Mpox Outbreak 2024: A Global Public Health Crisis

Mpox has once again surged to global attention as WHO and the Africa Centres for Disease Control and Prevention (CDC) declare it a public health emergency. With the Democratic Republic of the Congo at the epicentre of this outbreak, the virus's spread beyond Africa has raised international alarm, particularly with the emergence of a new clade, 1b. Health authorities are scrambling to contain the virus amid limited vaccine supplies, inadequate testing, and the need to balance responses to multiple public health threats.

Mpox (formerly known as monkeypox), an infectious disease caused by the monkeypox virus (MPXV), was discovered in 1958 and first reported in humans in 1970. Before 2017, mpox primarily occurred in central and western Africa, with sustained MPXV transmission in local animal reservoirs and sporadic spillover into human populations, mostly in rural areas. Ongoing human-to-human transmission in western Africa has occurred since 2017 and led to occasional exportation to other countries from 2018 to 2021. The virus is primarily transmitted from person to person through direct contact with infected lesions and bodily fluids, but transmission through respiratory droplets and via contact with fomites might occur. Two genetic clades of the MPXV exist—clade I and clade II, which includes subclades IIa and IIb.

In India, 30 Mpox cases have been reported since the WHO's 2022 PHEIC declaration. Further, India is reportedly implementing preparatory measures and public health strategies to address potential Mpox cases.India has been taking proactive measures against Mpox. The country has implemented a comprehensive strategy involving expert consultations, enhanced surveillance, laboratory preparedness, and awareness campaigns. While remaining vigilant, Indian health authorities have assessed a low risk of a large-scale outbreak, demonstrating a balanced approach to public health management in the face of emerging infectious diseases.

References

Mpox declared a public health emergency, Adepoju, Paul, The Lancet, Volume 404, Issue 10454, e1 - e2

Gessain, A., Nakoune, E., & Yazdanpanah, Y. (2022). Monkeypox. The New England journal of medicine, 387(19), 1783–1793. //doi.org/10.1056/NEJMra2208860

Jezek, Z., & Fenner, F. (1988). VI. Epidemiology of Human Monkeypox. In Human monkeypox (Vol. 17, pp. 81-110). Karger Publishers.

Ulaeto, D., Agafonov, A., Burchfield, J., Carter, L., Happi, C., Jakob, R., ... & Lewis, R. F. (2023). New nomenclature for mpox (monkeypox) and monkeypox virus clades. The Lancet Infectious Diseases, 23(3), 273-275.

//ncdc.mohfw.gov.in/wp-content/uploads/2024/08/CD-Alert-Mpox-August-2024.pdf

On August 14, 2024, the director-general of the World Health Organization (WHO) declared mpox in the Democratic Republic of Congo (DRC) and neighboring countries to be a Public Health Emergency of International Concern (PHEIC) under the 2005 International Health Regulations (IHR) — the WHO’s highest-level alert.

Mpox has been endemic in the DRC for more than a decade, with cases steadily increasing. In 2023, the country saw a sharp increase driven by a genetically distinct and more transmissible subtype, clade Ib. This year, the DRC has already reported more than 15,600 cases and 537 deaths. But because of insufficient surveillance, testing and contact tracing, many more cases remain undetected. Cases have been reported throughout the DRC’s 26 provinces, initially spiking in Équateur Province and then expanding into South Kivu, which has been ravaged by armed conflict and social unrest — conditions that pose major challenges for health workers. Cases have been reported in Kinshasa, a city with more than 17 million inhabitants. Overall, at least 12 African countries have reported cases, including 4 that had had no reported cases before this outbreak.

Human-to-human transmission has primarily occurred within households, in health care settings. Tragically, most cases and deaths in the current mpox outbreak have occurred in children.

There are currently two mpox vaccines recommended by the WHO’s Strategic Advisory Group of Experts on Immunization. On August 9, the WHO invited mpox vaccine manufacturers to apply for an Emergency Use Listing (EUL), which African countries and supporting partners such as Gavi could rely on in deploying vaccines. The United States and other high-income countries have substantial mpox vaccine supplies, but affected African countries have not had affordable access — an enduring indicator of inequity.

Priorities for an effective global response should include major investments in health systems, including diagnostics, surveillance, and the health workforce; risk communication encouraging culturally appropriate behavior changes; equitable access to lifesaving countermeasures; and sustained financing and action in the region.

References:

Gostin, L. O., Jha, A. K., & Finch, A. (2024). The Mpox Global Health Emergency — A Time for Solidarity and Equity. New England Journal of Medicine. //doi.org/10.1056/nejmp2410395  

Monkeypox, now named mpox, is caused by a double-stranded DNA virus (mpox virus) which is a member of Orthopoxvirus genus that was originally mainly present in Central and West Africa (1) The severity of the m-pox outbreak in May 2022 marked a significant escalation in its impact which has led to the World Health Organization (WHO) declaring the disease to be a world public health emergency of international concern on 23^rd July 2022 (2).

Epidemiological Update

The disease, endemic in some African countries, has spread across continental boundaries to American, European, and Asian countries, affecting more than 1,02,977 humans till 31^st July 2024, due to m-pox clade I and clade II, including 219 deaths, have been reported by 121 countries globally, according to WHO. All cases of m-pox clade I have been reported from the African continent apart from one reported by Sweden and one by Thailand (3). India has reported 30 cases. These cases have been confirmed in Kerala, Delhi, Maharashtra, Uttar Pradesh, and the Union Territory of Chandigarh. On 23^rd September, 2024, m-pox (Clade-I) has been detected in a 38 year old man from Kerela, who had recently returned from United Arab Emirates (4,5).

Aetiology of m-pox

Genus Orthopoxvirus includes many species, among which variola (smallpox virus), vaccinia, ectromelia (mousepox virus), and cowpox viruses are most common (6). It has two strains namely Congo Basin (CB) or Central Africa clade and West Africa (WA) clade (7). WA clade comprises milder symptoms as compared to CB strain, which is more malicious among humans and animals. Existing literature indicates that CB strain has potential to supress the expression of host genes which are responsible for providing immunity, thereby hindering T-cell activation and preventing infected human cells from releasing cytokines linked to inflammation (8-10).

Risk factors associated with m-pox

Direct and close physical contact with mammalian species which includes infected rodents, gazelles, hedgehogs, prairie dogs, non-human primates, and humans, exposure to respiratory secretions, individuals with compromised immune system, sexual contact, travel to endemic regions, attending events with large gatherings, unsafe handing or consumption of products from infected animals are risk factors associated with m-pox (10,11)

Vaccination Update

Three vaccines which are currently licensed for mpox are 1) modified vaccinia Ankara-BN (e.g., MVA-BN or JYNNEOS, Imvamune or Imvanex), a 2-dose 3rd generation smallpox vaccine that is a highly-attenuated replication-deficient vaccinia virus vaccine, approved in the USA, Canada and Europe; 2) LC16-KMB (licensed in Japan) and 3) OrthopoxVac (licensed in the Russian Federation). The WHO advises vaccination for only individuals at high risk of exposure, such as those with certain occupations or circumstances, and travellers who may be at risk, as determined by a healthcare provider. Further, based on currently assessed risks and benefits, mass vaccination is not recommended by WHO for Mpox at present. India has also not issued any advisory pertaining to Mpox vaccination till date (4).

Future Prospects

It is imperative for researchers to undergo deep analysis to evaluate and comprehend mutations in mpox viral protein and its key role in interspecies transmission, pathogenesis and disease severity. Eventually this will help to develop specific treatments strategies and predict its future outbreak to minimize its effect globally.

References

1. Doshi R.H., Guagliardo S.A.J., Doty J.B., Babeaux A.D., Matheny A., Burgado J., Townsend M.B., Morgan C.N., Satheshkumar P.S., Ndakala N. Epidemiologic and ecologic investigations of monkeypox, Likouala Department, Republic of the Congo, 2017.  Infect. Dis. 2019;25:273. doi: 10.3201/eid2502.181222.
2. Wenham and Eccleston-Turner, 2022 C. Wenham, M. Eccleston-Turner Monkeypox as a PHEIC: implications for global health governance Lancet, 400 (10369) (2022), pp. 2169-2171
3. European Centre for Disease Prevention and Control //www.ecdc.europa.eu/en/news-events/mpox-epidemiological-update-monkeypox-2-september-2024#:~:text=3%5D%20and%20below.-Epidemiological%20update,(shinyapps.io)%20 (Accessed on September, 24, 2024)

4. //ncdc.mohfw.gov.in/wp-content/uploads/2024/08/CD-Alert-Mpox-August-2024.pdf (Accessed on September, 24, 2024)
5. //www.hindustantimes.com/india-news/india-reports-first-mpox-case-of-clade-1b-from-kerala-s-malappuram-district-101727098315453.html (Accessed on September, 24, 2024)
6. H. Rubins, et al. Stunned silence: gene expression programs in human cells infected with monkeypox or vaccinia virus PloS One, 6 (1) (2011), Article e15615
7. Zahmatyar, A. Fazlollahi, A. Motamedi, M. Zolfi, F. Seyedi, S.A. Nejadghaderi, M.J.M. Sullman, R. Mohammadinasab, A.A. Kolahi, S. Arshi, S. Safiri. Human monkeypox: history, presentations, transmission, epidemiology, diagnosis, treatment, and prevention Front. Med., 10 (2023), p. 1157670.
8. C. Johnston, et al. Cytokine modulation correlates with severity of monkeypox disease in humans J. Clin. Virol., 63 (2015), pp. 42-45
9. Sagdat, A. Batyrkhan, D. Kanayeva Exploring monkeypox virus proteins and rapid detection techniques Front. Cell. Infect. Microbiol., 14 (2024), p. 1414224
10. Duarte, P. M., Adesola, R. O., Priyadarsini, S., Singh, R., Shaheen, M. N. F., Ogundijo, O. A., Gulumbe, B. H., Lounis, M., Samir, M., Govindan, K., Adebiyi, O. S., Scott, G. Y., Ahmadi, P., Mahmoodi, V., Chogan, H., Gholami, S., Shirazi, O., Moghadam, S. K., Jafari, N., … Tazerji, S. S. (2024). Unveiling the global surge of Mpox (Monkeypox): A comprehensive review of current evidence. The Microbe, 4, 100141. //doi.org/10.1016/j.microb.2024.100141 .
11. Anwar, et al. Clinical manifestation, transmission, pathogenesis, and diagnosis of monkeypox virus: a comprehensive review Life, 13 (2) (2023), p. 522

Sharing an interesting read!

"What’s in a name?": Using mpox as a case study to understand the importance of communication,
advocacy, and information accuracy in disease nomenclature

//www.medrxiv.org/content/10.1101/2024.06.24.24309420v1.full.pdf

The name of the disease plays a significant role in its stigmatizations. Many diseases have been named based on location of discovery, species, most impacted population or the discovering scientists. However it has accentuated the stigmatization. In order to mitigate this concern, the WHO names the disease based on pathogen or symptoms. Recently this was applied to a disease which came at the center of an outbreak leading to stigma and misinformation and hence the name monkeypox was changed to mpox. As the disease is endemic to west and central Africa it prompted racists remarks when it spread globally in 2022. Also its increased prevalence among men who have sex with men lead to stigma against LGBTQ +community.  mpox is the first among infectious diseases with stigmatizing name earlier which lead to early revision in the disease name. 

Posted by: @ashishjoshi

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Mpox, formerly known as monkeypox, is a zoonotic viral disease caused by the monkeypox virus, a species of the genus Orthopoxvirus. There are two main clades: clade I (subclades Ia and Ib) and clade II (subclades IIa and IIb). The 2022-2023 global outbreak was driven by the Clade IIb strain, primarily spreading through human-to-human contact, which may mean sexual networks (1). Children under 15 years in Central and Western Africa have contracted mpox through contact with infected animals, household transmission, or patient care, with wild animals often serving as reservoirs in endemic areas (2).

The Democratic Republic of Congo (DRC) had an increase of over 15,600 cases and 537 deaths in 2024 (3). Since the declaration of a Public Health Emergency of International Concern (PHEIC) by the WHO in 2022, India has reported 30 cases (5). These cases have been confirmed in Kerala, Delhi, Maharashtra, Uttar Pradesh, and the Union Territory of Chandigarh. As of 31 August 2024, 106,310 laboratory-confirmed cases, including 234 deaths, have been reported to WHO (4).

According to the World Health Organization (WHO), MVA-BN was the first vaccine added to its list of approved vaccines for mpox. Currently, three vaccines are approved for mpox:

1. Modified vaccinia Ankara-BN (MVA-BN or JYNNEOS, Imvamune, Imvanex), a 2-dose 3rd generation smallpox vaccine licensed in the USA, Canada, and Europe.
2. LC16-KMB is licensed in Japan.
3. OrthopoxVac, licensed in the Russian Federation.

Currently, the WHO does not advise on mass vaccination for mpox (1). The key public health actions that are necessary to prevent or mitigate symptoms. The primary prevention method for Mpox involves awareness of risk factors and educating individuals to reduce exposure to the virus. This includes isolation of infected individuals, enhancing vaccination rates, and enhancing awareness in healthcare providers and the community regarding identification of symptoms and early reporting to surveillance systems (6).

References:

1. National Centre for Disease Control. (2024, August). CD Alert: Mpox. //ncdc.mohfw.gov.in/wp-content/uploads/2024/08/CD-Alert-Mpox-August-2024.pdf
2. CDC. (2024, September 6). Mpox in the United States and Around the World: Current Situation Summary. Centers for Disease Control and Prevention. //www.cdc.gov/poxvirus/mpox/outbreak/index.html
3. World. (2024, August 14). WHO Director-General declares mpox outbreak a public health emergency of international concern. Who.int; World Health Organization: WHO. //www.who.int/news/item/14-08-2024-who-director-general-declares-Mpox-outbreak-a-public-health-emergency-of-international-concern
4. 4. World. (2024, August 26). Mpox. Who.int; World Health Organization: WHO. //www.who.int/news-room/fact-sheets/detail/mpox
5. Prime Minister Shri Narendra Modi continues to monitor the MPox situation in view of its declaration as a Public Health Emergency of International Concern by WHO | स्वास्थ्य एवं परिवार कल्याण मंत्रालय | भारत सरकार. (2024, August 30). Mohfw.gov.in. //mohfw.gov.in/?q=hi/node/7596
6. Kuehn, R., Fox, T., Guyatt, G., Lutje, V., & Gould, S. (2024). Infection prevention and control measures to reduce the transmission of mpox: A systematic review. PLOS Global Public Health, 4(1), e0002731–e0002731. //doi.org/10.1371/journal.pgph.0002731

Thank you for sharing your comprehensive overview of Mpox. Here are a few specific suggestions to improve the clarity and flow . 

Transmission Section:

Instead of "Children under 15 years in Central and Western Africa have contracted mpox through contact with infected animals, household transmission, or patient care, with wild animals often serving as reservoirs in endemic areas (2)," you could simplify to:

"In Central and Western Africa, children under 15 years have contracted mpox mainly through contact with infected animals, household transmission, or while caring for patients. Wild animals often serve as reservoirs in these endemic areas (2)."

Recent Outbreaks Section:

For clarity, update the sentence structure for readability:

"In 2024, the Democratic Republic of Congo (DRC) reported over 15,600 cases and 537 deaths (3). Following the WHO's 2022 declaration of a Public Health Emergency of International Concern (PHEIC), India reported 30 cases in Kerala, Delhi, Maharashtra, Uttar Pradesh, and the Union Territory of Chandigarh. As of 31 August 2024, 106,310 laboratory-confirmed cases and 234 deaths have been reported to WHO (4)."

@dr-mansi Thank you for your detailed and insightful article on the current Mpox outbreak and the global response to this pressing public health emergency. I appreciate the comprehensive overview of the virus's history, transmission dynamics, and the measures India has implemented to address potential cases.

Monkeypox virus (MPXV) was first identified in 1958 in laboratory monkeys, hence the name, though the virus’s natural reservoir is believed to be small rodents. The variola virus, which causes smallpox, is closely linked to the orthopoxvirus that causes Mpox . Double-stranded DNA makes up the virus, which belongs to two different genetic clades: the Central African (Congo Basin) clade, recognised for having more transmissibility and virulence, and the West African clade, which has a lower rate of case fatalities. Humans can contract the virus by coming into close proximity to or direct contact with infected animals, especially rodents, tainted items or diseased people. Human-to-human transmission can happen through skin lesions, body fluids, or respiratory droplets. The two clades of Mpox have demonstrated varying transmission and severity patterns.

References: //www.infezmed.it/media/journal/Vol_32_3_2024_1.pdf

Dealing with mpox in South Asia:

Mpox was initially declared a Public Health Emergency of International Concern (PHEIC) in July 2022. The PHEIC designation was lifted in May 2023 as case numbers declined. However, by August 2024, the reported 15,600 cases and 537 deaths exceeded the totals from 2023. On Aug 14, 2024, Dr Tedros Adhanom Ghebreyesus, WHO Director-General, once again declared mpox a PHEIC. 

The 2022 mpox outbreak prompted low- and middle-income countries in Southeast Asia to prepare for potential outbreaks. Currently, several nations have stepped up screening for fever and mpox symptoms at entry points like airports and seaports. High-level meetings are being conducted separately in India and Pakistan, as advised by their prime ministers, to assess preparedness for a potential new mpox outbreak. In India, the most recent mpox case was reported in March 2024, and no active cases exist as of August 22, 2024. Around 32 laboratories across India are designated for mpox testing. Meanwhile, Bangladesh's Directorate General of Health Services has launched a hotline for mpox reporting, and 12 national reference laboratories in Indonesia are tasked with diagnosis and whole-genome sequencing.