Mpox - Democratic Republic of the Congo
14 June 2024
Situation at a glance
In December 2022, the Democratic Republic of the Congo declared a national outbreak of mpox and an incident management system has been in place since February 2023, based on the increasing number of reported cases. Since September 2023, an outbreak of mpox in South Kivu province has continued to spread within the province and recently to neighbouring North Kivu, driven by sexual contact transmission. A new variant of clade I MPXV has been described in South Kivu. It carries predominantly APOBEC3-type mutations, indicating adaptation of the virus due to circulation among humans. It was estimated to have emerged around mid-September 2023, and its human-to-human transmission has been ongoing since then. This is the first documented sustained community transmission of the virus in the country. It is not known if this variant is more transmissible or leads to more severe disease than other clade I MPXV strains. Additionally, it carries gene deletions that affect diagnostics in the Democratic Republic of the Congo. To date, only clade I MPXV has been detected in the country, which in the WHO African region, reports the highest number of cases. In 2024, as of 26 May, a total of 7 851 mpox cases were reported in the Democratic Republic of the Congo, including 384 deaths (Case Fatality Rate (CFR) 4.9%). These cases were reported in 177 of the 519 (34%) health zones across 22 out of the 26 provinces (85%). The continuing development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to the continuing high incidence of mpox reported in endemic areas of the country in recent years with high case fatality, the geographic expansion to previously unaffected areas, the appearance of a novel strain of clade I MPXV, the observed sustained community transmission driven by sexual transmission and other forms of close physical contact in the eastern part of the country, resource constraints to respond over such a wide geographic area, limited public awareness of mpox, the insufficient availability of treatment kits and lack of vaccines to date, multiple competing public health priorities, and insecurity. Based on the situation, WHO assesses that the risk associated with mpox in the Democratic Republic of the Congo remains high.
Description of the situation
Since 2022, an epidemic of mpox caused by monkeypox virus (MPXV) clade IIb has been ongoing globally, affecting many countries outside the African continent that had never reported mpox previously. Its spread has been mainly driven and sustained by transmission via sexual contact among men who have sex with men, who represent the most affected group.
Although, MPXV strains circulating in Democratic Republic of the Congo belong to clade I, and no cases of MPXV clade IIb have so far been detected, an increase of reported cases, as well as a geographical expansion of their distribution, has been observed in the country since 2022.
Transmission due to sexual contact of MPXV clade I was first formally documented in April 2023 in a small cluster of cases in Kwango province, as mentioned in the previous
Disease Outbreak News report.
The occurrence of sexual transmission of MPXV clade I was further established by the reporting in September 2023 of several new cases exposed through sexual contact with a known case in Kamituga health zone, in South Kivu province. Since then, the number of cases reported in South Kivu has continued to increase, including among sex workers and their contacts, and from an increasing number of health zones. Case investigations and subsequent outbreak investigations together with virus genetics confirm the sustained human-to-human transmission of MPXV clade I in the area without suspected animal exposure.
On 1 June 2024, the first case of mpox was confirmed in North Kivu Province, in Karisimbi Health Zone in the city of Goma[SUP][1][/SUP]. A 19-year-old woman presented with a macular skin rash, dysphagia (difficulty swallowing), dysuria (pain on urination), headache and genital lesions. PCR of swabs from the skin lesions tested positive for MPXV. A total of 45 contacts are being followed-up. In-depth epidemiological investigation identified a sexual contact with suspected mpox and a travel history to South Kivu Province. The contact reportedly traveled onwards to Masisi Health Zone, North Kivu, where the investigation continues. The case of mpox in Goma, North Kivu, which is characterized by insecurity, is the first ever reported case in that province.
Overall, in 2023, a total of 14 626 mpox cases and 654 deaths (CFR) 4.5%) were reported in the Democratic Republic of the Congo, representing the highest figures in the recorded in the country and the highest among countries in the WHO African Region. Among these cases, 1 461 (10%) were laboratory-tested, of which 966 were positive (test positivity, 68%).
In 2024, as of 26 May, a total of 7 851 mpox cases were reported in the Democratic Republic of the Congo, including 384 deaths (CFR 4.9%). These cases were reported in 177 of the 519 (34%) health zones across 22 out of the 26 provinces (85%). The new case in Goma raises this to 23 of 26 (88%) provinces. The most affected provinces in 2024 are Equateur, Sud Ubangi, Sankuru and South Kivu (Figure 1).
Figure 1. Geographic distribution of reported mpox cases, the Democratic Republic of the Congo, 1 January to 26 May 2024 (n=7 851).
Source: National mpox integrated disease surveillance data, Democratic Republic of the Congo; North Kivu will be included in the next update to include the new outbreak in Goma.
In 2024, children continue to represent the most affected age group (Table 1); of the 7 851 reported mpox cases, 39% were reported in children aged under 5 years (n=3 090), including 240 deaths (62% of the total).
Table 1. Age distribution of reported mpox cases and deaths in the Democratic Republic of the Congo, 1 January to 26 May 2024 (n=7 851). [TABLE="border: 1"]
[TR]
[TD]Age group(years) [/TD]
[TD]Reported cases(n, % of total) [/TD]
[TD]Deaths (n, % of total) [/TD]
[TD]Case fatality ratio (%) [/TD]
[TD]Crude OR of death (95% CI)[/TD]
[TD]P-value[/TD]
[/TR]
[TR]
[TD]<1 [/TD]
[TD]897 (11)[/TD]
[TD]77 (20)[/TD]
[TD]8.6[/TD]
[TD]3.8 (2.6-5.3)[/TD]
[TD]<0.001[/TD]
[/TR]
[TR]
[TD]1 - 4 [/TD]
[TD]2 193 (28)[/TD]
[TD]163 (42)[/TD]
[TD]7.4[/TD]
[TD]3.2 (2.4-4.3)[/TD]
[TD]<0.001[/TD]
[/TR]
[TR]
[TD]5 - 15 [/TD]
[TD]2 164 (28)[/TD]
[TD]81 (21)[/TD]
[TD]3.7[/TD]
[TD]1.6 (1.1-2.2)[/TD]
[TD]<0.001[/TD]
[/TR]
[TR]
[TD]>15 [/TD]
[TD]2 597 (33)[/TD]
[TD]63 (16)[/TD]
[TD]2.4[/TD]
[TD]1[/TD]
[TD]-[/TD]
[/TR]
[TR]
[TD]Total[/TD]
[TD]7 851[/TD]
[TD]384[/TD]
[TD]4.9[/TD]
[TD]-[/TD]
[TD]-[/TD]
[/TR]
[/TABLE]
Source: National mpox integrated disease surveillance data, Democratic Republic of the Congo.
Scabs, vesicles, and blood samples were taken from 1 415 reported cases. Of these, 994 were laboratory-confirmed as positive for MPXV, representing test positivity of 70%. Among the provinces with reported mpox cases in 2024, 15 out of 22 (68%) have confirmed at least one case this year (Figure 2). Among confirmed cases with the information available, 59% (502 of 852) are male; 50% of confirmed cases are under 15 years of age (Figure 3).
Figure 2. Geographic distribution of confirmed mpox cases, Democratic Republic of the Congo, 1 January to 26 May 2024 (n=994).
Figure 3. Age and sex distribution of confirmed mpox cases, Democratic Republic of the Congo, 1 January to 26 May 2024 (n=852*
*142 confirmed cases had missing age and sex data
Source: National mpox integrated disease surveillance data and national reference laboratory database (INRB), Democratic Republic of the Congo.
In 2024, the proportion of reported mpox cases tested at national level has fluctuated between 8 and 30% (Figure 4). As of 26 May 2024, 18% (1 415 of 7 851) of all reported cases had been tested. Supported by expanded testing capacity, this represents an 80% increase compared to the 10% of reported cases tested in 2023.
Figure 4. Epidemic curve of reported mpox cases and the proportion of reported cases tested in the Democratic Republic of the Congo, 1 January to 26 May 2024 (n= 7 851).
Source: National mpox integrated disease surveillance data and national reference laboratory database (INRB), Democratic Republic of the Congo.
The introduction of GeneXpert for field-based PCR diagnostics in two key provinces, Equateur and South Kivu, along with ongoing efforts to test for MPXV using GeneXpert in Tshopo and Tshuapa, is significantly improving the capacity for mpox diagnostics and surveillance. However, cases confirmed by GeneXpert in 2024 have not yet been included in the national case count pending completion of GeneXpert test validation exercise.
Currently, only clade I MPXV has been detected in the country. In late 2023, testing for clade II MPXV was introduced in the national laboratory and is used for new cases/clusters in previously unaffected provinces.
New variant detected in South Kivu
In South Kivu, between 1 January and 2 June 2024, 777 cases were reported through the national surveillance system after investigation of alerts. Following laboratory testing of samples from 426 out of 777 cases (55%), 373 cases were confirmed as positive (test positivity of 88%), including seven deaths (CFR 1.8% among confirmed cases).
The mpox cluster in South Kivu, initially detected in the Kamituga Health Zone and driven by sexual contact transmission, has been expanding geographically and currently 19 of 34 (56%) health zones have reported at least one mpox case.
The type of contact reported by cases includes sexual contact, non-sexual direct contact, as well as household and healthcare facility contact. No cases with suspected zoonotic transmission have been reported in the province since the start of the outbreak.
The majority of laboratory confirmed cases in South Kivu are among persons aged more than 15 years, and among those with age and sex data available, the sex distribution is similar, with 51% female and 49% male.
Through genomic sequencing of MPXV samples collected between October 2023 and January 2024, a novel variant of clade I MPXV was identified in the Kamituga health zone. This variant carries a deletion of a gene that widely serves as a target for clade-specific molecular assays. This deletion was confirmed by the national reference laboratory, the Institut National de Recherche Biomédicale (INRB), as well as other academic and public health institutes.
The new variant was found to have predominantly APOBEC3-type mutations, indicating adaptation of the virus due to circulation among humans. It was estimated to have emerged around mid-September 2023, with sequence data suggesting sustained human-to-human transmission since then. It is not known if this variant is more transmissible or leads to more severe disease than other virus strains circulating in the country.
All publicly available virus sequences from clinical specimens from South Kivu in 2024 identify the strain to be the novel variant. However, in all other publicly available sequences from the Democratic Republic of the Congo, including recent sequences from Equateur, Kinshasa and Tshopo, there is no evidence of APOBEC-3 type mutations. With the publicly available data, it remains unclear whether this novel variant evolved in South Kivu or in other under-sampled regions of the Democratic Republic of the Congo or the larger Congo Basin area. Additional sequencing data from across the country and the larger Congo Basin area are needed to better understand the origins of this novel variant, and better understand all virus strains circulating in the country.
Mpox situation in WHO Africa Region
Burundi
Verbal reports of suspected mpox cases have suggested potential cross-border transmission from South Kivu in the Democratic Republic of Congo. As of 30 May 2024, no suspected mpox case has been officially reported from Burundi. An assessment of the national level of preparedness for mpox has been conducted, procurement of testing kits and inventory of medical stocks are ongoing. Discussions to develop a mpox contingency plan are also ongoing.
Cameroon
From 1 January to 30 April 2024, there have been 23 suspected cases of mpox, with five confirmed cases (four males and one female) and two deaths (40% CFR). Genomic sequencing of these cases has identified clade II as the responsible variant. Over the years, Cameroon remains to date the only country to have reported both clades I and II MPXV. In 2024 the confirmed cases are distributed across three regions Nord-Ouest (n=2), Sud-Ouest (n=2), and Littoral (n=1) regions, highlighting the potential for regional spread.
Republic of the Congo (ROC)
On 23 April 2024, the government declared a national mpox epidemic, activating the Centre d’opérations d’urgence de santé publique (COUSP) and the Incident Management System on 3 May 2024. Genomic sequencing of MPXV samples confirmed clade I, similar to those found in endemic neighbouring areas of the Democratic Republic of the Congo. From 1 January to 30 May 2024, the Republic of Congo reported 19 confirmed and 10 probable mpox cases across four departments: Cuvette (14 cases), Likouala (two cases), Plateaux (two cases), and Pointe-Noire (one case). The modes of transmission for these cases have not been documented. As a result, there's a high risk of the outbreak spreading. The outbreak peaked during week 4 to 10 (from 21 January to 9 March) 2024, and no cases have been reported in more recent weeks. However, only 9 of the 35 suspected cases recorded in week 21 were tested (all negative), highlighting a low testing rate.
Rwanda
Given the proximity to South Kivu, preparedness activities have been ongoing in the country. Surveillance has been strengthened in districts bordering Bukavu. Between 28 April and 4 May 2024, teams from Rwanda Biomedical Centre, CDC, IOM and University of Rwanda (FETP residents) conducted mpox active case search, assessment of points of entry and health facilities readiness to detect and respond to mpox outbreaks, health worker sensitization and community awareness within Rusizi and Nyamasheke districts. As of 4 May 2024, 16 suspected cases were recorded from Rusizi (15) and Nyamasheke (1) districts. All the cases tested negative for mpox by PCR. The national mpox contingency plan is under finalization.
South Africa
From 1 January to 6 June 2024, five confirmed mpox cases have been reported, all of whom are men aged between 35 and 39 years old. All five cases have been sequenced as clade IIb MPXV. Two cases were reported in Gauteng province, and a cluster of three cases in KwaZulu-Natal province. The cases in these two clusters did not report any international travel history. Four of the five men initiated treatment with tecovirimat provided by WHO from the limited reserve for compassionate use, upon request of the Government of South Africa. The severity of all the cases identified in persons with immune suppressions suggests less severe cases are not being identified, tested or reported. Outbreak response is underway in collaboration with the HIV/AIDS control programme, including contact-tracing and clinician training. There is extensive travel between South Africa and the Democratic Republic of the Congo, linked to commercial and professional activity between the two countries.
Epidemiology
Mpox (monkeypox) is an infectious disease caused by the monkeypox virus (MPXV). There are two known clades of MPXV: clade I, previously called the Congo Basin clade; and clade II, previously called the West Africa clade, which includes subclades IIa and clade IIb. MPXV transmits between humans through close contact with lesions, body fluids, respiratory droplets or contaminated materials, or from animals to humans through contact with live animals or consumption of contaminated bushmeat.
Mpox causes signs and symptoms which usually begin within a week but can start 1–21 days after exposure. Symptoms typically last 2–4 weeks but may last longer in someone with a weakened immune system. Fever, muscle aches and sore throat appear first, followed by skin and mucosal rash. Lymphadenopathy (swollen lymph nodes) is also a typical feature of mpox, present in most cases. Children, pregnant women and people with weak immune systems are at risk of developing complications and death from mpox.
It is important to distinguish mpox from chickenpox, measles, bacterial skin infections, scabies, herpes, syphilis, other sexually transmissible infections, and medication-associated allergies. Someone with mpox may also concurrently have another sexually transmissible infection such as herpes. Alternatively, a child or adult with suspected mpox may also have chickenpox. For these reasons, laboratory testing is important for confirmation of mpox, particularly for the first cases in an outbreak or new geographic area, and implementation of relevant public health and social measures to curb transmission.
Detection of viral DNA by polymerase chain reaction (PCR) is the preferred laboratory test for mpox. The best diagnostic specimens are taken directly from the rash – skin, fluid or crusts – collected by vigorous swabbing. In the absence of skin lesions, testing can be done on oropharyngeal, anal or rectal swabs. However, while a positive result of oropharyngeal, anal or rectal sample confirms mpox, a negative result is not enough to rule out MPXV infection. Testing of blood is not recommended. Serology does not distinguish between different orthopoxviruses and is therefore restricted to reference laboratories where antibody detection methods may be applied for retrospective case classification or in special studies.
Treatment is based on skin scare, managing pain, and preventing complications. In addition, specific antiviral medications such as tecovirimat can also be used in the treatment of mpox, particularly for severe cases or individuals at higher risk of complications.
Public health response
Coordination
- The Ministry of Health (MoH), with support from WHO and other partners, continues to intensify surveillance, clinical case management, and laboratory capacities, improve IPC practices in health facilities, undertake risk communication and community engagement activities in the affected provinces and prepare vaccination strategies for emergency response.
Surveillance
- Surveillance of mpox throughout the country is being strengthened, especially in the eight priority provinces (Equateur, Mai’Ndombe, Maniema, Sankuru, South Kivu, Sud Ubangi, Tshopo, and Tshuapa) as defined by the national response plan.
- Additional information about confirmed mpox cases recruited into a treatment clinical trial in two Provinces have been shared with the surveillance pillar of the incident management team and included in the national surveillance database.
- Logistics support has been provided for collecting, transporting, and examining samples from suspected cases. GeneXpert cartridges have been procured for Equateur (Ingende, Mbandaka), North Kivu (Goma), Tshopo (Kisangani), Tshuapa (Boende), and South Kivu (Bukavu, Kamituga) provinces.
Diagnostic strategy targeting the new variant
- In line with the recommendation to couple assays, clade-specific PCR assays should be used in conjunction with an OPXV generic or MPXV generic PCR test that targets conserved genes, especially when confirming an outbreak or a new case in a previously non-outbreak area. This strategy ensures detection of the novel MPXV circulating in the country.
- Genome sequencing of virus from clinical specimens is being increased, particularly for South Kivu, to detect new variants from cases and gain a better understanding of the circulating viral strains.
Risk communication and community engagement
- Messages which integrate information on sexual transmission of mpox have been developed to support risk communication and community engagement. The risk communication messages have also been translated to local languages.
- Sensitization has been initiated in affected communities in Equateur, Kinshasa, Kwango, South Kivu, and Tshopo provinces.
- A national behaviour change communication plan for mpox has been developed.
Case management and infection prevention and control
- Immediate isolation of suspected and confirmed cases, in a health facility or at home for confirmed non-severe cases deemed eligible for home care, is recommended throughout the country to prevent transmission. Challenges are encountered as patients leave hospital against medical advice to seek food or medical care elsewhere, or to continue professional activity.
- Clinical care, including psychological support, for persons with mpox has been adapted to the context. Patients classified as having severe and critical mpox infection are hospitalized for treatment in the mpox treatment center (CT Mpox) while those with mild and moderate infection are treated as ambulatory cases at health centers and health posts. These guidelines also provide guidance for nutritional care for children with acute malnutrition.
- The clinical efficacy study of tecovirimat for patients with mpox continues recruitment in two provinces.
Vaccines and immunization
- The national immunization technical advisory group (Groupe technique consultatif indépendent sur la vaccination, GTCV)), in February 2024 recommended use of both LC16 and MVA-BN vaccines for emergency response.
- The national regulatory authority (Autorité congolaise de réglementation pharmaceutique, ACOREP), ) is reviewing the vaccine dossiers for LC16 and MVA-BN vaccines upon request of the Essential Programme on Immunization on 8 May 2024 to authorize temporary use of the vaccines for emergency response.
- The Institut national de recherche biomédicale (INRB) is leading coordination of development of clinical study protocols for mpox vaccines to address knowledge gaps on vaccine efficacy, particularly in children.
- Work is underway to develop vaccination strategies for emergency response and to initiate clinical vaccine studies to address knowledge gaps for mpox vaccines, including continuing immunogenicity, efficacy and safety studies.
Training and capacity
- WHO and partners continue to support the MoH to update the guidance and procedures for public health response to mpox including an update on national clinical case management guidance, risk communication and community engagement materials and updates to surveillance tools (Case definition and case investigation forms).
- WHO and partners are building the capacity of frontline health workers in surveillance, diagnostics, risk communication and community engagement and clinical case management through training, supportive supervision and mentoring.
WHO risk assessment
In the Democratic Republic of the Congo, most reported cases in known endemic provinces continue to be among children under 15 years of age, especially in young children. Infants and children under five years of age are at highest risk of severe disease and death, particularly where prompt optimal case management is limited or unavailable. The number of cases reported weekly remains consistently high while the outbreak continues to expand geographically. High test positivity among tested cases in most provinces also suggests that undetected transmission is likely ongoing in the community.
Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, mpox transmission is sustained through human-to-human contact (sexual and non-sexual).
The global outbreak 2022 — 2024 has shown that sexual contact enables faster and more efficient spread of the virus from one person to another due to direct contact of mucous membranes between people, contact with multiple partners, a possibly shorter incubation period on average, and a longer infectious period for immunocompromised individuals. The newly documented occurrence of mpox in North Kivu is very concerning. The additional public health impact of sustained human-to-human sexual transmission of mpox in the country indicates that a vigorous response is required.
One of the main risk factors for severe disease and death among persons with mpox is immune suppression, especially among those with advanced HIV infection. The prevalence of HIV in the general adult population in the Democratic Republic of the Congo is estimated to be approximately 1%, higher in the eastern provinces than elsewhere, and higher in key populations including estimates of a prevalence of 7.5% among sex workers and 7.1% among men who have sex with men. The higher HIV prevalence and the challenge in accessing antiretroviral treatment puts these groups at higher risk for severe mpox and death if they get infected. The occurrence of cases among a broad range of occupational groups and within households also suggests that the outbreak in South Kivu is already spreading into the wider community.
Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, a lack of timely access to diagnostics in many areas, incomplete epidemiological investigations, challenges in contact tracing and extensive but inconclusive animal investigations continue to hamper rapid response. While zoonotic spill over events are considered to still represent a major source of exposure in the country, the animal reservoir remains unknown. The new features of human-to-human transmission observed in South Kivu and North Kivu raise additional concern about a further rapid expansion of the outbreak in the eastern mining provinces, as well as the rest of the country and other countries which share national borders.
From 1 January to 26 May 2024, 7 851 suspected cases were reported, compared to 3 924 suspected cases reported during the same period in 2023. The geographic expansion to new areas, such as Kinshasa and North Kivu, continues in 2024. Only 3 of 26 provinces have not yet reported mpox in 2024. While some cases in the newly affected provinces are linked to travel from endemic areas, others represent secondary or sustained human-to-human transmission, and the source of infection for several of them remains unknown. The current situation remains extremely concerning as MPXV continues to move into the immunity gap left following eradication of smallpox.
Surveillance and investigating alerts are limited by logistical and resource challenges, and laboratory capacities are limited to two national laboratories, one in Kinshasa and one in Goma so only 18% of reported cases in 2024 have been tested by PCR. Testing through GeneXpert has begun in Equateur and South Kivu province, and validation of the findings is ongoing. Response capacities to mpox in the country rely to a great extent on the support of WHO and other partners.
Immunogenicity and safety studies of MVA-BN vaccine have been ongoing in the Democratic Republic of the Congo since 2016. The national immunization technical advisory group (GTCV) released recommendations on the use of mpox vaccines in the country for persons at risk. These included recommendations for preferred use of LC16 in children and use of MVA-BN in adults. The Ministry of Public Health, Hygiene and Prevention (MSPHP) has announced its intention to vaccinate persons at risk through use of LC16 and MVA-BN vaccinia-based mpox vaccines and asked the national regulatory authority (ACOREP),) to authorize temporary use of these vaccines. This regulatory review is underway. Further clinical efficacy and safety studies are being planned for LC16 in the country. The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners.
The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol.
Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from consumption of bushmeat, as well as for the newly described risk of sexual transmission, particularly among sex workers and other key populations. According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country exposes them to further risk. Anyone suffering from disfiguring skin conditions, including mpox, may suffer from fear and stigma, which can be further compounded for persons at risk of acquiring the disease through sexual contact.
The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to:
- The continuing high incidence of cases reported in 2024 compared to previous years, with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas.
- Transmission through sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas has led to sustained community transmission in South Kivu.
- The outbreak characterized by sexual contact transmission has revealed a new strain of MPXV with genetic mutations suggestive of extended human-to-human transmission and geographic expansion. This new MPXV strain is affecting newly reported areas in southern and eastern provinces. While it is not known whether this variant is inherently more transmissible or leads to more severe diseases than other virus strains circulating in the country, co-infections with HIV and other sexually transmitted infections are being documented.
- In 2023 and 2024, mpox cases have occurred in Kinshasa associated with river boat travel and leading to outbreaks in the city. At the time of reporting, new cases in the Nsele health zone in Kinshasa have been confirmed.
- There is high (around 70% overall) or very high (around 90% in South Kivu) test positivity among reported cases, despite efforts to significantly expand surveillance. This suggests significant under detection or underreporting of transmission.
- While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and resource mobilization is slow.
- Public awareness remains limited, resources are scarce, and technical as well as financial support is needed to ensure a robust response at provincial/local, national, and international levels.
- A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces.
- A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting extensive undetected circulation of the virus. Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries further puts populations at risk.
- In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.
WHO advice
General
Health authorities and clinicians/health workers of all countries should be aware that the global mpox outbreak linked to clade IIb MPXV is ongoing in all WHO regions, that incidence of mpox continues to be documented in endemic areas and that outbreaks due to sexual transmission of the more virulent clade I MPXV continue in eastern parts of the Democratic Republic of the Congo. The new strain of clade I MPXV linked to human-to-human transmission represents a renewed risk of cross-border and international spread which may potentially lead to an increased risk of severe illness.
WHO strongly advises that countries continue to follow the Standing Recommendations of the Director-General of the WHO issued in August 2023, particularly concerning epidemiological surveillance of mpox and strengthening of laboratory diagnostic capacities in line with updated WHO interim guidance, including genomic sequencing of viruses. The Standing Recommendations advise that all countries should have prevention, preparedness, control and elimination plans for mpox.
There must be sustained implementation of risk communication and community engagement appropriate to each context, maintenance or initiation of vaccination for persons at risk, optimal case management, adherence to infection control measures, strengthening research to better appreciate modes of transmission and effectiveness of countermeasures in different contexts, and sustained support for the development of rapid diagnostic methods and treatments adapted to the needs of patients.
Where the number of cases or clusters remains low, health authorities should strive to achieve elimination of human-to-human transmission of mpox and ensure maintenance of capacity for outbreak response. Given the decline in surveillance and silent circulation of the virus, health authorities should assume that mpox can appear at any time and be prepared to respond.
Anyone with a clinical or laboratory-confirmed diagnosis of mpox should follow the instructions of health authorities according to their local context, likely including isolation during the infectious period. Contacts of a confirmed case are asked to limit their movements (and to abstain from sexual relations) for 21 days, the monitoring period for the appearance of symptoms.
Smallpox/mpox vaccines composed of vaccinia virus protect against mpox due to the antigenic similarity of orthopox viruses. For this reason, several smallpox vaccines have been approved for prevention of mpox. Third-generation vaccines causing fewer side effects are available, such as MVA-BN approved in 2019 or the LC16 vaccine approved in 2022 for the prevention of mpox. A few countries maintain stocks of vaccines, especially since the start of the global mpox outbreak in 2022. Vaccination against mpox is recommended for people at risk.
The WHO SAGE updated its recommendations on the use of vaccines to prevent mpox in outbreak settings and preventive vaccination for high-risk groups in non-outbreak settings:
- In the context of an outbreak, to allow the greatest flexibility for local risk assessment, varied modes of transmission and response options, populations to consider for vaccination may include: (i) adults and children in a geographically defined area or community (e.g., villages) with a documented risk of exposure; (ii) persons with multiple sexual contacts; (iii) health workers at risk of repeated exposure; and (iv) known contacts of persons with mpox.
- Noting the endemicity of disease in the African continent, the distinct epidemiology of mpox in this region and the inequitable access to vaccination, SAGE issued a strong call to action to promote epidemiological and vaccine research on mpox in the region and urgent steps to facilitate equitable access to vaccination. Research should also be embedded in the outbreak response.
For antiviral treatments being assessed for effectiveness against mpox, requesting access through national health authorities is usually necessary.
It is essential to deepen knowledge of the epidemiological links between mpox and HIV, their respective and common risk factors for infection and progression to severe disease, optimal case management, and the effectiveness of vaccines and therapeutic approaches. It is important to offer relevant and appropriate health services for people at risk, and to integrate case management within a strengthened and agile health service to meet patient needs.
It is essential to emphasize the importance of case investigation with sensitivity and absence of stigma and in-depth understanding of the human-to-human transmission of mpox in communities while strengthening the One Health approach in areas where the monkeypox virus circulates in possible mammalian hosts or reservoirs.
In the community
Communication on the risks of sexual transmission of mpox must be strengthened, especially among the groups of people most at risk and individuals and households affected. Advocacy is needed at all levels to support, inform and engage community leaders in implementing measures to inform and engage their communities about mpox and how to stop its spread.
Risk communication and community engagement activities will be vital in motivating affected communities to become aware of risks and protective behaviours. Socio-behavioural data should be collected, and a situation analysis should be carried out to understand better the transmission factors and those affected. This information can then be used to improve decision-making, to ensure response efforts are aligned with community needs, priorities and capacities, and to inform the development of risk communications plans and evidence-based community engagement.
Key audiences should be identified, including health professionals, key populations including commercial sex workers, men who have sex with men, trans and gender-diverse individuals, people working at or attending venues and events where sexual activity takes place, and people at risk of more serious illness (including persons living with untreated or poorly controlled HIV infection).
Partnerships should be established with trusted networks working with these communities to facilitate community engagement. Two-way feedback systems should be established or activated. Particular attention should be paid to measures to understand, prevent and combat stigma and discrimination – these are never acceptable and can undermine the response to the epidemic and have a serious impact on health outcomes.
In addition to this, for patients with non-severe mpox for whom care at home is considered, some of the IPC measures that should be implemented include the following: patient should be isolated in an area separate from other household members and away from shared areas of the home (e.g., stay in a dedicated, well-ventilated room separate from others in the household).
Patients should wear a well-fitting medical mask and cover lesions when in close proximity to others, and when moving outside of the designated isolation area (e.g., to use the toilet). Dishes and utensils and household surfaces, such as furniture, beds, toilets or floors, or any location where the patient has had contact should be cleaned with water and soap and disinfected regularly (e.g., common household disinfectant or bleach products). Pay attention to frequently touched surfaces. Please refer to “Clinical management and infection prevention and control for monkeypox: Interim rapid response guidance” for further guidance on IPC measures for patients and health and care workers in community settings.
In healthcare settings
Implementing infection prevention and control measures in healthcare, congregate or household settings are necessary to prevent and control transmission of mpox. It is important to train staff on control measures, including standard and transmission-based precautions. Staff should also have access to and appropriately wear personal protective equipment, adhere to the WHO advice on 5 Moments for hand hygiene, and ensure frequent cleaning and disinfection of the patient environment, and implement appropriate patient placement and isolation. The transmission-based precautions for mpox are contact and droplet precautions and the recommended PPE for health and care workers are gloves, gown, respirator (e.g. N95, FFP2) and eye protection. In the healthcare setting, in addition to contact and droplet precautions, airborne precautions should be implemented if varicella zoster virus (e.g., chickenpox) is suspected and until it is ruled out. For further guidance on IPC measures that are required when caring for patients with mpox please refer to the “Clinical Management and infection prevention and control for mpox: Interim rapid response guidance”.
While protecting themselves with recommended measures, health and care workers should also ensure that stigmatization of patients with mpox is avoided, and that psychological support is provided to patients and their families.
When collecting clinical and laboratory specimens: Specimens collected from people and animals suspected of being infected with MPXV should be handled by trained personnel working in equipped laboratories. Confirmation of MPXV depends on the type and quality of the sample, and the type of laboratory test. Thus, specimens must be packaged and shipped in accordance with national and international requirements. RT-PCR is the preferred laboratory test, given its accuracy and sensitivity. For this, diagnostic samples should be taken from skin lesions - fluid from vesicles and pustules, and dry scabs. PCR blood tests are generally inconclusive due to the short duration of viremia compared to the time of sample collection after the onset of symptoms; they should not be systematically collected from patients. As orthopox viruses are serologically reactive, antigen and antibody detection methods are not specific for mpox. It is therefore essential that laboratories support health authorities in providing supplies for specimen collection that are appropriate for swabbing skin lesions.
At points of entries
According to the Director-General of the WHO, and in accordance with the International Health Regulations (2005) (IHR), States Parties are recommended to encourage authorities, health and care workers and community groups to provide travelers with relevant information to protect themselves and others before, during and after travel to events or gatherings where mpox may present a risk.
WHO recommends that countries refrain from implementing travel-related health measures specific for mpox, such as entry or exit screening, or requirements for testing or vaccination.
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https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON522
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