Availability of monkeypox vaccinations for low and middle-income countries: Challenges and recommendations

Dear Editor,

Since July 2022, the current monkeypox (MPX) multi-country outbreak has been declared a public health emergency of international concern (PHEIC) [1], and as of September 14, 2022, 59,147 confirmed and 489 suspected cases, including 22 deaths, have been reported to the World Health Organization (WHO). The ongoing outbreak is alarming because it is the first time since the discovery of monkeypox virus (MPXV) that there has been a widespread incidence of new cases in non-endemic countries outside of Africa. Since the first confirmed case of this outbreak in the UK in May 2022, the virus has spread globally, and the cases have been reported from 103 WHO member states [2]. The bulk of the current outbreak's cases have been recorded in high-income countries (HICs); however, the majority of the fatalities have been documented from low and middle-income countries (LMICs), particularly in the endemic regions of West and Central Africa. As of September 14, 2022, Africa have reported 493 confirmed cases of MPX and 10 deaths accounting for 1% and 45% of global cases and deaths, respectively [2]. The international scientific community, for many years, has understated the impact of the MPX virus, which remained endemic in Africa; however, the recent rise in cases in developed countries has prompted a swift response against it by undergoing steps to contain its spread [3].

In 1980, the WHO declared the successful eradication of smallpox, caused by the variola virus, which shares many structural and functional similarities with the MPXV. Both viruses belong to the Orthopoxvirus genus and cause symptoms like fever, rash, and lymphadenopathy; however, MPX symptoms are milder and more self-limiting. Apart from these similarities, the members in the genus share similar antigenic properties, due to which, historically, the administration of the smallpox vaccine resulted in 85% immunity against MPX, indicating the production of antibodies that are protective against both types of viruses. However, as the world abandoned smallpox vaccination in 1979 on WHO recommendation due to the nonexistence of the disease, the added protection against MPX has also been abated.

When it comes to monkeypox vaccinations, there are not many choices. In the USA, JYNNEOS (also known as Imvanex in the UK and Europe and Imvamune in Canada) and ACAM2000 are currently given to high-risk individuals for protection against MPX. JYNNEOS is manufactured by a single firm, Denmark-based Bavarian Nordic, while the ACAM2000, produced against smallpox only, has its reserves with the USA Strategic National Stockpile, which has kept this vaccine on hand as an emergency response to a bioweapon threat. In August 2022, and through funding from the US government ($11 million), the Danish biotech firm Bavarian Nordic (BAV.CO) has signed up a Michigan-based grand river aseptic manufacturer to package its 2 doses Jynneos MPX vaccine with the production expected in the US later in 2022.

Nations with the highest number of cases, such as the UK and several other European countries, are gradually running out of vaccine supplies, despite having the required resources to acquire new vaccines since manufacturing cannot keep up with demand [4]. Such a scenario indicates that the LMICs might be the last in the queue to get the much-needed vaccine for protecting their vulnerable population against MPX [5]. There is no ongoing global plan to supply vaccine doses to LMICs; meanwhile, the major bulk of doses is either held or preordered by HICs. The USA holds most doses, with the remaining supply secured by Europe, the UK, Canada, and Australia. While a recent announcement by the only MPX vaccine producer – Bavarian Nordic, has confirmed the agreement with Pan American Health Organization (PAHO) to provide vaccines for Latin America and the Caribbean. However, due to scarcity and other nations' preventative vaccination procurement, the African CDC claims that vaccinations are not readily available on the continent and that no supply has been established.

A robust international reaction is required to guarantee vaccination accessibility in LMICs to prevent future inequity and catastrophes like what happened with the COVID-19 pandemic. Even though the spread of MPX has been restricted in these nations, a more widespread outbreak is anticipated in LMICs due to insufficient resources, infrastructure, ineffective screening protocols, lack of established local guidelines, and poor public awareness of this illness. Lessons may be learned from the COVID-19 vaccine development experiences, which resulted in a vast manufacturing capability globally [6]. Because there is practically only one MPX vaccine manufacturer, exporting technology to developing nations might assist secure enough supply for them while also contributing to global inventory [7]. Many LMICs are already experiencing the economic burden of COVID-19, and many were only able to vaccinate their citizens with international financial assistance. This strategy may have to be repeated to ensure affordable vaccines for LMICs. Furthermore, governments in LMICs may need to work with the international community to ensure a consistent vaccination supply for their high-risk population and efficient procurement and delivery.