Mpox Surge in Africa: The Urgent Need for Better Community Engagement Strategies to Combat the Historical Context of Mistrust

The recent surge in Mpox cases in Africa, with over 18,737 cases and 541 deaths in 2024, highlights a growing public health crisis. The emergence of the virulent Clade 1b strain in the Democratic Republic of Congo (DRC) and its recognition as a sexually transmitted infection has prompted swift action from health organizations. Despite Mpox being endemic in parts of Central, East, and West Africa, socio-economic disparities, inadequate healthcare, and weak disease surveillance drive the outbreak. Effective community engagement, hindered by mistrust in public health interventions, is critical for containment. Countries like the DRC and Nigeria face public cooperation challenges due to previous campaign failures and limited local involvement. This article advocates for locally adapted health initiatives, involving community leaders and health workers, using culturally sensitive messaging and local languages while leveraging both mass and social media to enhance outreach. These efforts can increase vaccine uptake, improve prevention, and help curb the spread of Mpox in Africa.

The increasing spread of Mpox cases in Africa has raised alarm bells across the continent. Africa has recorded 18,737 cases (suspected and confirmed) and 541 deaths from Mpox in 2024 alone — about 126 percent of the total number of cases reported in 2023 ^[1]. Mpox has a case fatality rate of 3.9%, particularly among children younger than 15 years who make up to 60% of confirmed cases ^[1][2]. This sharp rise, coupled with detection of the more lethal Clade 1b in the Democratic Republic of Congo (DRC) and neighboring regions, has raised significant alarm. Mpox was previously thought to be a zoonotic disease endemic in parts of Central, East and West Africa; however, the global outbreak has shown that the disease is changing in various ways ^[3].

In response, both the World Health Organization (WHO) and the Africa Centres for Disease Control and Prevention (Africa CDC) promptly declared Mpox a Public Health Emergency of International Concern (PHEIC) and a Public Health Emergency of Continental Concern (PHEC) in August 2024. The recent emergence of a new clade and rise in Mpox incidence reflects a complex interplay of socio-economic factors, inadequate healthcare infrastructure, weak disease surveillance, and inadequate community engagement ^[2][4][5].

Every individual case of Mpox comes from within the community, most of the time through Primary Healthcare Centres de Santé ^[6]. Hence, effective community engagement and surveillance is perhaps one of the most important ways to checkmate the spread of Mpox. This article focuses on strategies to improve community engagement of cases, ensuring prompt identification, treatment, and acceptance of preventive measures — including vaccination. We examine the historical context of mistrust, highlight successful community engagement programs from both high-income countries and low- and middle-income countries, and provide actionable recommendations.

The Democratic Republic of Congo (DRC) exemplifies the longstanding challenges faced by public health interventions in gaining community trust. This mistrust is rooted in the perceived ineffectiveness of past health campaigns, inadequate local involvement, and historical exploitation by external organizations ^[7][8]. During Ebola outbreaks, many communities expressed skepticism toward foreign health workers, suspecting research priorities overshadowed genuine local health concerns ^[9][10]. Similar sentiments have emerged regarding Mpox, as public health campaigns are often viewed as top-down approaches that neglect local knowledge and practices.

As revealed by a qualitative Twitter-based study ^[11], one of the significant challenges with Mpox vaccination is the mistrust and stigma associated with Mpox, which has been inaccurately labeled as a disease primarily affecting the LGBTQ+ community. This stigmatization has led to widespread hesitancy. The stigma and misinformation not only deter vulnerable populations from seeking vaccination but also complicate the efforts of public health agencies to communicate effectively.

The 2017 Mpox response further reflected ongoing mistrust. Despite WHO involvement, many individuals remained reluctant to accept vaccinations. Local narratives suggested health workers focused more on data collection than on providing genuine care, leading to widespread refusal of vaccination ^[12]. The lasting effects of colonialism and medical experimentation significantly influence people's beliefs and their willingness to adopt recommended behaviors ^[13][14].

In Nigeria, misinformation spread rapidly through social networks during the 2017 outbreak, and local leaders were not sufficiently engaged. Reports noted that rumors circulated on social media that individuals in army uniforms were entering schools to administer monkeypox virus injections as part of a population-reduction scheme ^[15]. More recent misinformation includes Mpox being described as a side effect of the SARS-CoV-2 vaccine, or as a biological weapon ^[16].

During the 2022 Mpox outbreak in Nigeria, a study by our team found that only 58% of respondents were aware of Mpox, and only 15.5% had ever heard of the Mpox vaccine ^[17] — reflecting an urgent need for better community engagement strategies in Africa's most populous country.

During infectious disease outbreaks, community engagement campaigns that are culturally sensitive, evidence-based, and tailored to local contexts are necessities. A rapid review on community engagement during communicable epidemics ^[18] identified six crucial groups: local leaders, community and faith-based organizations, various community groups, health system committees, individual community members, and key stakeholders. Engaging communities fosters trust, which is crucial for encouraging early reporting of cases, adherence to preventive measures, and acceptance of vaccination.

Nigeria, the first country in Africa to receive the Jynneos Mpox vaccines, received 10,000 doses and was set to begin Mpox vaccination on 8 October 2024 ^[19]. Community members must be informed not only about evidence-based information on Mpox transmission and symptoms, but also about the importance and safety of vaccination as availability to high-risk groups is scaled up in Africa.

Some high-income countries have demonstrated the effectiveness of community engagement strategies in managing the 2022 Mpox outbreak. The "Get the Facts" campaign in the United States utilized social media, community events, and partnerships with trusted community leaders, resulting in increased awareness and vaccine uptake ^[20]. The US campaign also deployed targeted outreach collaborating with LGBTQ+ organizations to disseminate information and promote vaccination ^[21][22]. The CDC participated in approximately 50 community engagement campaigns with affected groups to develop Mpox-related communications.

Similarly, the United Kingdom implemented a comprehensive public health campaign emphasizing clear messaging about Mpox transmission and prevention. The NHS engaged local communities through workshops and informational sessions, significantly improving vaccination rates and reducing stigma ^[23].

Although high-income countries have effectively implemented community engagement strategies, low- and middle-income countries (LMICs) encounter distinct challenges requiring customized approaches. In Nigeria, public health campaigns must consider cultural beliefs, a highly diverse environment with over 250 languages, local practices, and the socio-economic realities of communities. The following strategies have proven effective:

• Involving Community Health Workers and Local Leaders

  Including local leaders and influencers in public health messaging leverages existing community structures and enhances credibility and reach. This approach proved successful in Nigeria's polio campaigns, where religious leaders in the northern region were actively involved ^{[24][25][26][27]}.
• Culturally Sensitive Messaging

  Campaigns must be designed with cultural relevance in mind. In Sierra Leone during the Ebola outbreak, health officials worked with traditional healers to incorporate local practices into prevention messages, leading to increased community acceptance of public health measures ^[28].
• Local Language Utilization

  Materials should be translated into local languages to improve comprehension and accessibility. SRHIN's #STOPCOVID project disseminated COVID-19 messages into over 100 languages, reaching millions of people across Africa and internationally ^[29]. Educational materials in local languages should also be printed and displayed in PHCs and local health centers.
• Community Workshops and Education on Vaccination

  Public health campaigns should emphasize the safety and efficacy of the Mpox vaccine, directly addressing concerns and misconceptions. Community-led dialogues, such as those organized by the Dean Initiative in Rivers State, Nigeria, helped address prevailing myths surrounding COVID-19 vaccination ^[30][31].
• Community Involvement in Planning and Mobilization

  Engaging local leaders and stakeholders in the planning and implementation of health initiatives fosters trust and enhances participation. During the Ebola response in Sierra Leone, community-led action plans resulted in an increase in safe burials and cases referred within 24 hours of symptom onset ^[32].
• Incorporating Feedback Mechanisms

  Establishing channels for community feedback helps public health authorities adapt strategies in real-time. In Kenya, a mobile phone-based feedback system for maternal health services led to a 36.6% increase in the facilities' ability to identify risk factors for adverse healthcare outcomes ^[33].
• Leveraging Mass Media, Social Media, and Information Technology

  Utilizing SMS alerts and social media platforms to provide timely updates on Mpox symptoms, prevention, and vaccination can significantly enhance community awareness. SRHIN's community work on the Canada-Africa Mpox Partnership project reached over 57,000 people on X/Twitter in August 2024 alone, indicating the massive potential of social media in making health information accessible ^[34].

The surge of Mpox in Africa underscores the urgent need for improved community engagement strategies. The historical context of mistrust in the DRC, Nigeria, and Cameroon has profound implications for current and future Mpox campaigns. Community members often view public health interventions with suspicion, leading to low participation rates and ineffective disease control measures. This skepticism is shaped by a history of inadequate responses to health crises and a lack of transparency from health authorities.

To combat this mistrust, public health initiatives must prioritize community engagement and cultural sensitivity. By learning from successful initiatives in high-income countries and adapting them to the African context, public health authorities can enhance awareness, acceptance, and adherence to preventive measures. Efforts should focus on building trust through local partnerships, involving community leaders in health campaigns, and ensuring that interventions are tailored to the specific needs and beliefs of the populations served. As Mpox vaccines roll out across Africa, prioritizing community engagement will be essential in mitigating the spread of this disease and protecting public health.