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Just over 10 weeks ago the WHO declared the Mpox outbreak in Central Africa to constitute a PHEIC (Public Health Emergency of International Concern) after reports that a recently emerged clade (Ib) of the virus had begun to spread outside of the DRC (see More African Nations Reporting Mpox - Africa CDC Mpox Update (Jul 30th)).
Nearly every WHO DON or disease Situation Report contains diplomatic reminders to member nations of their `duty to report' these cases under the IHR 2005 agreement, but compliance remains spotty at best.Although numbers are incomplete due to a lack of testing and reporting, the number of confirmed cases in Africa has risen sharply over the past 2 months. The WHO estimates that only about 20% of suspected cases in Africa are laboratory confirmed, making it difficult to accurately gauge the size of the outbreak.
• In September 2024, the last month for which complete global surveillance data is available, 2763 confirmed mpox cases were reported. This is the highest number of cases since November 2022 and marks an increasing trend in the number of reported confirmed mpox cases globally, driven by the increase in the African Region, followed by the Western Pacific Region.• Outside Africa, the highest number of confirmed cases in September 2024 was reported by Australia. The country is currently experiencing an increasing outbreak of clade IIb MPXV, affecting mainly men who have sex with men and are infected through sexual contact.• The rise in mpox cases in Africa is driven by the Democratic Republic of the Congo, Burundi, and an expanding outbreak in Uganda.• As of 20 September 2024, Clade Ib monkeypox virus (MPXV) has been detected in six provinces in the Democratic Republic of the Congo: South Kivu, North Kivu, Kinshasa, Kasai, Tshopo and Tanganyika.• In the Democratic Republic of the Congo, the number of new mpox cases continues to rise in South Kivu province, where clade Ib is spreading and making it the most affected province in the country. The spread is driven by close interpersonal human-to-human contact, including sexual contact and direct close contact in households and communities. The increase in cases is uneven within the province, with a few hotspots driving transmission. While the initial phase of the clade Ib epidemic in eastern Democratic Republic of the Congo was mostly affecting adults, as clusters expand in the community, the epidemic is affecting both adults and children, reflecting wider community transmission through close contact.• In Kinshasa, the capital of the Democratic Republic of the Congo, where both clade Ia and clade Ib are cocirculating, the epidemic is expanding too. Adults are disproportionally affected, although there are reports of infections across all age groups.• Further details about the epidemic dynamics in the Democratic Republic of the Congo can be found in the WHO mpox surveillance report, now displaying subnational level trends for the country.• In neighbouring Burundi, where the epidemic is also presumed to be driven by clade Ib, 182 cases were reported last week, compared to 134 the previous week and 157 the week before. The epidemic remains largely concentrated in- and around Bujumbura, with two main age groups being affected, similar to what is observed overall in South Kivu (young children <5 years and young and middle-aged adults), suggesting similar epidemic dynamics.• The epidemic in Uganda is expanding. It is presumed to be driven by clade Ib predominantly affecting adults and there is documented transmission that involved sexual contact and sex workers.• Zimbabwe reported its first two mpox cases, in a person with travel history to South Africa and in a person with travel history to Tanzania. Clade information is not yet available for these cases.• The first mpox deaths were reported in Kenya (one) and in Uganda (one). Both cases were adults living with HIV, and although clade information for the specific cases is not yet available, they are likely to be clade Ib MPXV.• Germany reported the first mpox case due to clade Ib MPXV in a person with travel history to an affected African country.• A rise in reported cases has also been observed in Côte d’Ivoire, where only clade IIa MPXV was detected in 2024.• This report includes the description of the mpox literature repository and the summary of the latest WHO interim guidance for mpox in school settings.
Since the eradication of smallpox in the 1970s, there has been a general feeling that poxviruses are a thing of the past, a relic of the 20th century. But as our collective immunity from the smallpox vaccine - which was discontinued in the late 1970s - wanes, there are increased opportunities for pox viruses to make a comeback.
As they spread from host-to-host, additional evolutionary changes seem likely (see Evolution of monkeypox virus from 2017 to 2022: In the light of point mutations).
All of which means the next Mpox virus to begin a world tour may not prove as mild as was the IIb clade, which emerged in 2022.
