On August 14, the World Health Organization (WHO) declared mpox (formerly known as monkeypox) a public health emergency due to a surge in cases in Congo and an increasing number of reports from other countries. This is the second emergency alert from the global health agency regarding mpox in the past two years.
The global mpox outbreak, a typically rare viral disease, was first declared a public health emergency of international concern on July 23, 2022. Reassuringly, the WHO has emphasized that mpox is "not the new Covid," much to the relief of people still haunted by the Covid-19 pandemic. Covid-19 was the fifth documented pandemic endured by the world since the 1918 flu pandemic.
Eighteen countries have reported mpox cases, including our South Asian neighbor Pakistan, as well as Asian countries like Thailand and the Philippines. Other countries affected include Burundi, Cameroon, the Central African Republic, the Democratic Republic of Congo (formerly Zaire), Ghana, Ivory Coast, Kenya, Liberia, Mozambique, Nigeria, the Republic of the Congo, Rwanda, South Africa, Uganda, and Sweden.
A concerning development for us is the recent reporting of mpox cases in the three Asian countries—the Philippines, Thailand, and Pakistan—all in August 2024. On August 22, authorities in Thailand confirmed Asia's first case of a new mpox strain, Clade 1b. The patient, a 66-year-old European male, reportedly returned from an unnamed African country. He did not exhibit severe symptoms and is believed to have transited through a Middle Eastern country before arriving in Thailand.
In the Philippines, authorities confirmed the milder Clade 2 variant in a recent case involving a 33-year-old Filipino male with no travel history. This patient is the country’s 10th confirmed case since 2022, and authorities believe mpox has likely been spreading quietly for some time.
The Pakistani authorities reported their first case of the year, involving a male infected with Clade 2. They are currently attempting to trace the patient, who is believed to have traveled to another province before his test results were released.
According to an August 21 report from USA Today, mpox reached the United States as part of the global outbreak in 2022, resulting in 32,000 known infections and 58 deaths. All cases in the U.S. have been linked to the less virulent and contagious Clade-II type, with no Clade-I infections found.
One of the world’s oldest and most impactful peer-reviewed medical journals, The Lancet, reported on August 24 that, unlike the 2022 mpox outbreak, which predominantly affected men who have sex with men, the 2024 outbreak is impacting a broader demographic. The virus, primarily spreading through direct contact, has been reported among men, women, and children. In the Democratic Republic of the Congo, where mpox cases have been reported in all 26 provinces, children under 15 years old account for 66% of reported cases and more than 82% of deaths.
Mpox Awareness in Bangladesh
As of this report, there have been no reported mpox cases in Bangladesh. Authorities at all international airports in Bangladesh have initiated comprehensive health screenings for incoming passengers, using thermal scanners to detect elevated body temperatures—a common early symptom of mpox—and have instructed airline operators to offload passengers at their point of origin if symptoms are detected.
Health sector experts believe Bangladesh must take all necessary precautions to prevent an outbreak, as the country is already grappling with a devastating deluge and political upheaval, making the spread of another viral disease particularly dangerous.
During a virtual workshop held on August 23, Dr Asadulghani, Chairman of the Bangladesh Biosafety and Biosecurity Society (BBBS), presented data indicating that as of August 2024, over 17,000 mpox cases and 517 fatalities have been reported, the vast majority in the Democratic Republic of the Congo. Over 96% of all cases and deaths have occurred in this single country.
Dr Asadulghani and other experts cautioned against underestimating the concentration of the virus in one country, as new cases have been reported in other countries as recently as August this year. They noted that COVID-19 also initially centered around Wuhan, China, before spreading worldwide.
Dr Saif Ullah Munshi, a professor in the Department of Virology at Bangabandhu Sheikh Mujib Medical University, stated: "We’ve eradicated smallpox, but we must maintain continuous surveillance as new diseases emerge and spread due to changes in people’s food habits, deforestation, etc."
Preventive Measures and Global Response
Professor Dr Be-Nazir Ahmed, former Director of Disease Control at the Directorate General of Health Services, Professor Dr Sanya Tahmina, former Additional Director General at the Directorate General of Health Services, Dr Md Giasuddin, Executive Vice Chair of BBBS and former Head of the Animal Health Division at the Bangladesh Livestock Research Institute, along with other health sector experts, participated in the workshop. They all emphasized the need for Bangladesh to take proactive measures to ensure that vaccines, quarantine facilities, labs, and medical treatment options are ready in case of an mpox outbreak.
Dr Asadulghani explained that mpox is a rare viral zoonotic disease caused by a DNA virus from the genus Orthopoxvirus in the Poxviridae family. mpox was first discovered in 1958 when two outbreaks of a pox-like disease occurred in colonies of monkeys kept for research.
Discussing the various strains of mpox, he noted, "Clade-I causes more severe illness and deaths, with some outbreaks resulting in up to a 10% mortality rate, though more recent outbreaks have had lower death rates. Clade-II, which caused the global outbreak beginning in 2022, results in less severe infections, with over 99.9% of people surviving."
Dr Asadulghani mentioned that vaccination with the smallpox vaccine is approximately 85% effective against mpox. "To help curb the outbreak, the Africa CDC announced a partnership with Bavarian Nordic, the manufacturer of the mpox vaccine JYNNEOS, to enhance local vaccine manufacturing capabilities and deliver 2 million vaccine doses to affected areas by the end of 2024, with an additional 10 million doses expected by the end of 2025," said Dr Asadulghani. He added that 215,000 doses have been procured through a partnership with the European Union and are expected to be rolled out by the end of August 2024.
Symptoms, Transmission, and Epidemiology
Feeling feverish, having headaches, backaches, lymphadenopathy (swelling of lymph nodes), and fatigue during a 2 to 3-day prodromal period (the period between the appearance of initial symptoms and the full development of the disease) are considered non-specific symptoms of mpox. More specific symptoms typically appear after a 2 to 4-week period, during which a rash develops and progresses from macules to papules, vesicles, and then pustules, followed by umbilication, scabbing, and desquamation. The rash usually spreads in a centrifugal distribution, often affecting the palms and soles of the feet. Lesions can also develop on mucous membranes, conjunctivae, the mouth, tongue, and genitalia.
The mpox virus is transmitted from infected animals through bites or direct contact with the animal's blood, body fluids, or lesions. It can also be transmitted from human to human via the respiratory tract, direct contact with body fluids of an infected person, or contact with virus-contaminated objects. Experts have noted that the rate of person-to-person transmission is increasing, with a secondary attack rate of approximately 10%. The virus is capable of sustaining human-to-human transmission, with chains of up to six sequential transmission events documented.
This virus affects all age groups; however, children under 16 have constituted the greatest proportion of cases. The virus occurs naturally in West and Central Africa, particularly near tropical jungles. The virus isolates from West Africa appear to be less virulent and/or transmissible to humans and non-human primates than those from the Congo Basin in Central Africa.
Additionally, the cessation of smallpox vaccination seems to have increased human susceptibility to severe mpox. In 1970, the first human case of mpox was identified in a 9-month-old child in the Democratic Republic of the Congo, in a region where smallpox was eradicated in 1968. The following year, six additional human mpox cases were reported in Liberia, Sierra Leone, and Nigeria. From 1970 to 1979, 47 human mpox cases were identified, 38 of which were in the Democratic Republic of the Congo. Between 1981 and 1986, a total of 338 cases were reported in the Democratic Republic of the Congo, and more than 400 cases were reported between February 1996 and October 1997.
In 2003, the first human mpox cases in the Western Hemisphere were reported following an outbreak in the Midwestern United States (Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin) due to the importation of mpox virus-infected West African rodents from Ghana. Between November 2005 and November 2007, a study found that mpox cases in the Democratic Republic of the Congo had spiked 20-fold compared to the 1980s. In Nigeria, a severe outbreak in 2017 occurred almost 40 years after the country's last reported case.