In Central Africa, a deadly monkeypox variant is surging

Experts are calling for stronger measures to stop a variant found in the Democratic Republic of the Congo that's 10 times deadlier than the global strain.

By Rene Ebersole
Published 20 Oct 2022, 14:02 BST
Woman with Child
After losing one daughter to monkeypox, 18-year-old Blandine Bosaku, who is pregnant, received antibiotic treatment at a rural health clinic in northern Democratic Republic of Congo. When a pregnant woman becomes sick with monkeypox, the disease can transmit to her fetus, shrinking the baby’s chance of survival. Health experts are calling for increased disease surveillance in such remote parts of Africa to better detect the first signs of an outbreak.
Photograph by Brent Stirton

A woman eight months pregnant covered head to toe with lesions. Small children suffering with fevers and painful sores. A father asking for money to buy antibiotics for his ailing five-year-old son after he’d buried two other small children infected with monkeypox.

These memories torment Divin Malekani, an ecologist at the University of Kinshasa, in the Democratic Republic of Congo, who consults on projects with the nonprofit Wildlife Conservation Society to help reduce human exposure to animal-borne diseases. “I saw many cases of people sick with monkeypox,” he says of a trip last year to a remote northwestern province.

The Sangha River is a popular trade route for goods and wild game such as monkeys, rodents, and deer hunted and sold in village markets in the Republic of Congo and neighboring Cameroon. Some researchers say the key to reducing the risk of infectious diseases “spilling over” from wildlife to people is protecting forests from human encroachment.
Photograph by Brent Stirton

Monkeypox, a smallpox-related viral disease with two known variants, was named in 1958 after it was identified in a colony of research monkeys in a laboratory in Copenhagen, Germany. (Scientists think rodents, not primates, are the main reservoir for the disease.)

The mildest form of the disease is Clade II, also known as the West African variant, which went global this May. To date, it has infected more than 70,000 people, killing at least 26, in more than a hundred countries and territories, with the overwhelming majority being gay men. Cases are declining, thanks to vaccinations and changes in sexual behaviour.

Meanwhile, another variant— ten times deadlier—is smouldering in Central Africa.

The Africa Centres for Disease Control reports that the majority of the 3,500 suspected Clade I (or Congo Basin strain) cases this year, including more than 120 deaths, are in the DRC. Nigeria, where the Clade II outbreak began, has had about 700 suspected cases, with fewer than 10 fatalities.

Health experts National Geographic consulted about the steady rise of the Clade I variant in Central Africa say countries should be concerned about its threat to global communities and take stronger action to prevent it and other animal-borne diseases from blazing around the world.

“If the West African strain can spread to Europe, America, and other parts of the world, the more virulent and pathogenic Congo Basin strain can also go there,” says infectious disease expert Dimie Ogoina at Niger Delta University, in the southern part of Nigeria. “International health stakeholders must be deliberate to help address monkeypox and other diseases in Africa. Because if we don’t do this, it will come back to haunt us.”

Unheeded warnings

Ogoina knows a thing or two about monkeypox: He’s the paediatrician who in September 2017 confirmed the disease in an 11-year-old boy—Nigeria’s first case of human monkeypox in almost 40 years. He’s also the researcher who warned, four years ago, that there appeared to be an alarming change not only in how the virus was transmitted but also in who was getting infected.

Arthur Bengo, 28, became infected with monkeypox after eating a sick monkey he’d shot to feed his family in northern Democratic Republic of Congo. As his fever soared, he developed the telltale painful lesions that left scars on his face and body. The Africa Centers for Disease Control reports upwards of 3,500 monkeypox cases in the DRC, including more than 120 deaths this year.
Photograph by Brent Stirton

In the early days of the outbreak, experts thought the disease was behaving as it always had elsewhere in Africa, afflicting mostly people who’d interacted with monkeypox-infected wildlife, often while hunting wild game, preparing the meat, or coming in close proximity to a person who’d contracted the disease from an animal. Typically, such outbreaks would fizzle.

But suddenly, Ogoina and his colleagues noticed an unusual trend: The majority of people diagnosed with monkeypox at his clinic didn’t live in rural areas—they were young, middle-class professional men from bustling cities, and their lesions were heavily concentrated on their genitals. The health community doubted Ogoina’s findings. “What we were seeing was out of the norm,” he says. “So people were not willing to accept it.”

Fast forward to the 2022 global monkeypox outbreak. In the United States, the Centres for Disease Control and Prevention recently reported that men account for 99 percent of monkeypox cases in the U.S., and 94 percent of those patients acknowledged recent male-to-male sexual or intimate contact.

Some disease experts say the sceptics missed an important opportunity to stamp out the outbreak before it took off. “Monkeypox should be considered a canary in the coal mine that we need be doing much better disease surveillance in high-risk populations,” says Anne Rimoin, an infectious disease researcher at University of California, Los Angeles, who has studied monkeypox for two decades in the DRC. “The hardest and most expensive places to do this are in rural, remote parts of Africa,” she says. “But with growing human populations, mobility, and trade, these viruses can just as easily land on our doorstep.”

Rimoin has warned for years that monkeypox cases are on the rise, particularly in the DRC, where the disease was first discovered in humans in 1970 in a nine-month-old baby. She and her colleagues published a study in 2010 revealing that the rate of monkeypox incidence in the country had increased 20-fold during the 30 years since the end of smallpox vaccinations, which simultaneously had suppressed monkeypox. The researchers said ignoring the rise could squander a chance “to combat the virus while its geographic range was still limited.”

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“Monkeypox cases have continued to increase over the past 12 years in the DRC, as well as other countries in Central and West Africa,” Rimoin says. Although the mode of Clade I’s transmission—still from infected wildlife to people—is different from the way the disease has spread from West Africa to the world, that could change. “Just because we’re not seeing it now, doesn’t mean that we won’t. If the COVID-19 pandemic has taught us anything,” she says, “it’s that an infection anywhere is potential for an infection everywhere.”

Preventing spillovers

More than 60 years after monkeypox was discovered in lab monkeys, scientists are still struggling to identify the wild animals in which the virus primarily lives, grows, and multiplies.

Back in 2012, Kinshasa University ecologist Divin Malekani joined a research team trying to narrow the pool of suspects. The scientists trapped or purchased from hunters more than 350 mammals in an area of the DRC where monkeypox infections exceeded 660 people a year on average. They found monkeypox antibodies in seven animals, including rope squirrels, an African dormouse, and a giant pouched rat, sources of food. Some 27 million people in the DRC—a quarter of the population—struggle with hunger, according to the United Nations. Many have no choice but to hunt for their survival.

The town of Oesso, on the banks of the Sangha River in the Republic of Congo, is a major hub for the wild meat trade. Animals and other goods are transported by wooden dugouts, automobiles, and motorbikes. Local sellers offer the meat for half the price it can fetch in big cities, where a disease outbreak could rapidly spread, infecting millions.
Photograph by Brent Stirton

The spectre of monkeypox-infected wild meat making its way to a market in Kinshasa, Africa’s largest city, where it’s eaten as a luxury—a taste from home—worries Malekani and others. Countries need to help people cut down on wild meat consumption to prevent pandemics from arising, says Sarah Olson, an epidemiologist with the Wildlife Conservation Society. “It’s not going to put this genie back in the bottle, but it could reduce future transmission of monkeypox and other diseases from wildlife to people.”

To prepare for and respond to infectious diseases by aligning countries, the World Health Organisation is taking steps toward a legally binding international pandemic treaty. Some researchers are concerned that the focus is weighted too heavily on treating disease once it gets to humans rather than on efforts to block pathogens from “spilling over” from animals into people in the first place.

Spillovers happen because humans meddle with nature. Chopping down forests for timber, farming, and towns penetrates ecosystems brimming with wildlife. When people trade wild animals for food, pets, and medicinal purposes, they risk exposure to pathogens. And for impoverished people living in remote parts of Africa, medical care—when available—can be unaffordable.

We can prevent spillovers, says Aaron Bernstein, interim director of the Centre for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health, by protecting forests, banning or strictly regulating commercial wildlife trade, and improving farming conditions. Another crucial step: helping people living in disease hot spots gain access to job opportunities and food sources other than wild meat.

“We’re always going to need vaccines, testing, drugs, and public health infrastructure,” Bernstein says, “but focusing on that alone is like trying to address climate change only by building seawalls while letting greenhouse gas emissions go through the roof.” That’s what’s happening with infectious disease, he says. “We’re essentially saying let’s spend tens of billions of dollars trying to contain these things after they happen, while not recognising the root cause.”

Henriete Bakete Wanda, 13, sits in a hospital isolation room where she’s receiving antibiotic treatment for a monkeypox infection after her mother quickly recognized the symptoms and sought help. One in 10 people infected with the virulent Clade I monkeypox strain die from the disease.
Photograph by Brent Stirton

Meanwhile, in the DRC, educators with the International Conservation and Education Fund are travelling village to village, showing a video featuring local people talking about their experiences with monkeypox and how to avoid it.

One man said his baby’s fever soared so high that he felt as if he was sleeping next to a fire. At the hospital, the infant developed painful lesions that spread across his entire body, face, hands, and feet. The disease became so severe, the baby died, leaving his parents bewildered. Other villagers shared similar stories of the intensity of the deadlier monkeypox strain—children with “bumps” on their faces and throats so swollen they could barely drink or eat.

“If we had to toss a dice, we actually got lucky with which variant took off around the world,” Olson says. “There's still an opportunity to understand what's happening with this other variety of the virus before it gets out of hand.”


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