Lack of funding for disease research affecting Africa – Prof Ogoina

Professor Dimie Ogoina, an infectious disease specialist and Chief Medical Director, Niger Delta University Teaching Hospital, Okolobiri talks about the Mpox disease, the challenges facing the continent in tackling infectious diseases and more, in this interview with SAMUEL ESE

Many Nigerians are still unaware of Mpox and how it’s transmitted. Can you shed more light on this?

Mpox was previously called Monkey Pox because the first cases of the disease were subscribed in monkeys but the name was changed to Mpox because monkeys are not the only hosts for Mpox or Monkey Pox virus. Nigeria reported three cases of Mpox between 1971 and 1978. Specifically, we had two cases in 1971 – in Abia State and one case in 1978 in Oyo State. So, we had no other case until 2017 when we had a resurgence of Mpox. The first case of Mpox in 2017 was reported in Bayelsa State in Niger Delta University Teaching Hospital. Then over a week, the infection was reported across 14 states, including the Federal Capital Territory. Classically, Mpox is known to affect children less than 15 and historically, that is how the epidemiology of Mpox has been, but what we observed in Bayelsa is that a substantial number of our cases are not children but adults; adults between the ages of 20 to 40. And, a number of them had genital ulcers – clustering of lesions around the genital area. So, that made us to make the assertion that Mpox could be transmitted through sexual contact. Before now, the traditional knowledge of transmission was that Mpox was a zoonotic disease, meaning it can be transmitted from animals to humans, then sometimes, from humans to humans but it’s not sustained. So, what we observed in Bayelsa here was a new knowledge that the disease has a new route of transmission and a new method of presentation. Since 2017, we’ve had recurrent outbreaks of Mpox in Nigeria. Cases are fluctuating. Sometimes, it may appear as if the cases are disappearing. Within three months in 2017, we recorded 88 cases. Cases in 2018 were slightly over those of 2017, and then the cases started declining until 2022 when we recorded the highest number of cases so far. We had up to 780 cases reported in 2022, but the cases declined in 2023 to 98.

And, now in 2024, from January to August 29, we reported about 48 cases of Mpox in 20 states and the FCT had one or more cases (now 67 confirmed cases in 23 states and the FCT). Majority of the confirmed cases were in Bayelsa, which had eight cases. So, Mpox is with us in Nigeria. We won’t say it’s as serious as other outbreaks such as Lassa Fever and cholera, but the thing about Mpox is that we have a number of uncertainties about how it’s transmitted. It is my view that the number of cases we have in Nigeria is a gross underestimation –  we have more cases. So, it’s important we strengthen our surveillance system so we can detect more cases in order to stop transmission of the virus.
From what you’ve said, there’s been a recurrence of the disease in Nigeria. Why is it taking so long to find a cure and stop its spread?

Mpox has been with us for up to 54 years, but unfortunately, it was referred to as a neglected tropical disease and the reason is that it has been restricted to parts of Africa, and usually the rural settlements in the rainforest areas – West Africa and Central Africa. So, the number of those affected was from the poor communities who don’t have opportunities to health facilities in urban settlements. They also don’t have support from the central health system. To that extent, there has been no investment in Mpox. That’s why we have a disease that is 54 years and we don’t have specific therapeutics, we are not clear about the mode of transmission. And it only took the 2022 outbreak for us to repurpose a vaccine because the vaccine was actually meant for small pox, but because it provides cross protective benefits to cases of Mpox, it’s been deployed.

So, we have not been able to address this challenge because of neglect. The disease has been neglected from outside and within Africa. We’ve not given too much commitment and ownership and investment on Mpox.
The second reason for the neglect is lack of capacity. Most African countries are poor with competing demands and challenges so they don’t have sufficient resources and the health system is also weak to address the problem. That is why it has festered to the point WHO is now declaring it a public health emergency of international concern.

What is the difference between Mpox and smallpox and then Mpox and chicken pox?

Smallpox is a historical disease because currently it has been eradicated. Since 1979, there have been no reported cases of smallpox. It existed for more than 3,000 years before eradication. The illness was characterised by a pox-like skin eruption. If you know chicken pox, what you see in chicken pox is the pox-like skin eruption. Smallpox was very deadly, 30 per cent of people with smallpox died. Fortunately, we were able to eradicate smallpox with the use of vaccines. Mpox is like a younger sibling of smallpox because they belong to the same genus of virus. They are different viruses but from the same family. So, Mpox is a sibling to smallpox and the clinical presentations are similar. The only difference between the two is the difference in the viruses and the fact that monkeypox is not as severe as smallpox. In terms of the mortality rate, Mpox will be about one to 10 per cent but smallpox will be up to 30 per cent. Chicken pox is another viral disease, but it doesn’t belong to the same family as Mpox and smallpox. It belongs to a different family of viruses and is caused by a viral infection. Unlike Mpox and smallpox, chicken pox is airborne. Skin-to-skin contact is not necessary for transmission. It’s very common in children, but in Nigeria adults are also infected. Chickenpox is hardly self-limiting except for people with underlying problems that will make it severe.

Sometimes, it is difficult to distinguish between chicken pox and Mpox clinically, so what we do is lab tests. Now that we are having a resurgence of Mpox, it is important for people to recognise that not all pox-like eruptions are chicken pox, even in children. It’s important you come to the hospital so your samples will be subjected to diagnostic tests so we can be clear if it’s chicken pox, Mpox or both. We’ve observed that some people have both. People with both diseases are likely to die. Also, people with advanced HIV with Mpox are likely to die. Studies outside Africa show that children with Mpox are at greater risk of having severe diseases than adults. Pregnant women are also at risk of having greater diseases. So, these are the vulnerable and are the differences between smallpox, chicken pox and Mpox.

What has been the response of government and international agencies towards this growing epidemic in Nigeria?
There was a global spread of Mpox in 2022; for the first time Mpox left Africa and went global and there was public transmission of Mpox in more than 100 countries across the globe. These cases were not linked to travel history or Africa. There was local transmission of Mpox and it called for global attention, and WHO declared it a public health emergency of international concern.

It included a lot of vigilance and since then there has been some investment in Mpox. Unfortunately, investment, research and development are in favour of the developed countries and it is recently that African countries are getting medical countermeasures. Vaccines, therapeutics and medical support were not made available to Africa in the 2022 outbreak. The outbreak and transmission were reduced but not in Africa. The epicentre is the DR Congo, where they reported a number of cases and they are still reporting. It was on account of that, and because of the increasing number of cases, that WHO declared it a public health emergency. The second reason is that a new strain of Mpox arrived and it is referred to as Grade 1B. The strain that was peculiar to Central Africa was more of animal origin, but now, it is sexually transmitted. It is of significant concern as it is spreading to countries that have had no cases before like Kenya, Rwanda, Uganda and Burundi. So, African CDC and WHO have declared a global emergency. What is done now is to intensify surveillance. There’s a call for increased availability of countermeasures; vaccines and therapeutics are to be made available to Africa. There’s a call for increased research to understand the disease. In Nigeria, we are aware that the NCDC is coordinating the efforts to respond to the Mpox outbreak and the health ministries in the various states are responsible for coordinating this response. Nigeria has established an emergency operational centre and an incident management team and they made a call to all the health ministries from the NCDC to see that they intensify efforts on how to curtail this outbreak. As we are aware too, Nigeria has received 10,000 doses of Mpox vaccines that is going to be coordinated via the National Primary Healthcare Development Agency. Being the President of the Nigerian Infectious Disease Society, our call is to invest more to understand Mpox in Nigeria because the number of cases is a gross underestimation – there are more cases of Mpox in Nigeria. So, we need to be proactive in our surveillance so that we can detect more cases and stop transmission because we don’t want the virus to evolve into another strain that will be more deadly. The more we allow the virus to multiply the likely it will evolve to another strain and we cannot tell if the next strain will be deadlier.
What has been the response of Bayelsa State Government so far bearing in mind that there are several cases reported in the state?

The Bayelsa State Government through the Ministry of Health has been proactive about Mpox. Of course, we have historical knowledge and capacity because of our 2017 experience. In the NDUTH, we have admitted and cared for the largest number of patients in the whole country so, we have a lot of experience and our public health system is looking at cases. Perhaps, that is partially one of the reasons we are getting more cases in Bayelsa than any other part of Nigeria. Our hospital is supported by the state government, so, any case of Mpox that comes here does not pay any money for treatment. Treatment is covered by the Bayelsa State Government. I’m also aware that the Ministry of Health, through the state Commissioner for Health, has established an emergency operation centre and an incident management team that are intensifying efforts to improve surveillance. Our call is for the state government to invest more in surveillance so we detect cases early and prevent their spread. Mpox generally is a mild disease but the danger is that we don’t want it to spread to vulnerable people like children under five years, pregnant women and people with advanced HIV. If we allow it to circulate, there will come a time it will get to these groups, that’s why it’s important we focus on surveillance. So, Bayelsa is doing a lot and our call is that more is to be done to increase surveillance to stop the transmission of the disease in Bayelsa and across Nigeria.

How many cases have you treated so far and what is the success rate and fatalities?

NDUTH has been at the forefront of managing Mpox in Nigeria and we’ve also been at the forefront of the research globally. We’ve published both in local and international journals. And, as I said earlier, my hospital was the first in the world to record a new route of the transmission of Mpox and a new type of Mpox, which had not been recorded anywhere in the world. On account of that, we are recognised by Nature Magazine and I was listed in The Times 100 Most Influential Persons in 2023. With my team, we’ve been able to manage several suspected and confirmed cases of Mpox and I will say over 100 or 200 since 2017.

We have seen different types of patients both outpatients and inpatients. The majority of our patients have done well and survived. We’ve had a few persons that have died. All the patients that died had advanced HIV and in most cases, they came late to the hospital. That is why we emphasise that if you suspect you have Mpox, it is important you come to a formal health system so you can be cared for. You don’t necessarily have to be admitted. You can be advised by the health system so you can seek care at home. Most of our patients have done well. This year, we have admitted, in the past three months, 10 patients and we have discharged most of them, but we have two currently on admission, suspected cases awaiting laboratory results. So, our patients have been doing well because we pay attention to their care and we received support from the Bayelsa State Government to ensure that whatever they require to recover is given to them. So, our experience has been a good one.

What’s your advice to uninformed people about the Mpox menace?

It is important to tell the general public that Mpox, which is caused by the monkeypox virus, is real. It is in Nigeria and Bayelsa and we have practical examples of cases that we are seeing in our hospital. People we know have come out with Mpox. The second thing to know is that largely, Mpox is a mild disease. Most people that have Mpox will have a mild disease but it can develop to a severe one if they don’t seek care early, especially for children less than five years, people with HIV and people that have concomitant chicken pox and any form of illness are at risk of having severe disease. Mpox can be transmitted from animals and humans and also via a second route. There should be no stigma or discrimination. Anybody can get infected with Mpox irrespective of age. We should be vigilant. We should not spread falsehood about Mpox. It is caused by a virus and it’s treatable, 99 per cent of people that come early to the hospital and are treated and get medical advice will do well and recover with no challenge. And so, we call on the general public to be alert. If there’s anyone with symptoms of Mpox, it should be reported to the healthcare centre so that diagnostics can be made and it will be managed properly. It is important because you may think that you are protected, that you have a mild disease, but your neighbour may be prone to a severe disease and when you transmit this infection to them, that person will be at risk of dying. So, it’s not only about us, but our family and community and it’s important we take action. So, I call on everybody to cooperate with the public healthcare system and seek for authoritative source of information like NCDC and the various health ministries.
Is there any hope of developing local medication?

That is something we need to look at. As I’ve always said, in Africa we should not focus on help outside Africa. Sometimes, the help resides in Africa. So, it’s left for us to look deeply inward to solve our problems. Unfortunately, we’ve not invested in research and development including therapeutics for Mpox and many other diseases affecting Africa and I think in this outbreak we have currently, we are waiting for the global north.

Everything that relates to Mpox, there’s nothing that is being developed in Africa. We are waiting for countries outside Africa to support us. So, it’s a charge for us, we that are scientists, those of us that are researchers, academicians, industry players and also governments at all levels to see how we can boost our development so that we don’t have to be waiting for the global north for handouts because that’s what we do repeatedly for every outbreak. So, for now, I’m not aware of any local treatment, but it’s possible that there is something that would be effective. So, it’s for us to open our eyes to clearly search for it and I believe we will find something.