WHO declares mpox outbreak a ‘public health emergency of international concern’

• The World Health Organisation (WHO) has determined that the upsurge of mpox in the Democratic Republic of the Congo (DRC) and a growing number of countries in Africa constitutes a ‘public health emergency of international concern’ (PHEIC) under the International Health Regulations (2005) (IHR).

• The designation is WHO’s highest level of alert.

• The declaration came on the advice of an IHR Emergency Committee of independent experts who met on August 14 to review data presented by experts from WHO and affected countries. 

• The Committee informed WHO Director-General Tedros Ghebreyesus that it considers the upsurge of mpox to be a PHEIC, with potential to spread further across countries in Africa and possibly outside the continent.

• This PHEIC determination is the second in two years relating to mpox.

• In July 2022, the multi-country outbreak of mpox was declared a PHEIC as it spread rapidly via sexual contact across a range of countries where the virus had not been seen before. That PHEIC was declared over in May 2023 after there had been a sustained decline in global cases.

• Sweden confirmed an infection with a new strain of the mpox virus and linked it to a growing outbreak in Africa.

• Mpox has been reported in Congo for more than a decade, and the number of cases reported each year has increased steadily over that period. Last year, reported cases increased significantly, and already the number of cases reported so far this year has exceeded last year’s total, with more than 15,600 cases and 537 deaths.

• In the past month, over 100 laboratory-confirmed cases of clade 1b have been reported in four countries neighbouring the DRC that have not reported mpox before: Burundi, Kenya, Rwanda and Uganda. Experts believe the true number of cases to be higher as a large proportion of clinically compatible cases have not been tested.

• Several outbreaks of different clades of mpox have occurred in different countries, with different modes of transmission and different levels of risk.

What is mpox?

• Mpox (monkeypox) is an infectious disease caused by the monkeypox virus (MPXV). 

• Mpox virus belongs to the Orthopoxvirus genus in the family Poxviridae. The Orthopoxvirus genus also includes variola virus (which causes smallpox), vaccinia virus (used in the smallpox vaccine), and cowpox virus.

• Mpox has symptoms similar, but less severe, to smallpox. While smallpox was eradicated in 1980, mpox continues to occur in countries of central and west Africa.

• Mpox is zoonosis: a disease that is transmitted from animals to humans.

• Mpox was formerly called monkeypox. Following a series of consultations with global experts, WHO began using “mpox” as a synonym for monkeypox. 

• Monkeypox was first discovered in 1958 when outbreaks of a pox-like disease occurred in monkeys kept for research, hence the name ‘monkeypox’.

• The first human case was recorded in 1970 in the Democratic Republic of the Congo (then known as Zaire), and since then the infection has been reported in a number of central and western African countries. Most cases are reported from Congo and Nigeria. 

• In 2003, monkeypox was recorded in the United States when an outbreak occurred following importation of rodents from Africa. Cases were reported in both humans and pet prairie dogs. All the human infections followed contact with an infected pet and all patients recovered. 

• Mpox is endemic in densely forested regions of West, Central and East Africa, particularly in the northern and central regions of Congo. 

• Mpox outbreaks are caused by different viruses called clades. Clade 1 has been circulating in Congo for years, while clade 2 was responsible for the global outbreak which began in 2022.

Transmission

• Mpox does not spread easily between people.

• Spread of mpox may occur when a person comes into close contact with an animal (rodents are believed to be the primary animal reservoir for transmission to humans), human, or materials contaminated with the virus. 

• The virus enters the body through broken skin (even if not visible), the respiratory tract, or the mucous membranes (eyes, nose, or mouth).

Person-to-person spread is very uncommon, but may occur through:

• Contact with clothing or linens (such as bedding or towels) used by an infected person.

• Direct contact with mpox skin lesions or scabs.

• Coughing or sneezing of an individual with a mpox rash.

Symptoms

Initial symptoms include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion. A rash can develop, often beginning on the face, then spreading to other parts of the body. The rash changes and goes through different stages before finally forming a scab, which later falls off.

Treatment

• Detection of viral DNA by polymerase chain reaction (PCR) is the preferred laboratory test for mpox. 

• Mpox, in most cases, is a mild condition which will resolve on its own and have no long-term effects on a person’s health. Most people recover within a few weeks. However, severe illness can occur in some individuals.

• Treatment of mpox patients is supportive dependent on the symptoms. Various compounds that may be effective against mpox virus infection are being developed and tested.

• Prevention and control of human mpox rely on raising awareness in communities and educating health workers to prevent infection and stop transmission.

• Currently, two mpox vaccines have been approved by WHO-listed national regulatory authorities, and which its expert group on immunisations have also recommended.

What is PHEIC?

A PHEIC is defined in the IHR (2005) as, “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response”. 

This definition implies a situation that is:

i) Serious, sudden, unusual or unexpected.

ii) Carries implications for public health beyond the affected State’s national border. 

iii) May require immediate international action.

WHO has to consider five elements to decide whether an outbreak constitutes a public health emergency of international concern.

1) Information provided by countries – which in this case shows that the virus has spread rapidly to many countries that have not seen it before.

2) The three criteria for declaring a public health emergency of international concern under the International Health Regulations — being an extraordinary event, a public health risk to other States and a potential need to require a coordinated international response.

3) The advice of the Emergency Committee — which did not reach a consensus.

4) Scientific principles, evidence and other relevant information – which are currently insufficient.

5) The risk to human health, international spread, and the potential for interference with international traffic.

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