一種長期被忽視的病毒在兩年內第二次構成全球威脅。它能被遏止嗎？
喬恩‧科恩 / 2024 年 12 月 9 日 / 科學
這個故事的一個版本出現在 Science，第 386 卷，第 6728 期。
這個故事得到了普立茲中心的支持。
2023 年 9 月下旬，剛果民主共和國 (DRC) 偏遠礦業城市卡米圖加 (Kamituga) 的一名與他人共同擁有一家酒吧的 33 歲男子，其生殖器出現病變並發燒。他先向醫生尋求幫助，醫生給他注射了藥物，然後又向傳統治療師尋求幫助，後者給他塗抹藥膏並進行灌腸。但病變不斷擴散，最終出現在他身體的大部分地方。
他的親戚說服這名男子來到布卡武市的家中，天氣好的時候需要 6 個小時，雨季時則需要兩倍的時間，因為雨季時大部分道路都會變成泥濘。那裡的衛生工作者擦拭取樣了他的病灶，首都金薩沙的一個實驗室證實，這名男子患有剛果民主共和國該地區罕見的疾病：MPOX，這是一種由天花病毒的近親引起的痛苦且有時致命的疾病。
《科學》雜誌獲得的剛果民主共和國公共衛生部布卡武分部 1 月份的一份報告稱，這名男子是目前席捲全國的MPOX疫情中的「指標病例」，即首例已知患者。報道稱，他在拜訪隔幾個省份之外的城市基桑加尼後生病了。它沒有解釋他是如何被感染的，但生殖器病變顯示是透過性接觸感染的。
報導稱，酒吧老闆在離開卡米圖加之前接觸過的98 人中，有11 人也出現了症狀，其中7 人還「逃往」南基伍省擁有130 萬人口的城市布卡武，然後前往鄰近盧安達北基伍省首府的戈馬。在接下來的幾個月裡，所有這些地方以及蒲隆地、烏干達、肯亞和尚比亞都出現了病例。該病毒也穿過剛果民主共和國到達金薩沙，旅客將其帶到泰國、歐洲和美洲。
《科學》雜誌在 11 月見到了這名不願透露姓名的男子。他說，感染非常可怕：「我感覺我的生殖器快要脫落了」。他最初認為有人可能對他下了詛咒，當他得知這是MPOX時，他想知道是否可能是因為他參觀了基桑加尼動物園。當社群媒體上的人們點名批評他將這種疾病帶到卡米圖加時，他感到憤怒。 「我感到被冒犯了，甚至想提起告訴」，他說。他認為，卡米圖加的一名兒童同時患有MPOX，這可能是真正的指標病例。
無論卡米圖加在傳播這種疾病中扮演的具體角色如何，卡米圖加——那裡的第一批患者中有很多是礦工和性工作者——已經成為這一迅速蔓延的流行病的中心，世界衛生組織 (WHO) 8 月將其列為國際公共衛生緊急事件。
這場危機是在另一種MPOX病毒株爆發後不到兩年發生的，該病毒株始於奈及利亞，最終導致120個國家的10萬多人患病，其中大多數是男男性行為者 (MSM)。這也導致世界衛生組織從 2022 年 7 月到 2023 年 5 月宣佈為國際關注的突發公共衛生事件，當時因疫苗接種、教育運動和高危險群免疫力的增強導致疫情平息。
對於長期以來世界上最被忽視的病毒性疾病之一來說，連續的流行病是一個戲劇性的轉變。
朱利安·姆溫賈（左）在剛果民主共和國利維羅的治療中心給患有嚴重mpox的兒子餵食。該中心一直在努力尋找抗生素和其他急需的基本資源。圖：阿萊特·巴什茲
Mpox 在剛果大部分地區屬地方性流行，但在過去 50 年裡，疫情主要影響剛果西部和中部地區熱帶雨林中偏遠村莊的兒童，每次從動物「儲存庫」跳躍至人體，有時會緊隨其後，造成人與人之間的有限傳播。由於受影響的社區規模較小且相對孤立，這種蔓延通常會在幾個月後消失。
卡米圖加爆發的疫情引發了全新的事件：一場流行病，在以前從未出現過mpox的地方病例激增。今年前 11 個月，剛果民主共和國的地方性流行和廣泛的流行蔓延已導致超過 47,000 例疑似病例，而 2023 年僅為 14,626 例。
現在，人們正在積極努力控制這種疾病。捐助者與世衛組織和聯合國兒童基金會密切合作，已空運了數十萬劑麻疹疫苗。主要由外國政府和聯合國分支機構資助的援助團體和當地診所已經建立了治療中心，可以對疑似患者進行檢測，如果被感染，則需要隔離數週。法語國家各地的海報警告說，「mpox存在」，鼓勵人們在出現發燒和典型皮膚損傷時就醫。
從地方性流行到廣泛地流行
數十年來，MPOX 一直在剛果民主共和國為地方性流行。該病毒偶爾會從野生動物傳染給人類，主要是兒童，有時會出現人際傳播。然而，自2023年9月以來，該國的疫情在人與人之間迅速廣泛傳播流行，鄰國蒲隆地和烏干達也是如此。 （盧安達、肯亞和尚比亞報告的病例數較少。）
Mpox 開始在鄰國傳播。
（圖）V. Penney/Science； (數據來源)世界衛生組織截至2024年12月1日
但《科學》雜誌 11 月對南北基伍和金薩沙的訪問顯示，挑戰是巨大的。針對高風險族群的疫苗劑量太少，而且疫苗在全國（超過歐盟面積一半）的分發速度極為緩慢。兒童佔病例的一半，並且最有可能患上嚴重疾病和死亡，但他們根本沒有接種疫苗。
診斷手段稀缺：今年只有 22% 的疑似病例確診。人們有時會在檢測結果出來之前就離開治療中心，這可能會讓其他人受到感染。衛生和教育工作參差不齊，監測很大程度上係依賴來尋求照護的人，而不是積極尋找病例的團隊。
多個政府機構參與了應對工作，有時會造成誰該負責的混亂。 「看到正在發生的事情真是太瘋狂了」，金薩沙國家生物醫學研究所 (INRB) 的流行病學家和資深MPOX 研究員普拉西德·姆巴拉 (Placide Mbala) 說，他是研究卡米圖加疫情的一個團隊的共同領導者。 「有時，當你去參加會議時，你會與那些相信自己比你更知道該做什麼的人一起工作。他們試圖複製並貼上從書本上學到的東西」。
剛果民主共和國能否控制MPOX，對該國和世界來說都是一個關鍵問題。如果不這樣做，這將給該國脆弱的衛生系統帶來永久性的額外壓力。輸出病例將對其他國家構成持續威脅。
姆巴拉認為，這種傳播至少可以大大減緩，就像之前 MSM 的全球流行一樣。 「我們知道這種疾病在哪裡更為盛行，以及在哪裡我們看到更多的人際傳播，」他說。 「在這些地方很容易建立良好的監測和良好的診斷，而且很快我們就可以阻止這種疾病。 ……這只是意願和金錢的問題」。
Mpox 已在剛果民主共和國戈馬附近尼拉貢戈火山山麓為境內流離失所者修建的 Rusayo 營地內迅速蔓延。圖：阿萊特·巴什茲
mpox 病毒於 1958 年在遠離非洲的地方被發現，當時哥本哈根實驗室的亞洲猴子患病。科學家分離出這種病毒，並將這種疾病命名為「猴痘」(monkeypox)，這是一個用詞不當的說法：非洲松鼠和其他囓齒動物可能是該病毒的「儲存宿主」。實驗室猴子可能被感染，因為國際動物貿易商將幾個物種關在一起。 （為了避免恥辱，該名稱於 2022 年更改為 MPOX。）
直到 1970 年 8 月，第一例人類病例才出現：一名來自剛果民主共和國赤道省的 9 個月大的男孩，該省仍然是MPOX 的熱點地區。醫生最初認為他的病變是由天花引起的，並將樣本送到莫斯科實驗室，該實驗室正確診斷了這種疾病。男孩康復了，但出院前死於麻疹。
調查人員指出，與沒有感染mpox的父母和 10 個兄弟姐妹相比，男孩沒有接種天花疫苗。他們猜測對天花的免疫力也可以預防mpox——這一預感被證明是正確的。 1980 年天花被宣布消滅後，全球停止了疫苗接種，mpox報告開始增加。 （在此之前，整個非洲只有59 例病例，其中80% 在剛果民主共和國。）1996-97 年，Katako-Kombe 鎮附近爆發了一場令人震驚的疫情，有511 例疑似病例，其中大部分是由於人傳人感染所致。
一旦研究人員開始積極尋找病例，他們就意識到MPOX的傳播範圍比人們想像的要廣泛得多。在2010 年一項具有里程碑意義的研究中，由時任國家生物醫學研究所 (INRB) 主任Jean-Jacques Muyembe 和加州大學洛杉磯分校流行病學家Anne Rimoin 領導的團隊報告稱，在2 年內在Katako-Kombe 和8 個鄰近衛生區發現了760 例病例。 「這是把牌擺在桌面上並說，『嘿，聽著，這是一個問題』」，裡莫安說。
不過，mpox很少見，大多數人都能康復，而且輕症很容易被誤認為是水痘，因此醫生常常忽略它。剛果民主共和國還有許多更迫切的健康問題，包括麻疹、霍亂、結核病和瘧疾。里莫安說：「我們都知道將會發生流行病，而你們卻沒有採取任何行動，這是不公平的」。
病毒在移動
自 1970 年在赤道省發現世界上第一例 MPOX 病例以來，剛果民主共和國 (DRC) 已出現的病例比其他國家都多。直到最近，大多數都是名為Ia 分支的病毒株，但在過去15 個月中，Ib 分支在該國東部地區爆發（該地區以前從未爆發過mpox疫情），並已溢出蔓延到剛果民主共和國的鄰國。
（圖）M. Hersher/《科學》； (數據來源)世界衛生組織截至2024年12月1日
隨後爆發了卡米圖加 (Kamituga) 疫情，包括 Mbala、Rimoin 和 Muyembe 在內的大型國際研究團隊在 4 月的預印本中對此進行了描述。 （《自然醫學》6月在網路上發表了這篇論文。）研究發現，在疫情爆發的前5個月，108例確診病例中，29%是性工作者。基因定序顯示，該病毒與流行地區的第 I 型病毒株不同，因此該病毒株被重新命名為 Ia，而在 卡米圖加 (Kamituga) 循環的病毒譜系（比十多年前更早在兩名患者中發現）則被命名為 Ib。
研究人員警告說，卡米圖加「高度流動」的礦工和性工作者群體很容易將這種疾病廣泛傳播：「我們主張地區性流行的國家和國際社會迅速採取行動，以避免另一場全球性mpox疫情爆發。
兩年前，當另一種 MPOX 病毒株（進化枝 IIb）從奈及利亞傳播到歐洲的 MSM 社區時（首次在同性戀節日上流行），迅速採取的行動使其屈服。但卡米圖加並沒有發生這種情況。 「這就像在兩個不同的星球上爆發了兩次疫情」，比利時熱帶醫學研究所的臨床醫生勞倫斯·利森博格斯 (Laurens Liesenborghs) 說，他在該鎮工作並幫助領導這項研究工作。 「有一個機會之窗可以在其軌道上阻止這場疫情的爆發，但隨後沒有資金，也沒有引起關注」。
生病後，Jean Marie Magadju（右）離開了他工作的礦井，前往利維羅的這個治療中心尋求治療。中心的訪客可以隔著柵欄與病人交談。圖：阿萊特·巴什茲
豬、山羊和雞在卡米圖加綜合醫院的院內閒逛，該醫院建於 1935 年，正值比利時殖民時期，院內都是由庭院隔開的單層建築。病人自己洗衣服，然後鋪在醫院草坪上或掛在樹上晾乾。沒有正常運作的廚房，因此家庭為住院的親屬提供食物。但在大型設施的後方，可以欣賞到鬱鬱蔥蔥的 Mitumba 山脈的壯麗景色，是一個最先進的 MPOX 治療中心。該中心由國際醫療行動聯盟 (ALIMA) 於 7 月開設，這是一個總部位於巴黎的組織，其營運總部位於塞內加爾，主要由非洲人經營。當時，醫院的五名護士感染了mpox。
如今，工作人員在探訪疑似MPOX患者之前必須佩戴口罩、長袍、手套、髮網和鞋套，這些患者被安置在一個帶有私人房間的臨時塑膠小屋中。 INRB 營運的一家醫院實驗室擁有一台 GeneXpert 機器，這是一種對使用者友善的方便攜帶式設備，可以運行聚合酶鍊式反應來檢測傷口或血液樣本中的病毒 DNA，這一過程只需幾個小時。
如果患者檢測呈陽性，他們將被隔離在另一個有磚房和大帳篷的區域，在那裡他們接受膳食和治療。外展工作人員試圖識別患者的接觸者以檢查他們的健康狀況，但這可能很困難，特別是當傳播涉及性行為時。 《科學》雜誌訪問時，兩名男性患者都是礦工，主要患有生殖器病變，但他們堅稱自己已經幾個月沒有發生性行為。該中心的一名醫生格蕾絲·卡米弗拉 (Grace Kamifula) 表示，這種情況並不少見。 「男人們都很害羞，這是道德問題，」他說。 「大約 80% 的人從未說出自己如何感染 MPOX 的真相」。
在該中心接受治療的患者很少死亡。 「自開業以來，我們已經照顧了 300 名病人，僅兩人去世」，ALIMA 該中心的首席醫生之一 Fiston Nepa 說。 Kamituga 研究小組在medRxiv 上發布了一項針對該醫院5 月至10 月期間收治的427 例確診病例的研究，結果顯示死亡率為0.5%，遠低於過去剛果民主共和國疫情爆發時的3% 至10%。 （這些數字不包括四次流產。）
在戈馬綜合醫院翼樓內的mpox治療中心，一名患者的手、前臂和背部都出現了病變。白色氧化鋅可保護病變部位免受真菌或細菌感染並促進癒合。這名女士是公司高階主管，要求匿名。
圖：阿萊特·巴什茲
到了 11 月，卡米圖加的疫情似乎正在減弱，其特徵也發生變化。 「以前，有很多mpox病例是透過性接觸感染的」，負責該實驗室的 INRB 流行病學家 Guy Mukari 說。現在，許多性工作者已經從中康復，有些人已經接種了疫苗。但受感染的成年人已將病毒傳播給了他們的孩子。該病房裡的大多數患者都是嬰兒，並與接種了疫苗的母親共用床位。一名接受治療的性工作者說在她來到中心之前，她並不知道一直都有疫苗。
卡米圖加的治療中心設備齊全，人員齊全。南北基伍省的許多其他中心卻並非如此，其中包括位於距離布卡武 45 公里的農業城鎮利維羅 (Lwiro) 的一個中心，自 8 月開業以來已收治了 870 名患者。這裡的診斷很困難，因為中心沒有 GeneXpert 機器；該中心的負責人阿爾弗雷德·比西姆瓦 (Alfred Bisimwa) 表示，該中心依賴布卡武的一個實驗室，結果可能會很慢才能到達。 「有時我們會在病人離開後才能得到結果」。 （降低檢測成本可能會有所幫助。支持者正在向機器生產商Cepheid 施壓，將檢測盒的價格從20 美元降至5 美元）。疑似病例被安置在一起，這意味著沒有MPOX 的人可能會在等待診斷時被感染。 「這令人沮喪，」比西姆瓦說。
床位、毯子和食物的短缺已經有所緩解，但該中心的抗生素、輸血用血液和氧氣仍然經常耗盡，而且晚上也沒有電力。比西姆瓦說：「我們已經習慣了失去病人，但當你知道如果有足夠的資源就可以拯救他們時，情況就不一樣了」。他補充說，工作人員的工資過低，而且工作過度。「在那些時刻，很難激勵自己回去工作」。
儘管如此，在男子的帳篷裡的氣氛仍然是一種宿舍友情。有些人坐在外面，隔著柵欄與遊客聊天。一名 40 歲的礦工接住朋友從另一邊扔來的一疊鈔票。他不斷地抓撓臉上、軀幹、手臂和腳上的 100 多個傷口。 「我聽說它可以透過性行為傳播，但我和這裡其他男人的不同之處在於我的生殖器上沒有這種病毒，」他說。如果他的腹股溝受到影響，他不知道自己怎麼能從他工作的礦坑騎長途摩托車到利維羅。
在卡米圖加這座擁有近 25 萬人口的城市，一名護士騎著摩托車正在運送 11 月僅有的幾劑mpox疫苗。 圖：阿萊特·巴什茲
ALIMA 營運的另一個治療中心位於戈馬郊區之魯薩約的境內流離失所者營地當中，該營地收容了 8 萬多名逃離北基伍叛亂分子入侵的人。營地由擁擠且間隔緊密的帳篷組成，即使沒有性接觸，也是mpox病毒在人與人之間傳播的好地方。在該中心，10 名疑似患有mpox的兒童被安置在單獨大帳篷裡。
兩天前採集的樣本的結果剛從戈馬的 INRB 實驗室回來。讓–克洛德·恩達安巴傑 (Jean-Claude Ndayambaje) 護士說道，其中兩個孩子的檢測結果呈陽性，他進入帳篷尋找他們。他空手而歸。 「確診病例又回到了社區」，恩達安巴傑說。 「我們的一些病例，當他們感覺好些時，他們就會逃跑」。
疫苗是剛果民主共和國遏制努力的基石。復活天花疫苗是不可能的，因為它可能會導致嚴重的副作用，尤其是對免疫系統受損的人。相反，該國依賴丹麥巴伐利亞北歐公司生產的一種名為安卡拉改良牛痘（MVA）的MPOX疫苗。政府的計畫是首先給病例接觸者注射疫苗，在他們周圍建立免疫「環」。該計畫還針對性工作者、他們的顧客和醫護人員。
一天清晨，在卡米圖加(Kamituga) 的卡林吉(Kalingi) 社區，一隊外展工作人員正在木屋之間穿行，為5 名年齡在24 歲至64 歲之間的男性和女性採集健康史，這些人曾與一名mpox患者（一名妻子和一名兒子）和一個鄰居有密切接觸。然後，一名護士氣急敗壞地騎上摩托車，肩上挎著一個裝有mpox疫苗的冷藏箱。所有人都毫不猶豫地同意接受注射。理想情況下，他們將在一個月後接種第二劑。
在卡米圖加 (Kamituga) 附近的卡林吉 (Kalingi)，迪達斯·巴瓦托 (Didas Bwato)（右）正在為一名婦女接種mpox疫苗。她是卡林吉今天早上接受注射的少數人之一，因為他們接觸過確診病例。
圖：阿萊特·巴什茲
卡米圖加衛生工作者也與性工作者的「太后」合作，她在家裡經營一家客廳，婦女和嫖客在這裡分享啤酒、閒聊，並讓她解決糾紛。 「當我們開始推廣疫苗時，很多人認為疫苗會殺死他們，但因為我是領導者，也是第一個接種疫苗的人，所以每個人都開始相信它，」這位女士說。
但該市的疫苗劑量太少，無法嚴重遏止疫情。直到最近，剛果民主共和國資金短缺的政府還認為mpox病例太罕見，而且致命性不夠，不足以保證購買和接種疫苗。即使男男性接觸者的全球爆發也沒有改變這個想法。 2023 年初，美國國際開發署 (USAID) 希望發送 50,000 劑 MVA，當時該疫苗已在其他國家的 MSM 中廣泛使用。但政府並不急於接受它們，捐贈工作陷入停滯。 「他們不相信MPOX是一個非常大的問題」，INRB 病毒學家 Steve Ahuka 說。「別忘了，我們從 1970 年起就已經有了這種疾病」。
即使在今天，事情進展緩慢。剛果民主共和國監管機構直到 6 月才批准用於治療 MPOX 的 MVA（在美國食品和藥物管理局批准後 5 年），並且第一批捐贈直到 9 月才到達。到 10 月疫苗接種開始時，這個擁有 1.1 億人口的國家只有 265,000 劑疫苗，由美國國際開發署、歐盟和巴伐利亞北歐捐贈。
卡米圖加有近 25 萬人，最初接受了 6,300 劑疫苗。但鑑於其他地方出現短缺，政府決定收回一半的庫存，並只給每個人兩劑中的一劑。 「看起來疫苗有腿，可以走開」，尼帕說。綜合醫院的一個小冰箱裡保存著剩餘的 800 劑藥物。 Nepa 的老闆 Dally Muamba 說，就連醫護人員也沒有接受第二劑疫苗。這 觸動了他的心，「他們為什麼這麼做？」，穆安巴問道。「 這是一個大問題」。
事實證明，分配可用劑量非常困難。剛果民主共和國一片混亂，城市交通擁堵，城市之間的航班很少。許多道路沒有鋪砌，非常狹窄，只允許摩托車通行，而雨水會把它們變成泥潭。河裡的船很慢。根據衛生部的記錄，截至11 月28 日，僅使用了55,266 劑疫苗——「低於我們此時預期或希望看到的情況」，聯合國兒童基金會免疫副主任安德魯·瓊斯(Andrew Jones) 表示。
Mpox 首先在卡米圖加的性工作者及其客戶中站穩了腳跟，其中主要是在金礦工作的男性。一項mpox疫苗接種計畫稱，像這名離開礦坑主軸的男子這樣的礦工應該是第一批接受少數疫苗接種的人之一。 圖：阿萊特·巴什茲
18 歲以下的兒童如果感染 MPOX，死亡風險最高，但他們根本沒有接種疫苗。世衛組織和歐洲監管機構都表示，MVA 可以安全地給予兒童，但擔心如果發生傷害誰將承擔責任，加上監管障礙，推遲了其使用。
聯合國兒童基金會表示，11 月中旬，剛果民主共和國又收到了122,000 劑MVA 捐贈，還有64 萬劑「等待發貨」。並計畫與疫苗聯盟合作，為非洲國家再購買數百萬劑疫苗。日本已承諾捐贈略多於 300 萬劑的另一種疫苗 LC16m8，但官僚問題再次阻礙了運輸。 （LC16m8 是一種單劑量疫苗，會引起傷口並留下疤痕，一些專家擔心這可能會減少其採用，甚至導致人們迴避 MVA。）
所有捐款加起來都無法達到非洲疾病管制與預防中心為控制非洲大陸mpox疫情所設定的目標。其因應計畫要求到 2025 年 2 月分發 1,000 萬劑疫苗。
在金薩沙市中心的Vijana 醫院，一群人和幾名記者（包括一名日本電視台工作人員）聚集在該市的三個mpox治療中心之一，省衛生部長和聯合國兒童基金會官員將於今天上午訪問該中心。 Mpox 曾經是一種被忽視的疾病，如今已成為流行的傳染病。
「「我真的很驚訝金沙薩竟然出現了 MPOX，」負責該中心的醫生傑裡·范德姆 (Jerry Vandam) 說道。直到 2023 年，該市才爆發 MPOX 疫情。研究人員於 2023 年 8 月開始發現一些 Ia 分支的散發病例，Ia 分支是流行地區的長期病毒株。 該病毒中所謂的 APOBEC3 突變的數量（隨著病毒在人體內傳播而不斷累積）顯示當時幾乎沒有人與人之間的傳播。相反地，病毒反覆從動物身上傳播到人類身上。
但到了 7 月，病例開始上升，人際傳播現已成為金薩沙Ia 型和 Ib 型病例的唯一驅動因素。 Mbala 和同事在 11 月 16 日的預印本中寫道，今年到目前為止，該市已出現 1,200 多例疑似病例，其中大多數發生在「職業的性工作者密度很高」的地區。成人佔患者的80%。
卡米圖加MPOX治療中心的性工作者坐在蚊帳下。今年春季發布的一項研究發現，卡米圖加 29% 的 MPOX 患者是性工作者。 阿萊特·巴什茲
姆巴拉和他的同事在預印本中寫道，病毒在擁有 1,700 萬人口和繁忙國際機場的首都「對區域和國際傳播構成了重大威脅」。但在金薩沙，疫苗也供不應求。當地衛生部高級醫生 Emeryrodolphe Mungyengi 表示，迄今為止，該市 20 個衛生區中只有 1 個接受到了疫苗。「這是我們合作夥伴支持的問題」，Mungyengi 說。
為什麼mpox兩次從森林中爆發並引起重大流行病，部分是透過透過性接觸，一直困擾著研究人員。直到2022年MSM流行之前，有些人甚至懷疑它可以透過性行為傳播。 「這讓我徹夜難眠，」美國疾病管制與預防中心的安德里亞·麥科勒姆 (Andrea McCollum) 說道，她在剛果民主共和國研究mpox已有 15 年之久。 「為什麼是現在，為什麼在這兩個地方？」。
愛丁堡大學演化生物學家安德魯蘭伯特說，沒有證據顯示突變使病毒更具傳播性。相反，他認為它只是在短時間內進入了許多人擁有多個性伴侶的社區，足以引發流行病並維持快速傳播。 MSM 流行可以追溯到 2017 年在奈及利亞哈科特港爆發的疫情，哈科特港是一個石油和天然氣中心，吸引了許多地方的男性和性工作者。在卡米圖加和金薩沙，性工作也是一個驅動因素。
蒙彼利埃大學的病毒學家馬丁‧皮特斯 (Martine Peeters) 與阿胡卡(Ahuka) 一起在剛果尋找病毒儲存庫已有五年，她將mpox與愛滋病毒進行了比較，愛滋病毒也在非洲農村地區悶燒了數十年，然後到達同性戀社區並爆發。 「如果它在正確的時間到達正確的地點，就會成為一種流行病，」皮特斯說。
麥科勒姆說，在剛果民主共和國，森林砍伐、人類流動、城市發展、動物狩獵增加、營養不良和免疫力下降也可能導致了流行病的傳播。但是，她補充道，「老實說，我告訴人們我的水晶球壞了。我沒有預見到mpox會變成什麼樣子」。
也沒有人能夠預測接下來會發生什麼事。阿胡卡指出，如果南北基伍的遏制失敗，病毒很可能在那裡建立一個永久的人類宿主，這可能會給它一個進化的機會，並變得更具傳播性。 Rimoin 指出，它也可能導致新動物物種的儲存，就像 SARS-CoV-2 在 COVID-19 大流行期間在美國白尾鹿中建立的方式一樣。
儘管有許多障礙，有些人仍對剛果民主共和國能夠阻止MPOX疫情的蔓延抱持希望。尼帕說：「控制這種疾病很容易。」他相信，由於病例隔離、教育、已感染者的免疫力以及疫苗接種，卡米圖加的病例很快就會大幅下降。里莫安也很樂觀。 「我們當然可以減輕MPOX及其全球傳播的影響」，她說道。
卡米圖加的MPOX治療中心的一名護士正在為嬰兒的傷口塗抹消毒劑，孩子的母親多里卡·穆坦迪(Dorika Mutandi)則抱著她的頭。 阿萊特·巴什茲
但一些研究人員表示，因應措施不應僅限於大城市的疫情熱點地區。幾十年來一直被忽視的農村地區的地方性流行疾病死亡率更高，並且隨時可能引發另一場大的流行病。研究人員表示，透過集中針對地方流行地區的兒童，疫苗接種工作可能會挽救更多生命。耶魯大學流行病學家格雷格‧貢薩爾維斯 (Gregg Gonsalves)、里莫因 (Rimoin) 和姆巴拉 (Mbala) 在《刺胳針全球健康》 10 月發表的一篇論文中計算出，在一年內，為農村地區80% 的15 歲以下兒童接種疫苗將使剛果民主共和國病例減少54%，死亡人數減少71%。但這需要多達 2,660 萬劑。
阿胡卡發現了另一個問題。他說，國際社會動員起來幫助剛果民主共和國對抗mpox病毒「確實很棒」，但這是一把雙刃劍。 「支持我們照顧好自己，」阿胡卡說。 「如果長期支持，就會變成一種疾病，我們就會變得依賴。我們正在遭受這種痛苦」。他說，快速的病例發現、診斷和疫苗接種都是至關重要的。「剛果人現在應該將這些介入措施納入常規，因為mpox永遠不會結束」。
儘管眾所周知，mpox 會引起病變，但有些人（例如這個孩子）的症狀看起來更像是皮疹。兩者都經過消毒劑處理。 圖：阿萊特·巴什茲
系列相關照片
阿萊特·巴什茲 (Arlette Bashizi) 是一位屢獲殊榮的紀實攝影師和攝影記者，居住在剛果民主共和國，業務範圍涵蓋西非和東非。她關注健康、環境和文化議題，同時將婦女和青年置於工作的中心。
doi：10.1126/science.zax93iq
關於作者
喬恩·科恩
喬恩·科恩 (Jon Cohen) 是《科學》雜誌的資深記者，獲得加州大學聖地牙哥分校科學寫作學位。他專門研究生物醫學，專注於傳染病、流行病、免疫學、疫苗和全球健康。他在《紐約客》、《大西洋月刊》、《紐約時報雜誌》和《衝浪者雜誌》等其他媒體上廣泛發表文章，並撰寫了四本關於科學主題的非小說類書籍。科恩的文章曾兩度入選美國最佳科學與自然寫作選集（2008 年和 2011 年）。他的書籍和故事曾獲得美國國家科學院、美國科學作家協會、科學寫作促進委員會、美國微生物學會、美國熱帶醫學和衛生學會等機構的獎項。他因與他人共同創作了 PBS NewsHour 系列節目《愛滋病的終結？》，並因其在 HBO 的 COVID-19 疫苗紀錄片《如何在流行病中生存》中的角色而二次獲得艾美獎。
Congo’s mpox crisis
For the second time in 2 years, a long-overlooked virus poses a global threat. Can it be contained?
Jon Cohen / 9 Dec 2024
A version of this story appeared in Science, Vol 386, Issue 6728.Download PDF
This story was supported by the Pulitzer Center.
In late September 2023, a 33-year-old man who co-owned a bar in Kamituga, a remote mining city in the Democratic Republic of the Congo (DRC), developed lesions on his genitals and a fever. He first sought help from a doctor, who gave him an injection, and then from a traditional healer, who applied ointments and performed an enema. But the lesions kept spreading, eventually appearing on most of his body.
His relatives convinced the man to come to the family home in the city of Bukavu—a trip that takes 6 hours on a good day and twice as long during the rainy season, when much of the road turns to mud. Health workers there swabbed his lesions, and a lab in Kinshasa, the capital, confirmed the man had something rarely seen in that part of the DRC: mpox, a painful and occasionally fatal disease caused by a relative of the smallpox virus.
A January report from the Bukavu branch of the DRC’s Ministry of Public Health, obtained by Science, called this man the “index case”—the first known patient—in the epidemic of mpox now sweeping the country. The report said he fell ill after visiting Kisangani, a city a few provinces away. It did not explain how he might have become infected, but the genital lesions suggested it was through sexual contact.
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Eleven of the 98 people whom the bar owner was in contact with before leaving Kamituga also developed symptoms, the report says, and seven of them also “fled”—to Bukavu, a city of 1.3 million in South Kivu province, and on to Goma, the capital of North Kivu province, and neighboring Rwanda. In the months that followed, cases surfaced in all of those places, as well as in Burundi, Uganda, Kenya, and Zambia. The virus also made it across the DRC to Kinshasa and travelers took it to Thailand, Europe, and the Americas.
Science met the man, who asked not to be identified, in November. The infection had been horrendous, he said: “I felt like my genitals were going to fall off.” He initially thought someone might have put a curse on him, and, once he learned it was mpox, wondered whether it might be from his visit to the Kisangani zoo. It outraged him when people on social media criticized him by name for bringing the disease to Kamituga. “I felt offended and even wanted to sue,” he said. A child in Kamituga had mpox at the same time and could have been the real index case, he argued.
Regardless of his exact role in spreading the disease, Kamituga—where many of the first patients were miners and sex workers—has become the epicenter of the burgeoning epidemic, which the World Health Organization (WHO) in August labeled a Public Health Emergency of International Concern (PHEIC).
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The crisis came less than 2 years after the outbreak of another mpox variant that started in Nigeria and eventually sickened more than 100,000 people in 120 countries, most of them men who have sex with men (MSM). It, too, led WHO to declare a PHEIC, from July 2022 until May 2023, when vaccinations, education campaigns, and the buildup of immunity in people at high risk led the outbreak to subside.
The successive epidemics are a dramatic turn of events for what was long one of the most neglected viral diseases in the world.
Julienne Mwinja (left) feeds her son, who has a severe case of mpox, at the treatment center in Lwiro, Democratic Republic of the Congo. The center has struggled to find antibiotics and other desperately needed basic resources.Arlette Bashizi
Mpox is endemic in large parts of the DRC, but for the past 50 years, outbreaks mainly affected children in remote villages tucked into the rainforest in the western and central regions of the DRC, each time jumping from an animal “reservoir,” sometimes followed by limited transmission between people. The spread would typically burn out after a few months because the affected communities were small and relatively isolated.
The outbreak that began in Kamituga sparked something entirely new: an epidemic, with cases soaring in places that had never seen mpox before. Combined, endemic and epidemic spread in the DRC have caused more than 47,000 suspected cases in the first 11 months of the year, compared with only 14,626 in 2023.
Now, an aggressive effort is underway to bring the disease under control. Donors, working closely with WHO and UNICEF, have flown in hundreds of thousands of mpox vaccine doses. Aid groups and local clinics, funded largely by foreign governments and United Nations branches, have set up treatment centers where suspected patients can be tested and, if infected, kept in isolation for several weeks. “Mpox existe,” posters across the francophone country warn, encouraging people to seek care if they have fevers and the characteristic skin lesions.
From endemic to epidemic
Mpox has been endemic in the Democratic Republic of the Congo for decades. The virus occasionally jumped from wild animals to people, mainly children, sometimes followed by some human-to-human transmission. Since September 2023, however, the country has seen rapid epidemic spread between humans, as have neighboring Burundi and Uganda. (Rwanda, Kenya, and Zambia have reported smaller case numbers.)
Mpox starts spreading in neighboring countries.
(Graphic) V. Penney/Science; (Data) World Health Organization as of 1 December 2024
But a November visit by Science to the Kivus and Kinshasa revealed the challenges are enormous. There are far too few vaccine doses for the population at high risk, and their distribution throughout the country—more than half the size of the European Union—has been agonizingly slow. Children, who account for half the cases and are most at risk of severe disease and death, are not being vaccinated at all.
Diagnostics are scarce: Only 22% of suspected cases this year have been confirmed. People sometimes leave treatment centers before their test results are in, potentially exposing others. Hygiene and education efforts are spotty, and surveillance largely relies on people seeking care, rather than on teams actively hunting for cases.
Several government agencies are involved in the response, sometimes creating confusion about who is in charge. “It’s really crazy to see what is happening,” says Placide Mbala, an epidemiologist and veteran mpox researcher at the National Institute of Biomedical Research (INRB) in Kinshasa, who co-led a team studying the outbreak in Kamituga. “Sometimes when you go to meetings, you are working with people who believe that they know better than you what to do. They are trying to copy and paste what they learned from books.”
Whether the DRC can get mpox under control is a pivotal question for both the country and the world. If not, it will become a permanent additional stress on the country’s fragile heath system. And exported cases will pose a continual threat to other countries.
Mbala thinks the spread can at least be dramatically slowed, just as the earlier, global epidemic in MSM was. “We know where the disease is more prevalent and where we are seeing more human-to-human transmission,” he says. “It would be easy in those places to set up good surveillance and good diagnostics, and very quickly, we can stop this disease. … It’s just a matter of willingness and money.”
Mpox has rapidly spread through the Rusayo camp for internally displaced people, built in the foothills of the Nyiragongo volcano near Goma, Democratic Republic of the Congo.Arlette Bashizi
The mpox virus was discovered in 1958, far from Africa, when Asian monkeys in a Copenhagen lab became ill. Scientists isolated the virus and named the disease “monkeypox,” a misnomer: African squirrels and other rodents are the likely “reservoir host” of the virus. The lab monkeys presumably got infected because international animal traders caged several species together. (The name was changed to mpox in 2022 to avoid stigma.)
The first human case did not surface until August 1970: a 9-month-old boy from the DRC’s Équateur province, which is still an mpox hot spot. Doctors initially thought his lesions were caused by smallpox and sent samples to a Moscow lab, which correctly diagnosed the disease. The boy recovered but died of measles before leaving the hospital.
Investigators noted that in contrast with his parents and 10 siblings, who did not get mpox, the boy was not vaccinated against smallpox. They guessed immunity to smallpox protected against mpox as well—a hunch that would prove correct. After smallpox was declared eradicated in 1980, vaccinations ended worldwide and mpox reports began to increase. (There had only been 59 cases in all of Africa until then, 80% of them in the DRC.) In 1996–97, a startling outbreak near the town of Katako-Kombe had 511 suspected cases, most of them due to human-to-human transmission.
Once researchers started to actively look for cases, they realized mpox was far more widespread than believed. In a landmark 2010 study, a team led by then–INRB Director Jean-Jacques Muyembe and epidemiologist Anne Rimoin of the University of California, Los Angeles reported finding 760 cases over a 2-year period in Katako-Kombe and eight neighboring health zones. “It was putting the cards on the table and saying, ‘Hey, listen, this is a problem,’” Rimoin says.
Still, mpox was rare, most people recovered, and mild cases were easily mistaken for chickenpox, so doctors often ignored it. And the DRC had many more pressing health problems, including measles, cholera, tuberculosis, and malaria. “It’s unfair to say, well, we all knew an epidemic was going to happen, and you guys didn’t do anything about it,” Rimoin says.
Virus on the move
Since the world’s first mpox case was found in Équateur province in 1970, the Democratic Republic of the Congo (DRC) has seen more cases than any other country. Until recently, most were of a variant named clade Ia, but during the past 15 months clade Ib has exploded in the eastern part of the country—which never saw an mpox outbreak before—and has spilled over to the DRC’s neighbors.
(Graphic) M. Hersher/Science; (Data) World Health Organization as of 1 December 2024
Then came the Kamituga outbreak, described in an April preprint by a large, international team of researchers that included Mbala, Rimoin, and Muyembe. (Nature Medicine published the paper online in June.) During the first 5 months of the epidemic, the study found, 29% of the 108 confirmed cases were sex workers. Genetic sequencing revealed the virus was distinct from the variant in endemic regions, clade I, so that was renamed Ia, while the lineage circulating in Kamituga—which had been found in two patients more than a decade earlier—was christened Ib.
Kamituga’s “highly mobile” population of miners and sex workers could easily spread the disease far and wide, the researchers warned: “We advocate for swift action by endemic countries and the international community to avert another global mpox outbreak.”
When a different mpox variant, clade IIb, spread from Nigeria to MSM communities in Europe 2 years ago—first taking off at a gay festival—swift action brought it to heel. That did not happen in Kamituga. “It’s like two outbreaks on two different planets,” says Laurens Liesenborghs, a clinician based at Belgium’s Institute of Tropical Medicine who works in the town and helps lead the research effort. “There was a window of opportunity to stop this outbreak in its tracks, but then there was no money, there was no attention.”
After he fell ill, Jean Marie Magadju (right) left the mine where he was working and sought care at this treatment center in Lwiro. Visitors at the center can talk to patients through a fence.Arlette Bashizi
Pigs, goats, and chickens roam the grounds of the Kamituga general hospital, a campus of one-story buildings separated by courtyards that was built in 1935, during the Belgian colonial era. Patients wash their own laundry and sprawl it across hospital lawns or hang it from the trees to dry. No functioning kitchen exists, so families provide food for hospitalized relatives. But in the rear of the large facility, which features a glorious view of the lush Mitumba mountain range, is a state-of-the-art mpox treatment center. It was opened in July by the Alliance for International Medical Action (ALIMA), a Paris-based group that has its operational headquarters in Senegal and is largely run by Africans. At that point, five nurses at the hospital had contracted mpox.
Today, staff are required to wear masks, gowns, gloves, hair nets, and shoe coverings before they visit patients with suspected mpox, who are housed in a makeshift plastic hut with private rooms. A hospital lab run by INRB has a GeneXpert machine, a user-friendly portable device that can run the polymerase chain reaction to detect viral DNA in lesions or blood samples—a process that only takes a few hours.
If patients test positive, they are isolated in a different area that has brick buildings and a large tent, where they receive meals and treatment. Outreach workers try to identify patients’ contacts to check their health, but that can be difficult, especially when transmission involved sex. When Science visited, two male patients, both miners, mainly had genital lesions, but they insisted they had not had sex for months. That’s not uncommon, says Grace Kamifula, one of the center’s doctors. “The men are shy and it’s about morality,” he says. “About 80% of them never say the truth about how they contracted mpox.”
Few patients treated at the center have died. “Since we’ve opened, we’ve taken care of 300 sick people and lost only two,” says Fiston Nepa, one of ALIMA’s lead doctors at the center. A study of 427 confirmed cases seen at the hospital between May and October, posted on medRxiv by the Kamituga research team, put the mortality rate at 0.5%—much lower than the 3% to 10% seen in past DRC outbreaks. (The figures do not include four pregnancy losses.)
Lesions cover the hands, forearms, and back of a patient at the mpox treatment center inside a wing of the general hospital in Goma. The white zinc oxide protects the lesions from fungal or bacterial infections and promotes healing. The woman, a company executive, asked not to be identified. Arlette Bashizi
By November the outbreak in Kamituga appeared to be waning, and its character had shifted. “Before, there were many cases that were infected through sexual contact,” says INRB epidemiologist Guy Mukari, who runs the lab here. Now, many sex workers have recovered from mpox, and some have been vaccinated. But infected adults have spread the virus to their children. Most patients in the unit were babies, sharing beds with their mothers, who had been vaccinated. The one sex worker receiving treatment says she didn’t know there was a vaccine until she came to the center.
Kamituga’s treatment center is well equipped and staffed. Not so in many other centers in the Kivus, including one in Lwiro, an agricultural town 45 kilometers from Bukavu that has seen 870 patients since it opened in August. Diagnoses are difficult here because the center does not have a GeneXpert machine; it relies on a lab in Bukavu, and results can be slow to arrive, says Alfred Bisimwa, the doctor running the center. “Sometimes we get results back after patients have left.” (Lowering the cost of testing might help. Advocates are pressing Cepheid, the producer of the machines, to drop the price of testing cartridges from $20 to $5.) And suspected cases are housed together, which means people without mpox could become infected while they wait for a diagnosis. “It’s frustrating,” Bisimwa says.
Shortages of beds, blankets, and food have let up, but the center still regularly runs out of antibiotics, blood for transfusions, and oxygen, and there’s no electricity at night. “We’re used to losing patients, but it’s different when you know you could have saved them if you had enough resources,” Bisimwa says, adding that the staff are underpaid and overworked. “And in those moments, it’s difficult to motivate ourselves to go back to work.”
Still, the mood in the men’s tent is one of dormitory camaraderie. Some sit outside and chat with visitors through a fence. One 40-year-old miner catches a wad of bills that a friend throws in from the other side. He’s constantly scratching the more than 100 lesions on his face, torso, arms, and feet. “I heard that it can be transmitted through sex, but the difference between me and the other men here is I don’t have it on my genitals,” he says. Had his groin been affected, he doesn’t see how he could have made the long motorbike ride from the mine where he works to Lwiro.
In Kamituga, a city of nearly a quarter of a million people, one nurse on a motorbike is delivering the few available mpox vaccine doses in November. Arlette Bashizi
Yet another ALIMA-run treatment center is in the Rusayo internal displacement camp, in the outskirts of Goma, which houses more than 80,000 people who fled rebel incursions in North Kivu. The camp consists of crowded, closely spaced tents, a good place for mpox to spread between people even without sexual contact. At the center, 10 children suspected of having mpox are housed in a single large tent.
Results from samples taken 2 days earlier have just come back from an INRB lab in Goma. Two of the children are positive, says nurse Jean-Claude Ndayambaje, and he enters the tent to find them. He comes back empty-handed. “The confirmed cases are back in the community,” Ndayambaje says. “Some of our cases, they run away when they feel better.”
Vaccines are a cornerstone of the DRC’s containment efforts. Resurrecting the smallpox vaccine is out of the question because it can cause serious side effects, especially in people who have compromised immune systems. Instead, the country relies on an mpox vaccine called modified vaccinia Ankara (MVA), produced by the Danish company Bavarian Nordic. The government’s plan is to give shots first to contacts of cases, creating “rings” of immunization around them. The plan also targets sex workers, their clients, and health care personnel.
Early one morning in Kalingi, a neighborhood in Kamituga, a team of outreach workers is moving between wood shacks, taking health histories from five men and women ages 24 to 64 who had come in close contact with an mpox patient—a wife, a son, and a neighbor. Then, a nurse sputters up on a motorbike, a cooler containing mpox vaccine slung over his shoulder. All agree without hesitation to receive a shot. Ideally, they’ll get a second dose a month later.
In Kalingi, a neighborhood of Kamituga, Didas Bwato (right) is vaccinating a woman against mpox. She was one of a handful of people in Kalingi to receive a shot this morning because they had come in contact with confirmed cases. Arlette Bashizi
Kamituga health workers have also teamed up with the “queen mother” of sex workers, who runs something of a parlor in her home where women and clients share beers and gossip and bring her disputes to resolve. “When we started promoting the vaccine, many people thought it would kill them, but because I was the leader and the first to take it, everyone started to believe in it,” the woman says.
But the city has too few doses to make a serious dent in its epidemic. Until recently, the DRC’s cash-strapped government deemed mpox far too rare, and not nearly lethal enough, to warrant buying and administering vaccines. Even the global outbreak in MSM didn’t change that calculus. In early 2023, the U.S. Agency for International Development (USAID) wanted to send 50,000 doses of MVA, then already widely in use among MSM in other countries. But the government was not eager to take them, and the donation stalled. “They didn’t believe mpox is a very big problem,” says INRB virologist Steve Ahuka. “Don’t forget that we have had this disease since 1970.”
Even today, things are moving slowly. DRC regulators did not approve MVA for mpox until June—5 years after the U.S. Food and Drug Administration did so—and the first donations did not arrive until September. By October, when vaccinations began, the country of 110 million people only had 265,000 doses, donated by USAID, the EU, and Bavarian Nordic.
Kamituga, with almost a quarter-million people, at first received 6300 doses. But given shortages elsewhere, the government decided to take half that stock back and give everyone just one of the two doses. “It seemed like the vaccine had legs and walked away,” Nepa says. A small freezer at the general hospital holds the 800 remaining doses. Even health care workers have not received a second dose, says Nepa’s boss, Dally Muamba. “Why did they do that?” Muamba asks, touching his heart. “That’s a big question.”
Distributing the available doses is proving hard. The DRC is chaotic, with gridlocked traffic in its cities and few flights between them. Many roads are unpaved and so narrow they only allow passage by motorbike—and rain can turn them into quagmires. River boats are slow. As of 28 November, only 55,266 vaccine doses had been used, according to Health Ministry records—“behind what we would have expected or wanted to see at this point,” says Andrew Jones, deputy director of immunization at UNICEF, which plays a central role in procuring and delivering mpox vaccine to the DRC.
Mpox first got a foothold in Kamituga among sex workers and their clients, mainly men who work at gold mines such as this one. An mpox vaccination plan says miners, like this man exiting the main shaft, should be among the first in line to receive the few shots available. Arlette Bashizi
Children under age 18, who are most at risk of dying if they get mpox, are not getting vaccinated at all. WHO and European regulators both have said MVA can safely be given to children but concerns about who will assume liability if harm occurs, along with regulatory hurdles, have delayed its use.
In mid-November the DRC received another donation of 122,000 doses of MVA, and 640,000 more are “awaiting shipment,” says UNICEF, which has plans to purchase millions more doses for African countries in collaboration with Gavi, the Vaccine Alliance. Japan has promised to donate just over 3 million doses of another vaccine, LC16m8, but again, bureaucratic issues have hampered shipment. (LC16m8, a one-dose vaccine, causes a lesion that leaves a scar, which some experts worry could reduce its uptake and even lead people to shun MVA as well.)
All of the donations combined won’t meet goals set by the Africa Centres for Disease Control and Prevention to control the mpox outbreak on the continent. Its response plan calls for 10 million doses to be distributed by February 2025. For the DRC, that would be a massive increase from current numbers, and a dramatic scale-up of the distribution effort.
At the Vijana hospital in downtown Kinshasa, a crowd and several journalists—including a Japanese TV crew—have gathered at one of the city’s three mpox treatment centers, where the provincial health minister and UNICEF officials will make a visit this morning. Mpox, once a neglected disease, has become the infection du jour.
“I’m really astonished that mpox is in Kinshasa,” says Jerry Vandam, the doctor running the center. The city never had an mpox outbreak until 2023. Researchers began to detect a few sporadic cases of clade Ia, the longtime variant in endemic regions, in August 2023. The number of so-called APOBEC3 mutations in the virus—which accumulate as it circulates in people—showed there was little human-to-human transmission at the time. Instead, the virus popped into humans from animals repeatedly.
But in July, cases started to rise, and human-to-human transmission has now become the sole driver of both Ia and Ib in Kinshasa. So far this year, the city has had more than 1200 suspected cases, most of them in an area that has “a high density of professional sex workers,” Mbala and coworkers wrote in a 16 November preprint. Adults made up 80% of the patients.
A sex worker at the mpox treatment center in Kamituga sits under a mosquito net. A study released in the spring found 29% of mpox patients in Kamituga were sex workers. Arlette Bashizi
The presence of the virus in the capital—with 17 million people and a busy international airport—“represents a significant threat for regional and international dissemination,” Mbala and his co-workers wrote in the preprint. But in Kinshasa, too, vaccine is in short supply. Only one of the city’s 20 health areas has received doses to date, says Emeryrodolphe Mungyengi, the top doctor for the local health ministry. “It’s a question of support from our partners,” Mungyengi says.
Why mpox has twice burst out of the forest to cause major epidemics, in part through sexual contact, has perplexed researchers. Until the 2022 epidemic in MSM, some even doubted it could be spread through sex. “This is what keeps me up at night,” says Andrea McCollum of the U.S. Centers for Disease Control and Prevention, who has studied mpox in the DRC for 15 years. “Why now, and why in these two places?”
There is no evidence that mutations have made the virus more transmissible, says Andrew Rambaut, an evolutionary biologist at the University of Edinburgh. Instead, he thinks it simply found its way into communities where many people have multiple sexual partners in a short time frame—enough to spark an epidemic and sustain rapid spread. The MSM epidemic traces back to a Nigerian outbreak that started in 2017 in Port Harcourt, an oil and natural gas hub that attracts men from many places and sex workers. In Kamituga and Kinshasa, sex work has been a driver as well.
Martine Peeters, a virologist at the University of Montpellier who has hunted for viral reservoirs in the DRC for 5 years with Ahuka, compares mpox to HIV, which also smoldered in rural Africa for decades before reaching the gay community and exploding. “If it arrives at the right time at the right place, it becomes an epidemic,” Peeters says.
In the DRC, deforestation, human movement, the growth of cities, increased hunting of animals, malnutrition, and decreasing immunity may have all contributed to epidemic spread as well, McCollum says. But, she adds, “I’ll be honest with you, I tell people my crystal ball is broken. I did not foresee what has become of mpox.”
Nor can anyone predict what comes next. If containment fails in the Kivus, the virus may well establish a permanent human reservoir there, Ahuka notes, which could give it a chance to evolve and become even more transmissible. It could also lead to reservoirs in new animal species, Rimoin notes, the way SARS-CoV-2 established itself in white-tailed deer in the United States during the COVID-19 pandemic.
Despite the many obstacles, some are hopeful the DRC can stop the epidemic spread of mpox. “It’s easy to contain the disease,” says Nepa, who believes that Kamituga will soon see cases plummet, thanks to the isolation of cases, education, immunity in people already infected, and vaccination. Rimoin is optimistic, too. “We can certainly mitigate the impact of mpox and the global spread,” she says.
A nurse at the mpox treatment center in Kamituga applies a disinfectant to a baby’s lesions as the child’s mother, Dorika Mutandi, cradles her head. Arlette Bashizi
But some researchers say the response should not be limited to the epidemic hot spots in big cities. The rural pockets of endemic disease that have been neglected for decades have higher mortality rates and could always ignite another epidemic. Vaccination efforts might save more lives by concentrating on children in endemic areas, researchers say. In an October paper in The Lancet Global Health, Yale University epidemiologist Gregg Gonsalves, Rimoin, and Mbala calculated that over a 1-year period, vaccinating 80% of children under age 15 in rural areas would decrease DRC cases by 54% and deaths by 71%. But it would take a whopping 26.6 million doses.
Ahuka sees another problem. The international mobilization to help the DRC battle mpox is “really great,” he says, but it’s a double-edged sword. “Support us to take care of ourselves,” Ahuka says. “If support is long-standing, it becomes a disease, we become dependent. And we’re suffering from that.” Rapid case finding, diagnostics, and vaccination are all essential, he says. “The Congolese should now integrate these interventions as routine, because mpox will never end.”
Although mpox is well known for causing lesions, some people, like this child, have what appears to be more like a rash. Both are treated with disinfectant. Arlette Bashizi
Relacted Photography
doi: 10.1126/science.zax93iq
About the author
Jon Cohen
Jon Cohen, senior correspondent with Science, earned his B.A. in science writing from the University of California, San Diego. He specializes in covering biomedicine with a focus on infectious diseases, epidemics, immunology, vaccines, and global health. He has published widely in other outlets, including The New Yorker, The Atlantic, The New York Times Magazine, and Surfer’s Journal—as well as written four nonfiction books on scientific topics. Cohen’s articles have twice been selected for The Best American Science and Nature Writing anthology (2008 and 2011). His books and stories have won awards from the National Academy of Sciences, the National Association of Science Writers, the Council for the Advancement of Science Writing, the American Society for Microbiology, the American Society of Tropical Medicine and Hygiene, and others. He won a National Emmy for the “The End of AIDS?” PBS NewsHour series he co-created, and a second Emmy for his role in the HBO COVID-19 vaccine documentary How to Survive a Pandemic.