1 OVERVIEW

Mpox, a zoonotic viral disease endemic in Central and Western Africa, is caused by the double-stranded DNA virus called Monkeypox virus (MPXV), belonging to the Orthopoxvirus (OPXV) genus. The mpox infection presents initially with an invasion period marked by fever, headache, lymphadenopathy, back pain, asthenia, and muscle aches, followed by a skin eruption on the face and extremities, typically occurring 1–3 days after the onset of fever.¹ Mpox transmission occurs through animal-to-human or human-to-human routes, predominantly affecting pregnant or immunocompromised individuals and men who have sex with men (MSM).² The diagnostic testing for mpox requires a polymerase chain reaction test on a viral swab obtained from skin lesions.

2 EPIDEMIOLOGY

The MPXV was originally discovered in 1958, and the Democratic Republic of Congo reported the first human case in 1970.¹ On May 13, 2022, a familial cluster of two mpox cases was identified in the United Kingdom. The sudden emergence of the mpox outbreak in May 2022 has led to its rapid dissemination across various regions, including Europe, the Americas, and all six World Health Organization (WHO) regions. Consequently, WHO declared it a public health emergency on July 23, 2022. Since May 2022, WHO has reported 87,113 laboratory-confirmed mpox cases and 130 fatalities across 111 countries.³ Most confirmed cases in the 2022 outbreak were transmitted within national borders, although the original cases have a travel history to Europe and North America instead of Central or West Africa, where the virus is endemic. The recent mpox virus mutation belonging closely to the West African clade presents as unusual because most recorded cases have no epidemiological link to the endemic countries.⁴ As of May 2023, Pakistan has confirmed its first five cases of mpox.⁵ All the infected individuals had a travel history from abroad, reflecting the potential of the virus to cross borders through international travel and trade. Additionally, it underscores the lack of international cooperation on travel restrictions and inadequate screening measures to prevent the spread of the disease across borders.

3 CHALLENGES FOR PUBLIC HEALTH

Although JYNNEOS vaccine has been approved for mpox, there is no medically approved drug specific for mpox. However, the viruses belonging to the OPXV genus are genetically similar, antiviral drugs, namely, Tecovirimat, Cidofovir, and Brincidofovir used against smallpox, have been used to treat mpox infections. Even so, there is a dearth of information regarding the efficacy of Cidofovir in mpox infections, whereas Tecovirimat shows promise as an effective therapeutic agent against severe mpox infections.⁶ Additionally, the variant involved in the current outbreak contains a mutant genome, thereby increasing the chances that the virus will acquire resistance against the current medications, making mpox a challenging disease to treat.^{7, 8}

The emergence of the first few mpox cases in Pakistan poses a significant threat to the country's already struggling public health system, particularly in the aftermath of the COVID-19 pandemic. Financial constraints due to limited health budget impede the provision of resources like sufficient healthcare personnel and critical medical equipment, including ventilators, hospital beds, and adequate laboratory facilities.⁹ This further compromises the capacity to deal with additional burdens of emerging infectious diseases like mpox. The Centers for Disease Control and Prevention (CDC) has warned of severe mpox infection in immunocompromised individuals due to Human Immunodeficiency Virus (HIV) infection. As reported in the year 2020,¹⁰ approximately 183,705 people are living with HIV in Pakistan, making it the second largest country in South Asia in terms of the HIV epidemic.

Studies have demonstrated that the actual number of mortalities caused by mpox in the recent outbreak is expected to be even higher because testing and monitoring resources in low- and middle-income countries are often insufficient to record all fatalities.² Given Pakistan's underdeveloped healthcare infrastructure, providing widespread access to testing for mpox is challenging. The WHO has recently collaborated with the Pakistani government to investigate the spread of the virus and has pledged to support the li nun the situation develops.¹¹

4 STRATEGIES TO COMBAT PUBLIC HEALTH THREATS AND PRIORITIZE EFFECTIVE RESPONSE

Implementing appropriate infection control strategies is critical in mitigating the spread of the disease. Avoiding unprotected contact with animals and restrictions on their global trading, maintaining good hand hygiene, refraining from intimate contact, and ensuring safe sex practices are crucial to prevent mpox infection and spread. Prompt isolation of the suspected case and vaccination of the exposed individuals and their close contacts should also be ensured. Homosexual communities are disproportionately affected by mpox, but stigmatizing attitudes against this group can weaken the outbreak response, emphasizing the need for combined efforts to address this concern.¹² Moreover, it is critical to deduce and implement the lessons learned from the Covid-19 pandemic. Studies have reported that healthcare workers accounted for 50% of the mortalities during the Covid-19 pandemic,¹³ thus highlighting the need for effective prevention methods, including avoiding direct contact with the lesions, wearing personal protective equipment, and masking the suspected individuals. Additionally, delayed reporting of the initial outbreak, lack of coordination on infection control strategies, and inadequate resource allocation facilitated the spread and persistence of Covid-19, further worsened by vaccine hesitancy, noncompliance with preventive measures, and delayed genetic surveillance for the emergence of more pathogenic strains.¹⁴ However, targeted vaccination can address vaccine hesitancy in high-risk individuals as mass vaccination is not necessary for mpox, making it a containable virus with proactive measures, unlike COVID-19.¹⁵ Investment in public health infrastructure, including hospitals, medical supplies, and trained healthcare workers for adequate surveillance and acute response, is required to be better equipped to handle potential disease outbreaks.¹⁶ Therefore, addressing the gaps mentioned above in rapid detection, effective surveillance system, and international cooperation on infection control strategies are crucial to curb mpox at the current stage before it turns into an epidemic in Pakistan.

Recently, consolidated guidelines on mpox prevention, detection, surveillance, and response have been developed and distributed by the National Command and Operation Center at the National Institute of Health,¹⁷ which is a welcomed initiative. The country has implemented stricter screening measures for inbound passengers, and the Border Health Services issued an advisory to enhance screening at international airports. Proactive measures must be taken to prevent the primary transmission of disease and protect Pakistan's fragile public health system. In short, mpox is a viral disease that warrants enhanced surveillance all over the world. Health authorities must take this matter seriously and implement an enhanced surveillance system and effective contact tracing method to limit the spread of the disease and prevent potential spillover to corresponding countries.

AUTHOR CONTRIBUTIONS

Sanila Mughal: Conceptualization; Validation; Writing—original draft; Writing—review and editing. Hadiya Javed: Conceptualization; Validation; Writing—original draft; Writing—review and editing. Muhammad Hasanain: Supervision; Validation; Writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

This article did not involve patients; therefore, no ethical approval was required.

TRANSPARENCY STATEMENT

The lead author Sanila Mughal affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.