Regulatory Collaboration on Mpox Treatments Summarized in Report

The European Medicines Agency (EMA) announced on Oct. 25, 2024 that international regulators have published a report based on outcomes of a workshop held on Oct. 2, 2024 by the International Coalition of Medicines Regulatory Authorities (ICMRA) (1). The workshop, which was held virtually, included representatives from international medicine regulatory authorities, such as FDA, EMA, and the Japan Pharmaceuticals and Medical Devices Agency, and the World Health Organization (WHO) to discuss access to mpox medicines during an outbreak. WHO declared mpox a public health emergency of international concern in August 2024.

The current epidemiological status and the availability of mpox vaccines in African countries was discussed during the workshop. The use of mpox vaccines in pregnant people and in children was also discussed, specifically efforts to fill the gap of evidence for these patient groups. Attendees also discussed effectiveness surveillance systems and regulatory pathways for mpox vaccine and drug approvals. The need for large clinical trials was emphasized by participants so that the appropriate evidence may be generated to quickly develop and approve these medicines.

“One of the major challenges during these outbreaks has been the unequal availability of medical interventions, such as antivirals and vaccines, with low-income countries in Africa facing the greatest difficulties. While high-income countries were able to access vaccines more readily, African countries, where mpox is endemic, have struggled with delayed regulatory approvals and inaccessible prices,” the report states (2).

According to the report, children are the most vulnerable group in the Democratic Republic of Congo and have the highest fatality ratio. Because of this, the workshop discussion prioritized pediatric treatments. FDA granted emergency use authorization for the MVA-BN vaccine for children; this vaccine has been used in the United States safely. Canada has authorized the vaccine for people 18 or older but has made a discretionary recommendation for use in children. EMA expanded the indication for the vaccine to be used in children 12 to 17 years old.

“There is limited evidence for the use of MVA-BN vaccine in pediatric populations under 12 years of age; the safety profile is however not expected to be different in this population. The WHO Strategic Advisory Group of Experts on Immunization has also recommended that the MVA-BN vaccine can be used in children if the benefits outweigh the risks,” the report states (2). “For these reasons, regulators within ICMRA stand ready to support decisions in countries most affected, including for use in children less than 12 years of age. However, misinformation is of concern and robust communication strategies need to be implemented.”

During the workshop it was recommended that a dose-sparing strategy using the intradermal route of administration be considered due to the gaps in the vaccine supply and the number of doses that are needed for high impacted countries. It was also recommended that a different vaccine, LC16m8, be considered, as it is currently approved for use in all age groups in Japan.

New vaccine development discussion brought to attention the different regulatory pathways for approval and that alternatives to placebo-controlled studies should be considered, as well as alternative methods of administration.

“ICMRA unanimously agreed that fragmentation in clinical research, as has happened so far with mpox, must be avoided, as studies need to be conducted rapidly and efficiently in the best interest of patients. More collaboration towards merging efforts from investigators into larger unified clinical trials is advocated,” the report states.

References

1. EMA. Fostering Regulatory Collaboration to Improve Access to Mpox Medicines. Press Release. Oct. 25, 2024.
2. ICMRA. Summary Report of the International Coalition of Medicines Regulatory Authorities (ICMRA) Workshop on Mpox, October 2, 2024. https://www.icmra.info/drupal/news/mpox_news_announcement_25oct2024/mpox_ws_report_2oct2024 (accessed Oct. 25, 2024)