Mpox in South Africa: here’s what we know

Stages of mpox lesion development. Photos by Dr O.O. Afuye 15 September 2019, UK government via Wikipedia. (Open Government Licence)

• South Africa has recorded its second mpox death. There have been six confirmed cases.
• The health department said the 38-year-old patient had HIV and tested positive for mpox after presenting with extensive lesions, oral ulcers, muscle pain and a sore throat.
• Infectious diseases specialist, Dr Jeremy Nel said that men who have sex with men have been disproportionately affected by mpox since the 2022 outbreak across the world.

The Department of Health confirmed on Thursday that a second person has died from the mpox virus. On Wednesday, the department announced the first death in the country.

There are six confirmed cases in South Africa. All patients are males in their 30s.

The National Institute for Communicable Diseases (NICD) explains mpox (previously named monkeypox) is caused by infection with the mpox virus, a member of the genus Orthopoxvirus in the family Poxviridae. There are currently more than 80 poxviruses known to science.

The incubation period for mpox is on average seven to 14 days but can range from five to 21 days.

Initial symptoms include fever, headache, muscle aches, backache, chills and exhaustion. Within the first three days of onset of the disease, blister-like lesions will develop on the face, the extremities including the soles of the feet and palms of the hands. The lesions may, however, occur on other parts of the body.

There is no registered treatment for mpox in South Africa.

However, the NICD said the World Health Organization (WHO) recommends the use of tecovirimat (often known by the brand name Tpoxx) for treatment of severe cases, such as in people with a CD4 count of less than 350 cells per mm³. (People with advanced HIV disease typically have a CD4 count this low but if they are on antiretroviral treatment, their CD4 count recovers to normal levels, typically above 500.)

The NICD said the health department has obtained tecovirimat via a mechanism known as a Section 21 authorisation. Section 21 of the Medicines Act allows SAPHRA to approve the use of an unregistered medicine. This is typically done on a compassionate-use basis for patients who have no other reasonable treatment options.

The latest patient is a 38-year old male who was admitted at a local hospital in uMgungundlovu, KwaZulu-Natal. Minister of Health Dr Joe Phaahla stated that the patient tested positive for mpox on Wednesday after presenting with extensive lesions, lymphadenopathy, headache, fatigue, oral ulcers, muscle pain and sore throat.

The patient, who was HIV-positive, died the same day his test results came back positive, Phaahla said.

“Mpox is a preventable and treatable disease if diagnosed early. People are urged to avoid physical contact with someone who has mpox, practice hand hygiene and respiratory etiquette,” Phaahla said.

Wits University infectious diseases specialist Dr Jeremy Nel explained that people with moderate-to-severe levels of immunosuppression are at risk of having a more severe course if they contract mpox.

“This includes those with poorly-controlled HIV who have low CD4 counts, but the good news is that people with well-controlled HIV don’t appear to be at any significantly elevated risk”.

Asked whether any other groups are at a greater risk of contracting a severe case of mpox, Nel said: “For people in countries like South Africa, which is not a historically endemic area for mpox, the risk to gay and bisexual men, other MSM (men who have sex with men), trans people and sex workers is considered moderate. For all other population groups, the risk is low,” said Nel.

He said there is not enough information to determine trends in South Africa because only a handful of cases have been diagnosed. “But people whose HIV isn’t well controlled do appear to be at higher risk factors for severe disease,” he said.

Nel explained that mpox is predominantly spread by direct contact with infectious sores, scabs or body fluids, and so activities that involve close, personal contact with an infected individual can certainly spread the infection.

He said that since the outbreak in multiple countries in 2022 “the MSM community has certainly been disproportionately affected, and most of it does appear to have been transmitted by close sexual contact”.

Nel explained that the virus can sometimes be spread in other ways, such as from infected material - linen or clothes, or to household members and healthcare workers who are in close contact with people who have active mpox disease. “Although these ways aren’t as common,” he added.

He said a vaccination program focused on groups at high risk for exposure to mpox can help reduce the size of an outbreak.

“Spreading the word to key risk groups is very important, so that people stay informed and can take whatever precautions they feel they need to. Spreading the word amongst healthcare workers is also important so that they become comfortable with deciding when and how to test for mpox, and how to treat it,” Nel said.

According to the NICD, there have been 95,912 mpox cases documented from 118 countries for the period 1 January 2022 to 08 May 2024. As of 31 March 2024, the number of deaths reported from the outbreak was 185 from all six World Health Organisation (WHO) regions, with 139 deaths reported from the Americas alone.

The fact that South Africa has had two fatalities from only six cases suggests we are massively under diagnosing the real number of cases, since we know from the WHO statistics that most cases are not fatal.

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