Genetic sequencing analysis of monkeypox virus clade I in Republic of the Congo: a cross-sectional, descriptive study.

Background: Monkeypox virus clade I is endemic in several central African countries and characterised by an increase in disease severity and mortality. Since October, 2023, a large-scale mpox outbreak has emerged in DR Congo, and in March, 2024, the first individuals with mpox were reported outside the endemic areas in Republic of the Congo. We aimed to provide insight into the epidemic by sequencing samples obtained from individuals with mpox in Republic of the Congo.

Methods: In this cross-sectional, descriptive study, samples were collected from individuals with suspected mpox between Jan 15 and April 8, 2024, in Brazzaville, Pointe-Noire, Likouala, Cuvette-Centrale, and Plateaux (Republic of the Congo). Blood samples, skin or oropharyngeal swabs, or skin crusts were obtained for molecular diagnosis via real-time PCR. Monkeypox virus sequences were obtained and analysed using newly established nanopore sequencing methodology and bioinformatic pipeline. The sequences obtained were aligned and used to construct a maximum likelihood phylogenetic tree using IG-TREE.

Findings: 61 samples were collected from individuals with suspected mpox, 31 of which were positive for monkeypox virus and were included in our analysis (four positive samples were excluded due to unavailability of epidemiological data or insufficient biological material). Individuals who tested positive for monkeypox virus were from Cuvette-Centrale (19 [61%] of 31), Likouala (eight [26%]), and Pointe-Noire (four [13%]). 20 (65%) were male and 11 (35%) were female. Phylogenetic analysis of sequences showed two major clusters within clade Ia. One cluster was made up of four sequences from this study clustering with two monkeypox virus sequences from the current DR Congo outbreak, three older sequences from Central African Republic sequenced between 2017 and 2018, and seven sequences from DR Congo sequenced in 2006-07 and 2022. The second cluster was made up of 16 sequences from this study clustering with sequences from the current DR Congo outbreak. In addition, sequences from Republic of the Congo show multiple phylogenetic positioning suggesting the occurrence of multiple co-circulating strains in the human population.

Interpretation: Our findings suggest that multiple monkeypox virus strains are co-circulating in the human population, highlighting the need for implementation of expanded mpox surveillance, especially in countries bordering DR Congo and Republic of the Congo, in combination with control measures focused on containing the current outbreaks in these countries to prevent escalation into a larger-scale epidemic.

Funding: Intramural Research Program of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health.