Lancet Infectious Diseases｜The global alarm bell is ringing due to the threat of potential severe cases and deaths caused by clade I of monkeypox virus
The global alarm bell is ringing due to the threat of potential severe cases and deaths caused by clade I of monkeypox virus
Min Du, Min Liu, Ben Niu, Jue Liu
Lancet Infect Dis 2024 Published Online
doi: 10.1016/ S1473-3099(24)00530-9
WHO reported that as of the end of June, 2024, the multicountry mpox outbreak had caused a total of 99 176 laboratory-confirmed cases.1 The WHO has proposed developing mpox control and elimination plans from 2024 to 2025 in the Strategic Framework for Enhancing Prevention and Control of mpox 2024–2027.2
However, an ongoing severe outbreak of mpox in DR Congo has presented new challenges for mpox control and elimination. More than 14 000 cases and 511 deaths have been reported in DR Congo since the beginning of the year. Although outbreaks have been reported in DR Congo for decades, the caseload for the first 6 months of this year matches the total for all of 2023. It has been over a year since the WHO announced that the mpox epidemic did not constitute a public health emergency of international concern (PHEIC), on May 11, 2023. However, on Aug 13, 2024, the Africa Centers for Disease Control and Prevention declared a public health emergency of continental security. The following day, the Director-General of WHO announced that the upsurge of mpox in DR Congo and a growing number of countries in Africa constituted a public health emergency of international concern (PHElC) under the International Health Regulations (2005). We should note three crucial points about the recent outbreak in DR Congo. First, unlike other countries, the current outbreak in DR Congo is caused by a new offshoot of clade I, called clade Ib, which causes more severe disease than clade I.3 Second, in late July, 2024, some cases caused by clade I were confirmed in Rwanda and Uganda due to DR Congo's proximity, posing the possibility of international spread for clade I. Third, the deaths are concentrated in vulnerable populations, such as children aged 15 years or younger (nearly 78%), and there have also been stillbirths.4,5
What actions could we take to counteract the threat posed by the recent mpox outbreak in DR Congo? First, the previous prevention measures for the public should be maintained, including avoiding close contact with suspected cases and considering vaccination against mpox for individuals with risk factors. Meanwhile, ensuring equitable access to tests, treatments, and vaccines for all individuals, and focusing priorities in the epidemic area, are crucial for the public to prevent a global mpox epidemic.2 Second, considering the poor availability of mpox vaccine, high mortality rates, and household transmission for children, it is recommended that family members seek medical care immediately and avoid contact with children if they have been in DR Congo or its neighboring countries in the last 21 days and develop suspected symptoms.6 It is also necessary to avoid indirect contact with children (eg through contaminated clothing and furniture) to reduce the risk of household transmission. Third, environmental surveillance signals for early detection of clade I within nations might be useful. For example, wastewater monitoring, as a valuable, efficient, and robust tool, can be used to guide public health decision making across the nation for public health officials. Based on the experience of wastewater monitoring in COVID-19, the US Centers for Disease Control and Prevention have used wastewater samples to monitor the presence of mpox virus.7 Fourth, numerous important scientific questions for clade I remain to be addressed, including regarding the efficiency and effectiveness of clinical diagnostic approaches, the effectiveness of mpox vaccine, and the robustness of surveillance methods. The low availability of point-of-care tests commonly means that the quick and early diagnosis of clade I mpox is potentially reliant on clinical information.8 Precise clinical assessment tools (ie, visual assessment for lesions and robust biological indicators) to diagnose clade I and predict severe outcomes in the early stages are required to inform clinical, public health, and research priorities.8 Last, but most importantly, in response to the aforementioned issues, international cooperation should be strengthened. Progress on vaccine development, clinical evaluation, and surveillance methods for clade I are inseparable from the collection, linkage, and analysis of cases and pathogen data. In addition to advancing scientific research, vaccine resource allocation through international collaboration across public and private entities is essential due to the high cost of the smallpox vaccine and its poor availability in DR Congo and other African countries. Collaborative international teams could contribute better to global responses and the control of infectious diseases including information sharing and resource allocation.
Given the recent mpox outbreaks in DR Congo, urgent action is required from neighbouring countries and other countries to prevent the broader geographical spread of clade I, with particular emphasis on addressing the needs of clinically vulnerable key populations.
