Introduction

Historically known as Monkeypox, Mpox is an endemic zoonotic disease mostly found in parts of Central and West Africa and is characterized by fever, rash, and lymphadenopathy, among other symptoms. Mpox was first identified in 1958 [1,2]; the first human case was reported in 1970 in the Democratic Republic of Congo (DRC) [3]. Since that time (1970s), there have been sporadic outbreaks with an increasing trend in incidence and geographical spread over the past months. The Mpox pathogen is primarily transmitted through direct contact with infected animals or humans and indirectly by contact with fomites [4–6]. In recent times, there have been reports of sexual transmission of Mpox [7–9]. Human transmission of Mpox is inefficient compared to smallpox, but changes in human behavior and environmental factors make such a transmission pattern more common. The role of animal reservoirs, especially rodents and small primates, is crucial in preventing the transmission of the Mpox virus in nature. However, there remains limited evidence on the role of animal reservoirs and sexual transmission in spreading Mpox. Understanding the specific animal species that act as reservoirs is crucial for predicting and preventing spillover events. Additionally, clarifying the mechanisms and prevalence of sexual transmission is essential for developing targeted public health interventions. Addressing these gaps will enhance our ability to control and eventually eliminate Mpox in affected countries and by extension regions.

Current Mpox situation in Africa compared with other regions

Mpox is endemic in several African countries. From January 1, 2022, to August 6, 2024, sixteen African countries reported laboratory-confirmed Mpox virus cases (Fig 1) [10], with a total of 2030 confirmed cases and 13 deaths [7–9]. There have never been any historically reported Mpox case for many of these countries, including Burundi, Kenya, Rwanda, and Uganda. To date, African countries have recorded more confirmed and suspected Mpox cases (a total of 17,500) in 2024 than in 2023 (a total of 15,000) [11,12]. The DRC is the epicenter of the current Mpox outbreak in Africa [13], and the majority of the Mpox cases in Africa in 2024 so far have been children ≤15 years. In the DRC, this sub-population accounts for two-thirds of Mpox incidence [14]. The spread of the virus in these countries is largely blamed on the ongoing conflict in the region, which has resulted in the mass displacement of civilians across their different borders. Other critical challenges to curtailing the Mpox outbreak in Africa include limited healthcare infrastructures compounded with limited medical supplies and professionals, community beliefs in seeking healthcare from traditional healers, and limited funding [15]. Worth noting that Ghana has no history of Mpox outbreaks; however, the country was identified in 2003 as the source of a shipment of wild mammals that led to Mpox outbreak in US that year.

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Fig 1. Distribution of Mpox cases in Africa, 2022–August 2024.

https://doi.org/10.1371/journal.pntd.0013148.g001

In September 2023, a new Mpox variant (clade 1b) emerged in the eastern DRC [14] which shares borders with Rwanda and Uganda. Rwanda, Uganda, and most recently, Kenya have reported cases of the new Mpox variant [11]. Four countries: Burundi, Kenya, Rwanda, and Uganda with no previous outbreaks of Mpox have reported cases since mid-July 2024. Epidemiological data from these countries indicates an increasing trend of Mpox cases in the past few months; this increase may be attributed to environmental and ecological changes, improved surveillance, and a waning level of population immunity following the cessation of smallpox vaccination programs.

Compared to other regions globally (Table 1), like Europe, specifically the United Kingdom, ranks in the eighth position worldwide regarding the burden of Mpox [16]. Most cases occur among men who identify as gay or bisexual or men who have sex with men, with transmission mainly occurring through close skin contact [16]. This pattern highlights the importance of targeted public health measures and awareness efforts to curb the spread within these communities. Similar patterns were also observed in North America, like Canada, where most of the cases occur among men who have sex with men, and the primary route of transmission is reported through sexual intercourse [17].

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Table 1. Differences in the epidemiology of the African Mpox outbreak with other regions.

https://doi.org/10.1371/journal.pntd.0013148.t001

Current public health response

Challenges and opportunities

Global implications

The limited vaccine availability and access, low public awareness, movements of people, and poor healthcare infrastructure within African countries make it difficult to curtail the infection. This poses a high risk of transmission globally. The widespread Mpox infection would not only result in high mortality and morbidity but would also disrupt several other activities including travel restrictions and slowing economic growth. Considering the weak immunity of children, becoming infected with Mpox as seen in the affected African countries, would increase their vulnerability to many other infections. Consequently, this will result in a high fatality rate, thereby reducing the continent’s future generation with a high potential of contributing to economic growth within Africa and beyond. The ongoing conflict in many countries globally poses a high risk of Mpox transmission, as evidenced in Burundi, Kenya, Rwanda, and Uganda. The emergence of Mpox in those countries will be extremely fatal, especially since their healthcare system is disrupted by the ongoing war. With the rapid spread of Mpox across the African continent, non-endemic countries must enhance their preparedness measures to prevent the importation of the Mpox virus. Key strategies include training healthcare workers, particularly those in border communities, on Mpox case detection and providing logistical support alongside establishing isolation units at designated health facilities, particularly in border communities. Similar to the COVID-19 pandemic, the spread of Mpox in non-endemic countries could increase the vulnerability of populations, especially children, to vaccine-preventable diseases and limit access to essential medical services, thereby elevating morbidity and mortality rates. Furthermore, the outbreak may reduce the productivity of healthcare workers, who would be overburdened with the provision of essential healthcare services.

Policy recommendations

Breaking the chain of Mpox transmission in Africa requires a multipronged approach. African countries should heighten public awareness campaign activities, solicit support for Mpox vaccines, train healthcare workers on Mpox case definitions, and enhance surveillance. Governments should provide funds to their respective public health institutes/agencies to heighten preparedness and response efforts. To ensure the swift distribution of Mpox vaccines, African countries should prioritize procurement and mandate vaccination for high-risk groups, including healthcare workers. Integrating Mpox vaccination into routine immunization programs is essential, with a focus on optimizing supply and cold chain systems, particularly in rural areas. The deployment of community health workers (CHWs) is crucial for effective vaccine distribution in remote regions and for enhancing social mobilization to boost vaccine uptake. Moreover, funding from government and international partners should support public health researchers in conducting groundbreaking studies to investigate the transmission patterns of Mpox related to sexual intercourse and identify the virus’s reservoir. Qualitative research in countries without known Mpox transmission is needed to understand the factors behind successful prevention, which can inform strategies to prevent future outbreaks in both endemic and non-endemic regions. Finally, a community-focused care framework is recommended, emphasizing the involvement of CHWs and stakeholders like religious and traditional leaders, youth, and women’s groups. Leveraging local resources and knowledge through this framework enhances vaccine distribution and social mobilization, which are crucial for controlling the outbreak and preventing further transmission.

Conclusion

Children make up the majority of those infected with Mpox, which is endemic in several African countries and has a high fatality rate. Several factors, including population immunity deficiencies and changes to the environment and ecology, have led to the widespread of Mpox in the African continent. Challenges such as the fragile healthcare system, limited vaccine availability and access, weak surveillance, and low public awareness make it difficult for the containment of the infection in affected countries. Because Mpox has the potential to disrupt the functioning of every sector globally, non-affected countries within and beyond Africa must provide support (financial and human resources) to fight against the infection.