WHO’s Director-General declared mpox a public health emergency of international concern (PHEIC) for the second time in 2 years, following an upsurge in new and concerning cases in the Democratic Republic of Congo (DRC) and several neighboring countries, including the emergence of a new strain – called clade 1b – which appears to be more severe than clade 2, which has been circulating in Europe since 2022.

Risk assessment

On August 16, 2024, the European Centre for Disease Prevention and Control (ECDC) published a risk assessment regarding mpox infection in Europe and for European citizens traveling to Africa. The overall risk of infection in Europe is considered low but is high for close contacts of infected individuals. An increase in imported cases is expected, making prompt isolation, testing, and contact tracing crucial when mpox is suspected.

Based on the latest risk assessments from international organizations, including the WHO and ECDC, the Chief Epidemiologist of Iceland assesses that the risk of mpox infection remains low for the general Icelandic population and low to moderate for certain subgroups, such as men who have sex with men (MSM) with multiple or changing partners. The likelihood of infection is significantly reduced for individuals who have been vaccinated or have a history of previous mpox infection. Please visit the Directorate of Health's website for information on who can receive the mpox vaccine in Iceland.

Increase in mpox cases in Africa

Since the beginning of 2024, there has been a noticeable increase in the number of mpox cases in the Democratic Republic of the Congo (DRC) in Central Africa, with the virus spreading to several surrounding countries. This rise is attributed to the mpox virus clades (variants) known as 1a and 1b (sub-clade 1a is often referred to simply as clade 1). While mpox has been circulating in Africa for many years, it typically caused only minor outbreaks before 2022, and there were few cases outside the continent. However, from 2022 onwards, mpox began spreading to numerous countries outside Africa, including Europe, involving the clade known as 2b.

What is mpox?

The mpox virus (formerly known as monkeypox) is related to the smallpox virus, which was eradicated globally in 1980. Generally, the mpox virus is less contagious and causes less severe illness than smallpox. Mpox spreads through direct close contact with infected individuals, including sexual contact, primarily from lesions on the skin or mucous membranes. Respiratory droplets are not considered a significant route of transmission. Mpox can also be contracted from animals, mainly rodents, which is a common transmission route in Africa for clade 1a.

Mpox infection typically presents with a rash, pustules and blisters (vesicles), which may be confined to the genitals and anal area in cases of sexual transmission. The infection can also be accompanied by fever, muscle pain, headaches, and swollen lymph nodes. The rash and blisters can be very painful. In some cases, depending on the virus variant and the individual, the disease can be fatal. Severe illness is more likely in individuals with underlying immunocompromising conditions or untreated HIV infection. Children and pregnant women are also at higher risk. In Iceland, 16 adults were diagnosed with mpox in 2022 and one in 2023, all with clade 2b, and none of these cases resulted in severe illness. No cases have been diagnosed so far in 2024.

The outbreak in Africa

Two variants of the virus have been known in Africa for many years, clade 1, primarily in central Africa, and clade 2, primarily in West Africa. In general, clade 1 mpox has been a more serious disease with a mortality up to 10%, while clade 2 has typically been a milder disease with a mortality around 1%.

In September 2023, a new variant of clade 1, known as 1b, was identified among infected individuals in eastern DRC. This variant appears to be driving part of the epidemic in the DRC and has recently spread to surrounding countries, including Burundi, Kenya, Rwanda, and Uganda.

Due to the unusual surge in cases, the emergence of a new variant, and the spread to previously unaffected countries, the African Center for Disease Control declared the mpox outbreak a public health emergency on 12 August 2024. The WHO Director-General followed suit on 14 August, declaring the outbreak a public health emergency of international concern. As of August 2024, the African CDC has reported more than 18,000 confirmed or suspected cases of mpox and 500 deaths, across 12 African countries, including the DRC and its neighbors. About 95% of these cases have been diagnosed in the DRC, with most linked to clade 1.

Mpox and Europe

In 2022, a global outbreak of mpox, specifically clade 2b, occurred outside of Africa, affecting the United States, Europe, the Americas, and Asia. The disease primarily spreads through sexual contact. According to the latest joint surveillance bulletin from the WHO and ECDC dated August 15, 2024, a total of 27,529 mpox cases have been reported in 46 European countries from 2022 through July 2024, all of which involved clade 2. The majority of these cases have been reported among men aged 18-40. Most individuals presented with a rash, along with symptoms such as fever, fatigue, and muscle pain. Of these cases, 885 (7%) required hospitalization, eight were admitted to intensive care, and 10 deaths were reported. In 2024, the number of cases reported in Europe has declined. This decrease is attributed to behavior changes, public health interventions, and mpox vaccination efforts, though approximately 100 new cases of mpox clade 2 are still diagnosed in the region each month.

The first confirmed case of the new, potentially more serious and contagious variant clade 1b outside Africa was detected in Sweden on August 14, 2024. It is likely that more imported cases of mpox clade 1 will occur in the Region.

Guidelines for handling mpox

The Chief Epidemiologist has issued guidelines for the general public and healthcare workers on managing mpox in Iceland, and these guidelines are regularly updated as new information becomes available. The guidelines cover a range of topics, including a description of the disease, hygiene measures, prevention, vaccinations, case definitions, use of personal protective equipment, diagnostic methods, and contact tracing. Mpox is a notifiable disease to the Chief Epidemiologist. The Microbiology Lab at Landspitali Hospital analyses tests for mpox and can detect both clades 1 and 2. The Chief Epidemiologist has stock of mpox vaccines, which are managed and administered by the Infectious Disease Clinic at Landspitali Hospital. Recommendations regarding vaccination are unchanged from 2022.

Mpox and travel

The WHO does not recommend restrictions on travel in response to the mpox outbreak, but health authorities are closely monitoring the situation. Currently, the Chief Epidemiologist does not recommend any travel restrictions to the affected African countries. However, if you plan to travel to a country with an ongoing mpox outbreak, it is advised that you:

• Avoid close contact with people with known mpox infection.

• Avoid people who are unwell or have an unexplained rash.

• Avoid new sexual contacts.

• Do not share bedding or personal items with individuals who have or may have mpox.

• Perform careful and repeated hand hygiene (hand washing with soap or using hand sanitizer).

• Avoid contact with animals, particularly rodents.

• Do not prepare or eat meat from wild animals (bushmeat).

• Be aware of symptoms of mpox.

• If you have been in close contact with someone with mpox, seek medical advice and guidance from local health services.

• If you develop symptoms of mpox, contact a doctor immediately and avoid close contact with others.

Mpox vaccination is not currently included as part of the general recommendations for travel to countries with a mpox outbreak, and it is not possible to purchase the vaccine as a traveller. Travel advice will be updated as needed based on changes in the epidemiological situation. It is recommended to stay informed about the situation in affected countries if you are planning to travel.

The Chief Epidemiologist