Mpox did not fade away. Africa faces two alarming outbreaks — and lacks vaccines

Two outbreaks of mpox in sub-Saharan Africa are raising concerns about the continued spread of the virus globally — and the surge of a deadlier strain than the one that began circling the globe in 2022.

That outbreak sickened nearly 100,000 people, with 203 deaths. It eventually slowed down, but mpox never went away. Formerly called monkeypox and caused by the monkeypox virus, mpox continues cropping up across the globe, from France to Mexico. In May, 26 countries reported a total of 646 new cases and 15 deaths.

The biggest share of new cases right now is in Africa.

Last week, the World Health Organization called attention to an mpox outbreak in South Africa. Officials there confirmed 20 cases between May 8 and July 2, with 18 hospitalizations and three deaths.

Another concern is the Democratic Republic of Congo, where an outbreak that began last year has been accelerating — and where the variant is dramatically deadlier than the mpox strain of 2022.

In 2023, DRC reported 14,434 suspected cases and 728 deaths. The pace seems to be increasing this year, with more than 11,000 cases and 445 deaths already reported in 2024, according to the World Health Organization.

A deadly outbreak in DRC

The variant circulating in DRC is dramatically deadlier than the one that swept the globe in 2022. About 6% of people who get this type of mpox are dying from it — compared to a 0.2% death rate for the 2022 strain. Most of the deaths in the DRC outbreak are among children.

Another 25 mpox cases were reported last Wednesday in Goma, the capital — sparking fears of more human-to-human transmission in an urban setting.

Scientists believe that the DRC outbreak has spread in two ways, driven partly by contact with infected animals and partly by human-to-human transmission that began after the virus spilled over from an animal host in 2023.

Global health experts believe this deadlier variant could spill beyond DRC’s borders, if it hasn’t already.

"We live in an interconnected world, so the spread of this virus can continue to happen, and that is something that requires strong surveillance," Maria Van Kerkhove, an infectious disease epidemiologist at the WHO, told reporters on Thursday. "In neighboring countries to DRC, we wouldn't be surprised if there were mpox cases."

South Africa's concerns

The current South African outbreak stands in a contrast to the mpox situation there two years ago, when there were only five cases and no deaths.

Scientists were concerned that these new cases could be caused by the deadlier strain now circulating in DRC. But genomic sequencing revealed the South Africa cases were the same strain behind the 2022 outbreak.

"We are sequencing our cases, and we're looking out for [the deadly strain] — but at the moment, it's the global outbreak" variant, Lucille Blumberg, an honorary consultant for the National Institute for Communicable Diseases in South Africa, tells NPR.

“That's the importance of … sequencing as part of your response,” she says. With genomic sequencing, scientists can know when a new variant has arrived.

Even so, the cases in South Africa are cause for concern.

The tally in South Africa had risen to a total of 23 laboratory-confirmed cases as of July 10, Blumberg says, but “what we're diagnosing in the laboratory is only a fraction of the number of cases out there.”

Experts are worried there are more patients not yet being treated.

With the reported cases, “none had reported any history of international travel, which suggests that confirmed cases are a small proportion of all cases and that community transmission is ongoing,” Tedros Adhanom Ghebreyesus, director-general of WHO, said at last Thursday’s press briefing.

Stigma plays a role

The reason the virus is spreading quietly may have to do with the population that’s affected.

The cases were all in men ages 17 to 43, and the majority were men who have sex with men — a group that faces heavy stigma and may not seek health care unless they’re very ill. Also, several of the men with severe cases were HIV-positive, but their illness was not well-controlled by HIV medications. That can often make mpox infections more severe.

In DRC, there are similar challenges reaching sex workers who are heavily stigmatized, Jason Kindrachuk, associate professor in medical microbiology and infectious diseases at the University of Manitoba, tells NPR.

And it’s particularly difficult to monitor the virus in expansive rural regions and amid ongoing conflict in DRC, he says. “There's not going to be a one-size-fits-all approach that's going to be able to control this.”

But, he says, “there still is an opportunity to try and at least gain some amount of momentum in getting things under control.”

Communication is critical, Kindrachuk says. That means reaching out to people at higher risk of contracting the virus, including men who have sex with men and sex workers, in ways that won’t further stigmatize them, he says.

South Africa, for example, could tap into established HIV programs where “many people have experience communicating sensitively and working with key population groups,” Blumberg says. “That's an important way to go.”

Waiting for vaccines

Efforts to curb mpox are also hampered by a lack of vaccines. While wealthy nations like the United States quickly stockpiled mpox vaccines in 2022, few of the shots reached the Global South.

“Vaccine is the right way to go,” Blumberg says, though she also pointed to the difficulty of getting and paying for the vaccines — and she highlighted “the need to ensure equitable access to vaccines and therapeutic agents for emerging diseases in Africa.”

DRC approved the two vaccines used for mpox at the end of June. South Africa began the process to approve and order vaccines in May when cases were first discovered, Blumberg says.

The U.S. committed to providing enough doses to vaccinate 25,000 people in the DRC, but none of the shots have reached the country yet. Japan has also pledged vaccines.

“We're still not at a point of seeing larger deployment of those vaccines,” Kindrachuk says. “Also, it's not enough to get vaccines delivered on the ground. You need the resources to be able to get those vaccines moved to different areas and ensure that the community engagement piece is funded and the clinics are funded.”

Beyond vaccines, fundamental public health work — communicating the risks, offering testing and treatment, doing contact tracing, and above all mobilizing the community — could also help, Van Kerkhove says. “What I think is really critical is that the countries have the support that they need for good surveillance, and that they report these cases, so that the right interventions can be provided to help people.”

The world stood up and paid attention to mpox much more closely in 2022, she says. Now, “we need to make sure that we have enough focus, enough energy, enough investment across the African region.”

“Everybody was worried about mpox in 2022 when it hit,” Kindrachuk says. “But then as soon as cases got controlled in the Global North and the richest areas of the world, people kind of forgot about mpox.”

But the virus didn’t disappear, he says, and the more it spreads, the more opportunities it has to wreak havoc. “The risk continues to be there, not only in the Global South, but for the rest of the global community as well.”

Melody Schreiber is a journalist and the editor of  What We Didn't Expect: Personal Stories About Premature Birth.

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