Mpox: What is it and what is Uganda doing to prevent it?

__________

On July 24, Uganda confirmed two cases of mpox in Mpondwe-Bwera metropolitan area in Kasese district at the border with the Democratic Republic of Congo (DRC).

The virus was detected in two women, one a 22-year-old pregnant Congolese woman who was seeking antenatal at Bwera hospital.

And the other a 37-year-old market vendor and salon owner married to a Congolese man, a first-time mpox is being confirmed in Uganda.

“The two women have since been treated and are now fine,” Dr. Henry Kyobe, the mpox incident commander in the Ministry of Health reveals.

Ever since no new cases linked to the two women have been confirmed. To date, 42 samples have been collected from suspected cases, and sent to the Uganda Virus Research Institute (UVRI) for PCR testing and all have tested negative.

However, cases of mpox continue to rise in the DRC where the two women are suspected to have been infected. And just like Uganda, three other Eastern African countries Burundi, Rwanda, and Kenya have all reported their first mpox cases.

In the entire Africa 16 countries have in recent months reported an increase in mpox cases and in the past month 26 countries have reported at least one confirmed case of mpox.

“We see more countries in Africa getting cases,” says Kyobe. Two in Uganda.
On Wednesday, August 14, 2024, the World Health Organisation (WHO) declared the mpox outbreaks a public health emergence of international concern.

Its Genesis

Mpox is an old disease seen over 60 years ago. Reports show it was transferred from animals to human beings, and it was first detected in humans in the DRC in 1970.

“Mpox was initially endemic to central Africa especially DRC and West Africa, and potentially referred to as a neglected disease. It gained prominence in 2022 when there was an explosion of the disease.

“Now it is a major emerging disease on the continent and changing in the transmission dynamics,” Kyobe reveals.

He explains that mpox is largely a self-limiting disease in immune-competent individuals (it resolves naturally without treatment) but in the severely immune compromised, it causes severe diseases including death and disfigurement of individuals.

He adds that Mpox has a very long incubation period of up to two weeks, meaning that in this period someone is able to transmit the disease.

The surge

Globally as of January 1, 2022, there was a global outbreak of mpox, according to WHO.  Nigeria was the most affected country in the Africa region.

However, in total, there were 116 member states across all the six WHO regions globally reporting cases of the highly contagious disease -formerly known as monkeypox.

And as of June 30, 2022, globally close to 100,000 laboratories confirmed cases- with 535 probable cases and these included 208 fatalities that were reported to WHO.

“However, suspected cases and death related to mpox were not all reported to WHO because we were just focusing on confirmed cases,” Dr Mitchel Muteba, a Public Health Specialist, Epidemiologist and Lead-Emergency Preparedness and Response at WHO Africa reveals.

“And for Africa alone, in 2022, we had 1,232 lab-confirmed cases and 15 deaths that were confirmed by 10 countries and Nigeria was the most affected in terms of cases and death.

“In 2023, the same 10 countries reported 1,145 cases. But from 2022, we started seeing the DRC taking over and becoming the most affected country. They reported 84% of the cases and seven deaths that could be confirmed as related to mpox,” he reveals.

Muteba says this year, only the number of cases reported in the Africa region doubled compared to 2023, “and we are only halfway through the year.”

From 2022 to date, Africa has registered 4,496 confirmed mpox cases, and 35 deaths, according to WHO.

The most affected countries during this period of time are South Africa, the DRC, Uganda, Kenya, CAR, Nigeria, and Ivory Coast.

Muteba adds that in the most recent months, 16 countries in Africa have reported an increase in mpox.

“We have active mpox transmission and we need to be careful with all neighbouring countries because of the high mobility of the population and business among these countries,” he enthused. 

Muteba says although mpox in other regions has been decreasing gradually over the past few months, in Africa the number of mpox cases is increasing.

So what causes mpox and who is at risk?

Mpox is caused by the pox virus in the same family of viruses as smallpox which was eradicated over 40 years ago.

“It was originally transmitted largely through casual contact. Subsequently, in 2022 we saw mpox transmission largely driven by sexual contact,” Kyobe reveals.

“On the current outbreak in DRC, we see transmission mainly driven by sexual activity mainly around commercial sex workers.

“We are also seeing more of this disease affecting children and the mortality rate is higher in children and HIV-positive persons with poorly suppressed viral load.
“It also has a bigger effect on pregnant mothers who get severe disease including fetal death.”

Kyobe says individuals at high risk of getting mpox including pregnant mothers, HIV-positive persons with poorly suppressed viral load, children aged 15 years and groups such as commercial sex workers, and truck drivers, need to take extra caution.

He also warns mpox transmission in congregated settings is very rapid and real. 
This includes places such as schools and prisons, “it can be explosive transmission,” Kyobe says.

“We also know that if it penetrates a certain social category for instance the commercial sex worker’s and truck driver’s transmission can be explosive there.

“However, we also know that individuals who are immune compromised are at risk of severe disease including death as we have seen in some countries in the continent,” he says.

Mpox can also be transmitted through contaminated surfaces.

Symptoms and misdiagnosis

Mpox presents with pustules which are small boils on the skin. They can be anywhere on the skin and they are visible,” Kyobe explains.

The boils can be on one part of the body but they can also be spread all over the body.

Mpox is often also associated with very high-grade fever, swelling of lymph nodes, headache and general body weakness.

“The boils or lesions on the skin may disappear within two to three weeks but leave scars,’ Kyobe explains.

“However, for immune-compromised people, it may result in extensive skin damage and tissue loss which is evident.”

Can mpox be misdiagnosed?

Kyobe explains that several other viruses are presenting the same way with skin lesions and most of them are self-limiting.

They are not associated with the current mpox outbreak sweeping across the continent, “but there is need to be cautious if we are to control mpox,” he says.

Kyobe says what looks like mpox needs to be reported early such that individuals affected are screened and tested.

“We advise that most of this pox-like presentations when they happen need to be reported to the health authorities and screened and classified as such.

“The potential misclassification is okay for us working in this area meaning that we are able to pick each and every other pox-like virus presentation.

“When we classify it as mpox, we launch the appropriate response measures,” he says.

The types

Principally there are two types of mpox- clade 1 circulating mainly in DRC and Central Africa, and clade 2 circulating mainly in West Africa.

“The current main transmission in DRC is being driven by clade 1b which stems from clade 1. We see it being more virulent and associated with poor clinical outcomes including mortality. It is what we saw in Uganda,” Kyobe says.

“The challenge with mpox is that as the virus is transmitted through populations just like we saw in COVID-19 we tend to start seeing changes.

“The virus changes as it gets pressure from the immune responses of individuals, and the new type starts circulating. Hence the current clade 1b predominately in DRC.”
Clade 1b is associated with poor clinical outcomes including mortality in children and specifically immune compromised individuals.

Muteba, in agreement, confirmed the current outbreak of mpox in the DRC is caused by a new offshoot of the clade 1, the clade 1b.

“This one causes a more severe form of mpox compared to clade 2 and it is mainly transmitted through sexual contact,” he reiterated.

Muteba says cases of clade 1b have been confirmed in all the East African countries including Burundi, Kenya, Rwanda and Uganda who have all confirmed cases of mpox for the first time, and also in the eastern part of the DRC.

Whereas Cases of clade1 have been reported this year in the DRC, the CAR, and the Republic of Congo. DRC accounts for more than 70% of the cases.

Cases are still going up. In terms of death and cases of mpox the DRC is reporting most cases. Burundi from July 25, 2024, up to August 12, 2024, reported almost 80 cases.

Muteba says mpox cases on the continent are increasing exponentially and also in the DRC although they still need to update the data. He says the DRC has recently reportedly had an increase in the number of new cases, new areas and districts affected by Mpox.

This year so far the DRC has registered 1,888 cases of mpox and 8 deaths the most cases on the continent. That’s because we have different clades ravaging the country; clade1a in the north and western DRC and clade 1b in eastern DRC.

“In the eastern part of DRC, we have more adults that are infected by mpox while in the northern and western part of DRC we have children who are the most affected.

For Ivory Coast, seven cases have been reported so far, Nigeria 37 cases, CAR 40 cases, Burundi 87 cases, Rwanda four, Kenya one and Uganda two mpox cases.

“In total, we have 2,119 cases in Africa. But the countries are still continuing investigations and following up on contacts,” Muteba says.

So what’s Uganda doing?

“We are taking the latest mpox outbreak seriously. We have launched an expansive response in the epicenter in Bwera which borders DRC,” Kyobe reveals.

He reveals that emergency response activities are in high gear. “We have a response plan, and we have deployed rapid response teams at the epicentre in Bwera to ensure that we don’t have or we don’t get any more transmission,” Kyobe disclosed.

“We have been able to get the contacts and since then we have not had any secondary transmission on the Ugandan side.”

The traced contacts did not get the mpox and were all released.

The Minister of Health Dr. Jane Ruth Aceng confirmed to parliament that Mpox transmission in eastern DRC is expanding rapidly with a new epicenter in North Kivu that is adjacent to Uganda which means a risk of importation of mpox, just like it happened with the two confirmed cases in Uganda.

She says 17 districts in Uganda share a border with DRC with regular movement of people. However, 23 districts have been classified as high risk including the 17 bordering DRC, five hosting refugees and the capital city Kampala due to its mobile population and trade.

She told parliament on Thursday that the Ministry of Health is working with WHO to enhance cross-border collaboration among countries in the region for real-time information sharing and cross-border surveillance.

Is the vaccine for mpox available?

Kyobe reveals there are two vaccines for mpox but the stocks are limited globally. “Everyone is looking for these vaccines,” he says.

Kyobe says due to the vaccine scarcity, the key right now is public health interventions.

That includes early detection and making the population understand the transmission dynamics to be able to deal with them.

“In the absence of definitive treatment, we must ensure we offer supportive treatment if the patients come to us early or if we get them early in the system.”