Welcome to TEDMED conversations. I’m Kelly Thomas. I’m joined today by Ed Kelly, the chief global health officer at ApiJect.

Prior to his work at ApiJect, Ed was the director of integrated health services at the WHO where he helped lead the agency’s response to the COVID nineteen outbreak. And thank you so much for sitting down with TEDMED today to talk about the evolving m pox outbreak.

It’s my pleasure, Kelly. Thank you.

Of course. So, Ed, what is m pox, and how is this strain most commonly spreading right now?

MPOX is a disease that has been endemic in Africa and approximately thirteen African countries for decades, and it jumped onto the scene, at least the media scene in recent times anyway, in twenty twenty two with an outbreak that, caught us still in the midst of COVID and struggling to get vaccines out. And all of a sudden, here was a smallpox related disease that was hitting the scenes. And at that time, was being spread within certain at risk communities, and there was a big effort to try and get vaccines for them. We’ve come around now a couple years later to a slightly different strain, and we can talk about that, outbreak that has really spread with more rapidity, and it seems more virulence in Africa and has gone global as well.

And the mechanism by which it’s moving from person to person more rapidly, is that different than the twenty twenty two outbreak?

It is different. You know, the twenty twenty two outbreak, while it’s not, strictly speaking, only a a sexually transmitted infection, there was a lot of reports of transmission by sexual contact and within certain communities, particularly men who have sex with men. The importance of that is for, yeah, people to understand when you have disease outbreaks, one of the first things you really look at doing is tracing contact. So how does the disease spread? With any disease, even if you have a vaccine ready, it is always a certain period of time to get the vaccine into the field and be able to protect people from it. So your first line of defense is the sort of public health measures as we call them during COVID that are out there with other diseases such as something more like the Ebola outbreak on which I worked where it’s by direct contact. You know, that’s all around things like hand hygiene and other protective equipment.

At the moment, this current outbreak of mpox seems to be spread primarily through contact. At present, there’s no real evidence that it’s airborne, and we think m pox is mostly spread by contact. Maybe we just take a minute, Kelly, to talk about why this is different than the twenty twenty two. People probably have heard the term clade.

Clade just really means sort of disease grouping. The clade two was the outbreak of twenty twenty two. Precisely, clade two b was what was really driving the twenty twenty two outbreak. This current outbreak is being driven by a clade one, AMPOXX, specifically clade one b, and it’s started in the Democratic Republic of Congo and has spread from there to a number of other African countries around the world.

But there’s been nearly twenty thousand cases this year, so that’s, significantly higher than the twenty twenty two outbreak.

Mhmm. Why do you think we are seeing reemergences of viruses that have previously been eradicated like smallpox?

There’s a couple of reasons. These diseases that also can have vectors in animals and spread from animals, we’re only gonna see more, not fewer outbreaks because the pressure on animal habitat and contact between humans and animals in places where we had very little or no contact is just increasing.

Secondly, and, you know, we can talk about this about almost any outbreak. If you were to look at the picture of global travel at any given time, the number of airplanes that are in the air and the the travel routes from one place to another, you almost cannot see the global map once you superimpose a picture of the airplanes or even the air routes on top of that. There’s so much connectivity. You have tons of travel from places where some of these diseases happen in central and eastern and southern Africa to all over the world within thirty six hours.

The last factor that I think is really driving some of this recent outbreak is that smallpox was eradicated in nineteen seventy eight, and the global vaccination campaign stopped in nineteen seventy nine. A big portion of Africa is quite young versus populations in Europe, Japan, North America. A big percentage of these populations that have been in countries that are affected is under forty. So they’ve never been exposed.

They’ve never had any immunization to a related disease, meaning smallpox. And so there’s literally no herd immunity, no immunity within the population for this disease or related diseases. So anytime you have that situation, like we saw with COVID, it can spread very quickly.

With those factors in mind, the increased travel all across the world and also looking at the end of the vaccination program for smallpox, do you think it’s important for world health agencies and public health officials to reconsider ending these vaccination programs that really were effective in eradicating certain diseases?

Yeah. It’s a very interesting question, Kelly. If your parent in in any country, actually, but particularly in some of these countries where the global program on immunization, which is called the expanded program on immunization, the EPI program, has been active for the past thirty years and you follow all the rules, you are bringing your child probably fifteen separate times back to the health center for the different shots kids get. If they get all of the shots, upwards of thirty separate injections.

It’s a good thing that we have invested in more and better vaccines, and we have vaccines now for diseases we never thought we’d have vaccines for. There’s, I think, a difference between the kind of regular routine immunization that we have for highly infectious diseases that can really devastate, young populations like measles. It spreads very quickly, and it can be quite deadly for young children versus diseases that are of outbreak potential. There, I think we need to do a much, much better job since we probably won’t keep vaccinating for these diseases we only see peaks of, or maybe have even been close to eliminated.

It doesn’t make sense for us to have mass polio vaccination programs in countries where we’ve eliminated polio. But the idea that we have vaccines on hand and can react to an outbreak much better than we’re doing with MPOX and and certainly much better than we’ve done with some of the other outbreak diseases, I think, would be important.

Mhmm. Absolutely.

And how is the response going? Are we seeing vaccines getting delivered to the DRC and helping to start to control the dread there?

Well, I guess the good news is that we actually do have a vaccine.

This is something that, for instance, during Ebola, we didn’t have a vaccine. During previous outbreaks of cholera, we haven’t had a vaccine. We do have one now. There’s also a second vaccine that’s not commercially available, but was produced and stockpiled by the Japanese government.

And WHO has made a call with a term an emergency use listing, call for considering other vaccines that might have been in the pipeline. For companies that are investing in an MPOX related vaccine, getting that blessing from a regulatory agency is the holy grail, and so getting a chance to do that on an accelerated basis is a big deal. But it has not resulted so far in massive number of vaccines or even vaccine doses being available. If you look at Bavarian Nordic, which has a very good, very effective vaccine, they have said that they could make about five hundred thousand doses available now, perhaps two million by the end of the calendar year, and could ramp up production to make ten million by next year.

While that’s a great thing, Democratic Republic of Congo has a hundred million people, and, normally, it’s a two dose regimen. There has also been a big program on trying to get donations of vaccine doses. The US just donated past Tuesday about ten thousand doses to Nigeria, and that’s the first donation, at least I’m aware of. Since the current outbreak, Nigeria has two hundred million people and probably at least twenty million health workers if you’re just considering sort of frontline health workers.

So, anyway, a long way to go in terms of making vaccine doses available. And I think it just points to the fact that with any of these outbreaks, while vaccines are important, it’s very rare that you’re going to vaccinate your way out of an outbreak like this. You really have to have strong public health measures and strong testing. So that just brings me to a last point I’ll make on this, which is that the first line of defense is knowing who has the disease and who doesn’t.

And, actually, you can see if you look at the numbers that are available on the outbreak, there’s big difference between the number of cases that people have reported and the number of confirmed cases. So through about mid August, Africa CDC talked about twenty thousand mpox cases, but only only been about six hundred confirmed big differences between the numbers in terms of what we’ve actually been able to test for. And I think that’s the next thing we need to really invest in.

Mhmm. Have you seen more development on the testing procedures and making it a little bit easier?

I think that MPOX will eventually be the beneficiary of some of the investments that have been made, some by public agencies like, CEPI and Gavi and the US government, but others by just enterprising companies that have gone out there where they’re looking at what you would term sort of multiplex tests that can be adjusted. They’re rapid tests for COVID, for instance, to be able to do multiple tests with one sample in order to catch much more. So there has been some advances in testing and potential for testing for m pox, but, you know, for some of these outbreak diseases in general.

Most of those innovations are barely making it to the market in North America and Europe, and certainly very, very few are making it to the African market, particularly central and southern Africa. Mhmm.

Since we don’t have enough vaccines right now to help out in the DRC and not in very simple way of testing, as a public health issue, what should we be focused on trying to control the the outbreak?

What I’d like to see, you know, more is more of a discussion of the prevention measures, the kind of things that you and I can do just in terms of recognizing good disease prevention and kind of good public and private health, measures that people learn during COVID. And having just had to travel a whole bunch recently, people seem to have put on the shelf at the moment. And so that I think having more of a push on that and personal kind of role, and that will have lots of side benefits.

There is the possibility of people getting tested where testing is available. For instance, you were thinking about the US and you have some of the symptoms and maybe we could cover some of them, then it’s important to try and get tested. Some of those symptoms are common to other diseases. Often people get flu like symptoms with fever or headache or fatigue.

You can have swollen lymph nodes. And there’s often these sort of lesions or pox on your skin or in the mouth or in the genital areas. And then in severe cases, you can get, you know, sort of other big problems such as organ inflammation. But in the minor cases and you have any of those symptoms, certainly certainly should get tested.

And, you know, there’s another area for development that hasn’t been a lot in terms of treatment.

So the kind of antiviral drugs that we’ve had available for smallpox in the past have not been so effective in some of the, research trials compared to placebos. But, you know, supportive care in terms of pain managements and topical treatment of the lesions as well as just staying hydrated is important. But important to get access to testing to the extent that you can and to isolate if you have those symptoms.

So in addition to testing and increasing vaccine delivery, there will be a large population that does contract MPOX, and they need to be cared for while they’re having these what can be pretty severe symptoms. What does supportive care look like, and how effective is it?

Supportive care is the primary approach since there’s very little that seems to be immediately available on the antiviral drugs that have been stockpiled or available for smallpox.

There’s a lot that’s in development by the time it’s ready, questionable as to whether it’ll be used in this outbreak. Supportive care means pain management, topical treatment, and hydration. For severe cases, that might be done in an inpatient setting where the patient can be isolated and can be really cared for by trained personnel who are wearing personal protective equipment according to standards and that kind of work. The issue of course, is that in West and Southern Africa and where this outbreak is happening, the possibilities for supportive care in an inpatient setting are extremely, extremely limited.

There’s very low bed to population ratios. Those are used often for kind of accidents, accidents, emergencies, deliveries, and these types of urgent situations. And so people have to get supportive care at home where it’s very likely that they don’t have a trained personnel coming to see them. It may be a very wonderful caregiver within the family, but often they won’t have personal protective equipment.

So I think we have to acknowledge that the background anytime these outbreaks happen, they happen in the context of an overall context for that health system. And so in the injection, pardon the pun, of sort of resources for a specific disease, whether it be related to vaccines or even related to testing, that still will fall into a health system that may or may not be really able to provide the full gamut of care for that outbreak for people who do contract the disease, much less than the rest of the disease systems that happen. And it’s another important element to remember is that there’s no sort of pandemic health worker army out there and then your regular health workforce.

It’s one health workforce that’s on the front line delivering babies and fixing broken bones at the same time that they’re seeing m pox cases. So that aspect of being able to provide supportive care for people who do contract MPOC can be really limited in countries with limited resources.

Is that part of the messaging for the strategic preparedness plan that the WHO has recently released on how families can take care of one another when there is someone in the house that does have MPox and they cannot be cared for in a hospital setting or by health care workers?

WHO does have some guidance on care for MPOX that includes guidance around caregivers, non trained caregivers can provide. It’s a separate document around the response plan. It does refer to those, and these guidelines were updated for the twenty twenty two outbreak. And I’m expecting there’ll be a slight update vis a vis the latest played, but it’s similar symptoms and that kind of thing.

So it probably won’t change that much. What I wish was a little bit stronger in the current WHO plan, which we really with a lot of effort, and I was personally in charge of it at WHO. It took a lot of effort to get people to realize, again, this point that this outbreak, even in the countries most affected, is it’s happening in the midst of lots of other strains on the health care system on a daily basis. DRC, in addition to having many other diseases, it’s had three other reportable disease outbreaks at the same time that it’s dealing with MPOX.

So there’s other disease outbreaks that are happening at a lower level, and then all sorts of other constraints, including internal unrest in the eastern part of the country to sort of put a very mild term on it, as well as all the regular things that happen in a big country’s health system. And that includes everything from sort of infectious disease to accidents and and emergencies as well as the care that they’re trying to provide for people with cancer, diabetes, and hypertension. So lots of things happen every day in a hospital, in a primary care center. MPOX is one further complication, but to try and tackle all of those and at least acknowledge that all of that’s going on, I think, is really important.

Mhmm. From the twenty twenty two outbreak, what did we learn from our response to that outbreak that we’re actually implementing now to help better manage the situation?

Well, I think we did learn that we need to have a stockpile of vaccines on hand, and the US has a certain number of vaccines prepared. WHO has also put out a preparedness and strategic response plan that came out just at the end of August, and it sets out a bunch of priorities around the kind of prevention and public health measures. So you can see that the plan came out much quicker than it did for COVID. So that means guidance to countries about how they should be thinking and organizing themselves.

And so that’s really important. And especially the guidance on organizing vaccines, the idea that you have focused populations, I e health workers, frontline responders, and just people who are more likely to be affected and then particular at risk population. So all of that took months, and I was in the middle of it at WHO to get down on paper under COVID. And this time around, we’ve benefited from that, and it’s come much quicker.

Ed, why do you have hope that we will be able to slow the spread of this MPOX outbreak?

Well, the bottom line is that this outbreak coming a bit on the heels of COVID or at least on the heels of what we all thought was the kind of end of the emergency time of COVID shows us that we’re constantly living on the edge of the next disease outbreak. It wasn’t this anomaly that COVID came, and that was the pandemic for our generation, and this won’t happen again. It shows that our systems that we need to have both the testing, systems of public health messaging, and also systems for our vaccination systems need to have more investment. And maybe I just spend a quick word on that, the investments that have been made in vaccines and the number of vaccines that are available and actually, you know, children are supposed to be getting these days.

We’ve spent billions, rightly so, on developing new and better vaccines. But, honestly, we spent almost nothing comparatively on the vaccination systems that we have to deliver those vaccines into arms. And I think one of the reasons I personally have hope working at a company, ApiJect, which is focused on vaccine delivery and on new technologies and sort of platform technologies that can increase access to injectable medicines in general, but vaccines in particular, is that there is the possibility with some of the innovations in delivery, like ApiJect’s developing, like other organizations out there are developing, to really change in a big way the kind of vaccine delivery problem that we have.

If I just take ApiTech, for instance, one of my inspirations has been doctor Paul Farmer, who started Partners in Health and was someone who worked for years in Haiti and he’s seen within the global health community as just this amazing, individual. And he used to say to us in our classes and also in collaborations that we had that if access to health care is considered a human right, who’s considered human enough to have that right? And so the issue is we have prefilled syringes and some technologies that help us deliver vaccinations at pharmacies or even work programs and that kind of thing in the US or in high income countries.

But those devices, even though they don’t seem like they would cost that much, they are way, way too expensive for the very, very low resources that we have to deal with in some of these countries like DRC, like Nigeria that we were talking about earlier. So some of the investments that are being made in that vaccine delivery and innovations like ApiJect, I think, give me a lot of hope that we’re gonna be able to tackle some of these vaccine challenges we have in the future. Mhmm.

Also, I’m hopeful about the fact that the energy we’ve seen this many, many, many, many times. Literally, every global outbreak that I’ve been a part of, whether it’s h one n one or h five n one or Ebola, Zika, now, you know, COVID that there’s always a period of intense attention and then this really waning worry in public attention to the matters. And I think it does give us a chance to refocus some of the efforts and come back to the recommendations that came out of COVID. There were many from both an international panel to the UN to, you know, recommendations to the US government about how to better set up for pandemic preparedness and really invest in both the early warning systems, as well as some of the response mechanisms that could be there.

We have, for instance, hundreds of drugs that are on drug shortage list in the US. Some of those are antivirals. Some of which could potentially, if we had more access to them, could be potentially be good treatment options for MPox. I think I’m, hopeful in a bizarre way that the MPox has shown the light back on our lack of preparation and to give us a bit of energy and trying to put that before both decision makers who hold public funds like congress and others, as well as private companies looking at this and saying this is an opportunity for us to step into an area and have a big impact and also potentially a big market.

That is hopeful, and I look forward to hearing about the developments of ApiJex devices and that we can have a quicker delivery of vaccines around the world. And we appreciate you sitting down with TEDMED today. Thank you so much.

Thanks, Kelly. Thanks for having me.