© Reuters. Dr. Fabien Congola conducts a morning briefing for nurses and interns at the Yakusu General Hospital in Tsopa, Democratic Republic of Congo, on October 5, 2022. “This is the first case I discovered in Yaboya Medical District. The case was reported, but u
Jafar al Qatanti and Edward McAllister
YALOLIA, Democratic Republic of Congo (Reuters) – At a rural clinic in central Congo, cut off from the world by entwined waterways and forests, six-year-old Angelica Lifafu clutches her dress and screams as nurses in hazmat suits dab at one of the hundreds of boils that plague her delicate skin .
Her uncle, 12-year-old Lisungi Lifafu, sits at the foot of her bed, turned away from the sunlight streaming through the doorway and tormenting his swollen, tear-stained eyes. As the nurses approach, he lifts his chin but can’t lift his eyes.
Children have monkeypox, a disease first identified in the Congo 50 years ago, but since 2019 cases have increased in West and Central Africa. The disease received little attention until it spread worldwide this year, infecting 77,000 people.
World health authorities have counted far fewer cases in Africa during the current outbreak than in Europe and the United States, which seized limited vaccines this year when the disease reached their shores.
But the outbreak and death toll in Congo could be much higher than official statistics show, a Reuters report shows, in large part because testing in under-equipped rural areas is so limited and effective drugs are unavailable.
During a six-day trip to the remote Tshopa region this month, Reuters reporters found about 20 cases of monkeypox, including two deaths whose cases had not been reported until the reporters visited. None of them, including Angelica and Lisungi, had access to vaccines and antiviral drugs.
More than a dozen health workers said shortages of testing supplies and poor transportation have made tracking the virus nearly impossible.
When asked about the undercount, the African Centers for Disease Control and Prevention (CDC) acknowledged that its data did not capture the full extent of the outbreak.
In the West, only about 10 people have died from monkeypox this year, according to figures from the US CDC. Europe and the United States have been able to vaccinate at-risk groups. Experts note that suspected cases are usually tested, isolated and treated early, which increases the survival rate. The number of cases in Europe and the United States has stabilized and started to fall.
But in poorer African countries, where many people do not have quick access to medical facilities or are unaware of the dangers, more than 130 have died, almost all in Congo, according to the Africa CDC.
There are no publicly available vaccines against monkeypox in Africa.
Without treatment, Angelique and Lisungi can only wait for the disease to end. They face a myriad of possible outcomes, including recovery, blindness, or, as in the case of a family member in August, death.
“These children have a disease that makes them suffer so much,” Lisunga’s father Litumbe Lifafu said at a clinic in Yalolia, a village of scattered mud huts 1,200 kilometers (750 miles) from the capital, Kinshasa.
“We demand that the government provide medicine for us poor farmers and a vaccine to fight this disease.”
HISTORY REPEATS ITSELF
Last year, the World Health Organization described the response to the COVID-19 pandemic as a “moral failure” as African countries found themselves at the back of the queue for vaccines, tests and treatment.
But those failures are being repeated a year later with monkeypox, said health officials consulted by Reuters. This threatens future outbreaks of the disease in Africa and around the world, experts say.
While sudden demand from Western countries has swallowed up available vaccines, poor countries like Congo, where the disease has been around long enough to become endemic, have been slow to seek supplies from WHO and partners.
Congolese Health Minister Jean-Jacques Mbungani told Reuters that Congo was in talks with the WHO to buy vaccines, but there had been no official request. A spokesman for Gavi, the vaccine alliance, said it had not received requests from African countries where the virus was endemic.
A WHO spokeswoman said that in the absence of available vaccines, countries should instead focus on surveillance and contact tracing.
“History is repeating itself,” said Professor Dimi Agoina, president of the independent Infectious Diseases Society of Nigeria. Time and time again, he said, disease containment in Africa does not receive the funding it needs until wealthier countries are threatened.
“It happened with HIV, it happened with Ebola and with COVID-19, and it’s happening again with monkeypox.”
Without adequate resources, the true spread of the virus cannot be known, he and other experts said.
“In Africa, we work blindly,” Ogoina said. “Case estimates are grossly understated.”
Monkey pox is transmitted through close contact with skin lesions. For most, this resolves within a few weeks. Young children and people with weakened immune systems are particularly vulnerable to severe complications.
The African CDC says Congo has had more than 4,000 suspected and confirmed cases and 154 deaths this year, based in part on data from public health authorities. This is significantly lower than the 27,000-plus cases reported in the United States and 7,000 in Spain. African countries with outbreaks include Ghana, which has about 600 suspected and confirmed cases, and Nigeria, which has nearly 2,000.
“Yes, there is a shortfall,” said Ahmed Oguel Uma, acting director of the Africa CDC. “Communities where monkeypox is spreading usually do not have access to conventional health facilities.” He said the CDC could not say at this time how large the shortfall was.
Congolese Health Minister Mbungani said there was a lack of testing capacity outside of Kinshasa, but did not respond to a request for comment on the missed cases.
THE FRONT LINE
African countries had hoped that the WHO’s decision in July to declare monkeypox a public health emergency of international concern would mobilize resources.
WHO has sent about 40,000 tests to Africa, including 1,500 to Congo, said Ambrose Talisuna, WHO’s manager of monkeypox incidents on the continent.
This month, Congo’s National Institute for Medical and Biological Research began clinical trials of the antiviral drug tecavirimate in monkeys with smallpox. Although there are no vaccines for public consumption, trials are underway in Congo with the Bavarian Nordic Imvanex vaccine on health workers, Health Minister Mbungani said.
But little has changed in central Congo.
Yalolia, where Angelica and Lisungi are patients, can only be reached by motorcycle tracks that tunnel through the dense jungle or by canoes carved from felled tree trunks. The old road connecting the nearby villages was cut off a few years ago when a series of wooden bridges collapsed.
In August, Lisunga’s older brother developed a rash and breathing problems. The family thought it was smallpox. When his condition worsened, the doctor put him on intravenous drips. He died without emptying.
Grief-stricken, Lisungi embraced his brother’s infected corpse. Two weeks later, in early September, he also developed a rash and closed eyes. Then Angelica fell ill.
Lisumbe took the children to Yalolia, where their symptoms were diagnosed with monkeypox. He sold his belongings to buy medicine to reduce the fever.
The nurses who care for them seethe from the lack of treatment.
“If there is a vaccine, we must have it. If there is a treatment, we must have it,” said nurse Marcel Osekasomba.
None of the cases were reported to authorities until Reuters visited Yalolia with local health official Theopist Maloko. He went to the village only at the suggestion of Reuters.
Without test results, they are now being registered as suspected cases.
Tshopa, almost the size of Great Britain, is densely wooded and cut by the Congo River and its many winding tributaries. Maloko’s task is to track cases in an area of 5,000 square kilometers. But he cannot afford gas and has no transport.
When the nurses took samples from the sores on Angelica’s leg and placed them in a polystyrene cool box strapped to the motorcycle’s body, Maloko was skeptical.
To avoid spoilage, samples should be refrigerated and delivered to the lab within 48 hours, but that often doesn’t happen, he said. The nearest testing laboratory is in Kinshasa; results take weeks or months.
“We are suffering. This is really our cry of alarm. We are raising our voice so that someone will hear,” he said.
Sometimes they don’t even take samples.
Yalanga village is a day’s journey from Yalolia by land and boat. Surrounded by jungle, there is no telephone network or electricity. When the lights go out, the treatment center’s patients lie in the dark on beds made of hard bamboo.
The clinic, a small building with a tin roof and five rooms, has had three cases in recent months. To notify authorities of a new case, nurses must travel half a day to get a phone call. If they are busy, it is impossible to leave. The recent cases were reported several weeks late, said Alinga Likaka Manase, a nurse.
Lituka Venda Detti, a 41-year-old mother, believes she got sick from eating contaminated bush meat. At the height of her illness in August, her throat was so sore that she could barely swallow her own saliva.
Round scars still dot Detty’s body, and her bones ache. She is sad. While she was in the hospital, her six-month-old son contracted monkeypox and died. He is buried in the sandy ground next to her mud brick house.
At the end of the day, Children and her family gather around a small rectangular grave. She whispers prayers.
“We want to have a vaccination campaign,” she said. “Based on what we’ve suffered, if a lot of people get this disease, it’s going to be catastrophic.”