Although malaria, compounded by malnutrition, seems the most likely cause of the mysterious illness in the Democratic Republic of Congo (DRC), haemorrhagic fever syndrome has not been ruled out.

Dr Ngashi Ngongo, mpox lead for Africa Centres for Disease Control and Prevention (Africa CDC), told a media briefing on Thursday that there were two “working hypotheses” currently being verified: either severe malaria against a background of malnutrition and viral infection, or a viral infection against a background of malaria and malnutrition.

The DRC had reported to Africa CDC earlier that day about the death of a man from the Panzi district suffering from the haemorrhagic fever syndrome, a term used for a group of viral diseases that can cause bleeding and damage to the body’s organs.

“His sample has been taken and sent to Kinshasa for laboratory testing,” said Ngongo.

However, with malaria confirmed via PCR in 86% of patients tested, “the diagnosis is leaning more toward malaria”, he said.

But the high case fatality rate of 6.2% (37 deaths out of 592 cases) triggered further investigation as this is way higher than usual for malaria.

The 37 deaths happened in health facilities but a further 44 community-based deaths are still being investigated, he added.

Of the 88 patients given rapid malaria tests, 55% were positive, while 25 of the 29 samples subjected to PCR tests were positive for malaria (86%). 

It is hard to confirm when an accurate diagnosis will be possible given the complications, including getting samples to laboratories, he added.

Mpox vaccinations too slow

Africa CDC is “not at all satisfied” with the fact that only 56,000 people have been vaccinated against mpox in DRC, said Ngongo.

The country has received over one million doses (people need two doses), so the DRC is “very far from reaching the target that they had set for themselves”.

Meanwhile, the arrival of 50,000 doses of the long awaited Japanese LC16 vaccines that are suitable for children is imminent. Japanese experts have been in the DRC training health workers on how to administer the vaccines.

Africa CDC convened a three-day mpox meeting in Ethiopia this week to review the continent’s response. This was attended by Burundi, Central Africa Republic, Cote d’Ivoire, DRC, Kenya, Liberia, Uganda, Nigeria and South Africa and seven partners including Africa CDC and Gavi.

One of the reasons the DRC gave for its slow vaccination rate at the review was “the demotivation of the response teams”, said Ngongo. While partners “have made allocations to provide some financial motivation, that will be conditional on performance”, he added.

The meeting identified eight priorities, the first being to “intensify resource mobilisation, including a funders conference”, as only 20% of pledges have materialised.

Other priorities include intensified country support for the hardest-hit countries, better data management systems and the acceleration and expansion of vaccinations. Countries also want to tackle co-infections like measles.

The mpox outbreak is now active in 15 countries, and continues to spread steadily. In the past week, 3,095 new cases were reported in comparison to 3,545 the previous week, said Ngongo.

Children below the age of 15 now represent about 34% of cases, while females now represent 54%. There has been a 789% increase in cases over 2023.

The DRC has the highest burden of cases, with 2,632 new cases and 29 deaths in the past week. Children under the age of 15 make up almost half its cases.

While Burundi, which has the second highest mpox burden, has not yet committed to vaccinating its citizens, its representatives at the review were “very interested to learn from the experience of DRC”, said Ngongo. 

The DRC shared their initial experiences at the review, and Burundi intends to integrate lessons from this into their country interaction review and make a recommendation on vaccinations.

Africa CDC will be part of Burundi’s action review in early 2025 “to be able to guide them in setting up priorities, including the decision on mpox vaccination”, Ngongo added.

Rwanda celebrates end of Marburg outbreak

Meanwhile, Rwanda has planned a celebration in its capital, Kigali, on Friday (20 December) to mark the end of its Marburg outbreak.

“This success is the result of the swift and coordinated effort that was laid by the [Rwandan] Ministry of Health, in collaboration with Africa CDC, WHO and all the key partners,” said Ngongo.

“Some measures that have contributed to this success include the leadership commitment with a prompt and transparent communication from the Minister of Health,” he added.

“We’ve also seen the enhancement of the national surveillance systems that allowed for early case detection, the intensified contact tracing and the early case isolation. 

“We also saw very high level of laboratory testing with a very short result to turnaround. We saw also the expansion and the upgrading of treatment facilities that were really of a global standard. 

“And finally, there was really an intensification of the awareness campaign to ensure that the public I got the necessary information on how to prevent the infection.”

Rwanda had one of the lowest case fatality rates in a Marburg outbreak, estimated at 22.7%, in comparison to previous outbreaks where the case fatality rate was around 50%.”

Image Credits: Africa CDC.