深度报告-2026-02-16-世界卫生组织-WHO_Rapid_Risk_Assessment_-_Mpox,_Global_v.6_36页_1mb

> **来源：[研报客](https://pc.yanbaoke.cn)** # MPOX, MULTI-COUNTRY Date and version of current assessment: 07 February 2026, v6 Date(s) and version(s) of previous assessment(s): 02 September 2025, v5; 04 June 2025, v4; 24 February 2025, v3; 20 November 2024, v2; 13 August 2024, v1 Overall risk and confidence Overall Public Health risk Global Moderate Confidence in available information Global Moderate Overall global public health risk * Individuals with multiple sexual partners Moderate All other individuals Low Confidence in available information Moderate Moderate Overall local public health risk * Children in historically endemic areas Moderate Confidence in available information Low * All mpx outbreaks must be considered in their local context to gain a comprehensive understanding of the epidemiology, modes of transmission, risk factors for severe disease, viral origins and evolution, and relevance of strategies and countermeasures for prevention and control. For more detailed description of the risk groups, please refer to this section. # Overall Global Risk Statement This global rapid risk assessment (RRA) aims to assess the current public health risk associated with the 2024 upsurge of mpx in in Africa, in the context of the continuing global reporting of mpx cases in other regions since 2022, with a focus on updates since the previous RRA in September 2025. # Global overview As of 28 January 2026, the monkeypox virus (MPXV) continues to spread globally, causing both localized and extended mpx outbreaks driven by various MPXV clades (la, Ib, Ila, and Ilb) in diverse settings. Furthermore, recombination of MPXV clades has been documented, with two cases of a recombinant clade Ib/Ilb MPXV strain reported in recent months. Globally, from 1 January 2022 to 31 December 2025 (latest global data available), 143 countries and territories across all WHO regions have reported 177 848 confirmed cases, including 477 deaths (case fatality ratio [CFR] - $0.3\%$ ). This marks an increase of five additional reporting countries (Kuwait, Mali, Madagascar, Namibia and Senegal), along with an additional 19 423 confirmed cases and 78 deaths since the last RRA in September 2025. Since the last RRA, an average of 616 new confirmed mpx cases per week have been reported across all affected countries. In addition, in January 2026, the Comoros and the French departments of Mayotte and la Réunion have reported cases linked to travel to Madagascar. Previous versions of this RRA have categorized risk based on MPXV clade. However, in absence of substantial data suggesting differences in the mode of transmission between different MPXV clades, and with relatively limited data suggesting higher case fatality for clade Ia MPXV compared to other clades, this version of the RRA assesses the risk for three population groups; global risk for individuals with multiple sexual partners, local risk for children in mpxx historically endemic areas, and global risk for all other individuals. # Individuals with multiple sexual partners - global risk Since the start of the global mpx outbreak in 2022, sexual activity in linked sexual networks has been the primary driver of sustained transmission and geographic spread, particularly in newly affected areas. In Europe and the Americas, up to $96\%$ of cases were among men who have sex with men driven by spread among individuals with multiple sexual partners in a short space of time and frequent partner change. While sexual behavior data for cases in newly affected African countries remain limited, the contribution of sexual transmission to the introduction, spread and establishment of mpx in communities has been recognized across all affected settings, as in the most recent outbreak in Madagascar. In several countries, transmission has involved sex workers and their clients, and sexual networks with frequent and multiple partner change. Sexual contact infection likely occurs during pre-symptomatic or less apparent stages of infection, the duration of which can vary between individuals. People with few or mild genital lesions might not even recognise the infection. Although the secondary attack rate for sexual contact is high (estimated at $16 - 73\%$ ), for the epidemic to spread it requires networks characterised by frequent partner change and high rates of partner turnover over short timeframe (days to few weeks). This pattern was observed during the initial spread of clade IIb among communities of men who have sex with men, as well as in more recent MPXV clade Ib outbreaks driven – in part – by key populations such as female sex workers and their clients. We therefore consider within this group of multiple sexual partners, individuals with frequent partner change, and those who may engage in at-risk sexual behaviour, such as people who buy sex. Studies have shown that the virus can be present in genital and anal mucosae, as well as in seminal and vaginal fluids of symptomatic infected individuals. Emerging data suggest that viral shedding from the genitals may occur up to four days before symptom onset, potentially contributing to undetected sexual contact transmission. This could explain the persistence of the virus in communities and the challenges in interrupting human-to-human transmission. Furthermore, the contribution of asymptomatic viral carriage to transmission remains unclear. In most healthy adults of this group, mpx infection is mild and self-limiting. However, severe disease and death have been documented in people living with uncontrolled HIV, as well as other immunocompromising conditions, including in countries such as Burundi, the Democratic Republic of the Congo, Sierra Leone and Uganda. While the overall case fatality ratio has remained below $1\%$ in most settings, substantially higher fatality has been observed among individuals with immunosuppression. Although most people living with HIV globally are on antiretroviral therapy, gaps in diagnosis and treatment persist in several low- and middle-income settings, exacerbated by the cuts to HIV programmes in many countries. Most countries have activated outbreak response mechanisms, including surveillance, case investigation, contact tracing, and infection prevention and control. However, control efforts have been impeded when sexual transmission is not adequately recognized and risk communication and community engagement do not effectively reach key populations and other individuals within sexual networks. A new recombinant clade Ib/Ib MPXV strain of MPXV has also been identified in this group at risk with, to date, apparently similar risk factors related to sexual contact. While targeted mpox vaccination has been implemented for groups at higher risk of mpox exposure in several countries, coverage remains uneven and most individuals in this group, particularly in countries outside Europe and North America, remain susceptible to mpox infection. In addition, new cohorts of individuals entering sexually active age groups are continually added, and the duration and level of protection conferred by prior infection and/or vaccination remain uncertain. Overall, while transmission in this population group is likely to continue and sustain geographic spread, severe outcomes most often occur among immunocompromised individuals and population-level health impact has remained limited. The overall public health risk for individuals with multiple sexual partners is therefore assessed as moderate. # Children in historically endemic areas - local risk In historically endemic areas in countries of West and Central Africa, particularly in the Democratic Republic of the Congo, the highest number of mpx cases and and incidence of deaths has been documented among young children (<5 years). Surveillance and diagnostic capacities in these settings remain suboptimal and have decreased since the last RRA, making the interpretation of available data more challenging. Children are less represented among mpx cases in surveillance data from other endemic countries outside of the Democratic Republic of the Congo. Among individuals younger than 50 years in the Democratic Republic of the Congo, mpox incidence appears broadly comparable across age groups, however, case fatality among suspected mpox cases in children under five years of age (CFR $3.2\%$ ) is almost twice that observed among individuals aged 15 years and older ( $1.8\%$ ). Of note, the case fatality ratio in historically endemic areas of the DRC remains much higher across all age groups than elsewhere (about 5-10 fold higher), for reasons that remain poorly understood and may stem in part from surveillance (almost all data are syndromic) and in part from specific vulnerabilities. The higher fatality observed in infants and young children, who are largely immunologically naïve, is likely driven by delayed or limited access to appropriate healthcare and compounded by concomitant health risks, including malaria, varicella, malnutrition, and complications of mpox such as dehydration and secondary infections. In the absence of established vaccination programmes against mpx and limited access to early and appropriate healthcare, children in these settings are likely to continue experiencing elevated health risks from mpx infection. The risk of geographic spread associated with non-sexual contact transmission is most predominantly local. Available data indicate secondary attack rates of less than $20\%$ following non-sexual household contact, suggesting children, while vulnerable to more severe disease, have a more limited role in driving viral spread. Children have also generally not been the source of introduction of the virus in new areas, and their contribution to wider geographic or cross-border spread remains negligible, compared to spread among adults exposed through sexual contact. Most historically endemic areas are rural forested territories, where there is a risk of insufficient control capacities of outbreak response, especially now as countries transition from an acute outbreak response approach to a longer-term disease control programme. Mpox programmes in these settings have previously been greatly under-resourced, and will again increasingly need to rely on routine care capacity. Evidence for this group is limited, as most available surveillance data are based on suspected cases and deaths. In addition, relatively few studies have been conducted in historically mpx-endemic areas, and many of these are outdated or have methodological limitations that restrict the generalizability of their findings. Overall, in the absence of vaccination programmes for mpx in historically endemic areas, and strong national programmes capable of conducting outbreak response activities, the virus will likely continue to circulate, disproportionately affecting younger children. The overall public health risk for young children in historically endemic areas is therefore assessed as moderate. # All other individuals - global risk For individuals outside the above two risk groups, mpox is typically mild and self-limiting, with most cases requiring only supportive care and no hospitalization. Severe disease and death are uncommon at the population level. While severe outcomes may occur among individuals with underlying immunocompromising conditions (including advanced HIV infection, malignancies under active treatment, immunosuppressive therapies, or poorly controlled chronic diseases), these individuals generally represent a small proportion of all cases in recent outbreaks. Some data suggest that adults vaccinated before the cessation of routine smallpox vaccination worldwide, in 1980 or earlier in many countries, are likely to retain partial cross-protective immunity and present lower disease severity. While breakthrough cases of mpox have been seen in some older previously vaccinated persons, epidemiological data indicate that few mpox deaths have been reported in this group. To date, there are no data regarding disease severity associated with the newly detected recombinant mpox virus strain beyond the two cases detected who experienced mild disease and recovered. The consequences for individuals in t are therefore considered minimal, resulting in an overall low risk to human health. New cases of mpox with clade Ib MPXV in various regions have predominantly been associated with sexual contact involving people who have travelled to an outbreak area, and developed symptoms upon return. Secondary transmission from these cases to their non-sexual contacts have been limited, while spread through multiple sexual partners has ultimately led to community transmission of clade Ib MPXV in several countries outside Africa. Overall community spread of clade Ib MPXV in newly affected areas has generally remained within groups at risk. In addition, since the start of the global outbreak in 2022, this population group has also not been greatly affected by ongoing circulation of clade Ib MPXV, nor implicated in its introduction or establishment in new geographic areas. Individuals in this group have mainly been infected through household or occupational contact, characterized by low secondary attack rates and limited onward transmission. Public health control measures have generally been sufficient to manage mpx in the wider population. Vaccination has been prioritized for groups at higher risk of exposure, and vaccine has, in addition, been offered to mainly health workers in areas with cases primarily for their individual protection. In all settings therefore, the general population remains largely immunologically naïve for mpx, but the risk for their health, contribution to international spread and insufficient response capacities, is low. The overall public health risk for all other individuals is therefore assessed as low. # Overall public health risk Mpox continues to pose a public health risk across all WHO regions, with the likelihood and impact varying by population group, transmission context, and local response capacity. The African Region will most likely continue observing sustained community transmission in several countries outside historically endemic areas. While all countries remain at risk of importation and limited local transmission, recent outbreaks have confirmed observations, initially made since 2022, that sustained transmission and geographic spread are largely driven by sexual contacts in specific population groups and network dynamics, rather than in the general population. While some countries have established robust response mechanisms, such as early detection and contact tracing that help in controlling viral spread, other countries are less prepared and are at a higher risk of missed chains of local transmission, especially where a low index of suspicion, stigma, and discrimination create barriers to access diagnostic testing, clinical care services and implementation of infection prevention and control measures. Despite improvements since 2022 in understanding mpx transmission and risk groups, important knowledge gaps remain. These include uncertainties regarding the role of asymptomatic or pauci-symptomatic infections, the duration and extent of immunity following infection or vaccination (particularly for specific groups such as those with immunocompromising conditions), the need for periodic revaccinations, risk factors for severe disease beyond known immunocompromising conditions, and the contribution of zoonotic spillover and potential human-to-animal transmission. Limited data regarding animal reservoirs and transmission at the human-animal-environmental interface further limits risk characterization in endemic settings. Several cases and larger outbreaks have been reported in humanitarian emergency settings such as camps of displacement persons and other congregate, overcrowded settings, but the risk of spread and modes of transmission in these settings due to the living conditions or other factors is still poorly understood. Additionally, transmission between children outside of the household is also not fully understood and its potential to sustain the virus in the community has not been quantified. In recent years, access to diagnostics, vaccines, and response tools has improved through coordinated efforts by WHO and partners, and several countries have implemented vaccination for populations at highest risk. However, funding constraints, competing public health priorities, and reliance on limited resources for vaccine supply continue to challenge sustained response efforts, particularly in low- and middle-income countries. Delays in vaccine introduction and limited coverage due to limited mpx vaccine supply reduce the potential impact of vaccination, underscoring the importance of prioritization and timely deployment. In addition, evidence on the effectiveness of available therapeutics for mpx remains limited, particularly in settings reporting the highest burden of disease. The detection of a recombinant MPXV strain with genetic elements of both clade Ib and IIb MPXV warrants continued monitoring. To date, two cases have been identified, genetically linked and implicating four countries in three WHO regions. The geographic areas where the recombination event occurred remains unknown and surveillance data suggest sustained undetected or unreported community transmission in several countries. While the current public health risk associated with this recombinant strain is considered low, ongoing genomic surveillance is essential given uncertainties related to viral evolution and recombination. Overall, mpox continues to circulate in all WHO regions and pose distinct risks across different population groups and settings, with generally mild disease in most individuals. However sustained transmission of this still-emerging and evolving orthopoxvirus continues, posing health risks for vulnerable individuals in all settings. While response capacity improved since the declaration of the second public health emergency of international concern (PHEIC), it remains uneven and highly resource-dependent. Since transition to longer term disease prevention and control is still in the early stages and limited resources in several countries might hinder the gains of the last one-and-a-half years, the overall public health risk at the global level is assessed as moderate. # Naming conventions for MPXV and definition of risk groups After consultations with experts, countries, and the general public, WHO has adopted the name "mpox" for the disease, which in 2024 became the preferred term in English. "Monkeypox" remains a synonym, to match historic information, and the virus causing the disease is the monkeypox virus (MPXV). 1 MPXV clades were also renamed in 2022, with nomenclature of a Roman numeral for each clade, with lowercase Latin characters for subclades; the Congo Basin clade became clade I and the West African clade became clade II. Each of the clades has two subclades, Ia and Ib for clade I, and Ila and IIb for clade II. Subclades Ia and Ib were defined after the emergence of subclade Ib in the South Kivu province of DRC in 2023, and subclade Ia is currently considered to encompass all other strains of clade I that are not Ib. Two cases of a new recombinant clade Ib/IIb MPXV have been detected, one in the United Kingdom and one in India. In this assessment, the population groups for which risk was assessed were selected based on known transmission dynamics, risk factors for infection and severe disease, as well as types of public health interventions and programmes for outbreak response and control. Recent mpox outbreaks, particularly in newly affected areas, have been predominantly driven by sexual contact, followed by non-sexual contact within households. Sexual contact with an mpox case results in more efficient transmission due to extensive skin and mucosal contact, the presence of virus on lesions, mucosae, and sexual fluids, the probable pre- and paucisymptomatic transmission, and the relatively long infectious period of the virus. These characteristics are further amplified in sexual networks characterized by multiple and concomitant partnerships, which facilitate repeated exposure events within a short time frame and can lead to sustained community transmission and geographic spread. Based on these considerations, the risk was assessed for the following population groups: - Individuals with multiple sexual partners: Individuals engaged in sexual networks characterized by frequent partner change, overlapping partnerships and/or anonymous sexual contacts. This group includes men who have sex with men (MSM) with multiple partners, sex workers and their clients, and anyone else who engages in sexual activity with multiple sex partners. These populations overlap with groups known to be at increased risk of other sexually transmitted infections (STIs), including HIV, which is relevant both for transmission dynamics and for the risk of severe mpx disease in individuals with untreated or advanced immunosuppression. Children in mpx historically endemic areas: This group is largely immunologically naive to mpx, and are considered as a distinct group due to different exposure pathways and health risks. In these settings, infection may result from zoonotic spillover or human-to-human contacts, particularly within the household. Combined with limited access to quality healthcare in many low-resource endemic settings, this places children at increased risk for adverse health outcomes, despite their limited role in driving wider geographic spread. - All other individuals This group includes the general population not captured above. In the absence of close or prolonged contact with a confirmed case, the likelihood of infection in this group remains low, and sustained community transmission has not been a major driver of recent outbreaks. # Risk questions The below risk questions assess the global public health threat posed by mpx by evaluating its potential likelihood and consequences on human health, its spread, and the sufficiency of current control measures. For further details on the information provided in this table, please refer to the section on Supporting Information that follows. Risk question Individuals with multiple sexual partners Assessment Risk Rationale Likelihood Consequences Risk for human health Global Likely Minor Moderate In most healthy adults, mpx is a mild and self-limiting infection that can be managed with supportive care. However, infection may lead to severe disease and death among immunocompromised individuals. Individuals with multiple sexual partners have a higher incidence and prevalence of sexually transmitted infections, including HIV. When HIV is untreated or poorly controlled, associated immunosuppression may increase the risk of severe mpx manifestations, including extensive lesions, secondary bacterial or pulmonary infections, organ failure, and death. These observations have been consistent across mpx viral clades. Case fatality ratio in this risk group has been overall below 1%, and up to 15% among immunosuppressed individuals with CD4 count lower than 200 cells/mm3. In many countries, the majority of people living with HIV are receiving antiretroviral therapy and HIV is virologically suppressed. Nevertheless, according to UNAIDS 2024 estimates, around 9 million individuals in different settings, especially in low- and middle-income countries, remain unaware of their HIV status or are not on treatment, which places them at higher risk of severe outcomes in case of MPXV infection. In addition, budget cuts in global health over the past year have affected HIV programmes in several low- and middle-income countries, which may further increase the vulnerability of people living with HIV. Studies have shown that MPXV can be detected in genital and anal mucosae, as well as in seminal and vaginal fluids of symptomatic infected individuals, providing biological evidence supporting sexual contact transmission. Emerging data further suggests that viral shedding from the genital tract may occur up to approximately four days before symptom onset, potentially contributing to undetected transmission through sexual contact. This pre-symptomatic infectious period may help explain the persistence of mpx within sexual networks and the challenges in interrupting human-to-human transmission. However, the contribution of asymptomatic viral carriage to transmission remains unclear. Two cases of a new recombinant clade Ib/IIb MPXV have been detected globally in individuals belonging to this group. The first in the United Kingdom of Great Britain and Northern Ireland (hereafter “United Kingdom”) - with travel history to a country in South-East Asia - and the second in India (with travel history to a country in Middle East), but no difference in clinical manifestation and disease severity from other known clades has been observed. This risk group, especially those who are immunocompromised, represent the most likely host where co-infection with different strains could lead to viral recombination. Risk of geographic spread Global Highly likely Minor Moderate Since the start of the global outbreak in 2022, transmission within extended networks of individuals with multiple sexual partners has been the primary amplifier of the geographic spread of mpx to new locations. In many instances, individuals travelling to areas with ongoing transmission are exposed through sexual contact with mpx cases, including during early or less apparent stages of infection, travel back during their incubation period, and develop symptoms upon return to their place of residence. Occasionally, pre-symptomatic individuals from areas with ongoing transmission have travelled to other places for work or tourism and have developed the disease in the country of destination. In several settings, sexual contact transmission has also been followed by secondary transmission within households, particularly when cases are not promptly detected and isolated. When these imported cases are promptly detected, diagnosed and isolated, further transmission in the destination setting has generally been limited. However, when initial cases are not detected in a timely manner and transmission occurs undetected within sexual networks, mpx has become established in new geographic areas.During 2022 and 2023, men who have sex with men were the most affected group, but since 2024, sex workers and their clients have increasingly contributed to the geographic spread of mpx or specific mpx clades to new settings. Given the extent and interconnectedness of these sexual networks, and the potential for transmission through sexual contact during the pre-symptomatic phase, continued geographic spread through this population group remains highly likely.There is insufficient information about the risk of spread represented by the recently detected recombinant Ib/Ib MPXV strain, since only two cases have been so far identified. Overall, secondary transmission (of any clade) through household or other non-sexual contact has been relatively limited, and sustained community transmission outside these networks has not been a major driver of spread. Consequently, at the global level, the overall consequences of geographic spread remain minor, and the overall risk of geographic spread is assessed as moderate. Risk of insufficient control capacities Global Likely Minor Moderate Most mpx outbreaks since 2022 have been limited in size, with the majority of reported cases occurring in countries in Africa. Almost all countries reporting cases have activated response capacities, including through implementation of an Incident Management System (IMS). However, several countries have faced challenges in securing adequate and sustained funding to maintain response activities over time. The risk of insufficient control capacities is higher in low- and middle-income countries facing multiple concurrent public health emergencies, where surveillance, laboratory and response systems are often stretched. Limited and unpredictable funding, shortages of trained health workers, and competing outbreak priorities may delay case detection, contact tracing, and implementation of targeted prevention and control measures. These constraints can reduce the timeliness and effectiveness of the response, increasing the likelihood of sustained transmission.Since 2025, 15 countries in Africa have implemented mpx vaccination for populations at the greatest risk, including healthcare workers, contacts of cases, sex workers, men who have sex with men, and other priority groups based on local epidemiology. While vaccination has strengthened prevention efforts in these settings, coverage remains heterogeneous and dependent on available resources and limited mpx vaccine doses. Globally, vaccination coverage among individuals with multiple sexual partners remains uneven, and most individuals in this group, particularly in countries outside Europe and North America, remain susceptible to mpx. In addition, new cohorts of individuals entering sexually active age groups are continually added, and the duration and level of protection conferred by prior infection and/or vaccination remain uncertain.The risk of insufficient control capacities is further increased when sexual transmission is not adequately recognized in outbreak response strategies, or when risk communication and community engagement activities do not effectively reach individuals with multiple sexual partners, resulting in delayed behaviour change, delayed health-seeking, and missed opportunities for early interruption of transmission. Overall, it is likely that some countries will face insufficient control capacities for mpx; however, the consequences are assessed as minor given the relatively limited number of reported cases and the extent of mpx spread to date, resulting in an overall moderate risk. Risk question Children in historically endemic areas Assessment Risk Rationale Likelihood Consequences Risk for human health Local Likely Moderate High Mpox historically endemic areas include several countries in West and Central Africa, where transmission has predominantly occurred in rural forested settings, with subsequent human-to-human transmission in peri-urban and urban areas. The highest burden has been reported in the Democratic Republic of the Congo, where surveillance and diagnostic capacities remain suboptimal for comprehensive investigation, sampling, and testing of all suspected mpx cases, and where surveillance performance has declined since the last risk assessment, further complicating interpretation of available epidemiological data. Although children are disproportionately affected in the Democratic Republic of the Congo, they are less represented among reported mpx cases in other historically endemic countries outside the Democratic Republic of the Congo. Among individuals younger than 50 years who are unlikely to have vaccine-derived immunity from prior smallpox vaccination, mpox incidence appears broadly comparable across age groups. However, the case fatality ratio among suspected mpx cases in children under five years of age (3.2%) is almost twice that observed in individuals aged 15 years and older (1.8%).The higher fatality observed in young children, who are largely immunologically naïve, is likely driven by delayed or limited access to quality healthcare and compounded by concomitant health risks, including malaria, varicella (chickenpox), varying degrees of malnutrition, and secondary bacterial or opportunistic infections. Immunity from potential prior mpx infection in older children and adults may also confer partial protection among individuals aged 15 years and older. In the absence of established vaccination programmes against mpx in these settings, children are likely to continue experiencing an elevated risk of adverse health outcomes following mpx infection. Combined with limited access to early diagnosis and quality pediatric care, these factors are expected to sustain a disproportionate disease burden among young children in historically endemic areas. Given the observed severity and fatality in young children, the consequences are assessed as moderate, resulting in an overall high risk to human health in this population group. Risk of geographic spread Local Likely Minor Moderate The risk of geographic spread associated with children in historically endemic areas is predominantly local, reflecting limited mobility and transmission occurring mainly through caregivers or other household contacts. While contact among children has been hypothesized as a factor contributing to sustained community transmission, conclusive evidence supporting this mode of spread remains limited. Available data indicate low secondary attack rates following non-sexual household contact (generally below 20%), suggesting that children are unlikely to be major drivers of wider geographic spread. Children have not been responsible for the introduction of mpx into new geographic areas, and transmission is therefore expected to remain largely confined to households or local communities, with limited contribution to long-distance or cross-border spread. Based on a likely occurrence of localized transmission and minor overall consequences at the regional and global levels, the risk of geographic spread associated with this population group is assessed as moderate. Risk of insufficient control capacities Local Highly likely Minor Moderate The likelihood of insufficient control capacities for mpx affecting children in historically endemic areas is high, particularly since these are mostly low-income countries facing concurrent public health emergencies. Surveillance, laboratory confirmation, and pediatric case management capacities are often constrained by limited funding, shortages of trained health workers, competing outbreak priorities, and weak referral and infection prevention and control systems at community and primary healthcare levels. As countries transition from acute outbreak response mechanisms to longer-term disease control approaches, mpx programmes, historically under-resourced in these settings, are increasingly reliant on routine health system capacity. These limitations may result in delayed outbreak control, however, transmission associated with children is predominantly local and limited, and children are unlikely to drive large-scale outbreaks. As a result, while insufficient control capacities are considered very likely in this population group, the overall consequences at the population and geographic levels are assessed as minor, and the overall risk as moderate. Risk question All other individuals Assessment Risk Rationale Likelihood Consequences Risk for human health Global Unlikely Minimal Low For individuals outside of the other two risk groups assessed in this RRA, mpx infection is typically mild and self-limiting, with most cases requiring only supportive care. Hospitalization is uncommon, and severe disease and death are uncommon at the population level. While severe outcomes may occur in individuals with underlying immunocompromising conditions—such as advanced HIV infection, malignancies under active treatment, immunosuppressive therapies, poorly controlled diabetes, or other chronic conditions—these individuals represent a relatively small proportion of this population group and have not been not the primary drivers of mpx-associated morbidity and mortality in recent outbreaks. In addition, a proportion of adults, particularly those born before the cessation of routine smallpox vaccination, are likely to enjoy the cross-protective benefits of smallpox vaccination. Although it may wane over time, this residual immunity is expected to reduce disease severity and the risk of adverse outcomes in older age groups. While breakthrough mpx infections have been reported among some previously vaccinated individuals, epidemiological data suggest that disease severity in these cases is generally lower, and mpx-related deaths in this population group have been rare. Available epidemiological data indicate that the case fatality ratio in this population group has remained below 1% across recent outbreaks, with no data showing any increased severity associated with newly detected or recombinant mpx virus clades. Given the generally mild clinical course, low observed fatality, presence of residual orthopoxvirus immunity in parts of the population, and the limited size of subgroups with increased vulnerability, the consequences of mpx infection for human health in this population group are considered minimal. The overall risk to human health among all other individuals is therefore assessed as low. Risk of geographic spread Global Unlikely Minimal Low Among individuals outside of the other two risk groups assessed in this RRA, the risk of geographic spread of mpx remains low. Since the start of the global outbreak in 2022, transmission within this risk category has not been a primary driver of the introduction or establishment of mpx in new geographic areas. Transmission in this population has largely occurred in the context of defined exposure events, such as household contact with a confirmed case or occupational exposure, rather than through sustained, widespread community transmission. Secondary transmission from such cases to non-sexual contacts has generally been limited, and community transmission of clade Ib MPXV in newly affected areas has largely remained confined to higher-risk population groups. Although international travel by individuals from areas with ongoing transmission may occasionally result in imported cases, onward transmission in destination settings has generally been limited when cases are promptly detected and appropriate public health measures are implemented. Available evidence indicates low secondary attack rates associated with non-sexual contact, further limiting the potential for wider spread. To date, no sustained transmission chains or large outbreaks have been attributed to this population group, and no evidence suggests increased transmissibility associated with recently detected or recombinant mpx virus clades in this context. Risk of insufficient control capacities Global Unlikely Minimal Low Among individuals outside of the other two risk groups assessed in this RRA, existing public health control measures to manage mpx outbreaks vary across settings but have generally been sufficient. In high-income countries, no major challenges in control capacities have been observed since the decline in cases during the second half of 2022. In low- and middle-income countries facing multiple public health priorities, while overall response capacities may be constrained, the impact of these limitations on this population group has remained limited.Transmission among all other individuals typically occurs through identifiable exposure events, such as household or occupational contact, which are more readily traced and managed through standard public health interventions, including case investigation, contact tracing, infection prevention and control measures, and risk communication and community engagement activities.Since 2022, most countries reporting mpx cases have activated response capacities, often through established Incident Management System (IMS) structures. Vaccination is currently not recommended for the general population and has been prioritized for specific higher-risk groups, including healthcare workers, contacts of cases, men who have sex with men, sex workers, and other individuals with multiple sexual partners. Despite the absence of population-wide vaccination, the number of cases in this group has generally remained within the capacity of existing public health systems.As a result, while gaps in funding or workforce capacity may occasionally delay response activities, the consequences for outbreak control in this population group are generally minimal, and the risk of insufficient control capacities for this group is assessed as low. Major actions recommended by the risk assessment team Action Timeframe □ Refer the event for review by IHR Emergency Committee for consideration as a PHEIC by DG (Art 12, IHR) Not applicable □ Immediate activation of WHO response mechanism as urgent public health response is required Not applicable ☑ Recommend setting up of WHO grading call Immediate □ Immediate support to response, but no WHO grading recommended at this point in time Not applicable □ Rapidly seek further information and repeat RRA (including field risk assessment) Not applicable ☑ Support Member State to undertake preparedness measures Continuous ☑ Continue to closely monitor Continuous □ No further risk assessment required for this event, return to routine activities Not applicable # WHO Immediate Actions at Global level - Convening of grading call to review findings of the rapid risk assessment, progress of the response, and the grading of the event. - Continue to support countries in implementing the roadmap for the transition of the current acute emergency response approach to a routine programmatic approach. # Supporting information # Hazard assessment Mpox is an infectious disease caused by the monkeypox virus (MPXV), which is part of the genus Orthopoxvirus, that includes the variola virus, the causative agent for smallpox. There are two known clades of MPXV: clade I (previously called the Congo Basin clade), which includes subclades Ia and Ib; and clade II (previously called the West Africa clade), which includes subclades IIa and clade IIb. Subclades Ia and Ib were defined after the emergence of subclade Ib in the South Kivu province of DRC in 2023, and subclade Ia is currently considered to encompass all other strains of clade I that are not Ib. $^{4}$ In December 2025, the United Kingdom detected the first case of a clade Ib/IIb recombinant, $^{5}$ and after its classification as a novel MPXV recombinant strain, one case detected in India in September was retrospectively reclassified. To date, these are the only known cases of this recombinant. Historically mpx has been primarily characterized by zoonotic transmission, with outbreaks occurring in tropical rainforest regions of East, Central and West Africa, with occasional exportations of cases to other areas. In the context of zoonotic transmission, MPXV is transmitted from animals to humans through direct contact with infected animals (e.g., hunting, trapping, or petting), and possibly through processing and consuming infected animals or their body parts and fluids. Once the virus transmits from animals to humans, it can spread among humans through direct close physical contact with an infected person, indirect contact (contact with contaminated materials), transmission through infectious respiratory particles, and mother-to-child transmission (vertical transmission). Since May 2022, a multi-country outbreak of mpx due to clade Ib MPXV has affected over 130 countries and territories worldwide, most of which had never reported mpx before. This outbreak has been sustained by human-to human transmission, mainly through sexual contact. This global event has also brought to light the long-standing and continuing expansion of areas affected by clade I MPXV across Africa, particularly in DRC, where in addition to zoonotic exposure, human-to-human transmission of clade Ib MPXV, including through sexual contact, has been ongoing since September 2023. Symptoms of mpox in humans include swollen lymph nodes, fever, and a skin and/or mucosal rash that may initially be mistaken for other rash illnesses such as chickenpox (caused by the varicella virus), or sexually transmitted infections like herpes or syphilis, if the rash or lesions appear in the genital or anal region. The ongoing 2022-2026 outbreak has shown that mpox can also present with very few lesions, and there have been some reports of asymptomatic infection.[11] There is currently very limited documentation of asymptomatic infection for the other subclades. The contribution of asymptomatic infection to transmission remains poorly understood. Cases of mpox due to clade Ib MPXV and clade IIb MPXV have presented with relatively more mucosal lesions than previously described, with many of these lesions located in the genital or anorectal area, linked to sexual contact transmission.[12] While ocular, genital and inguinal lesions had already been well described, newly recognized phenomena during the global outbreak include severe rectal pain and inflammation (proctitis), inflammation of the penile glans (balanitis) and urethra (urethritis) and urinary retention, and involvement of the colon, most likely related to contact transmission among men who have sex with men. In the Democratic Republic of the Congo in 2023 and 2024, ulcerative vulvo-vaginal lesions and peritonitis were seen in female patients with confirmed mpx due to clade I MPXV. While encephalitis and sepsis were known to occur, myocarditis $^{13}$ and parotitis $^{14}$ are now also recognized as rare complications. Generally, most healthy individuals with mpx in the global outbreak have presented with mild clinical manifestations, mostly not requiring hospitalization, often attributed to lower severity associated with clade Ib MPXV, but becoming more common as the spread of clade Ib expands to new setting with access to quality healthcare. $^{15}$ Globally the case fatality ratio among confirmed mpx cases from 2022 to end of 2026 is around $0.3\%$ (277/177 750), lower in Europe and the Americas, and higher in the African and South-East Asia Regions. The global outbreak, and the more recent cases in South Africa from May to August 2024, illustrated that clade Ib MPXV infection can cause severe disease in nearly all patients when it spreads within networks of persons with weakened immune systems due to a high prevalence of uncontrolled HIV or advanced HIV disease. $^{16}$ Over time the Democratic Republic of the Congo has reported one of the highest mpx case fatality, up to $4\%$ in 2024 among suspected mpx cases. Due to improved surveillance and better confirmation rates among suspected cases case fatality ratio has also decreased for cases in the Democratic Republic of the Congo. In endemic areas it is currently between $2 - 2.5\%$ among suspected cases, while in provinces with better confirmation rates such as Kinshasa, North and South Kivu, it is below $1\%$ . Higher case fatality ratio is observed among children, particularly those under the age of 5 years, which in endemic provinces have a case fatality ratio of around $3\%$ . wherein the Democratic Republic of the Congo cases present with more extensive body rashes, possibly linked to a multitude of factors such as potentially higher virulence of the virus, limited access to affordable quality health services, as well as age and underlying health status of affected individuals. Moreover, limited surveillance capacity and resources in DRC hinder access to care in less severe cases until illness progresses or complications develop, potentially skewing observations towards more severe cases. # Exposure assessment # Modes of transmission and exposure settings While human-to-human mpx transmission is possible through skin-to-skin contact, skin-to-mucosal contact, fomites, and infectious respiratory particles, epidemiological and surveillance data from the global 2022-2026 outbreak in newly affected countries, and more recently the spread of clade Ib MPXV, show that transmission of MPXV is mainly driven by sexual contact, followed by transmission within households. Sexual contact includes skin-to-skin and skin-to-mucosal contact, as well as contact with semen or vaginal fluids during sex. Studies have detected the presence of virus in semen, $^{17}$ vaginal fluid $^{18}$ and anorectal swabs, $^{19}$ indicating that transmission through this type of contact may be multifaceted. $^{8,20,21}$