In recent years, the global community has found itself in a relentless struggle against a series of infectious diseases. Amid the chaos of Covid-19, a more unfamiliar virus began to resurface in 2022 - Mpox, formerly known as monkeypox. Historically isolated to parts of West and Central Africa, the sudden spread of this virus to new regions raised global concern. This article explores the epidemiology, history, spread, symptoms, and global response to Mpox, as well as what the future may hold.
A brief history of Mpox
Mpox is caused by the monkeypox virus, a member of the Orthopoxvirus genus, which also includes the variola virus responsible for smallpox. First identified in laboratory monkeys in 1958 (hence the name), Mpox was later found to primarily infect rodents and other animals. The first human case was recorded in the Democratic Republic of the Congo (DRC) in 1970, when efforts to eradicate smallpox were in full swing.
For decades, Mpox outbreaks were sporadic and typically limited to small, rural communities in the African continent, with occasional cases traced back to animal-to-human transmission through direct contact. Human-to-human transmission was historically rare, and the virus remained largely unnoticed by the global population.
The 2022 global outbreak: A new era
In May 2022, health authorities in the United Kingdom confirmed several cases of Mpox in individuals who had not travelled to endemic regions. This was highly unusual. As weeks passed, cases were identified across Europe, the Americas, and other regions, signalling an unexpected and rapid spread. By the end of 2022, thousands of cases were recorded globally, prompting the World Health Organization (WHO) to declare Mpox a Public Health Emergency of International Concern (PHEIC).
The global outbreak was a stark reminder that infectious diseases, especially those previously thought to be region-specific, could pose a global threat if left unchecked. Experts speculated that multiple factors may have contributed to this sudden spread, including increased international travel, reduced immunity due to the end of routine smallpox vaccination, and possibly changes in the virus itself.
Symptoms and transmission of Mpox
Mpox symptoms typically appear 7-14 days after exposure, though the incubation period can be as long as 21 days. Early signs are flu-like, including fever, muscle aches, headaches, and swollen lymph nodes. These are followed by a distinctive rash that usually starts on the face and spreads to other parts of the body, including the hands, feet, and genitals. The rash evolves into raised bumps, which later become fluid-filled pustules, eventually crusting over and falling off.
While the symptoms may resemble those of smallpox, Mpox is generally less severe. The case fatality ratio (CFR) varies between strains, with the Central African clade having a higher mortality rate (up to 10%) compared to the West African clade, which has a CFR of less than 1%.
Transmission primarily occurs through close contact with an infected person or animal. This includes contact with bodily fluids, lesions, respiratory droplets, and contaminated materials, such as bedding. In the 2022 outbreak, a significant proportion of cases were identified in men who have sex with men (MSM), with evidence suggesting that the virus may be spreading through intimate, close-contact networks. However, it's important to emphasise that Mpox is not a sexually-transmitted infection (STI) in the traditional sense, as it can be spread through any close physical contact, irrespective of sexual activity.
The role of vaccination and immunity
One of the critical aspects of Mpox's resurgence is the role of immunity. In the pre-1980 era, routine smallpox vaccination provided a degree of cross-protection against Mpox, as both viruses belong to the Orthopoxvirus genus. However, following the successful global eradication of smallpox in 1980, vaccination efforts ceased. As a result, a growing proportion of the global population lacks immunity to Mpox, leaving them more susceptible to infection.
In response to the 2022 outbreak, health authorities scrambled to distribute smallpox vaccines, specifically the newer generation vaccines such as JYNNEOS (also known as Imvanex or Imvamune), which has been approved for use against both smallpox and Mpox. Mass vaccination campaigns were rolled out, particularly in high-risk groups such as healthcare workers and MSM communities. Despite logistical challenges, these efforts played a crucial role in slowing the spread of the virus.
The global health response
The global response to the Mpox outbreak highlighted several strengths and weaknesses in pandemic preparedness. On the one hand, lessons learned from the Covid-19 pandemic allowed health authorities to quickly mobilise resources, track the spread of the virus, and issue public health guidance. The establishment of robust contact tracing, testing, and quarantine protocols helped to limit further spread.
However, the outbreak also exposed gaps in global health infrastructure, particularly in resource-limited settings where access to vaccines, diagnostics, and treatment was limited. Countries that were already grappling with other health crises, such as HIV/Aids, tuberculosis, and malaria, struggled to contain the virus, and there were concerns about Mpox exacerbating existing health disparities.
The WHO's declaration of Mpox as a PHEIC underscored the need for a coordinated international response, especially in supporting affected countries with limited healthcare resources. International aid organisations, alongside governments and non-profits, played a critical role in delivering medical supplies, conducting educational campaigns, and ensuring that accurate information reached the public to counteract misinformation and stigma.
Addressing stigma and discrimination
A significant challenge during the 2022 Mpox outbreak was the stigma attached to the disease, particularly among the MSM community. With many of the initial cases identified in this demographic, there was a danger that the virus could be perceived as an issue affecting only specific groups. This narrative, reminiscent of the early days of the HIV/Aids epidemic, risked creating a climate of fear and discrimination.
Public health officials and advocacy groups worked tirelessly to counter this stigma by emphasising that Mpox can affect anyone, regardless of sexual orientation or behaviour. Transparent, non-judgmental communication became a key element of the response, aimed at both educating the public and ensuring that high-risk populations felt supported rather than vilified. This approach is essential for encouraging affected individuals to seek medical help, get vaccinated, and cooperate with contact tracing efforts.
The future of Mpox: What lies ahead?
The 2022 Mpox outbreak, though surprising, serves as a reminder of the dynamic nature of infectious diseases. While case numbers began to decline in late 2022 and early 2023, experts warn that Mpox is unlikely to disappear entirely. The virus is still endemic in parts of Africa, where periodic outbreaks occur. In regions where Mpox has newly emerged, it is possible that the virus may establish itself in local wildlife populations, creating a reservoir for future outbreaks.
Moving forward, there are several priorities for global health authorities. First, ongoing surveillance is essential, both in endemic regions and in countries where Mpox has recently spread. This includes strengthening laboratory capacity, improving reporting systems, and conducting research into the virus' transmission dynamics.
Second, there is a need for sustained investment in vaccine production and distribution. Although the rapid rollout of vaccines during the 2022 outbreak was commendable, ensuring equitable access remains a challenge. Countries must work together to ensure that vaccines reach those who need them most, particularly in low-income settings.
Finally, public education will continue to play a pivotal role in controlling Mpox. Clear, accurate information can help to reduce the stigma surrounding the virus and encourage responsible behaviour, such as reporting symptoms early and avoiding contact with potentially infected individuals.
Conclusion
The 2022 Mpox outbreak was a stark reminder of the ever-present threat posed by zoonotic diseases and the challenges of responding to unexpected public health emergencies. While the world was able to mount a relatively effective response, the long-term containment of Mpox will require continued vigilance, research, and international cooperation. By learning from this outbreak and building on the progress made, we can hope to minimise the impact of Mpox and other emerging infectious diseases in the future.
Renald Blundell is a biochemist and biotechnologist with a special interest in Natural and Alternative Medicine. He is a professor at the Faculty of Medicine and Surgery, University of Malta.
Photo: AI-generated image created by Prof. Blundell