The hands of a patient with skin rashes caused by the mpox virus are pictured at the treatment center of Vijana Hospital in Kinshasa, Democratic Republic of Congo on August 30, 2024
| Photo Credit: Reuters

Dozens of feverish patients lay on thin mattresses on the floor of a makeshift mpox isolation ward in east Democratic Republic of Congo, as overstretched hospital workers grappled with drug shortages and lack of space to accommodate the influx.

Congo is the epicentre of an mpox outbreak that the World Health Organization declared to be a global public health emergency last month.

Vaccines are set to arrive within days to fight the new strain of the virus, while Congo’s President Felix Tshisekedi has allowed a first USD 10 million disbursement to fight the outbreak.

But at the hospital complex in the town of Kavumu, where 900 symptomatic patients have been taken in over the past three months, health workers are desperate for support.

“We run out of medicine every day,” said head doctor Musole Mulamba Muva. “There are many challenges we struggle to overcome with our local means,” he said, noting that donations from international organisations rapidly dwindled.

Last week there were 135 patients in the mpox ward, children and adults combined, crammed between three large plastic tents pitched into damp earth without a floor cover.

Relatives that usually provide the bulk of meals in underfunded public facilities such as the Kavumu hospital were banned from visiting the mpox ward to avoid contamination. “We do not have anything to eat,” said Nzigire Lukangira, the 32-year-old mother of a hospitalised toddler.

“When we ask for something to lower our children’s temperature, they do not give us anything,” she said, coaxing honey into her daughter’s mouth.

The head of Congo’s mpox response team, Cris Kacita, acknowledged that parts of the vast central African country lacked medicine and that dispatching donations, including 115 tonnes of medicine from the World Bank, was a priority.

Traditional remedies

Mpox causes flu-like symptoms and pus-filled lesions and, while usually mild, it can kill. Children, pregnant women and people with weakened immune systems are all at higher risk of complications.

Like other mothers in the Kavumu mpox ward, Lukangira had started improvising with traditional remedies to ease her baby’s pain. They dipped their fingers in potassium bicarbonate or salty lemon juice and popped their children’s blisters. Adult patients did the same to themselves.

Most cases came from the town itself and surrounding villages. Two other makeshift mpox wards have been set up in the area.

Local health ministry representative, doctor Serge Munyau Cikuru, called on the government to continue pushing for vaccines.

Kacita said high-risk contacts and nine priority areas had already been identified for the first vaccination stage.

There were 19,710 suspected cases of mpox reported since the start of the year in Congo by August 31, according to the health ministry. Of those, 5,041 were confirmed and 655 were fatal.

Over 14,000 mpox cases and 500 deaths have been reported this year from 10 African countries

The ongoing multinational mpox (formerly known as monkeypox) outbreaks continue to be a significant threat to public health systems across the world. The outbreak that gained global attention in 2022 has persisted, and as of mid-2024, the WHO reports that over 97,000 laboratory-confirmed cases and 203 deaths have been recorded across 116 countries, including the recent one in South Africa, which affected over 20 patients, suggesting that the global outbreak which started in 2022 is continuing unabated. 

It is concerning that new massive outbreaks emerged last year in the Democratic Republic of the Congo (DRC), with significant human-to-human transmission. Over 14,000 cases and 500 deaths have been documented this year. Given the country’s ongoing struggle with internal conflict and health infrastructure challenges, this is a cause of global concern with cases now being reported from almost 10 African nations. The WHO has recently called an emergency meeting with experts in this context, to assess the situation and evaluate whether to declare it as a public health emergency of international concern.

The emergence of mpox in the DRC is caused by a new clade of the virus, clade Ib, which emerged late last year and is characterised by severe disease and higher mortality. Broadly, the monkeypox virus has two clades. Clade I has been present in the DRC for several years causing sporadic outbreaks, while clade II (previously the West African clade) and specifically IIb emerged during the global mpox outbreak that attracted global attention in 2022. The clades are also characterised by distinct disease severity, with clade I known to be associated with severe disease and mortality compared to clade II, which has a mortality rate of less than 4%.

The outbreak in the DRC is unique in many aspects. The unprecedented human-to-human transmission in a short period is in stark contrast with previous clade I infections, which were largely sporadic and potentially zoonotic in origin. While the initial spread was seemingly through sexual contact, the epidemiology of the disease rapidly shifted to affect children under 15 years who constitute over 60% of all cases and 80% of all deaths, with the largest case fatality rate in children aged less than one year. The rapid availability of whole genome sequencing of the virus from the outbreak could provide immense insights into the origin and spread of the outbreak.

A preprint has dated the emergence of the outbreak using a molecular clock to September 2023, apart from suggesting mutations in the binding site of primers used in diagnostics for clade I mpox. A recent preprint analysing 58 genome sequences of mpox suggests three potential clusters, driving the spread of infection in the DRC. Both analyses suggest a significant number of APOBEC3-induced mutations, confirming a significant human-to-human transmission.

The emerging situation in the DRC specifically and in Africa in general would potentially result in the declaration of a Public Health Emergency of Continental Security by Africa CDC with mpox spread across 16 countries in the continent. While there are many unanswered questions, including what drives the rapid spread and unprecedented emergence of clade I, the urgent need would be to enable the rollout of vaccines. With only two major vaccine producers for the smallpox vaccine which was repurposed for mpox, and with little emphatic support from global organisations to enable diagnosis and prevention, the world might be awaiting another global outbreak in the immediate future. Molecular surveillance could indeed be the best effort for countries like India, apart from international cooperation and developing indigenous capacity for vaccine manufacturing before it becomes too late. 

(Bani Jolly is a senior scientist at Karkinos Healthcare. Vinod Scaria is a senior consultant at Vishwanath Cancer Care Foundation and adjunct professor at IIT Kanpur)