At least 15,600 people have contracted mpox in the vast country so far this year, the majority of them children, while 537 have died, in an outbreak that prompted the World Health Organisation to declare a global health crisis earlier this month.
The most dangerous form of mpox, clade 1, has been endemic in the region for decades, but early last year the situation worsened dramatically. Tens of thousands of people have since been infected, while a concerning mutant variant, clade 1b, has emerged in the country’s east.
Yet there are still no specific treatments to cure mpox and those on the frontlines still face chronic shortages of even the most basic resources they need to save lives, according to Dr Nathalie Strub-Wourgaft, a delegate of the Pandemic Preparedness Platform for Health and Emerging Infections Response (Panther).
“People are suffering like hell,” Dr Strub-Wourgaft told the Telegraph. She recently spent time in two hard-hit provinces in western DRC and met patients in Equateur province who had hundreds of painful lesions and open sores across their bodies.
“What I saw was very sad,” she said. “There are fantastic, dedicated doctors and nurses, people who really wanted to help. But they have so little means to help – no antiviral treatment, no vaccine, scarce ways of detecting and diagnosing patients.
“Even the basics – soap, water, antiseptics – that you need to treat this disease, they aren’t available. So yes, I am frustrated. Very frustrated.”
Dr Strub-Wourgaft said she met a little girl, just two weeks old, who died not from the mpox virus but from a secondary infection. The lesions across her body burst but became septic as doctors had no antiseptics to keep them clean. As her situation deteriorated, there were no antibiotics to save her.
“This is not acceptable,” said Dr Strub-Wourgaft. “When we say there’s a lack of treatments, there are two aspects. One is the basic standard of care… When we speak about the death toll, it’s high because of the complications. We need hygiene, we need antibiotics, we need painkillers. Those are in the treatment guidelines. They are not necessarily available.
“On the other hand, we need specific mpox antiviral therapeutics [to] reduce the duration of the disease, which will help to reduce the risk of progression and super infections, and reduce transmission,” she said.
But while scientists race to develop and identify drugs that target the mpox virus, a recent placebo-controlled trial by the National Institutes of Health in the US and the DRC’s Institut National de Recherche Biomédicale (INRB) demonstrated the importance of the basics.
The study looked at the antiviral drug tecovirimat. It was originally developed to treat smallpox, a viral cousin of mpox, but scientists hoped it could be repurposed to tackle mpox.
Yet the small trial’s headline results were “disappointing”, said Dr Placide Mbala-Kingebeni, head of epidemiology and global health at the University of Kinshasa, as it found the antiviral did not reduce the duration of mpox lesions among children and adults infected with clade 1 in the DRC.
Still, the overall mortality rate for patients, regardless of whether they received tecovirimat or a placebo, was much lower than the average across DRC – 1.7 per cent of those involved in the trial died, compared to 3.6 per cent nationwide. The scientists said this was because all of the patients were hospitalised and given high quality supportive care.
“We showed that… hospitalisation and an appropriate standard of care can improve the outcomes of mpox patients,” said Dr Mbala. “It is not happening at the moment because of lack of resources. We need to focus on good standard of care for patients as there is no specific treatment yet.”
Many are incredulous that there remain no mpox drugs, given the virus was first discovered in the 1970s. For a long time, it was written off as a zoonotic disease that caused only sporadic cases. But for years before the epidemic exploded, transmission has been slowly accelerating.
“The clock was ticking a long time ago, but the world just wasn’t paying any attention,” said Dr Ayoade Alakija, a special envoy for the WHO’s Act-Accelerator panel, which focuses on medical tools for global health crises. “No one took mpox seriously, so the options [for vaccines and treatments] that we have now are all being repurposed from smallpox.”
She added that treatments were a significant element of the committee’s most recent discussions; the Act-A panel met the same week mpox was declared a public health crisis of international concern (PHEIC), and stressed that therapies are just as critical as vaccines.
“So far, what people are doing is scrambling to see what is there, and what out there is scalable… and affordable,” Dr Alakija said. “But the funding has been disappointing. Hopefully the PHEIC effect [will] unlock more [money].”
There are some drugs that hold promise. Brincidofovir was approved by the US Food and Drugs Administration in June 2021 for use against smallpox in adults and children, and is available as an mpox treatment option in America as an ‘investigational new drug’.
But it is “unclear how effective it is against mpox and is noted to cause elevated liver enzymes which can make it difficult to use”, said Dr Krutika Kuppalli, a spokesperson for the Infectious Disease Society of America and a former WHO medical official.
Other potentials that need to be studied include cidofovir, which was occasionally used as a topical treatment for severe mpox cases during the 2022 outbreak of clade 2, and NIOCH-14, which was developed and approved by Russia to tackle smallpox. Some institutions are also looking at developing monoclonal antibodies.
But scientists have also stressed that tecovirimat – which is appealing because it has a strong safety record, including in pregnant women and immunosuppressed individuals – should not be discounted quite yet.
“Of course the preliminary results [of tecovirimat] are disappointing, especially given its earlier promise… but that does not mean completely ruling out tecovirimat for now,” said Prof Li Yang Hsu, vice dean of global health at the Saw Swee Hock School of Public Health in Singapore.
He said the study was designed and executed well, but the preliminary results included everyone in the trial. There are hopes that more focused analysis – for instance looking at specific age groups or people given tecovirimat within seven days of developing symptoms – may still show that the drug has an impact on some patients.
“We know from experience with other antiviral drugs, including for influenza and Covid, that these tend to work better when initiated early,” Prof Hsu said.
Still, deciphering all this requires money. Dr Strub-Wourgaft – who also warned against jumping to final conclusions about tecovirimat before the sub-analyses are published – said several trials are ready to go, but lack the funds to begin.
This includes a rolling trial from Panther, called MOSA (Mpox Study Africa). This aims to test multiple drugs for mpox clade 1, 1b and 2 across Africa, in a study similar to the hugely successful Recovery trial – which rapidly identified drugs to treat Covid-19 during the pandemic.
“[Mosa] is platform adaptive,” Dr Strub-Wourgaft said. “As you go along, you have pre-planned analysis that you can do during the study, so you look at whether what you have is giving you a signal.
“If it’s not good, you should stop. If it’s better than what you had anticipated, you can stop as well because it’s successful. And then you can also add new treatments as science emerges.”
She added Panther has received some money from the European Union to support the research, but not enough to launch the trial.
“Mosa has been ready for a long time, but we’ve never managed to get sufficient funding. Which is very problematic to me,” Dr Dr Strub-Wourgaft said. “Research is part of the response, research is part of care – because if we don’t have the tools, we can’t deploy them.
“There have been more than 500 patients dying in 2024 in the DRC,” she added. “I’m not saying we could have prevented them all, but if more money had been given to Africa to control the disease… well, I am a bit desperate, what else do we need to say? We’re all saying we need therapeutics. So let’s look at therapeutics.”
