In Congo, a desperate struggle to control the deadly mpox outbreak

On august 14th mpox was declared “a public health emergency of international concern” by the World Health Organisation. In eastern Democratic Republic of Congo, the centre of the crisis, fear is widespread. “We did not flee the war at home to die with this disease here,” says 29-year-old Jean Munguiko, a refugee in a camp near Goma. A new and probably deadlier strain of mpox was discovered 500km away in South Kivu, where a guerrilla war rages. The disease has been found widely across Congo and beyond. Infected sex workers cross into neighbouring countries. In the camps families are spreading it by sharing washcloths and utensils. Aid workers are repurposing Ebola and covid-19 treatment centres into makeshift isolation sites.

Mpox, formerly known as monkeypox, is a zoonotic virus that has long flourished in Congo’s forests. Its symptoms resemble those of smallpox: fever and pus-filled blisters on the skin. It is transmitted by contact with infected animals and intimate contact with infected people. The new strain, clade 1b, is likely to have fatality rates between 1.4% and 10%, with the rate in children at the higher end. medair, a charity running an isolation site near Goma, says 75% of cases there have been kids under 10. These children are more likely to have weaker immune systems due to malnutrition, recent cholera and measles outbreaks, and missing regular jabs.

There have now been more than 17,000 cases of mpox since January, and more than 500 human fatalities. Most have taken place in Congo, but this outbreak is worse than the last one there in 2022. And this year mpox has spread to places where it has never been recorded before (see map), even outside Africa. But “mpox is not the new covid,” says the who. One reason is that children in rich countries are healthier and better nourished. But the who’s confidence also rests in part on the outbreak in Africa being contained.

In Congo that appears easier said than done. While aid workers and supplies can reach Goma, the disease is still spreading rapidly through crowded camps. So are misinformation and pictures on social media of the pus-filled lesions, stoking panic. Tracking the reach of the disease is very hard. The m23 rebels in control of swathes of North Kivu implausibly deny there are cases there. And samples have to be sent to the big cities for diagnostic testing.

Getting vaccinations to those most at risk is essential. The global population’s collective immunity against poxviruses has deteriorated as the eradication of smallpox in 1980 meant vaccines against it were no longer necessary. There is no jab that specifically targets the virus causing mpox, but the who says vaccines against related poxviruses provide some immunity.

An optimistic assessment is that 3m or more doses might be available soon if America, France, Japan and other countries donate theirs quickly. Yet in the long run that would still be too few. As a result vaccine production is being ramped up. One candidate is Bavarian Nordic’s mva-bn, although the two-shot vaccine costs $76 per dose. On August 17th the company and Africa cdc, a health agency which seeks to control and prevent disease, pledged to work to deliver 10m doses by 2025 in partnership with local firms in Africa. gavi, the global vaccine body, has committed up to $500m to purchase shots. The who has also released $1.45m from its contingency fund and may need to release more in the coming days. However it says that immediate funding of $15m will need to support surveillance and aid in the region.

In the long run far more needs to be learned about the circulating strains of mpox: who is most vulnerable, how and how fast it spreads and how it might best be treated. That requires far more widespread genetic sequencing and controlled clinical trials—which need to occur where epidemics take hold in order to understand local factors. “It’s not a process that should be rushed, because ultimately you want to generate evidence that would last for a long time,” says Dr Dimie Ogoina, who chairs the who’s emergency mpox committee. Mpox in Africa was largely ignored in the 2022 outbreak. Now in Congo and beyond it is back, and fiercer. The world must learn from its mistakes. ■