Historical Background

Mpox (previously called monkeypox) is a zoonotic orthopoxvirus infection, related to the virus that caused the now-eradicated smallpox. A zoonotic disease is infectious and transmitted between species from animals to humans. An orthopoxvirus is a genus of virus in which vertebrates serve as natural hosts. Characteristic symptoms of mpox include deep-seated lesions present in greatest concentration on the face and distal extremities - meaning arms, legs, hands and feet. Symptoms also may include fever, rash, headache, muscle aches, and swollen lymph nodes. Transmission of mpox occurs via respiratory droplets or contact with infectious lesions or bodily fluids of infected wild animals (alive or dead) or humans. Therefore, identification of individuals who have had significant contact with a mpox patient is important to limit the spread of disease. Mpox virus is endemic in areas of western and central Africa, with the overwhelming majority of reported cases from the Democratic Republic of the Congo (DRC). The first human case of mpox from the DRC was discovered in Basankusu, a rural and forested area of Equator Province, in 1970, one year after notification of the last confirmed case of smallpox in the region. Since the occurrence of the first case, the DRC continues to experience epidemic outbreaks and routine reports of disease.

The Center of Disease Control (CDC) has worked with the DRC for 15 years, helping the DRC expand its testing capacity by opening labs in some of the most affected, remote areas. Additionally, in September 2010, the CDC sent a team of four people to the DRC to assist with disease surveillance efforts and implement resources to address the burden of mpox in the country, focusing on the Equateur region. The CDC has also helped to fund local epidemiological teams that can provide a more granular understanding of mpox cases. Efforts to combat mpox virus continue to concentrate on case management, infection prevention, risk communication, and community engagement. Surveillance and government coordination surrounding the virus have only increased since 1970. In recent years, vaccine and immunization efforts, as well as diagnostic strategies to target new variants, have accelerated in hopes that residents of the DRC and other affected communities will soon be able to vaccinate against this dangerous disease.

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Recent Developments

On August 14, 2024, the Director-General of the World Health Organization declared the mpox outbreak in the DRC a public health emergency of international concern (PHEIC). There are a multitude of factors that culminated to trigger this announcement. Mpox has been reported in the DRC for more than a decade, and the number of cases reported each year has increased steadily over that period. In July 2022, mpox was declared a PHEIC as it spread rapidly via sexual contact across a range of countries where the virus had not been seen before. That PHEIC was declared over in May of 2023, after there had been a sustained decline in global cases. Unfortunately, reported cases increased significantly soon after. In 2024, the number of cases reported so far has already exceeded last year’s total.

On September 11, 2024, the U.S. Food and Drug Administration announced their approval of two vaccines for the prevention of both smallpox and mpox. Two days later, the World Health Organization (W.H.O.) also authorized the mpox vaccine, further clearing the way for its use in the DRC. In its announcement, the W.H.O. authorized the vaccine for adults and said that it could be used at the discretion of health care providers for adolescents under age 18. Notably, more than 70% of mpox cases in the DRC are currently in children, and the Africa CDC says four of every five deaths recorded are minors. Therefore, the W.H.O.’s expert committee on vaccination said that the benefits of using the vaccine for children at high risk of exposure outweigh the risk. The mpox vaccine is recommended regardless of gender identity or sexual orientation, especially for those who anticipate engaging in high-risk sexual activities during travel to countries with ongoing person-to-person transmission of mpox–such as the DRC.

The continuing development of the outbreak in the DRC remains concerning due to the high case fatality, geographic expansion to previously unaffected areas, and appearance of a novel strain of mpox virus. The level of danger is also increased by the sustained community transmission, resource constraints of responding to a wide geographic area, limited public awareness, and insufficient availability of treatment kits and vaccines. Additionally, providing mpox vaccines requires complicated logistics of transport, temperature control, staff training, and community education. Thus, the production of the shots is only the first piece of protecting against the virus. Health officials in the DRC said they would start administering mpox vaccinations on October 2, 2024, about a week sooner than initially planned, in a bid to counter the sharp rise of cases in the central African nation. There is a vast shortage of mpox vaccines in Africa as a whole, and the DRC is racing against the epidemiological clock to prevent a new mpox virus mutation.

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Implications

On August 15, 2024, Swedish authorities notified the W.H.O. of a confirmed case of mpox within Sweden’s borders. Like many viruses, mpox continues to evolve and become more easily transmitted. Consequently, along with the escalation in concentration of cases in the DRC, it has spread to a dozen other African countries and Sweden. If not contained, the virus may again rampage all over the world, experts warned. While most people with healthy immune systems are unlikely to become severely ill, those who have weakened immune systems are at high risk. The W.H.O. continues to support affected countries by deploying epidemiologists, anthropologists, and beginning the process for Emergency Use Listing, which accelerates access for lower-income countries who have not yet issued their own national mpox vaccine approval. Additionally, on October 4, 2024, the W.H.O. approved the first mpox diagnostic test for emergency use. This is a significant win, as medical professionals will now be able to detect mpox in patients before the disease has already wholly overcome their immune systems and bodies.

The surge of this disease has required a powerful international response. The United Nations is providing guidance to national immunization technical advisory groups to ensure readiness for vaccine rollout. The United Nations Children's Fund (UNICEF) is distributing hand washing kits, disinfectants, and training community workers to go from house to house, sharing information about the disease and answering questions. Furthermore, the DRC-specific UNICEF is appealing for $4,581,000 USD to scale up interventions. The DRC had already been suffering funding shortfalls for emergencies linked to other disease outbreaks and ongoing conflict. Therefore, the mpox outbreak is overwhelming a healthcare system already weakened by previous epidemics. Additionally, scientists do not yet fully understand how the virus is spreading so severely among children. This increases their risk in all areas of the world, along with healthcare workers who are at high risk of occupationally-acquired infection. It is clear that unless we invest in disease control everywhere, all global citizens will remain in jeopardy.

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