Andy Numbi, Senior Technical Advisor, FHI 360 

Mpox (previously known as monkeypox) is endemic across Central and West Africa, especially near dense forests where animals carrying the virus can be found. The Democratic Republic of the Congo (DRC) and Nigeria are currently reporting the most cases, along with other affected countries, including Angola, Benin, Burundi, Cameroon, Central African Republic, Congo, Gabon, Ghana, Liberia, Nigeria, and Uganda. 

In May 2022, a notable outbreak of mpox spread across the world. This global outbreak was primarily, but not exclusively, driven through transmission via sexual contact of men who have sex with men. In July 2022, the World Health Organization (WHO) declared the ongoing mpox outbreak a public health emergency of international concern. 

Since early 2023, the DRC has recorded an uptick in cases, primarily in Equateur province. Between January 1 and November 12, 2023, the DRC’s Ministry of Health (MOH) reported more than 12,569 suspected mpox cases and 581 suspected mpox deaths. According to the WHO, this is the highest number of annual cases ever reported. Currently, mpox cases are being detected in parts of the DRC where it has never been reported before, including Kinshasa, South Kivu, and Lualaba. 

More recently, between January 1 and August 30, 2024, the National Public Health Institute reported 19,201 new suspected cases, of which 4,893 were confirmed cases.i A total of 629 deaths were reported, resulting in a case fatality rate (CFR) of 3.3%. Two provinces reported their first case in August, indicating the virus was spreading: Haut Lomami in the health zone of Baka; and Tanganyika in the health zone of Nyemba. 

National Outbreak Response 

In February 2023, the MOH developed a budgeted national mpox preparedness and response plan. An Mpox Emergency Operations Centre and Incident Management Team was also established under the leadership of the National Public Health Institute to implement actions for outbreak detection, surveillance and response. The national response plan covers risk communication and community engagement (RCCE), case management, infection prevention and control, biosafety and biosecurity, laboratory services, surveillance, and capacity building. The USAID-funded Meeting Targets and Maintaining Epidemic Control (EpiC) project and partner organizations are supporting the national response.  

The EpiC project supports the MOH to strengthen DRC’s capacity for global health security (GHS) and reduce health threats posed by infectious diseases. The project has focused on strengthening disease detection and surveillance systems in the country. As the mpox outbreak has worsened in DRC, EpiC’s scope has expanded to provide mpox response support, aligned with the DRC’s national response plan.  

Rapid Assessment 

To align EpiC’s mpox outbreak preparedness and response plan with the MOH’s national plan, EpiC DRC leveraged its GHS program to conduct a rapid assessment in Equateur and South Kivu provinces in March and April 2024. The objectives were to assess the capacity and technical assistance needs of epidemiological surveillance systems and public health laboratories in supported health zones, and to adjust the EpiC workplan to respond to urgent needs on the ground.  

EpiC assessed a laboratory in Equateur province. Photo by EpiC DRC. 

Key findings from the assessment include: 

  • Insufficient resources, such as specimen collection kits, data collection tools, and personal protective equipment (PPE) for mpox interventions and control.
  • Limited capacities of staff in the areas of detection and surveillance of mpox and other priority diseases in most health zones and facilities (many new and untrained staff). 
  • Weak specimen transportation in Equateur province relying on a single partner and on the verge of collapse due to lack of funding. 
  • Very poor implementation of biosafety and biosecurity measures in all laboratories, demonstrating a significant gap in local capacity that must urgently be addressed (e.g., dried blood visible on surfaces; beverages kept in the same refrigerator as reagents; lack of PPE; absence of fire extinguishers; work benches used to charge phones, etc.). 
  • Poor management of biological waste in all laboratories visited. 
  • Insufficient involvement of communities in surveillance activities. 
  • Lack of surveillance data reporting tools, and inadequate capacity of staff to collect and report surveillance data. 

These findings were shared with the MOH, the USAID Mission and other key stakeholders. The MOH welcomed this up-to-date information as these remote and distant health zones are rarely visited or supervised due logistical challenges.  

EpiC staff arrive at Bolomba port for a lab assessment in a remote health zone that was accessible by river. Photo by EpiC DRC.

Addressing urgent needs 

In response to identified gaps, EpiC rapidly mobilized to adjust the project’s workplan to respond to the mpox outbreak in DRC. The revised workplan incorporates activities that address some of the challenges and gaps identified during the rapid assessment. The project collaborated with the MOH, USAID, and other implementing partners to ensure the workplan is responsive to local needs and to avoid duplication of efforts.  

EpiC operates in 154 health zones across six provinces, plus Kinshasa, where the project supports national-level mpox response with the MOH. 

EpiC’s preventative efforts include activities such as biosafety and biosecurity, infection prevention and control measures, and surveillance. EpiC is working with the MOH to adapt best practices to design, disseminate, and implement integrated infectious disease biosafety and biosecurity measures at provincial laboratories in priority provinces. From June–July, 2024, EpiC trained 128 health care workers across 52 health zones in Equateur and Sud-Kivu provinces as lead trainers on biosafety and biosecurity, sample management, biomedical waste management, quality assurance, and priority disease surveillance. The 128 lead trainers were composed of 56 technicians and laboratory biologists, 53 nurse supervisors in the supported health zones, one pharmacist, six animal health representatives (doctors and veterinary technicians), four environmentalists, two sample carriers and six other One Health staff members. The lead trainers are now equipped to build capacity of their colleagues in their respective health zones on these topics. The MOH has taken up the training tools, developed with support from EpiC, to continue training providers in other provinces and in collaboration with other implementing partners. 

To strengthen capacity for laboratory detection of Mpox cases, EpiC supported the MOH to quickly develop training tools to build capacity of providers in health zones in its intervention provinces (Equateur, South-Kivu, South-Ubangi and Sankuru) to detect and confirm mpox cases in the laboratory. Epic is a member of the diagnostic taskforce that supports the MOH on the decentralization and monitoring of mpox biological diagnosis in the DRC in collaboration with other partners—including the WHO, CDC, and USAID. To date, the project has supported the transport of over 900 samples from rural facilities to two laboratories for testing.   

Next steps 

To continue to respond to the Mpox outbreak as it evolves in DRC, EpiC is conducting assessments in two additional provinces (South-Ubangi and Sankuru), with plans to build capacity of the One Health workforce on biosafety and biosecurity, sample management, biomedical waste management, surveillance, and –pox sample transportation in those two additional provinces. To protect frontline health workers, EpiC is also purchasing and distributing PPE (expected to arrive in September) and mpox tests (anticipated in November) in supported provinces and health zones. The project will train healthcare workers on appropriate use of PPE.   

With extensive experience addressing evolving epidemics (including HIV, COVID-19, Ebola) and a deep bench of GHS capacity, EpiC is focusing immediate efforts on the urgent needs at the epicenter of the current outbreak in DRC while simultaneously preparing to support a growing response as the outbreak spreads across borders to neighboring countries. A comprehensive clinical training package has been updated to reflect the newest trends in the current outbreak with the newly identified Clade Ib, while reinforcing the unchanged recommendations about prevention, diagnostic approaches, and clinical management from the previous global mpox outbreak in 2022-2023.  

See the full training package here along with a factsheet of essential, at-the-ready information about the evolving public health emergency. 

References:

i Institut National De Sante Publique, Centre des Opérations d’Urgences De Santé Publique. COUSP – RDC, Systéme de Gestion d’Incident/SGI-MPOX.30 August 2024.