Five innovations that could help to bring mpox under control

Although it may have faded from international news headlines, mpox continues to spread, with sustained community transmission of the new Clade 1b strain ongoing in the Democratic Republic of the Congo (DRC) and Burundi.

Currently, much of the focus is on mpox vaccines. Though extremely useful, their availability remains limited - as are the resources, training and infrastructure to deliver them.

This means that vaccines alone cannot be relied upon to end this global health emergency. There is also much to learn about how best to deploy these life-saving interventions.

Yet progress is being made that could reduce the threat posed by mpox. Here are five areas of innovation that could help to bring the current mpox outbreak under control and reduce the risk of future outbreaks.

1. Vaccines

There are currently no mpox-specific vaccines: only those developed to protect against its deadly cousin, smallpox. These vaccines still provide good cross-protection and are expected to help contain the spread of mpox. For instance, available data suggests that, when given before exposure, a single dose of the Modified Vaccinia Ankara vaccine developed by Bavarian Nordic is approximately 76% effective at protecting people against infection, rising to 82% after a second dose.

Yet, there is still much to learn about the efficacy of existing vaccines in different groups, including children and immunocompromised individuals; against Clade 1 mpox - the form that's driving the current outbreak; and strategies to optimise the efficacy of these vaccines.

Although the vaccine is still expected to be highly effective, it will be important to collect as much data as possible as it is rolled out during the current emergency, as well as testing whether vaccination after exposure is effective. This data could be crucial in shaping mpox vaccination strategies as the outbreak continues.

Other mpox-specific vaccines are also currently being developed, including two mRNA-based mpox vaccines. Although these are unlikely to help stem the current outbreak, they could be useful during future outbreaks of the disease.

2. Drugs

There is currently no proven drug treatment for mpox. Instead, care currently focuses on managing symptoms such as pain and fever, looking after the skin rash to minimise the risk of scarring or infection, and ensuring that patients are well nourished, hydrated and that any co-infections, including HIV, are being treated.

Various antiviral drugs are being tested in clinical trials however, including those approved for the treatment of smallpox. In August, preliminary results from the PALM007 trial, which has been assessing the efficacy of an antiviral drug called tecovirimat (TPOXX) against Clade 1 mpox in the DRC were announced. Disappointingly, the drug did not appear to reduce the duration of skin lesions among children and adults who received it - although the trial did provide some clues about how to reduce mpox deaths (see section below). A separate trial of tecovirimat against Clade 2 mpox is ongoing.

Other antivirals, including brincidofovir (Texamba) and cidofovir, are also being assessed -as are other treatments, including intravenous vaccinia immunoglobulins (IVIG) - antibodies purified from the plasma of healthy donors who have previously received the smallpox (vaccinia) vaccine.

3. Improved standard of care

Even though the PALM007 trial suggested tecovirimat made no difference to the duration of their illness, the overall death rate among trial participants who received this drug or a placebo was 1.7% - roughly half the 3.6% fatality rate reported for other mpox cases in DRC.

Possibly, this was because all patients in the study were hospitalised for the duration of their treatment, to ensure that they had access to food and that accurate data could be collected from them, meaning they received a level of care unavailable to most mpox patients.

"The results show that study clinicians provided exceptional supportive care to all participants, which is a testament to the knowledge and skill that Congolese clinicians have acquired on managing mpox-related disease," said trial co-principal investigator Dr Jean-Jacques Muyembe-Tamfum at Kinshasa University Medical School in Kinshasa, DRC.

Learning from those with experience of treating mpox about how to best to care for such patients could help to improve outcomes everywhere.

4. Diagnostics

Testing is a critical tool in the fight against mpox. If infected people are rapidly identified, they can be isolated before they pass the virus to others. Their contacts can also be rapidly traced, tested and isolated where necessary, preventing further spread.

Currently, mpox testing is done by sending samples taken from skin lesions away to a laboratory and using a polymerase chain reaction (PCR) test to detect the virus's DNA. This method is highly accurate, and WHO has been working with partners to scale up laboratory testing capacity in response to the recent surge in mpox cases.

However, other types of tests are also urgently needed, some of which are already being developed and assessed. This includes simplified and more rapid PCR tests, and point of care tests that could be used in health clinics, ports of entry, or even people's own homes - including lateral flow-type tests.

5. Public health messaging

Worrying as the current outbreak of mpox is, it is not "the next COVID-19" because health experts already know how it spreads and how to minimise transmission: avoiding very close and/or prolonged contact with someone with symptoms, including within households.

As well as scientific innovation, health experts must seek innovative strategies to communicate this life-saving information, and the need to get tested - especially as the new Clade 1b strain is presenting differently to previous forms of mpox.

Authorities in DRC are currently battling low awareness and misinformation about the virus, with some patients seeking alternative or traditional treatment rather than consulting a doctor. Meanwhile, polling by UNICEF earlier this month suggested that only 56% of people in DRC had heard of the mpox virus.

Lessons could potentially be learned from the early days of the COVID-19 pandemic and 2022-2023 mpox outbreak, when false, misleading, or damaging information quickly began to circulate on social media, challenging efforts to provide accurate and timely information.

Devising strategies to combat the tide of fake news and misinformation is one of the greatest challenges of our time, but particularly when it comes to health information, the consequences of not doing so are deadly.

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