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Call for action as DRC mpox spreads via heterosexuals

Experts are calling for urgent focus on the outbreak of mpox that appears to be spreading through heterosexual contact in the Democratic Republic of the Congo, where research has detected infections among sex workers and people who have had more than one partner.

The study team said the outbreak has been seen in 22 of the country’s 26 provinces since being first recorded in August last year, with the responsible variant being tentatively classified as a novel subgroup – distinct from that which was responsible for previous global outbreaks.

Since 1 January last year, the DRC had reported 12 569 suspected pox cases and 581 deaths.

News24 reports that the study, which has not yet been peer-reviewed, drew on 51 patients drawn from Kamituga Hospital, of whom 37 (73%) tested positive for mpox. The group was young, with an average age of 24 for men and 19 for women, and 61% said they had been sexually active with more than one partner in the previous six months.

Nearly all (92% of the cohort) identified as heterosexual.

Most of the infected people fell into groups considered at high risk of sexual transmission of disease: 47% were sex workers, 10% were gold miners, 12% were students, and 8% were farmers.

According to the researchers, mpox viral DNA was detected in vaginal, penile and oral swabs in 73% of the group.

“Heterosexual partners dominated human-to-human contact transmission, suggesting that heterosexual close contact is the main form of transmission in this outbreak,” the study found.

The authors said professional sex workers (PSWs) were the dominant occupation among infected individuals, indicating that PSWs and clients “may be at higher risk for developing mpox virus infections”.

Lack of containment support

The DRC reported its first cases of mpox in humans in 1970, and the country is known for identifying MPXV clade I, the virus’ deadliest strand.

In the current outbreak, symptoms include fever, cough, sore throat, chills, headache, muscle pain, vomiting and rashes.

According to FIND, a global health non-profit based in Geneva, the lack of testing capacity in the DRC affects efforts to contain the outbreak.

“The situation … is deeply alarming, and the lack of tests for both mpox and HIV means it's unclear just how bad it is and what the underlying comorbidities are,” said Dr Ayoade Alakija, chairperson of the board at FIND.

She added that mpox cases that received more global attention were not in Africa, where the virus regularly occurs, and that failing to address this would lead to another international spread.

“Like the Covid-19 pandemic, those being prioritised for tests, treatment and vaccination are not in the outbreak countries in Africa.

“We can either mobilise resources and fight this now in the DRC, or we can let the virus continue to spread and fight it when it is imported into other countries,” she said.

Study details

Epidemiology, clinical characteristics, and transmission patterns of a novel Mpox (Monkeypox) outbreak in eastern Democratic Republic of the Congo (DRC): an observational, cross-sectional cohort study

Leandre Murhula Masirika, Claude Udahemuka, Luis Flores et al.

Published in MedRxiv on 5 March 2024

Summary (abstract)

In August 2023, an outbreak of mpox was reported in the eastern part, South Kivu Province, of Democratic Republic of the Congo. In this study, we aimed to investigate the origin of this outbreak and to assess how monkeypox virus spread among humans in the city of Kamituga.

We performed an observational cohort study by recruiting hospitalised patients with mpox-like symptoms. Furthermore, we compared structured, de-identified case report forms and interviews were conducted to determine the possible origins and modes of transmission of the mpox outbreak. We describe the clinical characteristics and epidemiology observed in reported infections.

During the study period (24 September 2023 to 29 January 2024), 164 patients were admitted to the Kamituga hospital, 51 individuals were enrolled in the study and interviewed, and 37 (73%) of 51 individuals received a molecularly confirmed mpox diagnosis. The median age for males was 24 years (IQR 18-30; range 14-36) and 19 years for females (IQR 17-21; range 1-59). The cohort was comprised of 47 (92%) of 51 individuals who identified as heterosexual, and two (4%) of 51 as bisexual, with 31 (61%) of 51 individuals sexually active with more than one partner within the last six months. The direct transmission routes are unknown; however, it is expected that the majority of infections were transmitted via occupational exposures. Out of the 51 individuals, 24 (47%) were professional sex workers (PSWs), while five (10%) were gold miners, 6 (12%) were students, and four (8%) were farmers; the remaining individual occupations were unknown. The most common symptoms associated with clinical mpox diagnosis were fever, which was described in 38 (75%) of 51 individuals, and rash, which was described in 45 (88%) of 51 individuals. Among those with a rash, 21 (41%) of 51 individuals experienced oral lesions, and 32 (63%) of 51 presented anogenital lesions. Mpox viral DNA was detected by qPCR from vaginal, penile, and oral swabs in 37 (73%) of 51 enrolled individuals. Two deaths were reported.

In this observational cohort study, mpox virus infection caused symptoms in a wide age range of participants with most cases presenting in sexually active individuals. Symptoms included fever, cough, lymphadenopathy, sore throat, chills, headache, back pain, muscle pain, vomiting, nausea, conjunctivitis, and rash (oral and anogenital). Heterosexual partners dominated human-to-human contact transmission suggesting that heterosexual close contact is the main form of transmission in this outbreak. Furthermore, Professional Sex Workers (PSWs) were the dominant occupation among infected individuals, indicating that PSWs and clients may be at higher risk for developing mpox virus infections.


MedRxiv article – Epidemiology, clinical characteristics, and transmission patterns of a novel Mpox outbreak (Open access)


News24 article – Mpox seems to be spreading via heterosexual contact in the DRC (Restricted access)


See more from MedicalBrief archives:


DRC records 581 suspected mpox deaths


Lessons – and mysteries – from fast-disappearing mpox


Africa fears monkeypox vaccine side-lining as disease spreads


Global vaccine inequality not unique to COVID vaccines – first WHO report







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