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WHO's declaration of mpox as a Public Health Emergency of International Concern (PHEIC) on Aug 14, 2024 highlights a disturbing pattern of repeated failures in the global response to epidemic-prone pathogens.1 This declaration marks the second PHEIC for mpox since 2022, underscoring ongoing vaccine inequities and substantial gaps in our understanding of mpox epidemiology, transmission, pathogenesis, and control strategies. Of note, between September, 2023, and January, 2024, the Mpox Research Consortium documented an outbreak of 241 suspected clade I mpox cases in Kamituga, a gold-mining town in eastern DR Congo.4 Of the 108 PCR-confirmed mpox-positive cases, the median age of individuals was 22 years, 51·9% were women, and 29% were sex workers, suggesting a role for sexual transmission.4 Genomic analyses identified APOBEC3-type mutations, indicating human-to-human transmission, with this new variant designated clade Ib.4 The spread of clade I cases from DR Congo to Uganda, Rwanda, Kenya, Burundi, and even Sweden in the past few weeks highlights the growing global threat. WHO has neither approved the MVA-BN vaccine for mpox—citing insufficient efficacy data despite its proven effectiveness during the 2022 clade II outbreak—nor issued an emergency use licence, which requires a PHEIC declaration.6 These approvals are essential for UNICEF and Gavi, the Vaccine Alliance, to purchase and distribute mpox vaccines.6 Additionally, preliminary results from the PALM007 trial in DR Congo funded by the National Institutes of Health and National Institute of Allergy and Infectious Diseases indicated that the antiviral drug tecovirimat did not to meet its primary efficacy endpoint, underscoring the urgent need for new drug trials to guide treatment strategies.7 In conclusion, WHO's PHEIC declaration must catalyse a renewed global effort to control mpox.

•JYNNEOS vaccination produces robust anti-orthopoxvirus antibody response.•Naive vaccinees generate OPXV-specific IgM early after vaccination.•IgG responses peak around 2 weeks after second vaccine dose.•Titers wane at 2 years, and more rapidly in naïve vaccinees.•Antibodies neutralize VACV and MPXV differently, but had similar rise from baseline. The current worldwide monkepox outbreak has reaffirmed the continued threat monkeypox virus (MPXV) poses to public health. JYNNEOS, a Modified Vaccinia Ankara (MVA)-based live, non-replicating vaccine, was recently approved for monkeypox prevention for adults at high risk of MPXV infection in the United States. Although the safety and immunogenicity of JYNNEOS have been examined previously, the clinical cohorts studied largely derive from regions where MPXV does not typically circulate. In this study, we assess the quality and longevity of serological responses to two doses of JYNNEOS vaccine in a large cohort of healthcare workers from the Democratic Republic of Congo (DRC). We show that JYNNEOS elicits a strong orthopoxvirus (OPXV)-specific antibody response in participants that peaks around day 42, or 2 weeks after the second vaccine dose. Participants with no prior history of smallpox vaccination or exposure have lower baseline antibody levels, but experience a similar fold-rise in antibody titers by day 42 as those with a prior history of vaccination. Both previously naïve and vaccinated participants generate vaccinia virus and MPXV-neutralizing antibody in response to JYNNEOS vaccination. Finally, even though total OPXV-specific IgG titers and neutralizing antibody titers declined from their peak and returned close to baseline levels by the 2-year mark, most participants remain IgG seropositive at the 2-year timepoint. Taken together, our data demonstrates that JYNNEOS vaccination triggers potent OPXV neutralizing antibody responses in a cohort of healthcare workers in DRC, a monkeypox-endemic region. MPXV vaccination with JYNNEOS may help ameliorate the disease and economic burden associated with monkeypox and combat potential outbreaks in areas with active virus circulation.

As in the ongoing Covid-19 pandemic, global outbreaks of infectious illnesses often develop quickly and resolve in unpredictable ways. In this report, strategies to develop high-quality evidence to guide the development of new therapies are proposed.

Ten days after the declaration of the Ebola outbreak in the Democratic Republic of Congo, rapid identification of the species Zaire Ebola virus using partial gene amplification and nanopore sequencing backed up the use of the recombinant vesicular stomatitis virus–Zaire Ebola virus vaccine in the recommended ring vaccination strategy.

Human monkeypox (MPX) occurs at appreciable rates in the Democratic Republic of Congo (DRC). Infection with varicella zoster virus (VZV) has a similar presentation to that of MPX, and in areas where MPX is endemic these two illnesses are commonly mistaken. This study evaluated the diagnostic utility of two surveillance case definitions for MPX and specific clinical characteristics associated with laboratory-confirmed MPX cases. Data from a cohort of suspect MPX cases (identified by surveillance over the course of a 42 month period during 2009-2014) from DRC were used; real-time PCR diagnostic test results were used to establish MPX and VZV diagnoses. A total of 333 laboratory-confirmed MPX cases, 383 laboratory-confirmed VZV cases, and 36 cases that were determined to not be either MPX or VZV were included in the analyses. Significant (p<0.05) differences between laboratory-confirmed MPX and VZV cases were noted for several signs/symptoms including key rash characteristics. Both surveillance case definitions had high sensitivity and low specificities for individuals that had suspected MPX virus infections. Using 12 signs/symptoms with high sensitivity and/or specificity values, a receiver operator characteristic analysis showed that models for MPX cases that had the presence of 'fever before rash' plus at least 7 or 8 of the 12 signs/symptoms demonstrated a more balanced performance between sensitivity and specificity. Laboratory-confirmed MPX and VZV cases presented with many of the same signs and symptoms, and the analysis here emphasized the utility of including 12 specific signs/symptoms when investigating MPX cases. In order to document and detect endemic human MPX cases, a surveillance case definition with more specificity is needed for accurate case detection. In the absence of a more specific case definition, continued emphasis on confirmatory laboratory-based diagnostics is warranted.

Ebola transmission has been ongoing in the Democratic Republic of Congo since August 2018. In this trial of MAb114, REGN-EB3, remdesivir, and ZMapp (as the control), mortality from Ebola virus disease was lower in the MAb114 and REGN-EB3 groups than in the other groups.

The Democratic Republic of the Congo has experienced the most outbreaks of Ebola virus disease since the virus' discovery in 1976. This article provides for the first time a description and a line list for all outbreaks in this country, comprising 996 cases. Compared to patients over 15 years old, the odds of dying were significantly lower in patients aged 5 to 15 and higher in children under five (with 100% mortality in those under 2 years old). The odds of dying increased by 11% per day that a patient was not hospitalised. Outbreaks with an initially high reproduction number, R (>3), were rapidly brought under control, whilst outbreaks with a lower initial R caused longer and generally larger outbreaks. These findings can inform the choice of target age groups for interventions and highlight the importance of both reducing the delay between symptom onset and hospitalisation and rapid national and international response. Ebola virus disease commonly causes symptoms such as high fever, vomiting, and diarrhoea. It may also cause muscle pain, headaches, and bleeding, and often leads to death. There have been seven outbreaks of Ebola virus disease in the Democratic Republic of the Congo (DRC) since 1976. The DRC is the country that has had the most outbreaks of this disease in the world. The most recent outbreak in the DRC was in 2014; this was separate from the outbreak that started in West Africa in the same year. Rosello, Mossoko et al. have now compiled the data from all seven of the outbreaks in the DRC into a single dataset, which covers almost 1000 patients. Analysing this data revealed that people between 25 and 64 years of age were most likely to be infected by the Ebola virus, possibly because most healthcare workers fall into this category. Age also affected how likely a patient was to die, with those aged under 5 and over 15 more likely to die than those aged between 5 and 15. Delaying going to hospital once symptoms had started, even by one day, also increased the likelihood of death. Rosello, Mossoko et al. also examined the Ebola virus effective reproduction number, which indicates how many people, on average, an infected person passes the virus on to. Outbreaks that initially featured viruses with a reproduction number larger than three tended to be stemmed quickly. However, when the reproduction number was lower, national and international organisations were slower to respond to the signs of the outbreak, leading to outbreaks that lasted longer. Further research is needed to understand why the likelihood of death is different for different age groups and to investigate the effect of the different routes of transmission of the virus on interventions such as vaccination.

First reported in humans in 1970, there has since been renewed interest in the disease due to altered transmission and spread mechanisms, and the increased number of cases in 2022.1 WHO declared mpox outbreak a Public Health Emergency of International Concern (PHEIC), following rapid and sustained spread beyond the endemic countries and increases in the number of cases in clusters. Previously, there had been an indication that the transmission in DR Congo was driven by homosexual interaction.2 This commentary describes the epidemiology of the current mpox outbreak in South Kivu using routine surveillance data and highlights what appears to be altered transmission dynamics from the traditional human–wild interactions and casual human-to-human transmission, to heterosexual transmission and the likely implications for cross border and potential global spread. More than half of the cases were women (53·8%), a result that diverges from previous studies where men were predominantly affected, yet aligns with the current epidemiology of Clade I in Central Africa.3 It appears apparent that heterosexual transmission could be driving the transmission rates in this region, unlike homosexual transmission especially in MSM, which was the main driver for the high infection rates in 2022.2 High prevalence in women could complicate control by introducing another route of transmission—ie, vertical transmission, which presents with adverse pregnancy outcomes.4 Furthermore, evidence of heterosexual transmission spread is supported by the fact that currently, female sex workers constitute a big proportion of cases (29%) in this cluster (figure).

Background Behavioural risk factors for cholera are well established in rural and semi-urban contexts, but not in densely populated mega-cities in Sub-Saharan Africa. In November 2017, a cholera epidemic occurred in Kinshasa, the Democratic Republic of the Congo, where no outbreak had been recorded for nearly a decade. During this outbreak, we investigated context-specific risk factors for cholera in an urban setting among a population that is not frequently exposed to cholera. Methodology/Principal findings We recruited 390 participants from three affected health zones of Kinshasa into a 1:1 matched case control study. Cases were identified from cholera treatment centre admission records, while controls were recruited from the vicinity of the cases' place of residence. We used standardized case report forms for the collection of socio-demographic and behavioural risk factors. We used augmented backward elimination in a conditional logistic regression model to identify risk factors. The consumption of sachet water was strongly associated with the risk of being a cholera case (p-value 0.019), which increased with increasing frequency of consumption from rarely (OR 2.2, 95% CI 0.9-5.2) to often (OR 4.0, 95% CI 1.6-9.9) to very often (OR 4.1, 95% CI 1.0-16.7). Overall, more than 80% of all participants reported consumption of this type of drinking water. The risk factors funeral attendance and contact with someone suffering from diarrhoea showed a p-value of 0.09 and 0.08, respectively. No socio-demographic characteristics were associated with the risk of cholera. Conclusions/Significance Drinking water consumption from sachets, which are sold informally on the streets in most Sub-Saharan African cities, are an overlooked route of infection in urban cholera outbreaks. Outbreak response measures need to acknowledge context-specific risk factors to remain a valuable tool in the efforts to achieve national and regional targets to reduce the burden of cholera in Sub-Saharan Africa.