Prof Colleen Aldous on Mpox: the next vaccine-equity test has already begun

A permanent global mpox vaccine stockpile has launched, meant to let countries request doses within 48 hours of an outbreak rather than negotiating after the fact. Financed by Gavi and run through the International Coordinating Group, it marks progress after the scramble seen during the 2024 emergency. But the mechanism's real test comes once demand outstrips supply. South Africa has recorded eight cases in 2026, mostly in the Western Cape, and began targeted vaccination in Gauteng, KwaZulu-Natal and the Western Cape last year. With most of the global caseload in Africa, how doses are allocated will matter directly here..By Prof Colleen Aldous.The next test of global vaccine equity has already started, and this time we cannot say we were taken by surprise. Mpox, formerly known as monkeypox, is a viral infection related to smallpox that can cause fever, a characteristic rash and, in some cases, severe illness. At the end of August 2026, a permanent global stockpile of mpox vaccines was launched. It was expected to begin operating during September 2026 and is intended to allow countries confronting outbreaks to obtain vaccines rapidly rather than negotiating for doses after an emergency is already under way.On the face of it, this sounds like a sensible piece of public-health administration. It may prove to be much more important. The stockpile provides an opportunity to find out whether global health has learnt one of the central lessons of recent epidemics. When medical products become scarce, principles of equity are much easier to proclaim before an emergency than to apply during one.Mpox has certainly not disappeared. The World Health Organization reports that between January 2022 and 31 July 2026, 145 countries and territories recorded 190,683 laboratory-confirmed cases and 529 deaths. Approximately two-thirds of currently reported cases are occurring in Africa. Mpox can cause severe disease, particularly in young children and people whose immune systems are compromised.South Africa is not removed from this picture. According to the National Institute for Communicable Diseases, eight cases had been reported in this country during 2026 by 28 August: six in the Western Cape and one each in Gauteng and KwaZulu-Natal. Four involved clade Ib virus and four clade IIb virus. South Africa began a targeted mpox vaccination programme in July 2025 in Gauteng, KwaZulu-Natal and the Western Cape, where most cases have occurred.These are not mRNA vaccinesOne point is worth clarifying because the word “vaccine” now often immediately evokes the controversies surrounding COVID-19 vaccines. The principal mpox vaccines are not mRNA vaccines. MVA-BN, marketed under names including Jynneos, Imvanex and Imvamune, is based on Modified Vaccinia Ankara, an attenuated vaccinia virus related to the virus historically used for smallpox vaccination. It has been weakened so extensively that it cannot replicate in human cells. LC16m8 is another attenuated vaccinia-based vaccine. Unlike MVA-BN it can replicate to a limited extent and produces a characteristic local vaccination reaction. Both technologies arise from the long history of smallpox vaccination rather than the mRNA platform used for some COVID-19 vaccines.The evidence is encouraging, although it should not be overstated. The WHO reports that current studies suggest that people receiving two doses of MVA-BN have about an 82% lower risk of developing mpox than unvaccinated people, while one dose is associated with about a 76% lower risk. These estimates come largely from observational evidence generated during outbreaks rather than from the sort of large placebo-controlled efficacy trials familiar from some other vaccines.Safety surveillance is continuing. More than a million MVA-BN doses have been administered, and the WHO's vaccine-safety committee has reported a generally favourable safety profile, while acknowledging that information remains more limited in groups such as young children, pregnant women, immunocompromised people and populations outside Europe, North America and Australia. That is how vaccine evidence should be discussed. Neither as unquestionable certainty nor as evidence-free experimentation.The WHO does not recommend indiscriminate mass mpox vaccination. Vaccination is targeted towards people at increased risk during outbreaks, including close contacts, people in areas with substantial transmission and healthcare or laboratory workers with occupational exposure. The more interesting question now is not simply whether these vaccines work. It is who gets them when there are not enough to meet every request.Building the stockpile before the crisisThe new system is being financed by Gavi, the Vaccine Alliance, and managed through the International Coordinating Group (ICG) on Vaccine Provision. The ICG is not a new organisation created for mpox. It has managed emergency vaccine stockpiles for diseases including cholera, yellow fever, meningitis and Ebola. Mpox becomes the fifth disease covered by this mechanism.Any country experiencing an outbreak will be able to apply for vaccines. Countries eligible for Gavi support will receive the vaccines without charge and may also receive assistance with implementation. Wealthier countries will be able to obtain vaccines just as rapidly, with Gavi initially financing the doses, but they will subsequently have to reimburse their cost.When a country applies, technical experts representing the WHO, UNICEF, Médecins Sans Frontières (MSF) and the International Federation of Red Cross and Red Crescent Societies will examine the epidemiological situation, the population proposed for vaccination, the strategy for delivering the vaccines and the number of doses requested. The intention is to reach an allocation decision within 48 hours.This is a significant improvement on trying to design an allocation mechanism after countries have already begun competing for scarce supplies. But the real test lies ahead. The precise size and composition of the mpox stockpile have not yet been announced. And that is important to know.Equity is relatively easy when there is enough vaccine for everybody who needs it. Allocation becomes ethically difficult when several countries face significant outbreaks simultaneously and available supply cannot satisfy them all. Imagine that one country has the largest number of cases, another has rapidly accelerating transmission, and a third has fewer cases but a large population particularly vulnerable to severe disease. Which should receive the doses first? Or suppose one country can distribute 100,000 doses within days while another has a much weaker health system and will require substantially more logistical support. Should preparedness determine priority?There is a defensible argument that scarce vaccines should go where they can be deployed rapidly and prevent the most infections. But there is an equally important danger. If “readiness” becomes too powerful an allocation criterion, countries with the weakest health systems may repeatedly find themselves at the back of the queue precisely because their health systems are weak. Efficiency and equity are not always the same thing.Africa has heard promises about vaccine equity beforeThis question has particular resonance for Africa. The continent currently carries most of the reported mpox burden. Most of the vaccine manufacturing capacity required to respond lies elsewhere. During the 2024 mpox emergency, an ad hoc Access and Allocation Mechanism had to be created to distribute vaccines. International partners purchased or donated millions of doses, and vaccines began reaching affected African countries. Gavi acknowledges that the earlier global experience demonstrated the need for a more predictable system in which access did not depend primarily on a country's purchasing power.Creating a permanent stockpile in advance is therefore progress. But a global stockpile should not become a substitute for strengthening African capacity. Africa still needs better diagnostic capacity, surveillance, clinical services, regional procurement and vaccine manufacturing. A continent that continually depends on an international body to release emergency supplies remains vulnerable even when that body behaves impeccably.The same principle applies within countries. Vaccines sitting in an international warehouse do not control outbreaks. They must arrive quickly, reach the populations at highest risk, be accepted by communities and be incorporated into surveillance, diagnosis, contact tracing and clinical care. Vaccination is one component of mpox control, not the whole response.The real test comes when supply is tightThe new stockpile deserves cautious support. It is better to secure vaccines before an epidemic escalates than to scramble for donations afterwards. It is better to have publicly defined mechanisms for allocation than to allow purchasing power alone to determine who receives scarce medical products. The establishment of a mechanism is not proof that equitable allocation has been achieved though.When the first substantial competing requests arrive, we should watch closely. Which countries apply? How many doses do they request? How many do they receive? What criteria determine the decision? How long does delivery take? Are populations at highest risk actually vaccinated? And when requests exceed supply, who goes without? Those data should be public.Transparency is essential because equitable allocation is not simply a technical exercise performed by experts. Decisions about scarce lifesaving resources inevitably contain value judgements about whose need is greatest and where intervention is likely to achieve the greatest benefit. COVID-19 showed how quickly declarations of international solidarity can weaken when countries fear that their own populations may go without..Read more:.Prof Colleen Aldous: Measles is moving through South Africa. Is our response moving with it?.Mpox gives the global health system another opportunity. This time the mechanism is being built before the emergency reaches its worst point. The vaccines already exist. The organisations responsible for allocating them are known. The rules are being established in advance. This is progress. But vaccine equity will not be demonstrated by the existence of a stockpile. It will be demonstrated by what happens when there are not enough doses for everyone who needs them..*Prof Colleen Aldous, Professor and Health Care Researcher.Sign up for your early morning brew of the BizNews Insider to keep you up to speed with the content that matters. The newsletter will land in your inbox every morning on weekdays. Register here.Support South Africa's bastion of independent journalism, offering balanced insights on investments, business, and the political economy, by joining BizNews Premium. 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Prof Colleen Aldous on Mpox: the next vaccine-equity test has already begun

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