Lack of vaccines, tests and treatments: Congo lacks tools to fight smallpox

Health officials in the Democratic Republic of Congo, the epicenter of the MPox outbreak, say they lack even the most basic tools needed to contain and treat the virus.

The country has constrained capacity to diagnose mpox cases, even as transmission and presentation of the disease change. That complicates efforts to trace contacts and determine the true scale and spread of the epidemic.

There is no effective antiviral treatment for mpox in Congo. The country also lacks the drugs needed to treat people with painful mpox lesions. Its breakable public health system struggles to provide those infected with basic care, which has been shown to improve survival rates even in the absence of antiviral drugs.

The country is still waiting for vaccines to begin a campaign to protect health workers and those in close contact with infected people and try to stop the spread of the virus.

“We thought that when the World Health Organization declared a state of emergency in 2022, we would get assist in surveillance and really understanding this disease,” said Dr. Jean-Jacques Muyembe-Tamfum, director of the National Institute for Biomedical Research in Kinshasa.

“Then the number of cases in the West dropped very quickly and interest died down — but here our cases continued to grow,” said Dr. Muyembe-Tamfum, who has studied mpox since 1970, when the first cases were diagnosed.

Scientists in Congo are now trying to understand the behaviour of a recent variant of the mpox virus, which spreads through sexual and other intimate contact and may be more easily transmitted.

One form of mpox, known as Clade 1a, has been spreading in Congo for years, primarily affecting children who have had contact with wild animals in the forest. But last year, mpox began spreading among teenage adults in eastern Congo, where it was rarely seen.

Dr. Muyembe-Tamfum and his colleagues traced the outbreak of the epidemic to the mining town of Kamituga, where they discovered that sex workers and their gold-mining clients — many of them migrant workers from neighboring countries — were part of a network responsible for spreading the virus.

In some patients, the recent subtype of the virus, known as Clade 1b, appears to cause lesions only on the genitals, but not on the limbs or face, as was the case in Congo. Some may hide their infections if they fear stigma or loss of income while in treatment.

Some of these patients do not seek care or are not identified, said Dr. Placide Mbala, head of the epidemiology and global health department at the NIBR in Kinshasa.

Only 30 percent of suspected mpox cases in Congo are confirmed by molecular testing, said Health Minister Dr. Samuel-Roger Kamba. The rest are diagnosed based on clinical symptoms. (Some infections can be confused with chickenpox, the virus that causes smallpox, or a sexually transmitted disease.)

“We need to be able to test as many suspected cases as possible to make sure we find everyone who has the virus,” Dr Kamba said.

Congo’s capacity to conduct PCR tests, the gold standard for diagnostics, has been boosted by international aid during the Covid-19 pandemic. But Congo, a country the size of Western Europe, still has only six labs processing the tests.

As Dr. Mbala explains, in some places, samples taken from skin lesions of potential patients have to travel for two days before reaching the laboratory.

And the costs are prohibitive: The mpox test performed on the GeneXpert PCR machine requires two disposable cartridges, each costing about $11, while testing at a national lab costs $5 to $10 per test.

“We need at least a laboratory capable of carrying out these tests in each of the 26 provinces,” said Dr. Dieudonné Mwamba, director of the Congo’s National Institute of Public Health.

There are no rapid tests for mpox. When the spread of the virus caused a global emergency in 2022, diagnostic companies began developing recent tests — but put the effort on hold as the high-revenue market disappeared and mpox reverted to neglected tropical disease status.

None of these tests have been through field trials or regulatory review. “There are a few tests in the pipeline, but more funding is needed to validate them quickly,” said Dr. Emmanuel Agogo, director of pandemic threats at the Foundation for Groundbreaking Novel Diagnostics.

It is not yet clear whether the standard PCR mpox tests on the market can consistently and effectively detect clade 1b, the recent subtype of the virus, he said. On Thursday, the WHO launched an emergency apply license process for mpox tests and invited manufacturers to submit data to expand the options.

Congo is also struggling to provide care to patients diagnosed with the disease.

Mpox causes high fever and painful lesions. An antiviral drug called tecovirimat provided relief to patients in a study in the United States and Europe in 2022 and 2023.

However, an unpublished study conducted recently in Congo by NIBR and the US National Institute of Allergy and Infectious Diseases it turned out that tecovirimat does not work there.

Dr. Mbala and other researchers who worked on the study noted a key finding: The drug did not shorten the time patients had the lesions. Yet the mortality rates for those given the drug and those given a placebo were the same—and much lower than the usual mortality rate in Congo.

This suggests, the researchers say, that high-quality care, such as the one the study participants received, helps MPox patients survive. But the care is much more intricate than most Congolese clinics can offer.

Patients need painkillers, antibiotics to treat bacterial infections carried by the lesions, antipyretics and support to stay nourished and hydrated, Dr. Mwamba said, all of which may be in miniature supply.

Children, who make up the largest proportion of the more than 500 MPox deaths in Congo this year, are often more vulnerable due to other health problems such as malnutrition, measles and malaria, he added.

Another clinical trial of the potential antiviral treatment MPox is ongoing in Congo, said Dr. Nathalie Strub Wourgaft, head of PANTHER, a network created during the COVID-19 crisis to rapidly organize clinical trials related to the pandemic in Africa.

There are plans to expand this study to other African countries with mpox transmission. But beyond that, she said, there are few treatment options underway.

“We need antiviral drugs to shorten the healing time of lesions, reduce pain and the risk of disease progression and transmission,” she said.

Dr. Strub Wourgaft described cases of children with mpox who were close to starving to death because they were unable to swallow food due to the pain caused by the lesions.

Although no vaccines have been developed specifically against MPOX, health agencies in high-income countries have issued emergency authorization for vaccination against smallpox, the virus related to it, during the 2022 epidemic. Clinical trials showed that these vaccines provided significant protection against MPox.

The Congolese government has authorized the apply of vaccines, but none are available. Donations from the European Union and the United States are working through the logistical stages for delivery and distribution. Purchases of additional vaccine doses from Gavi and UNICEF, which supplies most of the vaccines to Congo, have been slowed by bureaucracy.

Scientists also believe children and teenage adults may be at greater risk because older people still have some immunity to MPox from smallpox vaccinations.

“The emergency situation in 2022 led to the production of vaccines in the countries of the North because they were affected, but these vaccines were not transferred to Africa,” said Dr. Kamba, the Minister of Health.

“We should have thought about protecting Africans earlier,” he added, “because there was no form of sexual contact that is now circulating in Africa and is gaining popularity.”