Intended for healthcare professionals


Monkeypox: Concerns mount over vaccine inequity

BMJ 2022; 378 doi: (Published 08 August 2022) Cite this as: BMJ 2022;378:o1971
  1. Luke Taylor
  1. Portsmouth

Global health experts, including senior World Health Organization officials, have expressed concern that the vaccine inequity that facilitated the spread and evolution of SARS-CoV-2 could be repeated with the latest viral threat, monkeypox.

Although many nations have introduced detection and education campaigns to stem the spread of the monkeypox virus, case numbers continue to rise. The virus has now been detected in 75 countries, most of which had not reported cases before March this year. The US has the world’s largest outbreak, with more than 6600 cases across 48 states.1 Previously, monkeypox cases were rare outside central and west Africa, where the disease is endemic.

Between 25 and 31 July a total of 5206 cases were reported around the world, WHO says, up 18.7% on the previous week.2 Cases have surged 166% since WHO reported its last monkeypox situation report on 6 July and has reached many previously unaffected nations. With contact tracing efforts failing to stem outbreaks, WHO declared monkeypox a public health emergency of international concern (PHEIC) on 23 July, in the hope of spurring greater action.

The declaration should increase international cooperation and boost the research and development of vaccines to ensure that global supplies are sufficient, experts have said.3 But there are concerns that, in practice, rich countries will hoard coveted vaccines, leaving the poorest and most vulnerable countries unprotected.

WHO’s director of global HIV, hepatitis, and sexually transmitted infection programmes, Meg Doherty, told the International Aids Conference on 1 August that there was “quite a possible risk” that rich nations would outbid poorer ones and that WHO was watching out for this.4 She said, “We can’t have a monkeypox response that’s only responding to the UK, Canada, the United States. We need a response that also addresses what’s happening in the DRC right now, in Nigeria, where cases are going up.”

Confusing vaccine situation

Whether vaccine supplies will be sufficient to supply all nations at their time of need is unclear, because of continuing uncertainty over vaccine production capacity and efficacy and the best strategies to contain the outbreak.

A model by researchers at Yale School of Public Health indicates that between 5% and 47% of high risk men who have sex with men would need to be vaccinated to stop the ongoing monkeypox outbreak, but one of the study’s coauthors told New Scientist, “There is so much uncertainty here.”5

WHO’s director general, Tedros Adhanom Ghebreyesus, recommended on 27 July that only people exposed to someone infected with monkeypox, at high risk of exposure, or with multiple sexual partners should be vaccinated. As yet WHO has not recommended mass vaccination.

There are several vaccines that could be used to target monkeypox.6 Some are licensed specifically for monkeypox and others for the related virus smallpox. Although smallpox vaccines are expected to provide some protection against monkeypox, clinical data are limited.7

There could be delays in getting the jabs that are available into people’s arms. There are 16.4 million doses of the smallpox MVA-BN vaccine, which is fully approved in Canada and the US and which is approved in the European Union for the prevention of smallpox under exceptional circumstances. It could take months to get doses ready for administration, however, as much of the vaccine is in bulk form, Tedros said on 27 July.

Around half of the 75 countries and territories with infections have secured MVA-BN, and WHO is discussing supply needs with the remaining half, Margaret Ann Harris, a WHO spokesperson, told The BMJ.

Wealthier nations, which are reporting the largest outbreaks, have so far got to them quickest.

The UK has acquired more than 100 000 doses of the MVA-BN vaccine, more than any other EU country.8 Spain has received 5300 doses, while Portugal, Germany, and Belgium are next in line to receive them, according to the European Commission’s Health Preparedness and Response Authority (HERA).

New York City is scrambling to get vaccines after it followed San Francisco in declaringmonkeypox a public health emergency on 1 August.9 Around 150 000 people there could be at high risk of contracting the disease, the city’s mayor said.

The US government is distributing 1.1 million doses across the nation, but health officials estimate that the country may need 3.5 million, the New York Times reported.10 The country declared monkeypox a public health emergency on 4 August, which could free up funding for vaccine procurement.11

Spread to poorest countries

The poorest countries with the weakest health systems were disproportionately affected by the covid-19 pandemic, in part because they could not get vaccines early on when they were most needed. Inequity in vaccine access has been blamed for higher proportional death tolls in low and middle income nations and also for prolonging the covid pandemic by giving the virus more opportunity to spread and mutate into more harmful forms.

Monkeypox has begun reaching more vulnerable countries outside Europe, North America, and Africa in the past month. Sixteen new countries or territories have reported outbreaks to WHO since 6 July, including India and Thailand, the first in south Asia to report infections.

Spain, followed by Brazil, Peru, and India, have reported the first deaths from monkeypox outside Africa.

Brazil reported its first case in São Paulo in early June and has reported more than 1000 further cases in July and August. Brazil expects to receive its first vaccine doses in September, when 20 000 should arrive, the country’s health minister said on 29 July.12

WHO is urging “countries with larger stockpiles to share and donate vaccines to countries that don’t have access,” WHO’s Harris told The BMJ.

Equally urgent to readying vaccine supplies is the global research effort to understand their effectiveness and how best to deploy them, said David Heymann, professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine. “I think, before we say how many vaccines are needed, we need to understand how they might be best used,” he said. “It’s not just a blanket vaccination like it was for covid-19.

“The important thing now is to do the efficacy studies to see exactly how effective it is, while at the same time partnering with African researchers to make sure they have the resources to do the research that they need, because the containment strategy in Africa may be different than it is in Europe or elsewhere in the world.”