Early Release – Mpox Vaccine Acceptance, Democratic Republic of the Congo – Volume 30, Number 12—December 2024 – Emerging Infectious Diseases journal

For our cross-sectional analysis, we used data from a larger longitudinal telephone survey on COVID-19–related topics and vaccine hesitancy that began in 2022. The survey included participants from all 26 provinces in DRC and primarily targeted healthcare workers (HCWs). Participants were selected from historical telephone survey records of >10,000 persons. During December 2023–February 2024, trained interviewers contacted 5,226 adult participants and administered surveys in Swahili, French, Lingala, Kikongo, or Tshiluba. Survey questions addressed behavioral and social drivers of vaccination and attitudes toward introduction of new vaccines, including for mpox. Mpox vaccine acceptance was measured by asking participants about their interest in inclusion of an mpox vaccine in the national vaccination schedule. Response choices were yes, for adults, children, or both; no; and I do not know this disease (Appendix Table 1). We collapsed all yes responses for analysis. We assessed attitudes, vaccine acceptance by province, and sociodemographic characteristics via 5- or 3-level Likert scale questions and used a χ² test for significance (α = 0.05).

Among respondents, 79.2% were male, 20.8% were female, and most (12.6%) were from Kwilu Province. Participant representation from urban or rural settings was roughly equivalent. Most (41.2%) respondents reported some college or university education, and 55.5% identified as HCWs (Table).

Figure 1

Figure 1. General mpox vaccine attitudes and perceptions from a telephone phone survey about mpox vaccine acceptance conducted during December 2023–February 2024, by province, Democratic Republic of the Congo. A) Reported responses…

Participants generally disagreed with the statement that new vaccines carry more risks than older vaccines. However, in 4 provinces, Sud Kivu, Nord Ubangi, Nord Kivu, and Lualaba, >50% of respondents agreed with or felt that greater risks exist with newer vaccines. Respondents generally agreed with the statement that information received from the vaccination program was reliable and trustworthy. In Sankuru Province, 29.5% of respondents felt neutral about the reliability of vaccine program information; the highest percentage of vaccine information distrust and disagreement with the statement were in Haut Katanga (7.6%) and Lomami (6.8%) Provinces (Figure 1; Appendix Table 2).

Figure 2

Figure 2. Geography of overall mpox vaccine acceptance perceptions from a telephone phone survey about mpox vaccine acceptance conducted during December 2023–February 2024, by province, Democratic Republic of the Congo. A) Reported…

Nationally, 61.0% (95% CI 59.6%–62.4%) of respondents expressed acceptance of an mpox vaccination, 21.7% had no interest, and 17.3% reported no knowledge of mpox. At the province level, >80% of respondents from Kwango, Tshuapa, Nord Ubangi, Tanganyika, and Maniema reported vaccine acceptance. Sankuru had the lowest acceptance rates (19.9%; 95% CI 14.3%–26.6%) and highest percentage (57.4%; 95% CI 49.7%–64.8%) of participants reporting no mpox knowledge. In general, rates of mpox vaccine acceptance and mpox disease knowledge were not influenced by the history of mpox cases within the province (Figure 2).

Figure 3

Figure 3. Percentage of mpox vaccine acceptance and demographic characteristic perceptions from a telephone phone survey about mpox vaccine acceptance conducted during December 2023–February 2024, by province, the Democratic Republic of the…

Interest in an mpox vaccine varied significantly by province (p<0.0001). When stratified by educational attainment, respondents with a high school diploma had much lower (49.8%; 95% CI 47.3%–52.3%) acceptance of the mpox vaccine than other groups. Among reported occupations, HCWs had the highest acceptance rates (69.4%; 95% CI 67.6%–71.1%). Respondents from rural locations indicated greater mpox vaccine acceptance than their urban counterparts (64.4% vs. 57.7%; p<0.0001). Among 4,396 respondents who reported receiving a COVID-19 vaccine, 63.2% indicated mpox vaccine acceptance. In addition, persons without chronic conditions reported higher rates of mpox vaccine acceptance than persons with chronic conditions (62.2% vs. 51.0%) (Figure 3).

Given the ongoing mpox clade Ia and clade Ib outbreaks in the DRC and identification of cases in adjacent countries in Central Africa, introduction of a vaccine is increasingly needed. However, a paucity of information has been available regarding mpox knowledge and vaccine acceptance across DRC. We observed greater interest in mpox vaccine deployment among respondents from rural than urban locations. That finding could be explained by the historic mpox burden in DRC, where mpox cases primarily were among children in rural regions. Currently, reported mpox cases are rising in urban centers, further challenging response and vaccine planning efforts.

Assessing mpox vaccine trust and acceptance across provinces that have and have not experienced mpox cases and across demographic variables did not yield clear or neatly described trends. Instead, we observed several outliers that may reflect the diversity of DRC. For example, differing vaccine acceptance rates between persons with and without chronic health conditions may indicate underlying health anxieties among persons with persistent health problems; further investigation is needed to clarify that relationship. In addition, Sankuru Province was consistently a vaccine-hesitant outlier in this survey. Sankuru had the lowest percentage of respondents who trust information received from national vaccine programs and the lowest mpox vaccine acceptance, primarily because 57.4% of respondents stated no knowledge of mpox. In DRC, most mpox-endemic provinces consist of rainforest or forest-savanna mosaic geographies; the southeast provinces are primarily savanna and grassland and have no history of reported mpox cases. However, in June 2024, Lualaba Province in the southeast reported its first mpox case. Of note, that province had the highest percentage of respondents believing that new vaccines have greater risks than older vaccines, although overall trust in national vaccine programs was high.

Although our results report an overall trend of vaccine trust and acceptance nationwide, they also indicate the need for a multifaceted approach to vaccine education and rollout. Strategies should be tailored to historically endemic regions and areas with lower vaccine acceptance, such as Sankuru or Kasai Central, and consider how personal experiences and cultural considerations intersect with mpox outbreaks. Of note, Haut Lomami Province has been the setting of long-standing routine immunization revitalization efforts (9,10), and 100% of respondents from that province reported that they feel information from the national vaccine program is reliable. That highly positive response is perhaps reflective of the many years of vaccine campaigns and education efforts in the region.

This survey was limited to persons with access to telephones; persons with a lower socioeconomic status, including those in largely rural regions, may have been inadvertently excluded. This study included respondents from all provinces in DRC and targeted HCWs. Past studies in DRC have demonstrated 54% acceptance toward outbreak-related vaccines, and HCWs continually express the highest acceptance among respondents (11). Because this study sought to enroll HCWs and community and religious leaders, we observed an overrepresentation of men because men primarily hold leadership roles in the country. Because HCWs and religious leaders serve as health recommenders for their communities, however, identifying and addressing vaccine acceptance among those groups is critical.

In conclusion, our findings provide insights regarding mpox vaccine acceptance within DRC. Our data highlight the need for increased community engagement and sensitization before widespread mpox vaccine deployment.