Health officials in the Democratic Republic of Congo, the epicenter of a shape-shifting mpox outbreak, say they lack even the most basic tools necessary to contain and treat the virus.
The country has limited capacity to diagnose cases of mpox, even as transmission and the presentation of the disease are changing. That is complicating efforts to trace contacts and establish the true scale and spread of the outbreak.
There is no effective antiviral treatment for mpox in Congo. The country is also short on the medications necessary to treat people with painful mpox lesions. Its fragile public health system is struggling to provide those infected with basic care, which has been shown to improve survival rates even in the absence of antiviral drugs.
And the country is still waiting for vaccines to begin a campaign to protect health workers and close contacts of those infected and to try to check spread of the virus.
“We thought when there was an emergency declaration from the World Health Organization in 2022 that then we would get help with surveillance and really understanding this disease,” said Dr. Jean-Jacques Muyembe-Tamfum, the director of the National Institute of Biomedical Research in Kinshasa.
“Then the number of cases declined very quickly in the West, and the interest ended — but here our cases were still growing,” said Dr. Muyembe-Tamfum, who has studied mpox since 1970, when the first cases were diagnosed.
Now, researchers in Congo are scrambling to understand the behavior of a new variant of the mpox virus, one that is spread through sexual and other intimate contact, and that may be more easily transmitted.
One form of mpox, known as Clade 1a, has spread in Congo for years, affecting primarily children who were in contact with wild animals in the forest. Last year, however, mpox also started to spread among young adults in the eastern Congo, where it had rarely been seen.
Dr. Muyembe-Tamfum and his colleagues traced the outbreak to a mining town called Kamituga, where they found that sex workers and their gold-miner customers — many of them migrant workers from neighboring countries — were the part of a network driving spread of the virus.
In some patients, the new subtype of the virus, known as Clade 1b, seems to be causing lesions only on the genitals but not on their limbs or faces, as it had in Congo. Some may therefore be able to hide the infections, if they are worried about being stigmatized or losing income while they spend time in a treatment center.
Some of these patients are not seeking care or being identified, said Dr. Placide Mbala, who leads the epidemiology and global health division at the N.I.B.R. in Kinshasa.
Only 30 percent of suspected mpox cases in Congo are being confirmed with molecular testing, the health minister Dr. Samuel-Roger Kamba said. The rest are diagnosed based on clinical symptoms. (Some infections may be confused with varicella, the virus that causes chickenpox, or with sexually transmitted infections.)
“We need the means to test the maximum number of people with suspected cases to be certain we’re finding everyone who has the virus,” Dr. Kamba said.
Congo’s capacity to do PCR testing, the gold standard for diagnosis, was bolstered by international assistance during the Covid-19 pandemic. But there are still only six labs processing the tests in Congo, a country the size of Western Europe.
In some places, samples scraped from the lesions of possible patients must travel for two days to reach a lab, Dr. Mbala said.
And the cost is prohibitive: An mpox test run on a GeneXpert PCR machine requires two disposable cartridges, each costing about $11, while testing at the national laboratory costs $5 to $10 per test.
“We need, at a minimum, a laboratory capable of doing these tests in every one of the 26 provinces,” said Dr. Dieudonné Mwamba, the director of Congo’s National Institute of Public Health.
No rapid tests are available for mpox. When the spread of the virus caused the global emergency in 2022, diagnostics companies began to develop new tests — but they shelved the effort when the high-income market disappeared, and mpox returned to the status of neglected tropical disease.
None of those tests were put through field trials or regulatory review. “There are some tests in the pipeline, but more funding is needed to validate them quickly,” said Dr. Emmanuel Agogo, the director of pandemic threats at the Foundation for Innovative New Diagnostics.
It is not yet clear whether the standard mpox PCR tests on the market can all consistently and effectively detect Clade 1b, the new subtype of the virus, he said. On Thursday, the W.H.O. began an emergency-use licensing process for mpox tests and invited manufacturers to submit data, in an effort to expand the options.
Congo is also struggling to provide care to the patients who are diagnosed.
Mpox causes high fevers and painful lesions. An antiviral drug called tecovirimat provided relief for patients in a trial in the United States and Europe in 2022 and 2023.
But an unpublished study recently carried out in Congo by the N.I.B.R. and the U.S. National Institute of Allergy and Infectious Diseases found that tecovirimat did not work there.
Dr. Mbala and other researchers who worked on that trial noted a key finding: The drug did not reduce the amount of time that patients had lesions. Yet, the mortality rates of those who received the drug and those who were given the placebo were the same — and were significantly lower than the usual mortality rate in Congo.
That suggests, the researchers said, that high-quality care like that received by participants in the study helps mpox patients survive. But that care is considerably more complex than what most Congolese clinics can offer.
Patients need painkillers, antibiotics to treat bacterial infections contracted through lesions, medication to control fevers, and support to maintain nutrition and hydration, all of which can be in short supply, Dr. Mwamba said.
Children, who make up the bulk of the more than 500 fatalities from mpox in Congo so far this year, are often more vulnerable because of other health problems, such as malnutrition, measles and malaria, he said.
There is one more clinical trial of a potential mpox antiviral treatment underway in Congo, said Dr. Nathalie Strub Wourgaft, who heads PANTHER, a network created during the Covid crisis to rapidly set up clinical trials for pandemics in Africa.
That trial is planned to expand to other African countries with mpox transmission. But beyond that, she said, there are few treatment possibilities in the pipeline.
“We need antivirals to reduce time of healing of lesions to decrease pain and the risk of progression and risk of transmission,” she said.
Dr. Strub Wourgaft described seeing children with mpox who were close to starving, as they could not swallow food because of pain from lesions.
While there are no vaccines developed expressly for mpox, health agencies in high-income countries gave emergency authorization to vaccines for smallpox, a related virus, during the 2022 outbreak. Clinical trials found that those vaccines offered significant protection against mpox.
Congo’s government has authorized use of the vaccines but has none. Donated doses from the European Union and the United States are moving through logistical steps for delivery and distribution. Purchases of additional vaccine doses from Gavi and UNICEF, which supply most immunizations to Congo, have been slowed by bureaucracy.
Researchers also believe that children and young adults may be more affected because older people still have some immunity to mpox because they were vaccinated against smallpox.
“The emergency in 2022 led to the production of vaccines in the countries of the North because they were affected, but these vaccines have not been transmitted to Africa,” Dr. Kamba, the health minister, said.
“We should have already thought about protecting Africans,” he added, “because you didn’t have the sexual form that now circulates in Africa and is gaining momentum.”
