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Story Publication logo November 22, 2024

‘I’m Really Shocked.’ Children Not Being Vaccinated for Mpox in Congo

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This project visits the epicenter of the DRC's outbreak.

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Children with mpox symptoms await diagnosis in Rusayo, a refugee camp on the outskirts of Goma, Democratic Republic of the Congo. Image by Arlette Bashizi.

Regulatory and liability issues are delaying immunization of the most vulnerable group


GOMA, DEMOCRATIC REPUBLIC OF THE CONGO—Two months ago, a sprawling refugee camp here named Rusayo opened a special treatment center for mpox, the viral disease that has spread far and wide this year in the Democratic Republic of the Congo (DRC). Last week, about a dozen patients, some with skin lesions from head to toe, were isolated in a white tent, waiting for lab confirmation they had mpox. If so, they would have to stay a few weeks.

All were children.

The center, run by the Alliance for International Medical Action (ALIMA), has treated some 370 suspected cases so far, and many have been adults, says Jean-Pierre Musavuli, a nurse who works there. “Today, it’s only kids,” he says. When children get mpox, they are more likely than adults to become severely ill and die. But despite their vulnerability, children are not eligible for the vaccines now being rolled out for the first time in the DRC. Instead, the vaccination campaign targets sex workers and their clients, health care workers, and people who have been in contact with cases.


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“I’m really shocked that children are not yet vaccinated,” says a Congolese health care worker who asked not to be named because of political sensitivities. A growing number of local physicians and international agencies agree and have urged the DRC to change course. But the government has moved slowly, apparently because of regulatory questions, concerns about liability, and bureaucracy.

The DRC has had mpox outbreaks for decades, predominantly affecting children, but they typically petered out quickly. Over the past year, however, a little-known variant of the virus exploded in the eastern DRC, which never had mpox before. It took off in the remote gold mining town Kamituga, spreading mainly among miners and sex workers, before making its way to Goma, a major city, as well as other parts of the region and neighboring countries. Infected adults spread the virus to their families and other contacts, especially in crowded camps such as Rusayo. The DRC has had more than 40,000 suspected and confirmed cases this year, and in the past 4 weeks 60% were in children.

In all of Africa, there have been more than 55,000 mpox cases so far this year, only 12,000 of which have been laboratory confirmed—diagnostics are in short supply—according to the latest update from the Africa Centres for Disease Control and Prevention (CDC). The DRC accounts for more than 75% of that total. In August, the World Health Organization (WHO) declared mpox in Africa a Public Health Emergency of International Concern.

The DRC received 265,000 vaccine doses from donors in October, but only 20% have been administered so far, according to the health ministry. The rollout is a major logistical challenge in a country almost one-quarter the size of the United States that has 100 million people, a crumbling infrastructure, and a weak health system.

Called modified vaccinia Ankara (MVA), the vaccine is a weakened, safer form of the smallpox vaccine used until the eradication of that disease in 1980. It was originally authorized only for people 18 years or older in the United States and Europe.

In the few small studies that have assessed MVA in children, no safety concerns have surfaced. An Ebola vaccine that uses MVA as a “backbone” also has caused no serious advents in some 50,000 children.

On 12 November, the European Medicines Agency said that given the safety data and the “limited options” to prevent pediatric mpox, MVA could be used in children of any age. WHO supports use in children as well. In a policy recommendation issued in August, it said the vaccine could be used “off label” in virtually all age groups during outbreaks, and on 18 October WHO granted MVA “prequalification”—a seal of approval—for the 12–17 age bracket. Without vaccinating children, “the impact of any control measures will be greatly mitigated,” WHO said in a statement to Science. In the DRC, a technical advisory group to the health ministry suggested earlier this year that MVA could be used in children.

 “Scientists have to convince politicians,” notes virologist Steve Ahuka, a veteran mpox researcher at the DRC’s National Institute of Biomedical Research. Officials are concerned about liability should children be harmed by the vaccine. Bavarian Nordic, MVA’s manufacturer, told the DRC government in an 8 November letter it would accept liability for its use in children as young as 12, but the DRC would have to amend its current emergency use authorization to include this age bracket. Top health officials are optimistic that will happen but don’t know when, and such an agreement would still exclude children under 12.


A woman in Kamituga, in the eastern part of the Democratic Republic of the Congo, receives an mpox vaccine after coming into contact with a confirmed case. Image by Arlette Bashizi.

Nanou Yanga, a doctor and mpox immunization leader in the DRC’s Ministry of Public Health, says her team worked around the clock over the past week to draft a vaccination plan for children, completed on 20 November. She’s hopeful it will be implemented soon. “It’s really important for the country to move quickly,” Yanga says.

Communities affected by mpox may have concerns as well, Ahuka says. “It is not easy,” he says. Mpox has long been a very neglected disease, “and then one day you come and say, ‘We have a vaccine for your children.’”

WHO and its partners have promised the DRC 765,200 more doses of MVA, the first 100,000 of which arrived on 14 November. The country plans to use them primarily in the capital, Kinshasa, which has become a new hot spot for mpox spread, primarily in adults.

The Japanese government has offered just over 3 million doses of a vaccine similar to MVA called LC16m8, which the WHO greenlighted on 19 November. But the doses haven’t arrived. Science has learned Japan does not want to accept liability should the vaccine cause harm. Also delaying the donation are political instability in Japan following its 27 October parliamentary elections, shipping costs, and questions about whether the DRC has enough freezers to properly store the product.

There are also some worries that the way the Japanese vaccine is administered may scare people away. Health workers use a so-called bifurcated needle that’s dipped into the vaccine solution, the same way the smallpox vaccine was administered. The procedure leaves a skin lesion that must be covered for up to 2 weeks to prevent spread of the vaccine virus to others, and it leaves a scar.

The dependence on foreign donors to make mpox vaccine purchases and cover liability is embarrassing to another person deeply involved with the mpox response, who asked not to be named. “It’s like a man wants to get married to his fiancée but the tie must be given by the uncle, the suit by his friends, and the ring by the pastor,” he says. “Don’t you think that’s ridiculous?”

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