Case management of mpox: Where we are and where we desire to be

[Find the meaning and references behind the names: Samuel, Daniel, Fiona, Solomon, Low, John, Abdou, Smart, Joseph, Addis, Ebenezer, Ramadan, Ras]

Journal of Public Health in Africa ISSN: (Online) 2038-9930, (Print) 2038-9922 Page 1 of 2 Editorial Read online: Scan this QR code with your smart phone or mobile device to read online http://publichealthinafrica.org Open Access Authors: Solomon F. Woldetsadik 1 Ebenezer O. Daniel 1 John Masina 1 Joseph C. Okeibunor 2 Samuel Boland 2 Hilary K. Njenge 2 Nicaise Ndembi 3 Ngashi Ngongo 3 Otim P.C. Ramadan 2 Fiona Braka 2 Abdou S. Gueye 2 Affiliations: 1 Regional Office for Africa, Emergency Preparedness and Response Hub, World Health Organization, Nairobi, Kenya 2 Regional Office for Africa, Emergency Preparedness and Response Cluster, World Health Organization, Brazzaville, Democratic Republic of Congo 3 Africa Centre for Disease Control, Addis Ababa, Ethiopia Corresponding author: Joseph Okeibunor, okeibunorj@who.int How to cite this article: Woldetsadik SF, Daniel EO, Masina J, et al. Case management of mpox: Where we are and where we desire to be. J Public Health Africa. 2025;16(1), a 1228. https://doi.org/10.4102/ jphia.v 16 i 1.1228 Copyright: © 2025. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License Introduction The resurgence of mpox and its declaration as a public health emergency of international concern (PHEIC) by the World Health Organization (WHO) twice in the last 2 years is alarming and demands attention. 1,2 This situation poses significant challenges and opportunities for improving clinical case management. Urgent collaborative efforts are needed to develop refined clinical guidelines, targeted pharmacological approaches, and effective preventive measures. Innovative approaches are particularly crucial in the WHO African region, where outbreaks of infectious diseases such as mpox further strain the already-fragile health systems 3,4 Current approach to case management and gaps Mpox case management currently draws on experiences from smallpox treatment, as both viruses belong to the orthopoxvirus family 5,6 Antiviral drugs such as brincidofovir and tecovirimat show promise, with tecovirimat recommended for severe cases under WHO Monitored Emergency Use of Unregistered and Experimental Interventions (MEURI) 7 Vaccination of at-risk populations is another promising strategy, but vaccine distribution has been slow, especially in the WHO African region because of limited supply and local manufacturing challenges 8 Further clinical evidence is required to validate the effectiveness of these therapeutics and vaccines, which remain largely inaccessible in the African region The current approach, involving isolation protocols, symptom treatment, and supportive care, falls short in achieving desired outcomes in both endemic and non-endemic regions 9 Treatment efficacy varies because of differences in clinical presentations, ranging from mild to severe cases requiring multidisciplinary management. 10 Symptoms include fever, headaches, pustular rash, lymphadenopathy, and muscle aches. Management focuses on pain relief, hydration, nutritional support, and antiviral therapy for high-risk patients, such as immunocompromised individuals 11 In response to the mpox epidemic in the WHO African region, public health stakeholders have introduced interventions to improve case management outcomes. Training clinicians in triage, isolation, and case management principles have been prioritised, with nearly 5000 health workers trained. This capacity building has documented evidence in reducing mortality rates in healthcare facilities. 12 In hotspot areas, such as the Democratic Republic of Congo (DRC) and Burundi, treatment units have been mapped and assessed. Infection prevention and control (IPC) assessments revealed critical gaps in screening (37 % ), isolation (27 % ), and hand hygiene (37 % ). In Kinshasa, hand hygiene compliance was as low as 6 % . Similar gaps were found in Uganda. These assessments have informed interventions, including health worker training on IPC protocols and the provision of personal protective equipment (PPE), which is vital for preventing nosocomial infections in healthcare settings. 13 Efforts to improve clinical data collection include training over 200 users on the mpox global clinical data platform. Furthermore, an essential medicines list for mpox management has been distributed to member states. A nutrition package developed with the World Food Programme (WFP) has been implemented in high-admission facilities in the DRC and Burundi, improving treatment outcomes and reducing case fatality rates as exemplified in a similar scenario laced with uncertainties. 14 Despite these efforts, critical gaps remain. Limited knowledge about mpox transmission dynamics, including the role of asymptomatic carriers, zoonotic reservoirs, and environmental factors, needs Case management of mpox: Where we are and where we desire to be Read online: Scan this QR code with your smart phone or mobile device to read online Note: The manuscript is a contribution to the themed collection titled ‘Mpox and Marburg Emergency Preparedness and Response in Africa,’ under the expert guidance of guest editor Prof. Nicaise Ndembi.

[Find the meaning and references behind the names: Ahmed, Mohamed, Ahmad, Malik, Real, Gupta, Martin, Zahra, Mani, Princy, Ganesan, Ahsan, Aluisio, Med]

Page 2 of 2 Editorial http://publichealthinafrica.org Open Access further research. Clinical manifestations and complications require expert collaboration to refine case classification criteria for more precise treatment. Limited access to antivirals and vaccines hampers healthcare systems, particularly in resource-limited settings with high mpox prevalence, such as the conflict-affected regions in eastern DRC Future directions in mpox management The future of mpox management must address current gaps while prioritising inclusivity and accessibility. Enhanced surveillance in the WHO African region is essential, including real-time data sharing, strategic contact tracing, and advanced molecular diagnostic techniques to quickly identify and prevent outbreaks. Integrating mpox into the One Health framework can help track zoonotic transmission and enable targeted public health responses 15 Scaling up clinical trials and research across all regions is critical. Efforts should evaluate the safety and efficacy of vaccines and antivirals, particularly tecovirimat. Research into novel antivirals especially for immunocompromised patients prone to severe disease outcome, 16 reinfection risks, and vaccine efficacy duration is also necessary to refine public health policies. Addressing disparities in access to therapeutics and vaccines is essential for improving treatment outcomes. International collaboration can enable pooled procurement, subsidised distribution, and innovative delivery systems such as mobile vaccination units to increase coverage in remote areas. 17 Developing specialised clinical guidelines, led by WHO and Africa Centre for Disease Control and Prevention (Africa CDC) with input from technical working groups, is vital. These guidelines should include protocols for managing severe and immunocompromised patients. Health worker training on these protocols will ensure effective application, improving patient outcomes 18 In conclusion, the surge in mpox cases since 2022 highlights vulnerabilities in global and regional healthcare systems, emphasising the need for improved case management. A more holistic approach, including research investment, increased accessibility, and updated guidelines, is essential. By adopting a globally inclusive strategy, the transmission and resurgence of mpox can be curtailed. The time to act is now! References 1. WHO. WHO declares mpox outbreak a public health emergency of international concern [homepage on the Internet]. 2024 [cited 2024 Oct 31]. Available from: https://www.rstmh.org/news-blog/news/who-declares-mpox-outbreak-apublic-health-emergency-of-international-concern#:~:text=In % 20 July % 20 2022 % 2 C % 20 the % 20 multi,sustained % 20 decline % 20 in % 20 global % 20 cases 2. WHO. Director-General declares mpox outbreak a public health emergency of international concern [homepage on the Internet]. 2024 [cited 2024 Oct 31]. Available from: https://www.who.int/news/item/14-08-2024-whodirector-general-declares-mpox-outbreak-a-public-health-emergency-ofinternational-concern 3. Malik S, Ahmad T, Ahsan O, et al. Recent developments in Mpox prevention and treatment options. Vaccines. 2023;11(3):500. https://doi.org/10.3390/ vaccines 11030500 4. Grosenbach DW, Russo A T, Blum ED, et al. Emerging pharmacological strategies for treating and preventing mpox. Expert Rev Clin Pharmacol. 2023;16(9):843– 854. https://doi.org/10.1080/17512433.2023.2249820 5. Fox T, Gould S, Princy N, et al. Therapeutics for treating mpox in humans. Cochrane Database Syst Rev. 2023;3(3):CD 015769. https://doi.org/10.1002/14651858. CD 015769 6. Adetifa I, Muyembe JJ, Bausch DG, et al. Mpox neglect and the smallpox niche: A problem for Africa, a problem for the world. Lancet. 2023;401(10390):1822–1824. https://doi.org/10.1016/S 0140-6736(23)00588-3 7. WHO. Clinical management of Mpox (Monkeypox) [homepage on the Internet]. [cited 2024 Nov 01]. Available from: https://www.who.int/teams/health-carereadiness/clinical-management-of-monkeypox#:~:text=For % 20 mpox % 2 C % 20 the % 20 initiative % 20 provides,monitoring % 2 C % 20 reporting % 2 C % 20 and % 20 sharing. 8. Duroseau B, Kipshidze N, Limaye RJ. The impact of delayed access to COVID-19 vaccines in lowand lower-middle-income countries. Front. Public Health. 2023;10:1087138. https://doi.org/10.3389/fpubh.2022.1087138 9. Gupta AK, Talukder M, Rosen T, et al. Differential diagnosis, prevention, and treatment of mpox (Monkeypox): A review for dermatologists. Am J Clin Dermatol. 2023;24(4):541–556. https://doi.org/10.1007/s 40257-023-00778-4 10. Gamo Guerrero M, Simón Gozalbo A, Martín Díaz M, et al. Interdisciplinary management of mpox-related local complications: Report on a series of cases. Front Med (Lausanne). 2023;10:1184924. https://doi.org/10.3389/ fmed.2023.1184924 11. Ahmed SK, Mohamed MG, Dabou EA, et al. Monkeypox (mpox) in immunosuppressed patients. F 1000 Res. 2023;12:127. https://doi.org/10.12688/ f 1000 research.130272.2 12. Aluisio AR, Barry MA, Martin KD, et al. Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted timeseries study. Afr J Emerg Med. 2019;9(1):14–20. https://doi.org/10.1016/j. afjem.2018.10.002 13. Sikora A, Zahra F. Nosocomial infections [homepage on the Internet]. 2024 [updated 2023 Apr 27]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 559312/. 14. Shea K, Borchering RK, Probert WJM, et al. Multiple models for outbreak decision support in the face of uncertainty. Proc Natl Acad Sci USA. 2023;120(18):e 2207537120. https://doi.org/10.1073/pnas.2207537120 15. Ghai RR, Wallace RM, Kile JC, et al. A generalizable one health framework for the control of zoonotic diseases. Sci Rep. 2022;12:8588. https://doi.org/10.1038/ s 41598-022-12619-1 16. Ganesan A, Arunagiri T, Mani S, et al. Mpox treatment evolution: Past milestones, present advances, and future directions. Naunyn-Schmiedeberg’s Arch Pharmacol. 2024. https://doi.org/10.1007/s 00210-024-03385-0 17. Dhaliwal BK, Seth R, Thankachen B, et al. Leading from the frontlines: Communityoriented approaches for strengthening vaccine delivery and acceptance. BMC Proc. 2023;17(suppl 7):5. https://doi.org/10.1186/s 12919-023-00259-w 18. WHO. New WHO study shows health workers feel more confident to recommend COVID-19 vaccination following a training on patient communication [homepage on the Internet]. 2023 [cited 2024 Nov 03]. Available from: https://www.who.int/ europe/news/item/24-05-2023-new-who-study-shows-health-workers-feelmore-confident-to-recommend-covid-19-vaccination-following-a-training-onpatient-communication.