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Mpox first made global headlines in 2022, when the virus suddenly exploded across the globe, rapidly spreading through sexual networks to dozens of new countries outside Africa.
The World Health Organization declared it an international public health emergency that same year. The global outbreaks have primarily affected men who have sex with men, causing a range of symptoms from mild illness to painful, debilitating injuries and, in some cases, hospitalization or death.
After global cases cooled, the WHO ended its emergency declaration. But the virus did not disappear.
Instead, new challenges have emerged over the past two years in the Democratic Republic of Congo (Congo, also known as Congo-Kinshasa), a country in the heart of Africa that has struggled with MPOX for decades.
Cases of a severe form of the virus in Congo have soared to new heights, with more than 15,000 known infections so far this year, along with hundreds of deaths. It’s an alarming spike fueled in part by the spread of an emerging new lineage, now emerging for the first time in several neighboring countries.
The growing crisis led to successive announcements this week, with the Africa Centers for Disease Control and Prevention (Africa CDC) and WHO launching a continental and then global health crisis.
Just one day after the WHO warning, Swedish health officials have announced A patient who had recently traveled to Africa was recently diagnosed with the Congolese form of mpox. This was the first known case outside the African continent and a possible harbinger of more infections worldwide.
What exactly is mpox, how does this dangerous virus change and spread, and why is the situation in 2024 different from previous outbreaks?
What is mpox?
This poxvirus, formerly known as monkeypox, was first identified in a human in 1970 and remained largely confined to parts of Africa in the decades that followed.
Mpox often causes mild illness and is known by its namesake pox lesions. They can be pus-filled, often cause excruciating pain, and leave lifelong scars—both externally and internally—including in the genital region.
The viral infection also causes fever, sore throat, headache, muscle aches, back pain and swollen lymph nodes.
The virus spreads in a variety of ways, including close contact in the home and through sexual contact, but scientists are still trying to unravel the exact transmission patterns.
The World Health Organization has declared a public health emergency of international concern over mpox, a new variant that could spread more easily and cause more severe illness in Africa.
What are the different types of mpox?
There are two main forms of mpoxvirus: clade I and clade II.
“Clade” is a virological term, similar to the variants used to describe offshoots of SARS-CoV-2, the virus behind COVID-19. In both cases, it’s a way for scientists to track the evolutionary tree of each virus.
The 2022 global MPOX outbreak was dominated by clade II, which typically causes milder disease and spreads globally through sexual contact.
Clade I, on the other hand, has long circulated in Congo. It is associated with more severe disease and higher mortality rates, but historically spread mainly from infected animals to people in rural areas of the country, often affecting vulnerable children.
More recently, the transmission patterns of clade I have changed.
In 2023, a Canadian-Congolese research team published findings showing that the mpox virus was circulating in Congo also spread through sexual networks.
In April of this year, the same researchers a new lineage identified — known as clade Ib — showed signs of efficient human-to-human transmission and affected many sex workers. At the time, the team warned that it could quickly spread beyond Congo.
This is the kind of MPOX that is now crossing the border into new countries such as Burundi, Kenya and Uganda, causing renewed concern worldwide.
“What is happening now in Congo is that most cases are still linked to [an earlier strain] — still associated with zoonotic transmission, with the highest mortality and morbidity still occurring among children — but we now have this increase in sexually based transmission with clade Ib,” explained research team member Jason Kindrachuk, a microbiologist at the University of Manitoba.
A Toronto resident shares his recovery from monkeypox disease. Government officials and advocates say more support is needed for patients during the long weeks of isolation.
How deadly is this new form of mpox?
According to estimates from the Africa CDC, approximately three to four percent of MPOX patients in Congo die from their disease.
That’s much higher than the sub-1 percent mortality rate reported during the global clade II outbreak, but it’s still well below the 30 percent mortality rate from the virus’s infamous cousin, smallpox, the only disease to have been eradicated globally thanks to mass vaccination efforts.
Children, pregnant women, and people with weakened immune systems, including people with HIV, are most at risk of serious illness from MPOX.
But without an accurate count of the total number of infections in Congo, it is difficult to determine the exact mortality rate of clade Ib, or how it compares to other offshoots of the virus.
This is partly due to the large differences in population demographics and the level of health care in the different regions. Nearly half of Congo’s total population is under 15 years oldand the country still struggles with high HIV rates. Both of these factors can affect the severity of the disease in ways that have nothing to do with the virus itself.
Kindrachuk said limitations to the tests, including the inability to transport samples across much of Congo and the fact that many mild cases go undetected, are hampering scientists’ efforts to get a complete picture.
“Ninety percent of cases are never actually tested, so we actually only diagnostically confirm about 10 percent,” he added.
Dr Maria Van Kerkhove, head of the WHO’s department for epidemic and pandemic preparedness and prevention, called for greater oversight during the organization’s briefing on Wednesday.
“We need standardized data collection on patients infected with MPOX to understand the course of the disease and its severity,” she said.
Why are scientists so concerned?
For months, researchers have been alarming that clade Ib could eventually explode globally, creating a repeat of the 2022 outbreak but with unknown, and potentially devastating, global consequences.
The case recently established in Sweden, a patient seeking care in the Stockholm regionprovided an early warning.
Congolese-American infectious disease epidemiologist Jean Nachega of the University of Pittsburgh called mpox a “ticking time bomb” that could spread again and again to other countries from a part of the world with few resources to contain the disease.
While higher-income countries including Canada have eradicated high rates of clade II cases through vaccination programs, Africa has not had the same resources. The Africa CDC aims to roll out 10 million doses of the MPOX vaccine, officials said Tuesday, but has procured only a small fraction of that total.
In addition, there is a lack of therapeutic agents across the continent. A drug used successfully elsewhere to treat mpox patients, an antiviral called tecovirimat or TPOXX, does not appear to work against clade I.
New findingsPublished Thursday by the U.S. National Institute of Allergy and Infectious Diseases (NIAID), TPOXX did not shorten the duration of mpox lesions in children and adults with clade I mpox in Congo, based on an initial analysis of data from a randomized, placebo-controlled trial.
In a statement, NIAID Director Dr. Jeanne Marrazzo called the initial results “disappointing.”
But the team also saw a bright spot: The overall mortality rate of 1.7 percent among study participants, regardless of whether they received the drug or not, was lower than the MPOX mortality observed in all known cases in Congo.
“This shows that better outcomes can be achieved in people with MPOX when they are admitted to hospital and receive high-quality supportive care,” the team wrote.
While Nachega called the MPOX crisis “worrying,” he expressed hope that WHO’s declaration of a global emergency this week could turn the situation around and encourage the international community to provide more support to Africa.
“This is an endemic disease, and a neglected disease, but hopefully now it is getting the right attention so we can get better diagnostics, better treatment, better prevention,” he said.
