Africa should research the long-term sequelae of mpox
Authors: Allan Komakech, Brian Ngongheh Ajong, Danny Kalala, Nora Efire, Cris Kacita, Emmanuel Hasivirwe Vakaniaki, Jonathan Izudi, Laurens Liesenborghs, Nicaise Ndembi
Journal: The Lancet Global Health (2024)

In July, 2022, WHO declared mpox—a viral zoonotic illness—a public health emergency of international concern, due to the rising number of cases and its spread to many countries outside Africa.1WHOWHO Director-General's statement at the press conference following IHR Emergency Committee regarding the multi-country outbreak of monkeypox—23 July 2022.https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-the-press-conference-following-IHR-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox-23-july-2022Date: 2022Date accessed: May 24, 2024Google Scholar By May, 2023, reported cases of mpox had reduced in regions outside Africa, leading to the lifting of the emergency declaration. In August, 2023, the WHO Director-called upon state parties to develop national mpox plans that incorporated lessons learned, to strengthen laboratory-based surveillance, to enhance community protection through risk communication, and to comprehensively support research for prevention and control.2WHOStanding recommendations for mpox issued by the Director-General of the World Health Organization (WHO) in accordance with the International Health Regulations (2005) (IHR).https://www.who.int/publications/m/item/standing-recommendations-for-mpox-issued-by-the-director-general-of-the-world-health-organization-(who)-in-accordance-with-the-international-health-regulations-(2005)-(ihr)Date: 2023Date accessed: June 13, 2024Google Scholar However, mpox remains a critical public health problem in Africa, where it was first identified among humans in 1970, in the Democratic Republic of the Congo (DR Congo).3WHOMpox (monkeypox)—Democratic Republic of the Congo.https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON493Date: 2023Date accessed: June 13, 2024Google Scholar Responses by stakeholders, both local and international, to increases in mpox cases have primarily focused on immediate containment and treatment strategies. However, it is equally important to understand the long-term sequelae of mpox, particularly in Africa, which has the largest burden of the disease. Although the literature is scarce, our field experience and a few reports indicate that the long-term sequelae of mpox range from cutaneous to systemic complications.4Smith AKJ Storer D Lancaster K et al.Mpox illness narratives: stigmatising care and recovery during and after an emergency outbreak.Qual Health Res. 2024; (published online March 10.)https://doi.org/10.1177/10497323241234482Crossref Scopus (3) Google Scholar, 5Ogoina D Iroezindu M James HI et al.Clinical course and outcome of human monkeypox in Nigeria.Clin Infect Dis. 2020; 71: e210-e214Crossref PubMed Scopus (310) Google Scholar, 6Berens-Riha N Bracke S Rutgers J et al.Persistent morbidity in Clade IIb mpox patients: interim results of a long-term follow-up study, Belgium, June to November 2022.Euro Surveill. 2023; 282300072Crossref Scopus (4) Google Scholar, 7Zeyen C Kinberger M Kriedemann H et al.Clinical spectrum and long-term outcomes of mpox: a cohort study spanning from acute infection to six-month follow-up.BMC Infect Dis. 2024; 24: 317Crossref PubMed Scopus (2) Google Scholar, 8Jezek Z Szczeniowski M Paluku KM Mutombo M Human monkeypox: clinical features of 282 patients.J Infect Dis. 1987; 156: 293-298Crossref PubMed Google Scholar The complications include atrophic scars, patchy alopecia, facial muscle contractures, proctitis, fatigue, blindness, deformed eyelids, keratitis, and sexual impairment.4Smith AKJ Storer D Lancaster K et al.Mpox illness narratives: stigmatising care and recovery during and after an emergency outbreak.Qual Health Res. 2024; (published online March 10.)https://doi.org/10.1177/10497323241234482Crossref Scopus (3) Google Scholar, 5Ogoina D Iroezindu M James HI et al.Clinical course and outcome of human monkeypox in Nigeria.Clin Infect Dis. 2020; 71: e210-e214Crossref PubMed Scopus (310) Google Scholar, 6Berens-Riha N Bracke S Rutgers J et al.Persistent morbidity in Clade IIb mpox patients: interim results of a long-term follow-up study, Belgium, June to November 2022.Euro Surveill. 2023; 282300072Crossref Scopus (4) Google Scholar, 7Zeyen C Kinberger M Kriedemann H et al.Clinical spectrum and long-term outcomes of mpox: a cohort study spanning from acute infection to six-month follow-up.BMC Infect Dis. 2024; 24: 317Crossref PubMed Scopus (2) Google Scholar, 8Jezek Z Szczeniowski M Paluku KM Mutombo M Human monkeypox: clinical features of 282 patients.J Infect Dis. 1987; 156: 293-298Crossref PubMed Google Scholar Most studies have described sequelae following infection with the clade II variant of monkeypox virus. Since outbreaks in central Africa are caused by the more virulent clade I monkeypox virus, the sequelae might be even more severe here. A 1987 study conducted in DR Congo identified blindness and impaired vision as sequelae in ten (3·5%) of 282 individuals infected with clade I monkeypox virus.8Jezek Z Szczeniowski M Paluku KM Mutombo M Human monkeypox: clinical features of 282 patients.J Infect Dis. 1987; 156: 293-298Crossref PubMed Google Scholar In light of the changing epidemiology of the monkeypox virus in Africa, including the emergence of sexual transmission in DR Congo,9Katoto PD Muttamba W Bahizire E et al.Shifting transmission patterns of human mpox in South Kivu, DR Congo.Lancet Infect Dis. 2024; 24: e354-e355Summary Full Text Full Text PDF Google Scholar the cessation of smallpox vaccination since smallpox eradication, and the already-strained health systems, there is a crucial need for up-to-date information regarding the long-term sequelae of mpox to help provide long-term care for survivors. This gap is a notable barrier to understanding the quality of life of people affected by mpox. In DR Congo, most reported cases are in children younger than 15 years, and long-term sequelae such as blindness could reduce their quality of life, educational productivity, and future earning potential. Past research on Ebola survivors in DR Congo and Uganda has helped provide contemporary survivors with proper treatment and rehabilitation embedded within existing health systems. To our knowledge, no such evidence exists for mpox; therefore, relevant research studies of these sequelae are needed to inform resource allocation and targeted interventions for the immediate and long-term sequelae among mpox survivors. Research priorities for the long-term sequelae of mpox in Africa should focus on three key areas. First, longitudinal clinical studies that follow survivors over time should be conducted to document the range and frequency of sequelae. Conducting these studies during the epidemic response will ease the timely identification of cases before the onset of any long-term symptoms. Further, evidence from such studies would inform case definitions, as was done during the COVID-19 pandemic with definitions for post-COVID-19 condition (also known as long COVID). The ultimate significance of contextualised case definition is important in the accuracy of the diagnosis of mpox sequelae, especially among biologically confirmed cases. These studies should be geographically diverse to capture variations among different populations. Second, research on the commonly identified symptoms such as skin disorders, neurological changes, mental illnesses, and reproductive system-related issues should be another priority, as these could help improve understanding of their true mechanisms, which are crucial to developing effective treatment regimens. Third, person-centred qualitative research will be important in sharing insights about the mpox sequelae at the individual and community levels, that would otherwise have been missed by epidemiological and clinical studies. To achieve these goals, strong multisectoral advocacy for funding and policy support is essential, as shown during the high-level emergency regional meeting on mpox in Africa, in April, 2024.10Africa Centres for Disease Control and PreventionCommuniqué: united in the fight against mpox in Africa—high-level emergency regional meeting.Available from: https://africacdc.org/news-item/communique-united-in-the-fight-against-mpox-in-africa-high-level-emergency-regional-meeting/Date: 2024Date accessed: April 18, 2024Google Scholar Government and non-government actors, international organisations (such as WHO and the Africa Centres for Disease Control and Prevention), civil society, academic institutions, research consortia, and community-based organisations must recognise the need to intensify research on the long-term sequelae of mpox as part of a comprehensive approach to managing mpox in Africa. Collaborations between these entities, including the sharing of expertise and resources, will ensure efficient, effective, ethical, and sound research conduct, timely and wider dissemination of research findings, and the translation of findings into policy and practice in Africa, improving public health. We declare no competing interests.