PATIENT ZERO: HOW ONE DOCTOR HELPED UNCOVER THE ORIGIN OF THE DRC’S MPOX OUTBREAK
Convinced the jungle was harbouring mpox, Dr Leandre Murhula Masirika grabbed his gear and headed towards the vast forests in the Democratic Republic of Congo’s eastern provinces.
His plan was simple: to look for the virus in bushmeat hunters and wild animals, and gauge the threat of a spillover to people in South Kivu. It was September 2023 and, so far, the area had escaped an escalating outbreak more than 1,000 miles away, in the DRC’s west and central regions.
But Dr Murhula Masirika was curious – might mpox be lurking in the province’s squirrels, rodents and monkeys, too?
Then his phone pinged. The message contained the last thing he expected: there, in his WhatsApp inbox, was a photo of the very virus he’d been looking for.
“I had it in my mind that maybe I’d find mpox in the jungle, in bushmeat hunters or wildlife. But then suddenly, as I was travelling to do research, a human mpox case appeared in my WhatsApp,” he says, slight disbelief still in his voice more than a year later.
A doctor in Kamituga – a crowded gold mining town 170 miles south east of Bukavu, South Kivu’s capital city – had sent him the picture. It showed a man languishing on a bed, covered in sore, bulbous lesions.
The healthcare worker wasn’t 100 per cent sure what it was – mpox had never been reported in the area. But Dr Murhula Masirika had recently returned home to the DRC after studying epidemiology in central Spain and he was sure mpox was the culprit.
What he didn’t know then was that the man, who ran a bar-come-brothel, was ‘patient zero’ in an outbreak of a new, more dangerous strain of mpox called clade 1b, which would trigger a global health crisis and infect thousands of people – including six in Britain.
Nor could he know that a year and a half later, epidemiologists would still be scratching their heads about how, and why, the concerning new strain emerged in the remote mining town.
‘He thought what he had was a curse’
Three days after the WhatsApp message, Dr Murhula Masirika reached Kamituga. After reporting to the South Kivu health department, the 36-year-old epidemiologist had hurtled hundreds of miles across the province to the town, keen to arrive before the rainy season – once the deluge sets in, the already dicey roads to town are rendered almost impassable for months and months.
When he arrived, the situation was worse than he expected.
“Reaching the hospital, I saw horrible things. There were people with no help, no mattress, really suffering from mpox,” Dr Murhula Masirika recalls. “The first case, he thought what he had was a curse.”
Patient zero – the manager of one of almost 70 drinking establishments in Kamituga – had initially gone to a traditional healer, who promised to cure him with cassava leaves.
Yet painful blisters were still multiplying across his body – by the time he went to hospital on September 29, 2023, his genitals were covered. The lesions were also attacking his eyes and his throat, making it difficult to speak or eat. Three recently recruited sex workers, who he had contact with, also fell ill. So did the healer’s son.
While the doctors treated them, Dr Murhula Masirika launched epidemiological investigations. Very soon, he was convinced something unusual was unfolding.
“The lesions were developing differently from the mpox that we knew, [they were] concentrated around people’s genitals,” he says. “And already, the disease was not transmitted from an animal to human, but human to human.”
This raised alarm bells, as it didn’t fit with descriptions of clade 1. This strain of mpox has been endemic in the DRC since it was first discovered in a child in 1970. Generally, small transmission chains were sparked after the virus jumped from animals to people, but in recent years the pathogen had exploded in the western and central provinces.
Yet clade 1 hits children hardest, with lesions mostly on their feet, hands and faces. That’s not what Dr Murhula Masirika and his colleagues were seeing in Kamituga.
Painful, large blisters were focused around patients’ genitals, and mpox was increasingly rampant in the town’s bars – especially among sex workers and their clients (later, disease mapping published as a preprint would conclude that 88 per cent of 371 cases in hospital between September 2023 and April 2024 were linked to this group of people).
Some suggested the outbreak might instead be clade 2, a less deadly strain which erupted across the globe in 2022. But this mainly affected gay and bisexual men, causing fairly mild symptoms. The severity of the situation in Kamituga didn’t seem to fit, either.
“From the start, I knew it must be something different,” says Dr Murhula Masirika, who moved from his family home to Kamituga, to research the virus and help organise the response. “This was heterosexual transmission, between men and women… and it was spreading in the bars with a lot of sex workers.”
Initial sequencing proved him correct: Kamituga’s already overstretched hospitals were inundated with patients suffering from a new strain of mpox.
“We were happy, as local researchers, to have discovered this new strain. But we were also very afraid of what it meant for South Kivu,” says Dr Murhula Masirika.
The last chance to contain the outbreak
His fears would prove well-founded; despite the best efforts of healthcare workers, the early response was limited.
Soon, some 50 people a week were heading to Kamituga’s colonial-era hospital – but there weren’t enough beds, enough food, enough blankets, enough soap, or enough drugs. Healthcare workers also fell ill: two lost the sight in one of their eyes, and at least one nurse in a nearby district died.
“At a certain point the hospitals were overloaded, the number of beds for inpatients was not enough,” says Dr Jean Claude Udahemuka, from the school of Veterinary Medicine at the University of Rwanda, who collaborated with Dr Murhula Masirika to sequence the virus.
“Leandre was temporarily using research funds or his own money to support patients. Some people didn’t want to stay in the hospital, they said their ability to buy food depended on them going to work in the bars. And they were scared. So he was supporting them in every way, so at least they could recover and stay in hospital, which would also limit the spread.”
By January 2024, Dr Udahemuka, Dr Murhula Masirika and the Global Health Network – led by the Oxford University professor Trudie Lang – had set up research projects in Kamituga to better understand the unfolding crisis, part-funded by the UK Medical Research Council.
But even as the situation spiralled, warnings and calls for help fell on deaf ears.
“I think when this started, during that rainy season, we had a chance to stop the spread – Kamituga is a remote area, so we had that window of opportunity to contain it,” said Dr Udahemuka. “But at that time, many people were not interested enough to get involved.”
Instead, the rainy season ended and election season began. By April 2024 – when an international consortium, led by the National Institute of Biomedical Research (INRB) in the capital Kinshasa, published a pre-print dubbing the new strain clade 1b and warning of “pandemic potential” – it was too late to halt the spread.
Although there had been a trickle of people leaving the mining town, movement had been minimal. But when Kamituga’s large migrant population, who travel from across the DRC and its neighbours to work in the mines, started to travel en masse, they took clade 1b with them.
By August 15, 2o24, when the World Health Organization declared an international public health crisis, the new strain had already been detected in Burundi, Kenya, Rwanda and Uganda. Cases have since been reported as far away as Thailand, China, the UK and the US.
“It was in late September 2023 that we were first hearing reports of cases being picked up among sex workers in South Kivu, and we were able to start research very quickly,” says Dr Jason Kindrachuk, an associate professor in medical microbiology and infectious diseases at the University of Manitoba in Canada, and part of the team behind the April pre-print.
“But I think there was also a situation where we’re all trying to respond to this massive, massive wildfire – and we had just a few bottles of water to throw at it.”
Five months later, the response has accelerated – more treatment centres have been established, community awareness campaigns launched, and by the end of December 55,000 people had been given at least one mpox vaccine, according to the latest WHO situation report.
But it has not been enough to curtail the epidemic. The arrival of more vaccine has been frustratingly slow, and the number of doses that have arrived has not been enough to even cover the at-risk population. In Kamituga, there were roughly 1,500 new cases last week, says Dr Murhula Masirika – the vast majority among children, who are not yet being immunised.
Diagnostics also remain limited – in 2024, just 22 per cent of suspected cases were officially confirmed. And 1,200 miles away in the capital Kinshasa, health officials are now battling to contain an outbreak of both clade 1a and clade 1b.
“There is not much change in Kamituga regarding the mpox situation,” Dr Placide Mbala-Kingebeni, head of epidemiology and global health at the University of Kinshasa and an associate professor at INRB, told the Telegraph. “And there are more cases even in Kinshasa.”
Uncovering the secrets of a deadly new strain
There are also unanswered questions. Researchers have uncovered many of clade 1b’s secrets – it is now estimated, for instance, that the mortality rate is fairly low at 0.5 per cent, but that high numbers of pregnant women infected go on to miscarry or have a stillbirth.
Yet experts still aren’t sure whether the virus is spread through direct contact during sex, or through semen and vaginal secretions – or both. Nor is it clear why children appear to be most vulnerable, while research is ongoing to determine whether the current vaccines can also be used to protect kids.
Dr Muruala Masirika says most of the cases in Kamituga are now among unvaccinated children, who typically infect each other when they play.
The virus is also rampant in the displacement camps close to Bukavu and Goma – the capital of the neighbouring province North Kivu, where conflict is raging. The cramped, unsanitary conditions are proving fertile ground for mpox to thrive, especially among children living and sleeping in close quarters.
But there’s another looming question: how did clade 1b emerge – and why in Kamituga?
“This is a mystery we are all wondering about,” says Dr Murhula Masirika.
There are a few theories. Patient zero, the man dubbed the “index case” in health ministry reports, had recently returned to Kamituga from Kisangani – a city in the more central Tshopo province. There, he’d recruited three professional sex workers before travelling home via Bukavu, the South Kivu capital.
“So he could have been infected in Tshopo, in Bukavu, or in Kamituga,” says Dr Murhula Masirika. “But when I interviewed him, he said he hadn’t been in contact with any wildlife. He had visited a zoo in Tshopo, but he had not touched the animals.”
This may mean that the bar manager wasn’t patient zero after all, but was infected by another person – potentially someone with mild symptoms, who never sought medical care.
“But until we find the virus in an animal, I think it will be difficult to answer this question,” says Dr Murhula Masirika.
Still, there is evidence that his initial project – to seek mpox in South Kivu’s wildlife – could offer answers.
In 2015, a paper in the American Society of Tropical Medicine and Hygiene reported on two human cases of mpox in South Kivu.
One patient was a farmer who had recently been in a highly forested area; a second man had handled monkeys killed by local hunters, and taken some monkey meat for an upcoming journey. Analysis of the viruses found they “may share some genetic traits that differentiate them” from the clades widely circulating in the country.
“We have the same impression that this strain has been there [since] some time ago,” says Dr Mbala, referring to the paper.
“The reality is that this is not something that just, kind of emerged out of thin air, there are all these little events happening in the background,” adds Dr Kindrachuk.
“I think it’s not so much that the virus suddenly adopted all these mutations that allowed it to move through sexual contact. It’s more the fact that it was there, but only recently found its way into a population where it could move efficiently.”
Still based in Kamituga, Dr Murhula Masirika is determined to help answer these questions, and many more.
“It is not easy,” he says, speaking over the phone. “I have spent my own money on food and mattresses and supplies for the patients, and I have stayed away from my family – last August I had my wedding, then I came straight back to the field.
“But I am determined not to abandon the people here. And there are many unknowns still to discover,” Dr Murhula Masirika adds. “I’m not working for myself, I’m not working for my family. I’m working for the world.”
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2025-01-23T15:57:52Z
