Mpox Outbreak: Impact and Public Health Response

Abstract

The re-emergence of mpox as a global public health threat has once again brought the viral disease to the attention of the international community. As mpox cases increase and spread beyond the shores of Africa, public health experts face the challenge of implementing effective measures to contain the disease. This review aims to examine the significance of mpox in public health, with a particular focus on recent outbreaks and understanding the public health response. The review explores recent approaches, including vaccination strategies, risk communication, and emergency preparedness. The paper also critically analyses limitations and offers possible future directions for improving the management of current and future outbreaks. Google and Google Scholar search engines as well as PubMed database were searched to identify literature concerning mpox public health impact and response. Websites of the WHO and similar organizations were also searched. The key search terms used were ‘‘mpox,’’ ‘‘public health,’’ ‘‘impact,’’ ‘‘response,’’ and ‘‘outbreak.’’ The review findings highlighted the challenges and gaps in the ongoing mpox outbreak response, ranging from vaccine shortage to limited surveillance and testing capacity and infrastructure, as well as inequitable access to vaccines and medical countermeasures. Other challenges include logistical issues and ongoing conflicts. This article emphasized the urgent need for multi-sectoral collaboration among key stakeholders, including embracing a One Health approach in case detection and investigation. The prevention and control of mpox require a more effective response that prioritizes rapid and equitable access to vaccines, diagnostics, and other necessary countermeasures.

Introduction

Mpox is an infectious disease caused by the monkeypox virus.1 This disease is widespread among primates and small animals.^1,2 It is endemic in Central and West Africa, where regular outbreaks are common, particularly in the Democratic Republic of Congo (DRC).^1,2 In 2022, a global outbreak of mpox occurred suddenly, spreading across Europe, the Americas, and other areas, including traditionally endemic and non-endemic regions.^1,2 From May 2022 to April 2023, over 85,000 mpox cases were reported in 111 non-endemic countries³ (see Figure 1 below). Unlike other mpox outbreaks, which predominantly affected children in endemic regions, the 2022 epidemic was particularly prevalent among men who have sex with men (MSM).^1,2 Transmission was driven by unprotected sexual intercourse, spreading the disease through sexual networks.^1,2

Since the 2022 outbreak, mpox cases and deaths have surged in the DRC, leading to a persistent global threat in 2024 as the disease spreads to other countries in Africa and beyond.¹ Between January 2022 and August 2024, there have been over 100,000 confirmed cases and more than 220 deaths attributed to the ­disease.¹ Vaccination is a key public health strategy in preventing and controlling mpox outbreaks.^1,2 Individuals who receive the mpox vaccine exhibit milder symptoms of the disease.² Vaccination campaigns typically target high-risk population groups in endemic regions, including health workers and animal handlers.² Others include people with multiple sex partners, MSM, and those living in close communities with infected individuals.¹ The rapid spread of the current mpox outbreak beyond Africa to countries like Sweden and Pakistan has raised the global threat levels of the disease.⁴

The urgent need for vaccines and other medical countermeasures in affected countries amid limited supplies has raised international concern and calls for a coordinated response to the outbreak.⁴ However, similar to the 2022 mpox outbreak and the COVID-19 pandemic, the current outbreak faces challenges in access to vaccines and other vital resources, including testing and surveillance, especially in low-and middle-income countries.⁴ Apart from these challenges, the current dynamics of the disease are still poorly understood.5 Because the reason is that despite being around for decades, mpox has not been a priority for global public health.⁵ As the natural reservoir of mpox virus has yet to be discovered,^1,2,6 it is not yet known how it is maintained in nature.6 The absence of this knowledge limits how changes such as climate and human activities impact the prevalence of the mpox virus in nature and the risk of human acquisition.⁶ In light of the current outbreak, research is required to understand the gaps in existing mpox outbreak response. There is an urgent need to analyze current approaches to improve global preparedness for mpox outbreaks. This paper aims to provide an overview of the mpox outbreak, focusing on assessing the current public health response. In exploring trends from previous outbreaks, lessons learned, and current approaches to emergency preparedness, it is hoped that this paper will highlight solutions for existing gaps to support a more equitable and efficient response.

Methods

A literature review addressed the global impact of mpox outbreaks, the public health response, and ­current outbreak control strategies. Various search terms, search engines, and databases were used to ensure relevant literature was captured. Key search terms used in the search include ‘‘mpox’’, ‘‘public health’’, ‘‘impact’’, ‘‘response’’, and ‘‘outbreak’’. The searched articles included research studies, reviews, opinion pieces, and reports written in English. Google and Google Scholar search engines, the PubMed database, and WHO websites and similar organizations were searched.

Inclusion and Exclusion Criteria

Articles included were publications in English, covering the period from 2015 to 2024, and studies with content addressing the public health impact of mpox and response strategies against the disease outbreak. Non-English articles were not included and had inconsistent content with the research aim.

Disease Transmission

Transmission of the disease typically occurs in small animals, including squirrels, rats, and primates like monkeys, and in humans through direct contact with infected animals or their fluids² (see Figure 2 below). Mpox can also spread from person to person through close physical contact with a symptomatic person and from mother to child during pregnancy or birth.^1,2 However, the natural reservoir of the virus remains unknown.^1,2 The symptoms of mpox include rash, fever, fatigue, body pains, and swollen lymph nodes, and may last from 2 to 4 weeks.¹ Treatment is supportive, focusing on symptomatic management and preventing complications.1 Vaccines for mpox prophylaxis are available and are recommended for high-risk populations such as the immunocompromised, especially during outbreaks.¹

The first human case of mpox was reported in 1970 in the DRC, after which the disease steadily grew in Central, East, and West Africa1 (Figure 3). Thousands of cases of mpox have occurred in the DRC every year since 2005.¹ With increasing urbanization, the interaction between people and wild animals and global travel, the disease continues to spread across various African countries and beyond to non-endemic areas.^1,2

Unlike the outbreak in 2022, which mainly affected MSM, the current mpox outbreak affects a wider demographic.⁴ This time, the virus is primarily transmitted through direct contact rather than through sexual intercourse, as seen in the previous outbreak. It consequently affects individuals of all genders and ages.⁴ The DRC, which is the focus of the response, accounts for 95% of the reported cases and 99% of deaths from the disease.⁴ 

Public Health Response

Due to its considerable impact, upsurge in cases, and potential threat to global health, the WHO declared the mpox outbreak a Public Health Emergency of International Concern (PHIEC) in August 2024 – marking the second occurrence in two years.^1,4 As part of the outbreak response for mpox, WHO and other international partners are focused on enhancing health systems, advancing vaccine research and providing access to medical countermeasures (vaccines, diagnostics, and therapeutics).¹ Key priority areas for public health control measures required for an effective mpox response encompass vaccination, surveillance and testing, and risk communication.⁷ These issues were identified as common themes present across the literature.

Vaccine Access

Two vaccines have been identified for mpox by the World Health Organization (WHO) and their emergency use listing has been initiated.⁴ Two African countries, the DRC and Nigeria, have granted regulatory approval for these vaccines. However, the continent is experiencing a severe shortage of mpox vaccines.⁷ Only 200,000 doses are currently available, whereas according to the Africa Centers for Disease Control and Prevention (Africa CDC), the total vaccine requirement is 10 million doses.^4,7,8 Therefore, there is an urgent need for surge financing to procure vaccines. Although organizations like Gavi have started making funds available through their $500 million First Response Fund, regulatory barriers impede progress in this direction.⁸ Other donors and initiatives, including the Africa Epidemics Fund and various Development Finance Institutions, have indicated support but are yet to take concrete action.⁸ Overall, the response to the call for vaccines and medical resources has been slow and fragmented so far.⁸

Vaccine donations from other regions and nations are expected to offset the shortfall experienced by affected African countries. The European Union (EU), the United States, and Japan are among those that are expected to make donations.⁸ However, these donations might be hampered by legal, regulatory, and logistical challenges if not coordinated closely.⁸ Conversely, there are fears of vaccine hoarding–countries holding stockpiles and refusing to share with their more affected counterparts. High-income ­countries exhibited this practice of vaccine nationalism during the COVID-19 pandemic.⁹ This led to vaccine inequity and hampered the pandemic control efforts, particularly in low- and middle-income countries (LMICs).⁹ The high cost of vaccines also made them inaccessible to poorer countries, further exacerbating global health inequities.^9,10 The experience of the COVID-19 pandemic has prompted calls for African nations to be more proactive this time.¹¹ This way, less affluent nations will not be left struggling with limited access to critical medical resources.¹⁰

Surveillance and Testing

Like vaccination, surveillance, and testing are crucial aspects of the mpox outbreak response.^2,4,7 Early detection of cases, a strong surveillance system, and accurate diagnosis are essential to manage and control the further spread of the disease.^2,4 Robust laboratory networks supported by timely reporting are shown to strengthen case detection.^12,13 However, there is a significant lack of testing and surveillance in many mpox-affected regions, ^4,7,10, especially in the DRC, which conceals the full extent of the outbreak and limits diagnosis.⁴ In the DRC, less than 30% of cases are tested.⁴ This means many cases remain potentially undetected. Inadequate testing and surveillance also affect the reporting of actual incidence of death. This is because all deaths from mpox may not be captured due to limited access to testing.^7,14

Public health authorities also struggle with transporting samples from collection sites to laboratories for testing.⁴ Many mpox-affected areas face ongoing conflicts or are located in remote areas without good road networks.^4,7,15 These issues present significant logistical challenges for surveillance and testing. Global health inequities and disparities extend beyond vaccine access to surveillance and testing.¹⁰ Most countries affected by the mpox outbreak are notably resource-limited regions, which poses a significant challenge to the outbreak response.¹⁰ As mentioned, many mpox cases in these countries are not captured due to a lack of testing and surveillance resources.¹³ Conversely, middle- and high-income countries have better laboratory and surveillance capacity and infrastructure for outbreak response.¹⁶

Some experts suggest integrating a One Health approach in case detection and investigation will benefit the mpox outbreak response.^6,17 As such, contact tracing should not be limited to human-human contact tracing but also animal-animal and animal-human contact tracing.¹³ The concept of One Health acknowledges the interdependence of human and animal health and aims to improve coordination between human and veterinary public health services.⁶  In the United States, previous mpox outbreaks in 2003, as well as those in Cameroon in 2014 and 2016, highlighted the crucial role of veterinary public health services in the response efforts.⁶ However, animals were directly involved in the outbreaks in both instances.⁶ One Health can be significant in mpox surveillance and outbreak response efforts.⁶ By organizing control measures around multi-sectoral stakeholders, including the public and agricultural and animal health sectors, will greatly increase opportunities to identify and reduce primary sources of mpox virus.⁶

Risk Communication

Risk communication and community engagement also play key roles in the outbreak response.² It is essential to raise awareness about modes of transmission, risk factors, and preventive measures of mpox through public health education, which empowers individuals and communities.¹² The rapid growth of mpox cases and the wide geographical spread of the disease during the 2022 outbreak caused significant concern among experts.¹⁷ This also brought about confusion in achieving a delicate balance in clearly communicating the disease without risk of stigmatization.¹⁸ Comprehensive public health education and communication around mpox address the stigma and discrimination experienced by vulnerable groups, particularly MSM.¹² High rates of mpox cases were reported among MSM during the 2022 outbreak.¹³ As such, this helped to push the narrative linking mpox with sexual intercourse between men.¹³ This is even though other modes of transmission of mpox besides sex exist.13 Another stigma associated with mpox is racial due to the narrative of the media linking mpox to Africa.¹³ This narrative persisted even when the 2022 outbreak occurred outside Africa.¹³ The changes in transmission dynamics of the mpox virus are another cause for concern, as the risk it poses to different groups cannot easily be predicted.¹⁸ This implies that the disease has the potential to spread more widely than before.¹⁸ Moreover, the mutation and accelerated evolution over time strengthen the mpox virus’ ability to be transmitted more easily and behave in new ways.¹⁸ This poses a challenge for effective community engagement and risk communication.

Discussion

This review aimed to assess the mpox outbreak, focusing on its public health impact and understanding the current public health response. The literature was analyzed using three themes: vaccine access, surveillance and testing, and risk communication. These are also key priority areas in an outbreak response. The challenge of equitable access to vaccines was a major point emphasized in the reported literature. The current mpox outbreak response struggles with insufficient vaccines in most affected areas, particularly resource-poor settings. The issue of equitable vaccine access has persisted from previous disease outbreaks and epidemics. There are lessons to be learned from recent experiences during the COVID-19 pandemic about vaccine inequity.¹⁹ This was also highlighted in the literature. This observation aligns with previous literature that reports longstanding inequity in access to vaccines, diagnostics, and therapeutics.²⁰ Existing response strategies, therefore, need to be urgently reviewed to address these inequities. Countries or regions with a higher burden of mpox should receive more vaccines to reduce transmission rates.

Surveillance and testing, as well as risk communication, are key aspects of the mpox outbreak response that were also discussed in the literature. Several articles highlighted the challenge of poor diagnostic and testing capacity in affected regions. Research shows that countries with robust laboratory and ­surveillance infrastructure and effective risk communication have higher case detection rates and better outbreak and emergency response.¹⁶ Countries, like the United States, Spain, and Belgium, have been shown to have effective surveillance systems to manage emergencies.^21,22 Studies also show that risk communication strategies are effective in the detection of mpox cases alongside the implementation of good health infrastructure.^16,23 Therefore, improved health infrastructure and preventive measures, including communication strategies, are critical for a robust outbreak response. Health awareness and community engagement help to empower communities and are effective measures for prevention.

Previous research has shown that under-reporting of mpox cases is a significant problem in rural regions of Africa due to a lack of medical facilities and poor data.²⁴ A significant relationship exists between poverty and infectious disease outbreaks.²⁵ Inadequate surveillance capacity due to poverty negatively impacts the mpox outbreak response.²⁶ Poverty-alleviation strategies and health system strengthening programs, including robust surveillance infrastructure, are therefore required to effectively tackle the mpox outbreak.^27,28 The One Health approach suggested in some of the literature is also highlighted in another research. Studies show that a One Health approach integrating human, animal, and environmental sectors facilitates outbreak investigation.¹² Lewis R. indicated the importance of inter-sectoral collaboration between health and environment experts to reduce disease transmission and prevent zoonotic infections like mpox.²⁹ Awoyomi O. et al. emphasized the input of animal and human health workers to help improve knowledge of mpox disease and enhance surveillance and early detection.³⁰ Tambo E. and Al-Nazawi A. showed the importance of human-animal-environment transmission dynamics and suggested leveraging the One Health approach partnership in mpox programs.³¹ Considering the zoonotic origin of pox, it is crucial to institutionalize a multi-sectoral One Health strategy across local, regional, national, and global levels.³²

The challenge of availability and access to vaccines and other critical medical resources highlights the urgent need to establish structures and frameworks for effective vaccine distribution and local manufacturing. Expanding diagnostic and testing infrastructure will help strengthen existing surveillance systems in affected countries. This is essential for an effective mpox disease outbreak response.³² Greater commitment is needed from national governments to invest in health systems and strengthen infrastructure. Support from the international community, including high-income countries, through increased funding and knowledge sharing to LMICs will significantly improve the outbreak response.

Conclusion

Largely ignored by the international community, the mpox disease outbreak emphasizes the risks of neglecting diseases endemic in low-income regions. This review provided an overview of the spread and impact of the current mpox outbreak. Unlike the previous one in 2022, the ongoing mpox outbreak spreads by direct contact and affects a wider demographic. This makes it a significant threat to global health due to the rapid surge in cases and the risk of international spread. Existing key public health strategies include vaccination, surveillance and testing, and risk communication. However, gaps and challenges exist in the current mpox outbreak response approach. Most significant are vaccine shortage, inequity, and limited surveillance and testing capacity. Mpox-affected regions struggle with severe shortages of mpox vaccines, limited laboratory and surveillance infrastructure, inadequate funding, and ongoing conflicts – all of which negatively impact response efforts.

This review emphasizes the need for urgent and coordinated action to tackle these challenges and prevent the further spread of mpox. Both domestic and international collaboration is required to improve surveillance capacity, increase the availability of vaccines, and ensure equitable access to necessary resources and countermeasures. A multi-sectoral partnership is necessary, including leveraging the One Health approach in disease surveillance. Further research is required to better understand the changes in transmission dynamics of the disease. As the virus evolves, it has the potential to spread more widely, which necessitates the development of more effective risk communication and community engagement strategies.

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