Benjamin Mateus
On Sunday, World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus posted on Twitter/X that he is considering convening an advisory committee to determine if the public health agency should declare the growing Mpox outbreak with the deadlier strain (clade Ib) in the Democratic Republic of the Congo (DRC) a public health emergency of international concern.
Ghebreyesus wrote:
As a deadlier strain of Mpox spreads to multiple African countries, the WHO, Africa Centers for Disease Control and Prevention (CDC), local governments and partners are further scaling up the response to interrupt disease transmission. But more funding and support for a comprehensive response are needed. [Therefore], I am considering convening an International Health Regulations Emergency Committee to advise me on whether the outbreak of Mpox should be declared a public health emergency of international concern (PHEIC).
In a situation report published last week, the Africa CDC wrote that since the beginning of 2022, there have been a total of 37,583 cases and 1,451 deaths, a case fatality rate (CFR) of 3.9 percent across 15 African Union Member States. In 2023, there were close to 15,000 cases, a 78.5 percent increase in the number of new cases compared to 2022. The CFR in that year was 4.9 percent with 739 deaths.
From the beginning of 2024 up to July 28, another 14,250 cases (2,745 confirmed and 11,505 suspected) have been tallied and 456 more people have died (CFR 3.2 percent). When compared to the same period in 2023, these figures represent a 160 percent and 19 percent increase in the number of cases and deaths in 2024. The DRC accounts for 96.2 percent of all cases and 97 percent of all deaths in the last seven months.
What has public health officials concerned is that the outbreak with the deadlier strain of Mpox virus that began late last year in the mining town of Kamituga in South Kivu Province has been spreading unchecked in the DRC over the last several months and has now extended beyond the borders of the country. Last week it was identified in Uganda and Kenya.
The initial outbreak of this strain of the virus was first reported as a study in a preprint form by the Mpox consortium in April 2024 which has since been published in the journal Nature Medicine on June 13, 2024. The authors noted then that the emergence of the virus transmitting efficiently between people through direct contact raised immediate concerns, writing:
The sustained spread of clade I MPXV in Kamituga, a densely populated, poor mining region, raises important concerns. The local healthcare infrastructure is ill-equipped to handle a large-scale epidemic, compounded by limited access to external aid. The 241 reported cases are probably an underestimate of the true incidence of mpox cases occurring in the area. In conversations with local healthcare workers, they reported that many additional people in the community had mpox symptoms but did not seek care.
They continued,
Frequent travel occurs between Kamituga and the nearby city of Bukavu, with subsequent movement to neighboring countries such as Rwanda and Burundi. Moreover, sex workers operating in Kamituga represent several nationalities and frequently return to their countries of origin. Although there is no current evidence of wider dissemination of the outbreak, the highly mobile nature of this mining population poses a substantial risk of escalation beyond the current area and across borders. The international spread of clade I MPXV is particularly concerning due to its higher virulence compared to clade II.
Even more worrisome, cases of Mpox have now been registered in the capital Goma, the largest city of the North Kivu Province and home to nearly 2 million people, many only recently arrived as refugees escaping the ongoing conflict between Rwandan and Ugandan rebel forces known as M23 and the Congolese army.
Goma, 460 kilometers to the northeast of Kamituga along the N2 highway, sits on the shore of Lake Kivu and borders the Rwandan city of Gisenyi. It is a strategic site for mineral resources like uranium, copper and cobalt, whose value is estimated in the tens of trillions of dollars. It has also been a region that has seen decades of brutal conflicts that have killed millions, leading to a chronic state of impoverishment. Despite the vast wealth of natural resources, the DRC remains one of the poorest countries across the globe, lacking necessary public health infrastructure and access to advanced medical care.
Amid displaced people living in crowded makeshift tents, with food prices out of reach for many and under constant threat of a new armed conflict, international humanitarian workers have described Goma as a city “buckling under huge strain.” Lack of funds has made a difficult task even harder, with resources stretched thin. As most of the access roads that connect the city to other regions are cut off, basic goods have grown scarce. Precisely in such circumstances, the emergence of the deadlier strain of Mpox bodes a catastrophe.
The literature on public health in conflict zones is replete with empirical evidence that these regions quickly become breeding grounds for previously checked or non-existent pathogens. The recent declaration of a polio epidemic in Gaza after 10 months of the genocidal campaign by Israeli forces, and following a quarter century of having maintained zero polio cases, attests to these concerns. Given Goma’s overcrowded and dire conditions, it can afford ample opportunity for the virus that causes Mpox to run roughshod over the population.
Furthermore, the intimate connections between large urban centers with the rest of the world also raise the threat that this deadlier strain of Mpox could expand rapidly across the surface of the globe, just as the Mpox clade IIb did in 2022, which was eventually deemed a PHEIC by the WHO in July 2022.
One of the major direct causal factors for the emergence of the Mpox pandemic at that time was the erosion of the public health response to the COVID-19 pandemic, which had earlier included some degree of contact tracing, testing and tracking. There was no interest on the part of member states to address the threat posed by Mpox to their populations. By the time the WHO ended the PHEIC on Mpox clade IIb in May 2023, the virus had spread to at least 116 countries affecting almost 100,000 people. With 208 confirmed deaths by then, mostly among immunocompromised people, the CFR stands around 0.16 percent.
During a WHO press brief on July 27, 2022, Director-General Ghebreyesus in his opening remarks repeated his refrain used during the initial COVID-19 global epidemic. He said, “This is an outbreak that can be stopped if countries and communities and individuals inform themselves, take the risk seriously, and take the steps needed to stop the transmission and protect vulnerable groups.”
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