#18,231
Although it has been endemic there for decades, in November of 2023 we began to see escalating reports of Mpox activity in the DRC, including the first Confirmed Cluster Of Sexually Transmitted MPXV Clade 1, which led to both the ECDC and CDC issuing risk assessments in December.
ECDC Risk Assessment On Transmission & Spread of Clade I Mpox From The DRC
CDC HAN Advisory #00501: Mpox Caused by H-2-H Transmission with Geographic Spread in the Democratic Republic of the Congo
While the risk to Americans and Europeans from this clade I virus has been repeatedly assessed as `very low', the same was said about the clade II Mpox virus in the spring of 2022, before it began its world tour.
Since then, the news has only gotten worse; a new clade Ib MPXV was identified last March (see Preprint: Sustained Human Outbreak of a New MPXV Clade I Lineage in Eastern Democratic Republic of the Congo), and in recent weeks we've seen the spread of clade I from the DRC into neighboring countries (see map above).
Compared to the the clade II Mpox virus, clade I viruses tend to produce more severe illness, and have a significant fatality rate (variously reported between 3%-10%). While it still appears to be limited to African nations, in our highly mobile 21st century, there are no guarantees how long that will last.
Yesterday the CDC published an update, and a HAN (Health Alert Network) Advisory, on growing concerns over the spread of Mpox Clade I in Central Africa.
First stop, the CDC overview:
2023 Outbreak in Democratic Republic of the Congo
Updated August 7, 2024
Since January 2023, the Democratic Republic of the Congo (DRC) has reported more than 22,000 suspect mpox cases and more than 1,200 deaths.
There are two types of mpox, clade I and clade II. Clade I usually causes a higher percentage of people with mpox to get severely sick or die compared to clade II.
Clade I mpox occurs regularly, or is endemic, in DRC. The current outbreak is more widespread than any previous DRC outbreak, and clade I mpox has spread to some neighboring countries, including Burundi, Central African Republic, Republic of the Congo, Rwanda, and Uganda. These countries are all reporting cases of clade I mpox, and some of them have links to DRC.
Risk to the United States
No cases of clade I mpox have been reported outside central and eastern Africa at this time, including the United States.
The risk to the general public in the United States from the type of mpox circulating in the DRC is very low.
CDC has made this assessment due to the limited number of travelers and no direct commercial flights from DRC or its neighboring countries to the United States. The risk might change as more information becomes available, or if cases appear outside central and eastern Africa.
People in the United States who have already had mpox or are fully vaccinated should be protected against the type of mpox spreading in DRC and neighboring countries. Mpox needs close or intimate contact to spread, so casual contact like you might have during travel is not likely to cause the disease to spread. The best protection against mpox is two doses of the JYNNEOS vaccine if you’re eligible, People can also protect themselves by:
- Avoiding close contact with people who are sick with signs and symptoms of mpox, including those with skin lesions or genital lesions.
- Avoiding contact with wild animals (alive or dead) in areas where mpox regularly occurs.
- Avoiding contact with contaminated materials used by people who are sick (such as clothing, bedding, or materials used in healthcare settings) or that came into contact with wild animals.
- Avoiding eating or preparing meat from wild animals (bushmeat) or using products (creams, lotions, powders) derived from wild animals.
Situation in DRC
There are several outbreaks happening at the same time in DRC, with cases reported throughout the country, in the capital city of Kinshasa, and in some other large cities. In DRC, different provinces have outbreaks with different features.
In some provinces, patients have acquired infection through contact with infected dead or live wild animals, household transmission, or patient care (transmitted when appropriate PPE wasn’t used or available); a high proportion of cases have been reported in children younger than 15 years of age.
In other provinces, the cases are associated with sexual contact among men who have sex with men and female sex workers and their contacts. These are first reported cases of sexual transmission with clade I mpox.
CDC has been supporting DRC mpox research and response for more than 20 years. CDC and other U.S. government agencies are on the ground in DRC helping partners in the country with disease surveillance, laboratory capacity including testing materials, strengthening workforce capacity, case investigation, case management, infection prevention and control, border health, and risk communication and community engagement. DRC has approved the use of vaccines in-country, so CDC is working with other U.S. government and partners on a plan to get vaccines to them as soon as possible.
Situation in Central and Eastern Africa
The Republic of the Congo (ROC), which borders DRC to the west, declared a clade I mpox outbreak in April 2024. There have also been confirmed clade I cases in Central African Republic (CAR), which borders DRC to the north. Clade I mpox is endemic to ROC and CAR, but the new cases appear to be linked to spread from DRC. In late July 2024, Burundi, Rwanda, and Uganda, which sit on the eastern border of DRC, reported confirmed cases of mpox. Clade I mpox has not been known to be endemic in these countries.
Although contact tracing is ongoing, some cases have links to DRC. Rwanda and Uganda have confirmed these cases are clade I MPXV. In Burundi, clade-specific testing is underway, but cases are presumed to be clade I because of DRC and Rwanda’s shared borders with Burundi. Person-to-person transmission has occurred during this outbreak, including through sexual contact, household contact, and within the healthcare setting. People have also gotten mpox through contact with infected wild animals.
CDC is working with Ministries of Health and in-country partners across the region on disease surveillance, laboratory capacity including testing materials, strengthening workforce capacity, case investigation, case management, infection prevention and control, border health, and risk communication and community engagement.
The CDC also issued a HAN Advisory - primarily geared to clinicians and public health officials - on this evolving crisis. Due to its length, I've only posted the link and summary below. Follow the link to read it in its entirety.
I'll have a postscript after the break.
Mpox Caused by Human-to-Human Transmission of Monkeypox Virus in the Democratic Republic of the Congo with Spread to Neighboring Countries
Distributed via the CDC Health Alert Network
August 7, 2024, 3:15 PM ET
CDCHAN-00513
Summary
The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Update to provide additional information about the outbreak of monkeypox virus (MPXV) in the Democratic Republic of the Congo (DRC); the first Health Advisory about this outbreak was released in December 2023.
Since January 2023, the DRC has reported the largest number of yearly suspected clade I mpox cases on record. While clade I MPXV is endemic, or naturally occurring, in DRC, the current outbreak is more widespread than any previous DRC outbreak and has resulted in clade I mpox transmission to some neighboring countries. The Republic of the Congo (ROC), which borders DRC to the west, declared a clade I mpox outbreak in April 2024, and there have been confirmed cases in the Central African Republic (CAR). While clade I mpox is endemic in ROC and CAR, the epidemiologic pattern of recent cases suggests a possible link to DRC.
In late July 2024, Burundi, Rwanda, and Uganda, which sit on the eastern border of DRC, reported confirmed cases of mpox, with some cases having linkages to DRC. Rwanda and Uganda have confirmed these cases are due to clade I MPXV; in Burundi, clade-specific testing is underway, but cases are presumed to be clade I due to DRC’s proximity. Mpox is not known to be endemic in these countries.
No cases of clade I mpox have been reported outside central and eastern Africa at this time. Because there is a risk of additional spread, CDC recommends clinicians and jurisdictions in the United States maintain a heightened index of suspicion for mpox in patients who have recently been in DRC or to any country sharing a border with DRC (ROC, Angola, Zambia, Rwanda, Burundi, Uganda, South Sudan, CAR) and present with signs and symptoms consistent with mpox. These can include: rash that may be located on the hands, feet, chest, face, mouth, or near the genitals; fever; chills; swollen lymph nodes; fatigue; myalgia (muscle aches and backache); headache; and respiratory symptoms like sore throat, nasal congestion, and cough.
Prior to May of 2022, the detection of a single case of Mpox clade II outside of endemic regions of Africa was so rare that it would set off major public health investigations. Today, it has become so commonplace, that many countries don't even bother to report them.
Its perceived mildness, and the availability of vaccines and antivirals, have made it less of a public health concern. But clade I Mpox is viewed as being far more serious, and it remains to be seen how effective our vaccines and antivirals will be against it.
Yesterday the WHO Director General Dr. Tedros announced he will Will Convene an IHR Emergency Committee On Mpox `As Soon As Possible' to discuss whether this crisis has become a PHEIC (Public Health Emergency of International Concern).
