並最終改善健康結果。
由於國際傳播的風險以及全球協調努力的必要性，世界衛生組織將最近在非洲爆發的mpox 列為國際關注的公共衛生緊急事件。最近在瑞典和泰國發現了與旅行相關的I 型分支病例，這是非洲以外的首次報告，顯示I 型分支MPOX 有可能從非洲傳播到世界其他地區，讓人想起2022 年全球II 型分支的疫情。現在正是全球團結和建立夥伴關係的時候了。
本文所表達的觀點是作者的觀點，並不代表其各自組織、國家政府機構或世界衛生組織可能發表的官方立場或聲明。 DO 和 ID 是世界衛生組織國際衛生條例 MPOX 突發事件委員會的現任主席和副主席，JD 是該委員會的成員。 KK 曾於 2022 年 5 月至 2024 年 4 月期間擔任 WHO MPOX 技術團隊成員。
*Krutika Kuppalli、Jake Dunning、Inger Damon、Daniel Mukadi-Bamuleka、Placide Mbala、Dimie Ogoina krutika.kuppalli@gmail.com
德州大學西南分校醫學系，達拉斯，TX 75390 9113，美國 (KK)；德州大學西南分校公共衛生學院，美國德州達拉斯（KK）；英國牛津大學流行病科學研究所（法學博士）；埃默里大學醫學系，美國喬治亞州亞特蘭大（ID）；剛果民主共和國金薩沙大學金薩沙醫學院醫學生物學系微生物學服務處 (DM-B)；剛果民主共和國金薩沙國家生物醫學研究所 (PM)；尼日爾三角洲大學/尼日爾三角洲大學教學醫院，巴耶爾薩，奈及利亞（DO）
The worsening mpox outbreak in Africa: a call to action
Flickr/NIAID
www.thelancet.com/infection Vol 24 November 2024 / Published Online September 10, 2024 https://doi.org/10.1016/ S1473-3099(24)00577-2
The escalating incidence of mpox in Africa has led the Africa Centres for Disease Control and Prevention to declare its first-ever Public Health Emergency of Continental Security and prompted WHO to issue its highest global health alert—a Public Health Emergency of International Concern (PHEIC). This underscores the extraordinary nature of the outbreaks, the public health risk to other countries, and the urgent need for a coordinated international response.
In 2022, when WHO declared mpox a PHEIC following the global outbreak, African countries reported fewer than 1300 confirmed cases from 13 countries, with DR Congo and Nigeria reporting the highest number of laboratory-confirmed cases on the continent.4 The PHEIC was lifted in May, 2023, as global case counts dropped substantially over time, especially in the Global North. In contrast, challenged by low capacity for laboratory confirmation, African countries witnessed a 78•5% increase in the number of suspected cases—from roughly 8000 in 2022 to about 15 000 in 2023. By August, 2024, the continent had reported over 18 000 suspected cases (including over 5000 confirmed cases) and over 600 deaths, representing a 160% increase compared with the same period in 2023.
DR Congo remains the epicentre of disease, accounting for over 96% of new cases and deaths. The virus has spread across 22 of the 26 provinces, with most confirmed cases reported among children younger than 10 years. In March, 2023, DR Congo reported its first cases of clade I mpox among gay, bisexual, and other men who have sex with men, and between September, 2023, and August, 2024, sustained chains of human-to-human transmission of mpox were reported among sexual networks of adult heterosexuals and female sex workers in North and South Kivu, caused by a newly described variant of the clade I strain, now referred to as clade Ib.
In the beginning of July, 2024, due to mobile populations in eastern DR Congo, clade Ib mpox crossed the border, leading to over 300 mpox cases in Burundi, Kenya, Rwanda, and Uganda—countries that had never reported a single case of mpox in the past. Since the beginning of 2024, clade IIb mpox has also resurfaced in South Africa, with 24 confirmed cases and three deaths, with high morbidity and mortality among people with advanced HIV disease. More than 100 confirmed mpox cases have been reported across other African countries in 2024, including Côte d’Ivoire, Nigeria, Central African Republic, and Republic of the Congo, among others. However, like in DR Congo, these case counts are considered a gross underestimation due to challenges of under-reporting and under-ascertainment.
Addressing the upsurge of mpox in Africa, the shift in transmission dynamics from zoonotic-related disease to sexual transmission and community transmission, the cross-border spread to new countries, and the attendant morbidity and mortality among children and people living with HIV requires urgent understanding and cross-cutting interventions in the most impacted countries with global partnerships.
Low testing rates, especially in DR Congo, and prevalent under-reporting of cases in Africa calls for the implementation of enhanced and proactive surveillance activities that include active case finding targeting both formal and informal health-care settings, depending on the health care-seeking behaviour of the population in both urban and remote rural areas, hotspots for transactional sex, and sexually transmitted infection (STI) clinics where available. Surveillance and health education at points of entry is essential for prevention, detection, and containment of further cross-border spread, but this should be done without implementing travel restrictions or instigating stigma. Laboratory capacity requires strengthening and substantial investment to improve PCR testing rates for diagnosis, especially in DR Congo, as well as to enable the development and deployment of cost-effective point of-care tests and mobile laboratories for ease of mpox diagnosis in remote areas and conflict zones.
54 years after the first human case of mpox was reported in DR Congo in 1970, there are still gaps in understanding the natural history, transmission dynamics, and risk factors for mpox in Africa.12 Multi country collaborative studies are urgently needed to address these knowledge gaps, including the extent of sexual transmission of clade I and II mpox in Africa and how it presents differently from classical mpox, the interplay between zoonotic and human-to-human transmissions, the role of co-infections such as HIV and other STIs, varicella zoster virus infection, measles, and malaria, among others, duration of protection after natural infection, and the long-term sequelae of mpox.
Mpox-related medical countermeasures, such as vaccines and therapeutics, are still lacking in all affected African countries, with an estimated need of over 10 million doses while just 2•6–3•6 million doses are available for the continent, mainly through donations from global partners.13 The recent WHO Emergency Use Listing of mpox vaccines and the regulatory approval of mpox vaccines in Nigeria and DR Congo should hopefully help facilitate access and uptake of vaccines across African countries. However, more financial resources and commitment from vaccine manufacturers are needed to meet the target of 10 million doses by 2025.13 African leaders must commit local resources to this effort and work to scale up regional manufacturing capacity while simultaneously leveraging global partners to provide the needed support. Vaccination programmes should target the most vulnerable populations and should embed community engagement and clear communication about uncertainties regarding the duration of vaccine protection, among other advocacy-related interventions that promote sustainable population vaccine acceptance. Vaccine rollouts in Africa should necessarily include vaccine effectiveness and efficacy trials for the continent to reveal context-specific vaccination outcomes, if any.
Following the aggregate absence of clinical benefit of tecovirimat in improving time to resolution of mpox skin lesions compared with standard care among individuals with clade I mpox in DR Congo, similar efficacy trials are needed for clade IIb in Africa, as well as the development and testing of novel drugs for the treatment of the disease. The PALM (Pamoja Tulinde Maisha: Together Let’s Save Lives) 007 trial demonstrated that hospitalisation with high-quality supportive care led to a substantially lower mortality rate of 1•7% in participants versus 3•6% as currently reported in DR Congo.14 The study underscores the critical need for the availability and accessibility of essential medications—such as pain relievers, antipyretics, antimicrobials, supplies to care for skin lesions, and intravenous fluids—to ensure high-quality clinical care. These medications are vital for managing symptoms, reducing complications, and lowering mortality rates in patients with mpox.
Tailored community outreach to educate on disease prevention and control relies on accurate information on disease transmission dynamics. Laboratory and molecular epidemiology may be influential to accurately educate on different transmission modes, clinical presentations, and populations affected compared with the 2022 epidemic. Public health efforts must adapt to local contexts to address mistrust, cultural differences, and misinformation. Involving community leaders, at-risk groups, and survivors is vital. As vaccine campaigns roll out, community engagement will be key to ensuring uptake and controlling the spread of mpox. Prioritising this approach can foster cooperation, reduce stigma, and ultimately improve health outcomes.
The recent upsurge of mpox in Africa was declared a PHEIC by WHO because of the risk of international spread and the need for a coordinated global effort. The recent detection of travel-associated clade I cases in Sweden and Thailand, the first reports outside Africa, is indicative of the potential for clade I mpox to spread from Africa to the rest of the world, reminiscent of the 2022 global clade II outbreak.15,16 The time for global solidarity and partnership is now.
The views expressed here are those of the authors and do not represent official positions or statements that may be made by their respective organisations, national government agencies, or WHO. DO and ID are the current Chair and Vice Chair of the WHO International Health Regulations Emergency Committee for mpox, and JD is a member of the same committee. KK was previously a member of the WHO mpox technical team from May, 2022, to April, 2024.DM-B and PM declare no competing interests.
*Krutika Kuppalli, Jake Dunning, Inger Damon, Daniel Mukadi-Bamuleka, Placide Mbala, Dimie Ogoina krutika.kuppalli@gmail.com
Department of Medicine, University of Texas Southwestern, Dallas, TX 75390 9113, USA (KK); School of Public Health, University of Texas Southwestern, Dallas, TX, USA (KK); Pandemic Sciences Institute, University of Oxford, Oxford, UK (JD); Department of Medicine, Emory University, Atlanta, GA, USA (ID); Service of Microbiology, Department of Medical Biology, Kinshasa Teaching School of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo (DM-B); Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of the Congo (PM); Niger Delta University/Niger Delta University Teaching Hospital, Bayelsa, Nigeria (DO)