Introduction
The global health landscape
shifted significantly on August 14, 2024, when the World Health Organization
(WHO) declared Mpox a Public Health Emergency of International Concern (PHEIC)
for the second time in just two years. Originally identified in 1958 among
captive monkeys in Denmark and first documented in a human in 1970, the virus
has transcended its traditional endemic boundaries in Central and West Africa.
The term “monkeypox virus” was first introduced, and in November 2022, the WHO
officially renamed it ‘Mpox’. As of late 2024, the infection has reached over
123 countries, resulting in more than 109,699 confirmed cases and 234 deaths.
In South Asia, a region characterized by high population density and varying
levels of healthcare infrastructure, the arrival of Mpox presents a complex
public health challenge that requires a detailed examination of regional
epidemiology and strategic readiness.
Virology and
Pathogenesis
Mpox is caused by the
monkeypox virus (MPXV), a double-stranded DNA virus belonging to the
Orthopoxvirus genus. It is structurally related to the smallpox virus but
generally results in less severe clinical manifestations. The virus is
categorized into two distinct genetic clades: Mpox is a DNA virus that can be
classified into Clade I and Clade II (sub-classified: subclade
IIa and IIb). Clade IIb is responsible for most global cases reported
during 2022–2024. In 2024, a newly identified subclade of Clade I, called Clade
Ib, was discovered in Africa.
Clade I, which is endemic to the Congo Basin and
associated with higher virulence and mortality (up to 10.6%), and Clade II,
endemic to West Africa, with a lower case fatality rate (around 3.6%). Subclade
IIb largely drove the global outbreak that began in 2022. However, the 2024
emergency was catalyzed by the emergence of Clade Ib in the Democratic Republic
of the Congo, which appears to spread more easily through sexual networks and
household contact.
It can be transmitted from
animals to humans and between humans through direct contact, respiratory
droplets, body fluids, or contaminated materials. The virus thus enters the
host through broken skin, respiratory droplets, or mucous membranes, including
the eyes, mouth, and genital tracts. After an incubation period typically
lasting 6 to 13 days—but potentially extending to 21 days—the infection
manifests in stages. Initial symptoms include fever, intense headache,
lymphadenopathy (swollen lymph nodes), and myalgia. The subsequent rash
progresses from flat macules to raised papules, fluid-filled vesicles, and
finally pustules that crust over and fall off. A distinguishing feature of Mpox
compared to other pox-like illnesses is the prominent swelling of lymph nodes
during the prodromal phase.
Epidemiological
Trends in South Asia
While South Asia has not seen
the massive case numbers reported in the Americas or Europe, the regional
spread is steady and concerning. As of August 2024, laboratory-confirmed cases
in the WHO South-East Asia Region totaled 942, with 11 deaths reported exclusively
in Thailand. Within South Asia, India has reported at least 32 cases, Pakistan
11, Sri Lanka 4, and Nepal 3.
India’s experience has been
the most documented in the region, with over 350 publications originating from
Indian institutions. Since its first reported case in 2022, the country has
conducted extensive genomic analysis, identifying multiple sub-clusters within
the A.2 lineage. Notably, India reported a case of the more transmissible Clade
Ib form in September 2024, linked to travel from Africa. Pakistan’s cases have
also been primarily linked to international travel, prompting the activation of
its National Command and Operation Center (NCOC) to manage the threat. Sri
Lanka, while reporting few cases, faces a heightened risk due to ongoing
economic instability and the pressure of concurrent outbreaks such as dengue
and influenza on its healthcare system.
Nepal: Reports
and Risks
In Nepal, the public health
response has focused on the risk of local transmission stemming from imported
cases. The National Public Health Laboratory (NPHL) has confirmed three cases
of Mpox in the country, all of which were linked to recent travel history to
Saudi Arabia. Sequencing identified these cases as belonging to Clade IIa.
Microbiological experts have
identified two primary areas of vulnerability for Nepal. First, the high volume
of labor migration to and from the Middle East serves as a potential conduit
for the virus. Second, Nepalese individuals serving in UN peacekeeping forces
in Africa are at an elevated risk. These troops are often stationed in endemic
regions and live in shared conditions where human-to-human transmission through
direct contact or respiratory secretions is more likely. In response, the
Government of Nepal has launched a dedicated hotline (1115) for reporting
symptoms and has emphasized the need for strengthened molecular diagnostics at
border entry points. Moreover, MPOX is not endemic in Nepal, and the Nepali
public is unfamiliar with it; most respondents scored poorly. Such poor
knowledge is influenced by increasing age, low level of education, and the
participants who did not use smart mobile phones for health-related
information.
Preventive
Strategies and Clinical Management
There is currently no
specific clinical treatment approved exclusively for Mpox, but several
antiviral agents developed for smallpox are being utilized. Tecovirimat (TPOXX)
is commonly used to reduce viral release, though recent studies have shown it
may not significantly shorten lesion healing time, and reports of drug
resistance are emerging. Cidofovir has shown high in vitro potency against the
virus but carries risks of kidney toxicity.
Vaccination remains the
cornerstone of prevention. Data suggest that traditional smallpox vaccines are
approximately 85% effective in preventing Mpox due to cross-immunity. The WHO
and regional authorities recommend the JYNNEOS (MVA-BN) vaccine for high-risk
groups, including healthcare workers and laboratory personnel. A significant
breakthrough for South Asia occurred in December 2024, when the Serum Institute
of India (SII) partnered with Bavarian Nordic to manufacture and distribute the
Mpox vaccine locally. This partnership is expected to improve vaccine
accessibility for low- and middle-income countries in the region.
Preparedness and
Public Health Challenges
Regional preparedness varies
significantly across nations. India has expanded its diagnostic network to
approximately 32 centers and has even approved indigenous test kits for more
rapid detection. Bhutan has activated its Health Emergency Operation Center and
enhanced surveillance at points of entry. However, the region as a whole faces
steep hurdles, including a shortage of trained healthcare workers often well
below the WHO recommendation and limited ICU capacity in rural areas.
One of the most insidious
barriers to effective control is social stigma. Mpox has been
disproportionately identified among men who have sex with men (MSM) in the
global outbreak, leading to harmful stereotypes. In many South Asian societies,
this association can lead to underreporting as infected individuals fear
discrimination or legal repercussions. Health ministries in the region, such as
those in Kerala, India, have found that prioritizing active surveillance and
community engagement over fear-based messaging is critical to maintaining
public trust.
Conclusion
Mpox is no longer a localized
African concern; it is a global threat that has firmly established a presence
in South Asia. While the current case numbers in the region are manageable, the
high population density and the presence of more virulent clades demand
rigorous vigilance. The path forward must involve a "One Health"
approach that integrates human, animal, and environmental monitoring.
Strengthening laboratory capacities for genomic sequencing is essential to
track the evolution of the virus and the potential emergence of
vaccine-resistant strains. Furthermore, South Asian nations must leverage the
lessons learned from the COVID-19 pandemic to ensure equitable vaccine
distribution and to combat the misinformation that fuels stigma.
