After two years of COVID-19 dominating the public health debate, another infection is now making international headlines: the Monkeypox virus. My name is Laurence Ivil - and I'll be your host today.

Monkeypox is a viral zoonotic disease, meaning it spreads from animals to humans. Though it can travel between humans, historically it hasn’t travelled far this way and wasn’t considered to be very contagious.

According to the WHO in just May of this year, Monkeypox was a disease that occurred primarily in tropical rainforest areas of central and west Africa and was only occasionally exported to other regions. 

But now things have changed. 

Less than three months later, and almost 20,000 cases of Monkeypox have been documented in Europe and more than 3,000 cases in Germany alone. Over 10,000 cases have been recorded in the USA. This is now the largest recorded Monkeypox outbreak in history and the WHO has declared it a public health emergency of international concern. 

With us today is a man who was described in a piece by NPR’s Michaeleen Doucleff as “the man who tried to warn the world” about the spread of monkeypox: Professor. Dimie Ogoina. Dimie is a Medical Doctor and Lecturer at the Department of Internal Medicine at the Niger Delta University, as well as Chief Medical Director at the Niger Delta University Teaching Hospital. He is also the President of the Nigeria Infectious Disease Society. 

Dr Ogoina, on behalf of the Global Perspectives Initiative, welcome and thank you for joining us.

Thank you very much. It's a pleasure to be here.

Wonderful. Dimie, let's just start off with this question. Three years ago, you co-authored a study about the 2017 human monkeypox outbreak in Nigeria. What did you find there and how did the public health community react to your findings?

So what we observed, essentially a young, 11 year old child came into our hospital, was referred from a private hospital to our hospital. It was suspected to be chickenpox. It was unusual because the person, the child, was not getting better in the private hospital and was referred to the paediatrics department. So some of the younger colleagues in the paediatric department, one of them suspected monkeypox. I'm an adult physician, but because I'm an infectious disease physician, I was called to come and see the patient and also to corroborate the suspicion. On seeing the patient, of course, at that time, I had not seen any case of monkeypox in my medical practice. I've only seen pictures on the Internet and in medical textbooks, but it looked a bit typical. What was a little bit different was the size of lesions. Lesions were very, very big, but they were typical in terms of their appearance. And so I also felt it was monkeypox.

Thanks for that, Dimie. And starting with this boy, in the weeks and months and then years after that, when did you first discover or begin to think that monkeypox may become a bigger health situation than we've seen in the past?

Yeah. So I am not sure if I considered it to be a very big problem at that point. What was very unusual was that after that boy came in. I felt that we will be seeing children with monkeypox, because historically, if you look at the data in endemic countries, monkeypox is a condition that affects children less than ten years or 11 years of age. And that index case sort of fits into that profile of cases that should be affected by monkeypox. But after that index case, the cases that we have in subsequent cases where young adults, most majority were males. So it felt very unusual to me and my colleagues at that time. And because most of them were young, sexually active males and they had concomitant genital ulcers and some even had HIV infection and also evidence of syphilis infection. And that's what brought this suspicion of sexual transmission. But I had never anticipated that it would become a worldwide outbreak now that it would be declared a public health emergency. But we also sounded the alarm to say that there's a potential for it to be transmitted via sexual contact and it's necessary for public health authorities. And that's what we said in that paper, to look at sexual contact as a as a route of transmission of monkeypox.

We had one other meeting, an international meeting in 2019 or so, where I also put forward this view because I was very enthusiastic and passionate about the fact that I made this observation and there was a need to also tell the story. And I stated this in that meeting, and somebody else then said, no, it's not possible, because my argument was that it appears the outbreak is evolving epidemiologically. Initially, it was a problem for children less than 11 years. Why are we seeing young adults now, mostly males? And why are they having genital ulcers? There should be something there. And I then said, I am suspecting transmission by sexual contact. And colleagues then said, some of the colleagues in the international meetings said no, it's not possible. And that it is not unusual that even in the DRC that there appears to be a change because in the DRC as you know, now the age group affected has also evolved from less than 11 years to 15 to 20 something years. And they felt that that evolution in terms of age is not unusual.

In Nigeria is it widely accepted that this is a disease that is being transmitted through sexual contact? Or is there still some scepticism? How are people talking about transmission in Nigeria?

The evidence available to the best of my knowledge at that time was that the country was not too sure about the source of transmission. Or the origin of monkeypox itself. Currently I am aware that there is still uncertainty about how monkeypox is transmitted in Nigeria. That's what I think. I think there's still uncertainty because nobody would come out to say it is predominantly transmitted via this route because we cannot accuse animal contact. Majority of the human monkeypox cases in Nigeria amongst young adults, 70% of them are males. All of them, almost all of them live in urban and semi-urban settings. They are not within the traditional rainforest areas that we know monkeypox is transmitted via animals, and the majority of them have no contact with animals. So that means that there are other factors that perhaps we are not seen or were not necessarily looked at to determine how monkeypox is transmitted in the country. But just to say that I still believe that monkeypox is transmitted via sexual contact in Nigeria. Whether that is the predominant mode of transmission is what I don't know. But to date, I know have seen cases that suggest that monkeypox is transmitted via sexual contact.

In Europe, and in America, statistically cases of Monkeypox are disproportionately affecting gay and bisexual men. Is there any indication that this demographic is also being affected in Nigeria? With the legal situation in Nigeria, are gay and bisexual men comfortable coming forward?

I'm not too sure whether it is because if the gay and bisexual men in Nigeria are not able to come out to the open to speak about it or to declare their sexual orientation, I don't think that's a challenge. Fortunately, the country has a process where through HIV, AIDS services, they provide care to key populations. Key populations include commercial sex workers, gay and bisexual men, people who use drugs, prison people that stay in prison settings and the like. And the idea is to see that they have access to preventive services, STI prevention services, HIV preventive services and also treatment. And so I  t's a very organised set up in Nigeria. And I've always said that if there is active, active transmission of monkeypox amongst a key population, if there is active, there could be underground, I don't know. If there is active transmission I believe we should have known by now. I believe we should have known by now. But also to say that the cases we saw in 2017, 2018, none of them self-declared as being gay or bisexual men. As a matter of fact, when asked what their sexual partners, what they declared was sexual partners of the opposite sex, not of the same sex. Although I admit we did not directly ask them. For their sexual orientation. We do not directly ask them that question, but it would be implied because if they admitted that their sexual partners were of the opposite sex, that the implication is that they are not likely to be gay or bisexual men.

In Nigeria, what are the barriers that may exist that prevent people with Monkeypox from receiving treatment?

I think there are a number of people that will have monkeypox that are not coming to the hospital setting or coming to the public system for diagnosis. So I've said this before and I'll say it again. I think the number of cases we have in our country is underestimated. And it is underestimated because of the nature of the health system, the nature of health seeking behaviour, the perception of disease and challenges of surveillance. So there are multiple factors that are responsible for this.

And I can give you a typical example, even from my own setting. And colleagues have also discussed it with me. One of the cases, for instance, a colleague called me to say they were referring a case of monkeypox to my hospital and in transit the patient was missing. And when we called the patient, he said that he cannot have monkeypox, that this is a spiritual attack. So he cannot come to the hospital. There are situations where people don't want to come to the hospital because they don't have the resources. Or they don't come to the hospital because of distance. So there are many factors and also health seeking behaviour. I also tell you that number, the number, most of the cases we had even this year, some of the cases we have had, in fact, most of the cases we have had. Most of them did not come to the hospital as the first point of call for their clinical illness. They actually went to a chemist or a traditional related setting for health care. It was because they are not getting better. That's what made them come to the hospital. So I believe that there are many cases. I think there are cases. How many they have it becomes difficult. There are cases out there because of some of these challenges we are not seeing them. And that means that there's a need for more hands and active surveillance in our country. I know the NCDC is doing a lot to see how this is achieved, but the healthcare system in Nigeria is decentralised and so there's only so much the Nigeria Centre for Disease Control can do without the support of the various states to see that there is surveillance.

Within the space of two months we're having triple the number that we had in four months. And that tells you that we had cases that were there that were not diagnosed because now the declaration of a public health emergency and the outbreak in global not as causes that made clinicians more, clinical suspicion has increased, awareness has increased. Even amongst the patients now when they have lesions, they want to be sure it's monkeypox. So they have a tendency of also presenting to the health system, then clinicians, when they see patients that they wouldn't have suspected monkeypox, they now suspect monkeypox and they do a referral. And that's why we are seeing an uptick in the number of cases in Nigeria. Last week alone, last week. There are 25 cases of monkeypox reported across Nigeria, which is unprecedented in a week. That's what we reported in four months.

In comparison to COVID 19, the relatively small number of monkeypox cases might create a perception that this infection is not a threat or not a risk. Perhaps you could explain just briefly why it's so important for people with suspected cases of monkeypox to be treated.

This is what it means, and I have argued that monkeypox was never endemic in West Africa. That's my argument, because we see in the literature recently I looked at the literature and the literature has always been saying monkeypox has been endemic in West Africa from the seventies. But in Nigeria, for instance, from 1971 to 1978, we have just three cases of monkeypox. Three cases. Three cases is not sufficient to say the disease is endemic in the country. It is possible that cases are there and were not detected. But if we are using the case counts to define endemicity, it means that we can see that monkeypox. The same thing applies for Liberia, Sierra Leone and other West African countries. But the only country that we could confidently say that monkeypox is endemic is in the DRC because they have thousands of cases every year and they have been doing and reporting these cases from the 1970s onwards. So the point I'm trying to make here is that we will need to identify all the cases. Do a contact tracing. Isolate. Treat. That way we reduce propagation of the outbreak and establishment of the infection in the community in the country.

Let’s talk about prevention, response and, more specifically, vaccines. There is a vaccine that is available currently in Germany. I read today that the UK has just vaccinated 25,000 people from at-risk groups. The US has allowed millions of vaccine doses to expire. What’s the situation like in Nigeria?

Yeah. So I'm not aware that the country Nigeria has received any monkeypox vaccine and I'm aware that the Nigeria Centre for Disease Control is working with the W.H.O. to see how the vaccines and therapeutics can be made available to our country. But I'm not aware. So this is not an official position, but I think the official position can come from the Nigeria Centre for Disease Control. But I'm actually not aware and most of the colleagues I have across the country have not seen or received therapeutics or vaccines to care for their patients.

Why haven’t your medical colleagues received therapeutics or vaccines to care for their patients?

Yeah. So I think it's reflective of so many things. There's always a delay in having some of these medical countermeasures really coming to Africa. There's always a delay. And that's because we have suffered challenges of inequity over time. And it didn't start today. And we have also suffered challenges of neglect. I always tell people that monkeypox has been with us for 50 years. And yet we don't, we have not necessarily defined the reservoir of the infection. We have not tried for 50 years. We have not done clinical efficacy effectiveness trials for any vaccine or for any therapeutics, because what is currently available is on account of smallpox, not monkeypox. There have been no published clinical trials on monkeypox for some of these therapeutics or even the vaccines. And these have not happened because it's a neglected disease that has affected countries in developing countries of Africa, West Africa and Central Africa. And so people, scientists, and health authorities did not necessarily pay attention to the outbreak. And because resources are available in the global north, they have the capacity to, manufacturing capacity, financial capacity, human resource capacity to ensure that these vaccines and therapeutics are available. And I'm aware that some countries are complaining that they don't have sufficient quantities even for their own population. Not to talk of making it available to Africa. But I think we need to look deeply at what we are doing and not be greedy because as much as possible, it doesn't sound right that a problem that started in Africa and we are still battling with this problem and it has appeared in the global north. For 50 years we did not have any vaccines or therapeutics, and they are now available. And this is three, how many? About one month after it was declared a public health emergency. So we still do not have vaccines and therapeutics. I think we need to have a rethink. And amongst all the stakeholders, we just need to have a rethink.

At GPI we work at the intersection of African and European, specifically German politics. If you could have a direct line of conversation to decision makers in Europe and Germany about vaccines, what would your message to them be?

I think the message is very clear that infectious pathogens once again have no borders. Whatever we're doing in the global north to contain the outbreak, either using therapeutics or vaccines, if we don't address the problem at the source, which is Africa, there will be a vicious cycle. It will come back to haunt us. So we should recognize that it's a global village. And the issue of vaccine nationalism. Therapeutics nationalism. We should have a rethink because the global village, whatever affects the country, may have a ripple effect on other countries. So whatever interventions we are currently rolling out to address the challenge of monkeypox. We should do it in such a way that African countries are also carried along. Because if we don't do that, we are setting ourselves in a vicious cycle where this outbreak will certainly come back to Europe.

COVID 19 has drastically changed the attention to global health, highlighting the need for global cooperation. With regard to vaccines, do you see this as a new dawn for cooperation? Or are you less optimistic?

Yeah. So I think there are a lot of lessons from COVID 19, and I think we need to take our destiny into our hands. I'm talking about African countries. I think that's a priority. It's not appropriate to always be waiting for handouts from the global north or from developed countries. We must, as much as possible, invest in ourselves, in our health systems so that we have the capacity and what is required to also produce vaccines and produce therapeutics. Of course, it has to be a journey because there are a lot of resource gaps. But the idea of always waiting for the Western world to assist us in Africa is something that we also have to rethink about this. And I think it's something that we need to start immediately. Whatever we need to do, we don't know what will happen in the next five years. The new outbreak that we're calling the next five years, the next ten years, are we still going to be dependent on the Western world for vaccines and therapeutics? So that's the bottom line. Secondly, we must address internal issues. It's not only… I have told people too… It's not only about making COVID, I mean, monkeypox vaccines are available. And we have typical examples of the COVID 19 vaccines. There were issues of inequity. It took a long time before COVID 19 vaccines came to Africa. In Nigeria, for instance, we have COVID 19 vaccines. They are available for people to get their jab. But currently, less than 30% of Nigerians have received a COVID 19 vaccine. And that tells you there are other problems apart from availability of vaccines. Issues of vaccine hesitancy. And I can tell you, a substantial number of these people that have not been vaccinated are even healthcare workers, they are healthcare workers. So this challenge of vaccine hesitancy and perception of disease is a challenge. And this is why I say that in our core desire to have vaccines available, especially vaccines, monkeypox vaccines available. We should ensure that we do a readiness assessment. We should ensure that we start to address myths, misconceptions. We should ensure that we create awareness about vaccines. We should ensure that we start creating buy in for the vaccines. Because if the vaccines are bought now, we don't address all those issues, we will have vaccine hesitancy and ultimately will not achieve what we have set out for ourselves.

Do you feel it’s possible for Nigeria to apply this combination of behavioural change work and vaccine scale up in the same way it is combined in Europe, for example?

I asked this question in a recent meeting: are we communicating the uncertainties? In the efficacy and effectiveness of vaccines to the people that are being vaccinated. Because there are so many uncertainties about this monkeypox vaccine. We don't know the duration of protection. We don't even know whether it offers good protection. That's the truth, because it's just by extrapolation, because there have been no clinical efficacy trials. And so it's important that while we are giving out these vaccines, we communicate uncertainties. We don't want a situation where somebody has been vaccinated, who feel they are protected. Then two months, three, three months down the line, you are developing monkeypox again. And that would mean that there will be a breach of trust in the public health system if we don't communicate those uncertainties

The other aspect is the behavioural change. I think that's very, very, very important and we should go beyond recommendations or policy statements or advisories. We should develop interventions to address behaviour. During COVID 19, if I go to the literature, for instance, during COVID 19, the first three months of COVID 19, you see several publications on interventions to address behavioural change in COVID 19. Non-pharmaceutical behavioural interventions and the likes. But with monkeypox, if you go to the literature, I'm not sure I've seen any. I'm not sure if I might be wrong. And what that means is that we’re neglecting that aspect, and it's not just to bring out policy statements or recommendations, we must implement interventions to see that behaviour changes and the behaviour that ought to change is the sexual behaviour that is driving this process. And so there's a need to implement interventions amongst the most affected groups to see that this changes. Otherwise if we don't do it concurrently, then it's like somebody said, it's like we are neglecting the leaky roof while mopping the floor. And that is completely not appropriate.

Going full circle here, how do you target monkeypox then in Nigeria?

 For Nigeria it becomes difficult to know what to recommend because even if vaccines come to Nigeria, I know NCDC is trying to see how stakeholders can come to see how we can necessarily approach vaccination. But the challenge is much easier in the global north. You have identified the high risk group, you know, these people affected mostly men who have sex with men. Very definite. So, you know, the group that is most affected and is at risk of monkeypox. So if you are ruling out a pre vaccination post vaccination campaign, you know the group to target. But if you come to Nigeria for instance. Who is the crucial target? If you want to do a pre pre-exposure vaccination. Is it healthcare workers? Ok, if you are going to contact patients. The other challenge we have too with delivering vaccination is getting contacts, especially sexual contacts. And that's a problem that even the Global North is facing. And that's why some countries are deciding to do pre-exposure vaccination instead of post-exposure, because that's been very difficult to get contacts of, especially sexual contacts. So I think we would necessarily need to understand the outbreak in Africa much more, especially in West Africa, because I'm not sure we understand the outbreak to a level where we can benefit from all the interventions that should be available, because if we don't know the source, we don't know the main mode of transmission of monkeypox in our country, and we still have cases that are not being reported. It means we are more or less walking blindly. We need to step up our effort to see that we are able to detect more cases and be able to do more research to understand the disease.

As a scientist, do you feel listened to in the Global North? What needs to change to ensure that good quality research coming from the Global South is prioritised?

So I think it's to recognize that good science can come from anywhere. And scientists can live everywhere, anywhere. So as much as possible. Wherever we work, we should not underplay findings, research findings from countries that are scientists that live within developing countries that they are living with in developing countries. Does not mean they don't have ideas, does not mean they cannot put out important findings. I think that's what all of us need to recognise.

And I think we African scientists, we should not just rest and wait for the global north to make discoveries for us and to tell us. Unfortunately, I don't know what is right to say this. Unfortunately, in most cases it may seem as if we are always waiting and we're not taking the initiative. Although we have challenges. There are a lot of challenges, but we have very bright people around, very innovative, and they have excellent ideas. I think we should tap into what we have and come together to see that we tell our story to the world and gradually, gradually, the world will listen to us. The world is listening to us now, indirectly, because it's affected the global north. I'm not sure if you have called me for this interview, if it was 2017, I'm not sure if you would have called me for this interview. But you have called me for this interview now because it's a problem, it's an international problem. And you need to get the perspective from Africa about it. So I think we need to tell our stories more and we should not be discouraged.

Brilliant. That was great. Dimie, on behalf of the Global Perspectives Initiative, thank you so much for joining us today.

It's a pleasure. It's a pleasure to be here. Thank you very much for inviting me.

Joining us today was Dr. Dimie Ogoina - Doctor and Lecturer at the Department of Internal Medicine at the Niger Delta University.

More topics and discussions are available on the GPI website and in the newsletter. And all of this information can be found at GlobalPerspectives.org. 

A special thanks today to podcast producers - Corinna Robertz and Hannah Hölscher 

I’ve been Laurence Ivil. On behalf of the Global Perspectives Initiative, thank you for listening.