The flu virus that has wreaked havoc on birds around the world appears to have surfaced among cows in the US. Texas authorities said this week they found the H5N1 strain, and the US Department of Agriculture said testing showed “consistency” with the clade of virus that has killed millions of wild birds and forced culling of poultry. https://www.science.org/content/article/news-glance-domestic-u-s-postdocs-edited-pig-organs-and-milky-way-s-central-black-hole?
Kansas and New Mexico also reported infected cows, which showed limited symptoms. There were no plans to cull them; pasteurization of their milk kills the virus. Dead birds were found on some of the affected dairy farms. H5N1 has infected dozens of other mammalian species but with limited spread within them. Officials have said the risk to humans remains low.
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Tools to fight HIV tend to come late to sub-Saharan Africa, the region hardest hit by the epidemic. After powerful, lifesaving cocktails of HIV drugs came to market in 1996, it took 7 years before they began to reach large numbers of people living with the virus there.
But with the next revolution in HIV prevention—an injectable, long-lasting version of PrEP—Africans may actually soon lead the pack. https://www.science.org/content/article/long-lasting-injectable-hiv-prevention-drug-set-aggressive-roll-out-africa?
Not many people in rich countries have started to take this formulation, mainly because of insurance hassles for the expensive drug. But injectable PrEP is now on the cusp of being widely introduced in Africa, thanks to the President’s Emergency Plan for AIDS Relief (PEPFAR), a US government program, which has purchased it at a steep discount.
“Over the next 2 years, we will see more injectable PrEP use in East and Southern Africa than we’ll see in the U.S.,” predicts Mitchell Warren, who heads AVAC, an advocacy group for HIV prevention. “That’s turning history on its head.”
PEPFAR had provided 24,000 doses of injectable PrEP in Zambia, Zimbabwe, and Malawi by 6 March and has plans for an “aggressive scale-up,” says PEPFAR head John Nkengasong. The drug has “the potential to bend the curve on the annual 1.3 million new HIV infections globally,” Nkengasong says, but the availability and cost of injectable PrEP “are still a big concern” and could limit its impact.
PrEP first proved its worth as daily pills made by Gilead, but they only work if people take them consistently—which many find difficult to do. The long-acting, injectable version of PrEP, made by the pharmaceutical company ViiV Healthcare, contains the antiviral cabotegravir (CAB-LA); a shot once every 2 months suffices.
But in the United States, CAB-LA costs more than $23,000 annually for the 2-month shots. Patients and health care providers have had trouble getting their health insurers to pay for injections, in part because PrEP pills, now available from generic companies, cost as little as $300 per year. As a result, only 11,000 people in the U.S. had started to use CAB-LA by the end of 2023, ViiV says.
ViiV will have at least 1.2 million doses of CAB-LA available for low- and middle-income countries through 2025, and about 30% of those will go to PEPFAR. But so far, not a single country in sub-Saharan Africa has put in an order to purchase the drug with its own money, says Linda-Gail Bekker, who runs the Desmond Tutu HIV Centre at the University of Cape Town.
For mass introduction the price will need to come down further. ViiV has signed a voluntary licensing agreement with the Medicines Patent Pool that makes it possible to cut deals with companies that can produce the drug more cheaply.
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“It’s just a matter of time, if nothing is done, that the transmission crosses the border in the African region and, again, globally,” says Dr Jean Nachega, an epidemiologist at the University of Pittsburgh.
Nachega is one of a number of public health experts expressing alarm over a major outbreak of mpox – formerly called monkeypox – in the Democratic Republic of Congo. www.npr.org/sections/goatsandsoda/2024/03/27/1239276957/mpox-outbreak-democratic-republic-of-congo-deadlier-strain?
They say the current situation represents a triple threat.
First, the DRC is seeing record numbers. About 400 suspect cases are reported each week – the majority in children. Second, the strain of the virus that’s circulating is especially deadly, with up to 1 in every 10 people who get the virus dying. And third, the virus is behaving differently.
“For measles, we know what to do. For cholera, we know what to do. For polio, we know what to do. These are things that have been around for a long time. For mpox, a lot of the elements are new,” says Dr Rosamund Lewis, the World Health Organization’s technical lead and emergency manager for mpox. “And we don’t yet have all the countermeasures in place that we need in place.”
Last year, the DRC recorded more than 14,500 suspected cases of mpox, and more than 650 deaths. Those figures dwarf previous years – and the numbers continue to rise. In the first two months of this year, there have been more than 3,500 suspected mpox cases and more than 250 deaths.
At this point, the majority of the cases follow a pattern that has become well-established over the past few decades: The outbreaks happen in remote villages in densely forested areas of the north and central DRC. They typically start when the virus jumps from an animal to a person. Imagine a child catching a rodent or a parent cooking bushmeat. And from there, the virus can spread within a household or a community, often through skin-to-skin contact or through contact with shared surfaces, like a bedsheet or towel.
For some, the mpox virus is mild – causing a few lesions. For others, it can be devastating: fever, malaise and painful lesions all over the hands, face and torso – and even death.
The strain of the virus that’s common in the DRC is called Clade I and it’s 10 times more deadly than Clade II, which is found in West Africa and caused the global outbreak. And with Clade I, about two-thirds of the cases in the DRC are in children under the age of 15.
Lewis, of the WHO, says this could be because many adults have been exposed and acquired some immunity. Plus, anyone who received the smallpox vaccine has some immunity. That vaccine was administered before the disease was eradicated in 1980.
In addition to focusing on children, experts are closely tracking a new situation that doesn’t fit the traditional mpox story. Attention has been focused on the gold-rich city of Kamituga in the South Kivu province, which never used to have mpox cases.
“It’s a rich region where there are several minerals and thousands of workers working in this mining setting,” explains Nachega of the University of Pittsburgh. “We have some recent evidence showing that some miners are circulating this virus and it’s been documented also in sex workers.”
This is concerning for two reasons, he says. First, the more virulent strain of the virus that’s present in the DRC – Clade I – was never known to transmit sexually until a few months ago. Now, this type of spread is firmly established. Second, many of the miners are transient, and many families in the area are on the move too, fleeing violence from ongoing strife.
About 90% of the mpox cases in the DRC are not confirmed by a laboratory test. That’s because in a country of over 100 million, there are only two labs that do mpox PCR – or polymerase chain reaction – testing.
Vaccines were a major piece of the strategy during the global mpox outbreak in 2022. However, the DRC government has not authorized use of any of the three vaccines available for mpox – nor has any other African government.
Several nations have offered to donate doses, and one vaccine manufacturer has drawn up plans to scale up production.
However, experts say, even if an mpox vaccine is licensed, a target population is decided on and supply issues are ironed out, it would still not be easy for the DRC.
“Congo is going through, eight or ten different epidemics,” says Dr Michael Ryan, executive director of the WHO’s Health Emergency Programme, noting that the country is dealing with measles, cholera, plague and anthrax, among other diseases.
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Nearly 5 decades after the last documented case, smallpox remains the only human disease that has been officially eradicated. But a new report concludes that the United States can do much to strengthen its ability to respond if the dreaded disease resurfaces, whether naturally, through a lab “leak” of the responsible virus, or from an act of terrorism. www.science.org/content/article/smallpox-may-be-gone-u-s-should-better-prepare-its-return-report-says?
The authors of the smallpox report, however, do not offer a recommendation on the long-running debate over whether the only two labs that still hold samples of variola, the smallpox virus, should destroy them for safety reasons—that issue was outside their remit, they say. But their report does conclude that investments in improved smallpox vaccines, better diagnostics, and more effective therapeutics are all needed. And, the report notes, this research could also benefit efforts against relatives of the smallpox virus, including the one that causes mpox and began spreading around the world in 2022 after largely being confined to African countries.
Many other emerging infectious diseases might seem more pressing than smallpox, acknowledges infectious disease clinician Nahid Bhadelia, head of the Centre for Emerging Infectious Diseases at Boston University and a co-author of the report. “But it’s the first disease ever eradicated, and the threat of smallpox cases in the future is nonzero,” she says. “Even one case would be a public health emergency. And so we need to maintain readiness.”
Bhadelia was part of a committee convened by the National Academies of Sciences, Engineering, and Medicine (NASEM) to write the U.S. government–requested report, which stresses that lessons for smallpox preparedness can be gleaned from shortcomings in the response to both mpox and the COVID-19 pandemic. “Gaps in the nation’s readiness and response posture against unfamiliar pathogens were exposed,” the report reads.
The smallpox virus now only exists in freezers of two government-run, high-security laboratories—one at the Centers for Disease Control and Prevention in Atlanta and the other at the State Research Centre of Virology and Biotechnology in Koltsovo, Russia. Scientists in each sometimes run experiments with variola to test new vaccines and drugs, which the new report, Future State of Smallpox Medical Countermeasures, says should continue. Aside from threats of a laboratory accident, the U.S. long has been concerned about terrorists obtaining the virus and using it in an attack.
The Institute of Medicine, now part of NASEM, has previously looked at arguments for maintaining the variola stocks, concluding in reports issued in 1999 and 2009 that they should be maintained at those two labs. And whether to destroy the samples is on the agenda of a May meeting of the World Health Assembly, which has periodically debated the issue. The new report stresses that the landscape of that debate has changed because there are publicly available genetic sequences of smallpox virus and scientists could, in theory, re-create copies of it with that information.
Variola, in the orthopox genus of viruses, killed an estimated 500 million people in the century before a global vaccination campaign eradicated it.
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Indian biotechnology company ImmunoACT has produced an innovative cancer treatment called chimeric antigen receptor (CAR) T cell therapy at one-tenth of the cost charged by global competitors. The treatment — called NexCAR19 — costs between US$30,000 and $40,000 whereas previous treatments cost between US$370,000 and $530,000. This cheaper product could make cellular therapies accessible for low- and middle-income countries, says haematologist Renato Cunha. “Hope is the word that comes to mind,” he says. “It lights a little fire under all of us to look at the cost of making CAR T cells, even in places like the United States.” says Terry Fry, an immunologist and paediatric oncologist who has advised ImmunoACT.
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Lalita Panicker is Consulting Editor, Views and Editor, Insight, Hindustan Times, New Delhi
