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Several concurrent mpox outbreaks are ongoing in the Democratic Republic of the Congo. We report a case of severe clade Ia mpox in an adult woman with indeterminate HIV status who died 16 days after symptom onset. She self-identified as a sex worker and had spent time in the capital city, Kinshasa.

Clade Ib, a new strain of clade I monkeypox virus, emerged in eastern DR Congo, sparking an international outbreak. Comprehensive studies are needed to assess its transmission dynamics and clinical presentation. We did a prospective observational cohort study at Kamituga General Hospital in South Kivu, DR Congo, between May 2 and Oct 9, 2024. Sociodemographic, exposure, and clinical data were collected from mpox-suspected cases. Cases were confirmed by Xpert Mpox PCR and followed through hospitalisation and on days 29 and 59 after diagnosis. Of the 510 suspected cases included, 407 (80%) tested positive via PCR. Among the 407 confirmed cases, 196 (48%) were women. Age distribution was bimodal, with 58 (14%) children younger than 5 years, and 267 (66%) individuals aged 15–34 years. Most cases (237 [58%] of 406) reported contact with a suspected or confirmed mpox case; primarily colleagues, spouses or sexual partners in adults, and parents or siblings in children. Self-reported comorbidities were rare (18 [5%] of 400), including 6 (2%) people infected with HIV. Prodromal symptoms were present in 331 (88%) of 375 patients, active skin lesions in 394 (97%) of 407 patients, mucosal lesions in 324 (82%) of 394 patients, and lymphadenopathy in 288 (73%) of 394 patients. In adults, 280 (89%) of 314 had genital skin lesions and mean lesion density was highest in the genital area. In contrast, only 35 (42%) of 84 children had genital lesions, as part of a more uniform rash. Among 403 hospitalised patients, two (<1%) deaths occurred. Among 296 patients with detailed hospital follow-up, complications were primarily genito-urinary (169 [57%]) or cutaneous (121 [41%]). Four (67%) of six pregnant women with recorded outcome had adverse pregnancy outcomes. On days 29 and 59, few sequelae were reported other than scars. Clade Ib infections in Kamituga showed distinct clinical patterns compared with clade Ia outbreaks elsewhere in the country and the global clade IIb outbreak. In adults, the disease primarily affected the genito-urinary system, compatible with sexual transmission, whereas children mostly manifested extragenital lesions. These findings highlight the need for updated case definitions and targeted public health interventions to address evolving transmission dynamics and mitigate risks for vulnerable groups, including pregnant women and young children. European & Developing Countries Clinical Trials Partnership (EDCTP2 and EDCTP3); Belgian Directorate-General Development Cooperation and Humanitarian Aid; Research Foundation–Flanders.

Monkeypox is a vesicular-pustular illness that carries a secondary attack rate in the order of 10% in contacts unvaccinated against smallpox. Case fatality rates range from 1 to 11%, but scarring and other sequelae are common in survivors. It continues to cause outbreaks in remote populations in Central and West Africa, in areas with poor access and weakened or disrupted surveillance capacity and information networks. Recent outbreaks in Nigeria (2017-18) and Cameroon (2018) have occurred where monkeypox has not been reported for over 20 years. This has prompted concerns over whether there have been changes in the biology and epidemiology of the disease that may in turn have implications for how outbreaks and cases should best be managed. A systematic review was carried out to examine reported data on human monkeypox outbreaks over time, and to identify if and how epidemiology has changed. Published and grey literature were critically analysed, and data extracted to inform recommendations on outbreak response, use of case definitions and public health advice. The level of detail, validity of data, geographical coverage and consistency of reporting varied considerably across the 71 monkeypox outbreak documents obtained. An increase in cases reported over time was supported by literature from the Democratic Republic of Congo (DRC). Data were insufficient to measure trends in secondary attack rates and case fatality rates. Phylogenetic analyses consistently identify two strains of the virus without evidence of emergence of a new strain. Understanding of monkeypox virulence with regard to clinical presentation by strain is minimal, with infrequent sample collection and laboratory analysis. A variety of clinical and surveillance case definitions are described in the literature: two definitions have been formally evaluated and showed high sensitivity but low specificity. These were specific to a Congo-Basin (CB) strain-affected area of the DRC where they were used. Evidence on use of antibiotics for prophylaxis against secondary cutaneous infection is anecdotal and limited. Current evidence suggests there has been an increase in total monkeypox cases reported by year in the DRC irrespective of advancements in the national Integrated Disease Surveillance and Response (IDSR) system. There has been a marked increase in number of individual monkeypox outbreak reports, from outside the DRC in between 2010 and 2018, particularly in the Central African Republic (CAR) although this does not necessarily indicate an increase in annual cases over time in these areas. The geographical pattern reported in the Nigeria outbreak suggests a possible new and widespread zoonotic reservoir requiring further investigation and research. With regards to outbreak response, increased attention is warranted for high-risk patient groups, and nosocomial transmission risks. The animal reservoir remains unknown and there is a dearth of literature informing case management and successful outbreak response strategies. Up-to-date complete, consistent and longer-term research is sorely needed to inform and guide evidence-based response and management of monkeypox outbreaks.

Mpox was first identified against the backdrop of the smallpox eradication campaign. Monkeypox virus (MPXV), the causative agent of mpox, has been maintained in animal reservoirs in the forested regions of West and Central Africa as 2 distinct clades; clade I has historically caused more severe infection in Central Africa than clade II, historically found in West Africa. However, rapid reemergence and spread of both MPXV clades through novel routes of transmission have challenged the known characteristics of mpox. We summarize mpox demographic distribution, clinical severity, and case-fatality rates attributed to genetically distinct MPXV subclades and focus on MPXV clade Ib, the more recently identified subclade. Broad worldwide assistance will be necessary to halt the spread of both MPXV clades within mpox endemic and nonendemic regions to prevent future outbreaks.

Monkeypox virus (MPXV) is endemic in western and Central Africa, and in May 2022, a clade IIb lineage (B.1) caused a global outbreak outside Africa, resulting in its detection in 116 countries and territories. To understand the global phylogenetics of MPXV, we analyzed all available MPXV sequences, including 10,670 sequences from 65 countries collected between 1958 and 2024. Our analysis reveals high mobility of clade I viruses within Central Africa, sustained human-to-human transmission of clade IIb lineage A viruses within the Eastern Mediterranean region and distinct mutational signatures that can distinguish sustained human-to-human from animal-to-animal transmission. Moreover, distinct clade I sequences from Sudan suggest local MPXV circulation in areas of eastern Africa over the past four decades. Our study underscores the importance of genomic surveillance in tracking spatiotemporal dynamics of MXPV clades and the need to strengthen such surveillance, including in some parts of eastern Africa. An analysis of all available mpox virus sequences, including 10,670 sequences from 65 countries collected between 1958 and 2024, unveils the circulation pattern and spatiotemporal dynamics underlying the spread of the different viral clades.

We designed a multiplex quantitative PCR to differentiate monkeypox virus clades. For clinical samples collected in the United Kingdom and Nigeria, sensitivity was 78% (95% CI 67.67%-86.14%) and specificity 94% (95% CI 80.84%-99.30%); for samples with cycle thresholds <35, sensitivity was 98% (95% CI 91.72%-99.96%) and specificity 94% (95% CI 80.84%-99.30%).

We used published data from outbreak investigations of monkeypox virus clade I in the Democratic Republic of the Congo to estimate the distributions of critical epidemiological parameters. We estimated a mean incubation period of 9.9 days (95% credible interval [CrI] 8.5-11.5 days) and a mean generation time of 17.2 days (95% CrI 14.1-20.9 days) or 11.3 days (95% CrI 9.4-14.0 days), depending on the considered dataset. Presymptomatic transmission was limited. Those estimates suggest generally slower transmission dynamics in clade I than in clade IIb. The time-varying reproduction number for clade I in the Democratic Republic of the Congo was estimated to be below the epidemic threshold in the first half of 2024. However, in the South Kivu Province, where the newly identified subclade Ib has been associated with sustained human-to-human transmission, we estimated an effective reproduction number above the epidemic threshold (95% CrI 0.96-1.27).

We report clade Ib monkeypox virus infection in a patient who returned to Thailand from the Democratic Republic of the Congo, the subclade epicenter. Improved diagnostic testing, public health response, and surveillance systems for mpox are needed in Thailand, and preexposure mpox vaccination should be considered, especially for high-risk persons.

We examined 89 travel-related clade Ib monkeypox virus cases detected in 33 countries during August 2024-July 2025. Most cases were approximately men; about one third led to secondary transmission. Secondary transmission risk was highest among sexual, then household, contacts. Those groups should be the focus of response strategies and interventions.

Early results from clinical trial show that the antiviral drug tecovirimat is no better than placebo against the clade I virus type. Early results from clinical trial show that the antiviral drug tecovirimat is no better than placebo against the clade I virus type.