Nigeria: Monkeypox - When the world didn't listen to Nigeria

Nigeria: Monkeypox – When the world didn’t listen to Nigeria

Once again, the world is paying attention to another infectious disease outbreak. This time it’s monkeypox, a rare disease not many people have heard of, until recently. It is named after a well-known primate – monkeys, due to the early origins of the disease. Its re-emergence and spread to many countries around the world has led global health leaders to do some deep introspection, while doing some Johari window analysis. In simple terms, the rapid spread of monkeypox has led to the now deep realization and analysis about many known, known, unknown and unknown things about the disease.

It sounds like déjà vu, where Nigeria went through a similar scenario in 2017 when it suddenly recorded a sudden appearance of monkeypox cases in several locations in the country, simultaneously – a situation very similar to what we are witnessing globally at the moment. At the time, there were deep discussions about the same well-known unknown, the unknown unknown, as we have today and suffice it to say, that it did not command much worldwide interest. Perhaps if the world had paid attention then, we would know more about this disease today.

As of June 2, 2022, reported cases of monkeypox continued to rise worldwide, with around 791 confirmed cases reported globally. In 2022, there were 21 confirmed cases of monkeypox in Nigeria, as of May 29, and one death.

Origins of monkeypox in Nigeria

The first case of monkeypox was reported in Nigeria in 1971, in a 4-year-old boy and a 24-year-old mother. The next known case was reported in 1978 and after that, all seemed to be quiet or at least no cases were reported. The disease is believed to be a zoonotic disease with incidental events indirect to humans, but no host animal has been identified. The human defense against monkeypox can also be explained, to some extent, by the widespread use of the smallpox vaccine which provides cross-protection against monkeypox. Smallpox vaccination was discontinued globally in the early 1970s, after the disease was eradicated.

Cases of monkeypox seemed to have completely disappeared in Nigeria, but in 2017, after 39 years, the disease reappeared unexpectedly. Theories about why this happened included the possibility that poor surveillance systems meant the virus could have spread undetected and that improvements in surveillance, following the strengthening of the Nigeria Center for Disease Control (NCDC) meant the virus was picked up faster. More cases were detected and by the end of 2017, of the 198 suspected cases, 88 had been confirmed, indicating a positive test rate of about 44%. At the beginning of the outbreak in 2017, the NCDC had limited testing capacity and initial laboratory diagnosis was performed at the Pasteur Institute in Dakar, the University of the Redeemer and the US Centers for Disease Control and Prevention (USA).

The resurgence of monkeypox

After the outbreak in 2017, Nigeria seemed to be doing it all by the rule book. The country met the International Health Regulations (IHR) reporting requirements, and notified the World Health Organization (WHO) about the outbreak. Data is freely shared with everyone who was interested, through every means possible. From 2017 to date, more than 14 articles have been published in peer-reviewed scientific journals relating to all aspects of this new disease. Several research gaps have been identified and despite calls for support in conducting research to fill knowledge gaps in published papers, there has been little interest in the disease as it appears to only affect those living in West and Central Africa. However, colleagues at NCDC, at Niger Delta University, Bayelsa State, Nigeria and partners, have continued to publish their findings on this disease.

Subsequently, cases began to be identified in travelers outside Nigeria. First, for the United Kingdom (UK), it is not surprising given the strong historical ties between the two countries. But then to Singapore, Israel and the United States (US). Despite all of these exported cases, the public health response has followed a similar pattern of intense media attention, deploying massive case management resources to high containment facilities, and deploying national public health response capacities to all countries with cases with a travel history. From Nigeria, back to base.

There appears to be no interest in conducting more in-depth research to learn more about the origins of the virus, especially in areas where the virus has been endemic. The only country that invested any resources in working with the NCDC was the United States through the US Centers for Disease Control and Prevention. Along with the NCDC, there have been particularly detailed studies into human-animal interaction for host identification. One of the major unknowns about the virus is knowledge of the virus’ natural reservoir, and as a result, any hope of understanding this further over the past five years has not been fully realized.

Lessons not learned

The COVID-19 pandemic has exposed deep challenges in getting governments to think beyond their national sovereignty and national interests to consider issues of equity and alignment with global solidarity. Additionally, there is the fact that given our understanding of infectious diseases, the ideas of national sovereignty upon which we build response instincts are irrelevant and do more harm than good in the long run. The COVID-19 pandemic will likely last much longer than necessary because the world has not sufficiently worked together. But it wouldn’t be the first time this has happened, and the response to monkeypox shows that we haven’t learned the lessons we need.

The global response to the monkeypox outbreak would certainly have been better if the world had come together over the past few years to respond to this threat that originated from “somewhere in Africa.” Perhaps, if countries with exported cases have also dedicated only a few resources to working with Nigeria to understand the origins and determine the response, we will know more today.