Mpox: Lessons From 2022 for Future Preparedness

The 2022 mpox outbreak caught many off guard, quickly spreading beyond endemic areas in Africa to other parts of the world, including Europe and North America. The World Health Organization (WHO) declared it a public health emergency of international concern (PHEIC), as the outbreak revealed gaps in global preparedness for zoonotic diseases. With more than 80,000 confirmed cases globally in 2022, the need for healthcare providers to be well-versed in the transmission, clinical presentation, and management of mpox became evident.

Mpox, a viral zoonosis, is typically associated with localized skin lesions and flu-like symptoms. However, as seen in 2022, the virus can have more far-reaching effects and systemic complications, particularly in immunocompromised individuals. This may be because of the particular clade involved: the 2022 outbreak was linked to the clade IIb variant. Unlike previous clades, cases in 2022 were primarily attributed to human-to-human transmission (largely through sexual contact). The outbreak emphasized that while mpox may appear as a self-limiting illness, healthcare systems must be prepared for its potential systemic complications.

Mpox cases peaked in August 2022 and then steadily declined due to public health efforts, including vaccination, education, and surveillance campaigns. These efforts significantly reduced transmission, and the 2022 outbreak was considered resolved. But a new outbreak emerged in the Democratic Republic of Congo in September 2023, primarily associated with clade Ib, and has spread to neighboring countries previously unaffected by mpox. This resurgence has prompted the WHO to again declare a PHEIC, with cases up 160% and deaths up 19% compared with the same period last year.

Drawing from the latest mpox research, evidence, and practice guidelines, I aim to enhance clinicians’ preparedness for managing the disease to prevent severe outcomes and ensure they are prepared to respond to future outbreaks.

Systemic Complications of Mpox

One of the most concerning aspects of the 2022 outbreak was the increasing recognition of systemic complications. While many patients experienced mild symptoms, some developed severe outcomes that required hospitalization. In a recent review I published with colleagues, we identified several systemic effects of mpox, including:

• Respiratory complications: In severe cases, patients developed pneumonia or other respiratory conditions, complicating recovery and increasing mortality risk.
• Neurological issues: Neurological symptoms, including encephalitis and seizures, were observed in some patients, especially those with underlying vulnerabilities such as HIV or weakened immune systems.
• Severe skin lesions: While skin lesions are the hallmark of mpox, widespread and necrotic lesions were observed in patients with extensive systemic involvement.

At-risk populations, particularly immunocompromised individuals and those with coexisting conditions, were more prone to these complications. Early recognition of these risk factors is key to preventing more severe systemic outcomes.

Clinical Management and Practice Guidelines

The management of mpox, particularly when systemic complications are present, requires a multidisciplinary approach. The CDC and WHO have published updated practice guidelines that focus on early recognition and supportive care. Key points include:

• Antiviral treatment: Tecovirimat (Tpoxx), an antiviral initially developed for smallpox, has shown promise in reducing disease severity. Healthcare providers should be aware of its availability and indications for use in severe or at-risk patients.
• Monitoring for complications: Clinicians must be vigilant in monitoring patients for signs of systemic involvement, such as respiratory distress or neurological changes. Early intervention can be lifesaving.
• Isolation and prevention: Strict infection control measures, including isolation of confirmed cases and use of personal protective equipment, remain vital in preventing further spread, especially in healthcare settings.

For clinicians, recognizing early signs of systemic disease — such as worsening respiratory symptoms or altered mental status — can prevent progression to severe complications.

Public Health Implications

The 2022 mpox outbreak underscored the importance of public health collaboration. Timely vaccination efforts played a significant role in curbing the spread, particularly in high-risk groups. Additionally, public education campaigns aimed at dispelling myths and encouraging protective behaviors were crucial in controlling the outbreak.

Healthcare providers must work closely with public health officials to ensure that proper surveillance systems are in place. This includes real-time tracking of cases, rapid deployment of vaccines, and transparent communication with the public to avoid misinformation and panic.

The outbreak also highlighted the need for healthcare systems to be agile and responsive. As seen during the COVID-19 pandemic, robust healthcare infrastructure and the ability to quickly mobilize resources are essential in outbreak situations.

Looking Forward: Preparing for Future Outbreaks

As with any viral outbreak, mpox provides important lessons for future preparedness. Researchers are already calling for ongoing studies to better understand the transmission, prevention, and treatment of zoonotic diseases like mpox. There is also a push for enhanced global surveillance of emerging infectious diseases, particularly in regions where zoonotic transmission is more likely.

To better prepare for future outbreaks, healthcare systems should consider the following strategies:

• Developing targeted treatment protocols: Standardized guidelines for treating systemic complications should be established, particularly for vulnerable populations.
• Ensuring access to vaccines: While the smallpox vaccine offers some protection against mpox, more accessible and targeted vaccines should be developed.
• Strengthening global health networks: International collaboration on disease surveillance and research is essential for early detection and containment.

The 2022 mpox outbreak was a stark reminder of the importance of understanding and managing systemic complications of viral diseases. As healthcare providers, we must stay informed about the latest research and guidelines to ensure the best outcomes for our patients. Continued research, preparedness, and vigilance are crucial as we face the ever-present threat of zoonotic outbreaks in the future.

Harshal Shah, MD, is a board-certified internal medicine physician and hospitalist with over a decade of experience in infection control and epidemiology. He has published extensively on viral outbreaks and the impact of systemic complications in infectious diseases.