Children dying of mpox are not first in line for a vaccine

Children account for over 80 per cent of mpox deaths in the Democratic Republic of the Congo, yet the first shots to arrive in the country won't be given to the youngest and most vulnerable patients.

A new vaccine from Danish drugmaker Bavarian Nordic A/S is set to arrive in Congo next week, but is notably absent from the government's pediatric vaccination plan, according to public health and aid agencies. Critics say the shot should be included.

Instead, the Congo is currently planning to vaccinate kids with Japan's LC16 vaccine, made by KM Biologics, which was used to immunize more than 50,000 children against smallpox in the 1970s, the Africa Centres for Disease Control and Prevention said on Tuesday. However, these vaccines aren't in the country yet and the arrival timeline is also uncertain as negotiations with Japan to secure doses are still under way, according to the Africa CDC.

This means Congolese children, who are bearing the brunt of the latest mpox outbreak with almost 9,000 infected since the start of the year, more than 460 fatally, are still awaiting inoculation. If the roll out of the LC16 happens it will likely require a steeper learning curve for parents and doctors too. Unlike the newer Danish vaccine, LC16 relies on a bifurcated needle, a 60-year-old device that pricks the skin multiple times, leaving a scar, said Sharmila Shetty, a medical adviser with Medecins Sans Frontieres.

"We feel strongly that a solution must be found to vaccinate children with this vaccine," Shetty said of the Bavarian Nordic shot. "Otherwise, children are just going to continue to needlessly die."

Regulatory authorities in the Congo issued an emergency use authorization for Bavarian Nordic's vaccine in June, and the company said this week that the authorization doesn't have an age limit. Among the world's most stringent drug regulators, the vaccine's status is more uneven: the US allows the use in teens, while in Europe, a review is still going on. Administering a vaccine "off label" to children could be considered risky for aid agencies and governments.

The delay in vaccinations for children underscores the ongoing failure of governments and health agencies to protect the most vulnerable from mpox, despite decades of experience with the disease. Children under the age of 15 account for two-thirds of mpox cases and 82 per cent of deaths, the Africa CDC said Sunday.

Rampant malnutrition, poor sanitation, and the absence of prior immunity "- unlike adults over 45 who may have been vaccinated for smallpox "- have left children the hardest-hit group in the escalating crisis. Compounding the challenge, early studies indicate that the antiviral drug tecovirimat is ineffective against the fast-spreading virus.

Doctors have yet to receive an immunization plan for children, said a pediatrician at Kalembe Lembe Pediatric Hospital in Kinshasa, Congo's largest children's hospital, who asked not be identified because the person isn't authorized to speak to the media.

An earlier version of Congo's vaccination plan didn't foresee immunizing children this year at all, MSF's Shetty said, because it wasn't anticipated the single-dose LC16 vaccine would be available. A revised plan discussed on Monday with the Africa CDC includes 3.5 million doses - the amount reportedly being committed by Japan - for children, the Le Monde newspaper said Tuesday.

Congo has now submitted a formal request to the government of Japan for the vaccine, Ngashi Ngongo, chief of staff at the Africa CDC, said Tuesday. A spokesperson for Japan's ministry of foreign affairs said talks with Congolese officials are underway, but declined to comment on the timing and volume of the vaccine donation. The Congo health ministry didn't respond to requests for comment.

Wild animals

The monkeypox virus, which causes mpox, has been infecting children and young adults in Africa for decades through contact with squirrels, rodents and other wild animals that carry the pathogen. But children typically didn't spread the virus beyond their households and didn't play a significant role in the global mpox outbreak of 2022, which was largely driven by sexual transmission among gay and bisexual men.

The crucial shift in the current outbreak is that the new monkeypox strain, clade Ib, may spread more easily via close physical contact, including care-giving by mothers or grandmothers. That means children are contracting mpox not only from animals but also from people. Meanwhile, many parents are struggling to differentiate between mpox and chickenpox, as the symptoms can be similar, according to the pediatrician at Kalembe Lembe.

The virus is sweeping through camps of displaced people where poor sanitation, scarce food, and rampant diseases like malaria are already taking a toll, said David Munkley, zonal director for eastern Congo at the charity World Vision.

"You get stories of families eating once a day, once every other day," Munkley said. "It's really rough on kids just because their immune systems are taking a beating."

A draft mpox response plan released by the WHO on Monday focuses on vaccinating health-care and front-line workers and people known to have been exposed, but makes no specific mention of inoculating children.

"In the fight against the mpox outbreak, prioritizing the needs of children is not just necessary - it's urgent," said Etleva Kadilli, Unicef's regional director for eastern and southern Africa, in a statement last week. "Their heightened vulnerability requires that we dedicate our full attention and resources to ensure their protection and wellbeing in this critical response phase."