Mpox Q&A: What you need to know about mpox

Mpox is a rare viral infection, previously usually found in forested areas of Central and West Africa. The disease originates in animals, but in the last 50 years or so has also been reported sporadically in humans. Previously, no sustained person-to-person transmission was thought possible. Since May 2022 a large mpox epidemic – not linked to an animal reservoir – has emerged in several countries in the WHO European Region, with mpox spreading from person to person through touching, kissing, and oral, vaginal and anal sex.

Less frequently, transmission may also occur through respiratory droplets and contact with contaminated materials.

In countries affected by the current outbreak, most people diagnosed with mpox were gay, bisexual, and other men who have sex with men (GBMSM) who got infected through sexual contact.

Someone who has contracted mpox usually starts to show symptoms 6–13 days after contact with an infected, symptomatic person or their belongings, but in some cases it can take up to 21 days.  

The most common symptom is an evolving rash that develops from vesicles into blisters. During the recent outbreak in the WHO European Region, most of the cases were detected in sexual health clinics, with patients presenting with lesions on their genitals and/or anus. 

The rash may be accompanied by fever, muscle aches, chills, exhaustion, headaches, sore throat, or swollen, painful lymph nodes (raised glands, particularly in the groin and potentially in the neck, under the chin and in the armpits).  

The symptoms in the 2022–2023 outbreak have often been mild, but even mild cases can include very itchy or intensely painful lesions that can become infected. Symptoms usually resolve on their own after about 14–21 days.

The disease can become more severe and potentially even fatal, especially among young children, pregnant women and people who are immunocompromised, such as people with poorly controlled HIV.

The disease is usually self-limiting, which means that symptoms usually go away without the need for treatment within 14–21 days. Some people may require antibiotics and analgesics to treat secondary infections and local pain. 

It is important that people get tested, report symptoms and take precautions to stop possible transmission to others, particularly those at high risk of developing severe disease. 

WHO’s recommendations are provided below.

• If you have an unusual lesion or rash, consult your doctor or health-care provider straight away.
• Try not to touch the lesions or rash as this could spread the disease.
• Wash any bedding or belongings of an infected person with whom you may have come into contact.
• Wash your hands regularly.
• Avoid close physical contact, including sexual contact, with others if you suspect you may have mpox.
• Anyone who has suspected, probable or confirmed mpox symptoms should isolate as much as possible until the symptoms have resolved.
• In particular, keep isolated from pregnant women, young children and immunocompromised people to protect them from infection. 

WHO recommends that people at high risk of becoming infected with mpox get vaccinated and complete the vaccination series (receive all recommended doses), and that countries offering vaccination ensure equitable and effective access to vaccines for these groups.

These include: GBMSM and trans people with multiple male partners but also other people with multiple sexual partners; sex workers; health workers at risk of repeated exposure; laboratory personnel working with orthopoxviruses; clinical laboratory and health-care personnel performing diagnostic testing for mpox; and outbreak response team members.

Vaccination is not recommended based on higher risk of severe disease alone (such as children, pregnant women, and people who are immunosuppressed) unless the group is also at high risk of being exposed to mpox. However, people living with HIV should be considered high-priority amongst these groups.

Vaccines reduce the risks of getting infected. One can become infected or reinfected with mpox after being vaccinated, but vaccines reduce the risk of this happening and reduce the risk of severe disease if infection does occur.

Vaccination can also be offered to prevent infection after high-risk exposure to the virus if given ideally within four days of first exposure (and up to 14 days in the absence of symptoms). In case of limited vaccine supply, people at risk of developing more severe disease, if exposed, should be given priority in vaccination.

By May 2023 mpox cases have decreased significantly across the WHO European Region, with many countries no longer observing mpox transmission for some time. A few countries are still reporting low numbers of mpox cases, predominantly amongst GBMSM.

The reasons behind this success are not fully known, but could include a combination of factors, such as strong intersectoral collaborations; effective engagement of key affected populations and the community organizations who serve them; public health and vaccination campaigns; as well as behaviour change and uptake of preventive measures by key affected populations.   

It is important that countries put in place medium- to long-term plans to sustain current achievements, and to prevent, detect and manage any potential future mpox clusters or outbreaks. 

With mpox transmission still occurring in endemic and newly affected countries outside Europe, mpox could be reignited in the WHO European Region. This could lead to new localized or dispersed outbreaks. There is also a risk of mpox resurging as large GBMSM-focused events as well as side events at sex-on-premises venues take place this spring and summer.  

It is uncertain what will happen in the coming months. Therefore, it is important that people at risk along with health authorities and providers continue to stay vigilant. 

Launched in April 2023, WHO/Europe’s regional 2023–2027 mpox policy brief – “Considerations for the control and elimination of mpox in the WHO European Region update 25 April 2023: the need for integrated national operational plans” – outlines the actions Member States in the Region need to take, both to prepare for the upcoming spring and summer season of mass gatherings, as well as to prevent sustained person-to-person transmission of mpox in the medium- to long-term.

Inspired by the policy brief, in May 2023 WHO/Europe launched an awareness-raising campaign – Eliminating mpox. Placing affected populations at the heart of our response.

The campaign conveys the message that mpox has not gone away and that we cannot afford to be complacent. The goals of the campaign are set out below.

• Highlight what affected communities, health authorities, event organizers, health workers can all do to help to control mpox and eventually stamp it out.
• Provide a platform for affected communities, including underserved populations, to talk about their mpox-related experiences, needs and hopes this year.
• Shine a light on the important contribution of organizations who represent gay, bisexual and other men who have sex with men. These organizations have played and continue to play a crucial role in fighting mpox. Some of their work and successes to date are illustrated in a compendium – a collection of case studies – that WHO/Europe will launch as part of its mpox campaign.

We recommend that affected populations keep having conversations with peers and sexual partners about mpox; stay up to date with the latest information; get tested, take a break from events and contact their health-care provider if they have symptoms (typically a rash) compatible with mpox, and get vaccinated/receive all vaccine doses if vaccination is available. We encourage safer sexual behaviour and good hygiene, like regular handwashing, to help to limit transmission of the virus.

Events can be good opportunities for event organizers and health authorities and providers to reach all affected populations with health advice, testing and vaccination.

We encourage organizers of mass gatherings to:

• make information about mpox available before, during and after an event;
• extend mpox information and advice to side events at sex-on-premises venues;
• share local information on where to get tested, and where to get vaccinated if eligible and if vaccination is available;
• have a refund policy in place and encourage people who develop mpox symptoms or are close contacts to skip the event and receive reimbursement for their tickets; and
• use mailing lists and other communication channels (social media, phone messaging groups) to encourage people who are symptomatic or close contacts to connect with their local public health authority and get tested.

We encourage owners of venues and spaces that host or hold sex-on-premises events to:

• coordinate with the organizers of the event to be held in their venue, including how to communicate information about mpox and follow up with attendees after the event; and
• if appropriate and possible, consider vaccination for staff and encourage relevant staff members to seek vaccination.

We encourage event organizers that promote and organize sex-on-premises events to:

• assist with post-event surveillance for mpox and follow up with attendees for a health check and testing for mpox and other sexually transmitted infections (STIs);
• work with venue owners, promoters, and community influencers to develop a process to support cases of mpox by providing information about health care and testing and encouraging notification of close contacts;
• ensure that information on safe behaviours for attendees is available, including through flyers, information accompanying tickets, the event website and posters in the event space; and
• consider partnering with sexual health clinics or service provider organizations to facilitate referrals for testing for HIV, STIs, and other infections at sex-on-premises events.

WHO/Europe’s regional 2023–2027 mpox policy brief – “Considerations for the control and elimination of mpox in the WHO European Region update 25 April 2023: the need for integrated national operational plans” – provides guidance to health authorities and a range of other stakeholders on what actions are needed to control and eventually eliminate mpox in the WHO European Region.

This includes:

• integrating the mpox response into national sexual health programmes;
• promoting and bringing testing closer to key affected communities – for example, by offering easy access to diagnostic tests;
• reaching underserved groups – for example, trans people, sex workers, men who have sex with men who are also migrants or refugees, as well amongst younger people, people who are homeless, and people in rural areas – with health advice, testing and vaccines;
• declaring mpox a nationally notifiable disease, which will help to detect mpox early, respond to outbreaks in a more streamlined way, and allocate resources where they are most needed; and
• developing national vaccination plans.  

WHO is working with concerned countries, facilitating information sharing and supporting surveillance, testing, infection prevention, clinical management, risk communication and community engagement. 

WHO is also working with vaccine manufacturers to assess the potential for scaling up mpox vaccines.

Launched in April 2023, WHO/Europe’s regional 2023–2027 mpox policy brief – “Considerations for the control and elimination of mpox in the WHO European Region update 25 April 2023: the need for integrated national operational plans” – outlines the actions Member States in the Region need to take, both to prepare for the upcoming spring and summer season of mass gatherings, as well as to prevent sustained person-to-person transmission of mpox in the medium- to long-term.

Inspired by the policy brief, in May 2023 WHO/Europe launched an awareness-raising campaign – Eliminating mpox. Placing affected populations at the heart of our response.

The campaign conveys the message that mpox has not gone away and that we cannot afford to be complacent. The goals of the campaign are set out below.

• Highlight what affected communities, health authorities, event organizers, health workers can all do to help to control mpox and eventually stamp it out.
• Provide a platform for affected communities, including underserved populations, to talk about their mpox-related experiences, needs and hopes this year.
• Shine a light on the important contribution of organizations who represent gay, bisexual and other men who have sex with men. These organizations have played and continue to play a crucial role in fighting mpox. Some of their work and successes to date are illustrated in a compendium – a collection of case studies – that WHO/Europe will launch as part of its mpox campaign.

Eradication means that transmission of a disease has been stopped across the world and there are no longer any cases of the disease anywhere (smallpox is the only disease affecting humans that has been eradicated to date). This will not be possible for mpox because it is a zoonotic disease, which means that it has animal reservoirs and can spread between animals and people. Elimination refers to interrupting sustained local transmission and working to ensure that this interruption is maintained.

There are 2 known types of mpox virus: type 1 and type 2.

So far, all the cases recently reported in the Region have been of type 2 (previously known as West African clade), which is known to cause milder, usually self-limiting disease, and only very rarely causes severe disease or death.

Sporadic cases have occurred over the past few years in the WHO European Region, usually as a result of travellers visiting Western and Central African countries and returning with an infection. These imported cases have not usually led to infections in other people, although some limited spread to household and health worker contacts has occurred.

We don’t currently know whether mpox can be spread through semen, vaginal or other bodily fluids. Using or wearing a condom will very likely reduce your risk or extent of exposure during sex and it will help to protect you and others from a range of other STIs. Condoms may not protect you from mpox during skin-to-skin, mouth-to-skin or mouth-to-mouth contact. Using condoms also helps anyone who has recovered from mpox to prevent transmission to others when having any form of sex, for up to 12 weeks following recovery from an mpox infection.

Though mpox is no longer defined as a public health emergency of international concern, it could still pose a risk to the health of vulnerable people in the WHO European Region – the region hardest hit by the outbreak in 2022.

We don’t know what the next months will bring, but we can prepare for another possible upsurge in mpox cases.