The Emergence of a Deadly Mpox Virus Outbreak in the Democratic Republic of Congo’s (DRC) South Kivu Province: Urgent Need for Diagnostic Testing Capacity to Protect Vulnerable Children


The outbreak of mpox virus (MPXV) clade I in the Democratic Republic of Congo’s (DRC) South Kivu province has intensified, raising concerns due to its evolving transmission routes and devastating impact on children. Despite efforts to contain the outbreak, the lack of comprehensive diagnostic testing capacity poses significant challenges, hindering both understanding and response efforts.

First identified in 1970, MPXV has historically afflicted the DRC, predominantly in its deadliest form, clade I. However, recent observations reveal a concerning shift in transmission dynamics, with heterosexual contact and close community interactions emerging as new routes of transmission. Children, in particular, constitute the majority of cases and fatalities, underscoring the urgent need for targeted interventions.

The limited diagnostic resources in the DRC have impeded disease verification, with only 16% of suspected cases undergoing PCR testing. This testing shortfall has resulted in a high positivity rate of 60%, indicating a potential underestimation of the outbreak’s magnitude. From 2022 to January 2024, the country reported a staggering 21,630 suspected MPXV cases and 1,003 deaths, with children under 15 years old accounting for approximately 85% of fatalities.

Closing the gap between suspected and confirmed cases is paramount to deploying precise response strategies and halting the spread of MPXV. Enhanced surveillance measures and expanded testing access are critical to gaining a comprehensive understanding of the outbreak’s scope and implementing targeted interventions effectively.

Dr. Ayoade Alakija, Chair of the Board at FIND, highlights the alarming situation in the DRC, emphasizing the need for urgent mobilization of resources to combat the outbreak. Without adequate testing for both MPXV and HIV, understanding the severity and underlying comorbidities remains obscured. Dr. Sergio Carmona, acting CEO and Chief Medical Officer at FIND, underscores the urgent need to address testing capacity deficiencies and develop rapid diagnostic tools for point-of-care use.

The global response to the MPXV outbreak requires concerted efforts to prioritize the affected regions, enhance surveillance, and ensure equitable access to vaccines, diagnostics, and treatments. Failure to address the outbreak promptly risks not only exacerbating the humanitarian crisis in the DRC but also facilitating the spread of the virus to other countries.

The Intricacies of Human Mpox Disease: An Overview

Human mpox disease, previously known as monkeypox, presents a significant challenge to global health due to its zoonotic origins and clinical similarities to the eradicated smallpox virus. This detailed exploration delves into the origins, transmission routes, clinical manifestations, and the evolving nature of the mpox virus (MPXV), aiming to provide a comprehensive understanding of its impact on human health.

The Virology of MPXV

The mpox virus, a member of the Orthopoxvirus genus within the Poxviridae family, is characterized by its double-stranded DNA genome. Clinically, mpox mimics the manifestations of smallpox, including symptoms such as rash, fever, chills, fatigue, and sore throat, although it represents a distinct clinical entity that has been observed increasingly since smallpox was eradicated in 1977. The mpox virus was first identified in 1958 following an outbreak among macaque monkeys in Copenhagen, Denmark, a discovery that preceded the first recorded human case in the Democratic Republic of Congo (DRC) in 1970.

Over the years, sporadic outbreaks, primarily in West and Central Africa, have underscored the virus’s endemic nature in these regions. However, the mpox virus has exhibited a capacity to cause outbreaks beyond these endemic areas, as seen in the multi-country outbreak of 2022. The genetic structure of MPXV has been divided into two primary clades: Clade I, associated with the Congo Basin, and Clade II, linked to West Africa. These clades, while sharing a high degree of nucleotide sequence similarity, demonstrate significant differences in virulence and clinical outcomes.

Clinical Manifestations and Public Health Implications

MPXV infection can lead to severe disease outcomes, particularly in individuals with underlying health conditions such as HIV infection, uncontrolled diabetes mellitus, and organ transplant recipients. The virus also poses a higher risk to certain demographic groups, including men who have sex with men (MSM), highlighting the importance of understanding and addressing the multifaceted nature of mpox transmission and impact.

The global health community has also observed mpox outbreaks amidst the COVID-19 pandemic, raising concerns about co-infections with MPXV and SARS-CoV-2 and their potential implications. Despite limited data, cases of co-infection have been reported, underscoring the need for further research to understand the synergistic effects of these viruses.

Transmission Dynamics

Mpox transmission primarily occurs through two classical routes: zoonotic transmission from rodents and small mammals, and human-to-human transmission. Clade I mpox has been noted for its minimal human-to-human spread but significant mortality rate, while Clade IIb has been implicated in the recent global outbreaks, primarily transmitted through sexual contact and resulting in distinctive genital and anorectal lesions.

An observational cohort study in Kamituga, South Kivu province (DRC), proposes a third route of MPXV transmission, documenting heterosexual transmission among professional sex workers and suggesting sustained community-level transmission driven by a novel Clade I mpox strain. This finding indicates the evolving nature of mpox transmission dynamics and underscores the importance of continuous surveillance and research to adapt public health responses effectively.


Human mpox disease remains a complex public health challenge, with its zoonotic origins, clinical similarities to smallpox, and evolving transmission patterns necessitating a multifaceted approach to surveillance, research, and intervention. Understanding the nuances of MPXV’s virology, clinical manifestations, and transmission dynamics is crucial for developing targeted strategies to mitigate its impact on global health.

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