Overview
Mpox, formerly known as monkeypox, re-emerged in Nigeria in 2017 after decades of absence, initially eluding diagnosis and international concern. Genomic, epidemiological, and social factors enabled its spread, ultimately fueling a global epidemic—highlighting missed warnings, challenges of sexual transmission recognition, and persistent stigma.
Early Nigerian Outbreak and Diagnosis Challenges
- In May 2017, puzzling cases with genital lesions appeared in Port Harcourt, initially misdiagnosed.
- Patients often had multiple sexual partners and concurrent HIV, but traditional STIs were ruled out.
- Similar cases surfaced in neighboring states, and only by September were they confirmed as mpox.
- Clinicians noted the unusual pattern: lesions in adults, genital involvement, and possible sexual transmission.
Historical Context and Global Spread
- Mpox was previously rare, primarily affecting children in Central and West Africa, with outbreaks soon fading out.
- Smallpox vaccination halted in 1980, eroding cross-immunity to mpox over time.
- Surveillance in the DRC detected rising mpox cases, but no significant international spread until the Nigerian resurgence.
Viral Origins and Genomics
- Genomic studies indicate the current outbreak originated from a single zoonotic spillover in Nigeria circa 2014.
- The virus spread quietly among humans, especially in urban centers with high mobility like Port Harcourt and Lagos.
- Models suggest human-to-human transmission was sustained, doubling slowly over years and often missed.
Missed Warnings and International Response
- Evidence of sexual transmission was initially dismissed or downplayed due to lack of precedent and stigma.
- Early travel-linked cases in the UK, US, Israel, and Singapore (2018–2021) failed to spark global alarm.
- Only after a 2022 outbreak among MSM in Europe did international awareness and genomic tracing link the cases.
Social and Structural Barriers
- Stigma, criminalization of homosexuality, and cultural taboos in Nigeria hindered disclosure and surveillance of sexual transmission.
- Patients and clinicians faced ridicule, fear, and professional skepticism regarding sexual transmission pathways.
- Mpox outbreaks caused public panic, misinformation, and discrimination against patients.
Current Status and Continuing Risk
- Nigeria has documented over 4,500 suspected cases since 2017, with persistent human-to-human spread.
- International aid for vaccination has been minimal compared to need, and vaccination strategies remain undecided.
- The new, deadlier clade I variant from DRC is spreading in Central/East Africa and appearing in travelers abroad.
Lessons and Recommendations
- Failure to act decisively in Nigeria, including underfunding surveillance and not using available interventions, facilitated global spread.
- Global health authorities and African governments are urged to improve coordinated response, surveillance, and vaccination deployment.
- Stigma and legal barriers need addressing to enable effective public health interventions, especially in sexual health contexts.
Decisions
- Rename monkeypox to mpox to reduce stigma and racism.
- Declare PHEIC (Public Health Emergency of International Concern) twice by WHO in light of global and continental spread.
Action Items
- TBD – Nigerian Health Authorities: Decide target populations for limited mpox vaccination campaign.
- TBD – Africa CDC: Implement EU-funded joint action plan using allocated vaccine doses and emergency funds.
- TBD – Nigerian/International Researchers: Analyze stored blood samples for retrospective study of mpox spread.