Why Ending the Mpox Emergency Could Put Africa’s Progress at Risk

Mpox has left the global emergency list, but it has not left Africa. Clade Ib transmission continues, vulnerable patients still face severe outcomes, and the systems that produced recent progress are now operating under shrinking donor support and weaker international attention.

In the commentary "Sustaining Mpox Surveillance, Research, and Care Integration in a Post-PHEIC, Resource-Constrained World," published in Viruses, Patrick D. M. C. Katoto and Liliane Nsuli Byamungu argue that the post-emergency period may prove more dangerous than the crisis itself. Their key argument is that mpox must be absorbed into permanent health-system structures before surveillance, diagnostic capacity and community outreach begin to erode.

Emergency Success Has Created a Dangerous Illusion

The African mpox response achieved measurable gains. According to the commentary, Africa CDC recorded 80,276 suspected cases and 1,340 deaths in 2024, with the Democratic Republic of the Congo accounting for 96% of reported cases and 97% of deaths. Between January 2025 and mid-June 2026, 31 African countries reported 49,176 laboratory-confirmed cases and 222 deaths among confirmed cases.

The response mobilised more than US$1 billion, expanded laboratory and genomic sequencing capacity more than tenfold and deployed over five million vaccine doses across 16 countries. From peak transmission in early 2025 to late 2025, suspected cases reportedly fell by 40%, confirmed cases by 60%, and the fatality ratio among suspected cases declined from 2.6% to 0.6%.

However, the authors caution against equating lower reported numbers with durable control. Surveillance activity also contracted, making undercounting more likely. Clade Ib continued to spread and was newly introduced into Madagascar in December 2025. The system may therefore be looking less intensely at a disease that has not disappeared.

This is the "post-PHEIC paradox": the formal emergency ends just as endemic countries enter the more difficult phase of maintaining control without surge funding, temporary staff deployments or emergency procurement. Similar transitions after Ebola and COVID-19 exposed the gap between mechanisms designed to mobilise quickly and institutions required to sustain action for years.

Once a disease appears to pose less danger to high-income countries, global attention can decline even while the burden remains concentrated in poorer settings. For affected communities, there is no clean endpoint, only the withdrawal of support.

Integration Is the Only Scalable Exit

The commentary's strongest operational proposal is to integrate mpox into existing HIV and STI services rather than build a stand-alone programme. The logic is epidemiological and institutional. Mpox risk overlaps with populations already served by HIV and STI programmes, including sex workers, mobile mining communities and people with multiple sexual partners. Severe mpox is also more likely among people living with HIV. Clinics in these systems already have trained personnel, supply chains, laboratory links, data platforms and community networks.

Routine integration could include symptom screening during HIV or STI triage, clinician training, PCR testing or referral routes, isolation protocols, mpox fields in electronic records and vaccination during pre-exposure prophylaxis visits. Community health workers could support case finding, contact tracing, education and vaccine uptake through networks that already have local legitimacy.

This approach offers a better chance of scale because it uses infrastructure governments already finance. Additional costs would centre on PCR reagents, specimen transport, staff training, protective equipment, vaccines, cold-chain extension and data-system modifications. Molecular-testing platforms already used for HIV, tuberculosis and human papillomavirus could potentially accommodate mpox assays more cheaply than dedicated equipment.

However, integration is not cost-free. HIV and STI services are already overstretched, and adding responsibilities can create "integration fatigue," particularly as donor support contracts. The paper notes that no published economic evaluation has yet established the cost-effectiveness of integrated mpox-HIV/STI delivery in sub-Saharan Africa.

Integration should streamline care through shared registers and harmonised workflows, not simply add duties to exhausted staff. Pilot programmes should measure workforce pressure, diagnostic turnaround, outcomes and costs before national expansion.

The Patients Routine Systems Still Miss

Integration may provide the backbone of routine care, but it cannot meet every clinical need. Pregnant women and neonates face some of the gravest consequences. The authors cite foetal-loss rates approaching 50% in clade I and Ib infections, yet antenatal screening remains rare. Routine symptom inquiry, pregnancy-specific clinical guidance and clearer evidence on vaccine and antiviral use are urgent.

Children also require dedicated attention. In a South Kivu cohort cited by the commentary, 14% of cases occurred among children under five, and every reported death was in that age group. Paediatric recognition should be included in fever-and-rash protocols, while community health workers need training to identify cases early. Research on antiviral dosing and supportive care remains limited.

Healthcare workers are another overlooked group. Their infection risk makes them both a priority population and a warning signal of uncontrolled transmission. Infection-prevention training, occupational reporting, vaccination where appropriate and paid sick leave are essential if isolation policies are to work.

Vaccination policy must also become more targeted. The commentary identifies MVA-BN as the preferred option for many high-risk populations because it is replication-deficient and suitable for immunocompromised people, including those living with HIV. Yet evidence on protection against clade I, duration of immunity and use in pregnant women and children remains incomplete.

This uncertainty strengthens the case for research after the emergency phase. Longitudinal cohorts are needed to examine immunity, reinfection, household transmission and long-term effects. Clinical research must also move beyond antivirals. Tecovirimat did not significantly shorten lesion resolution in a clade I trial cited by the authors, while pain management, wound care and nutrition remain understudied despite their importance to outcomes.

Endemic Control Requires Money, Trust and One Health

The transition from emergency response to routine control will fail without stable financing. The commentary argues that donor contraction, including the dissolution of USAID, threatens HIV services, laboratories, community health workers and surveillance systems that mpox integration depends on.

Governments cannot replace external assistance overnight. But they can reduce fragility by embedding mpox costs into HIV, STI, reproductive-health and immunisation budgets; including services in health-insurance packages; and using Africa CDC-led pooled procurement to lower prices. Vertical programmes may attract short-term funding, but they leave countries exposed when donors depart.

Domestic financing must also support public-health institutes, reference laboratories and regional testing. Several-week diagnostic delays are incompatible with effective care. Sequencing a meaningful share of confirmed cases, the authors suggest at least 10%, could help identify new lineages and cross-border spread, although feasibility will vary.

Control also depends on trust. Community organisations should be funded as implementing partners, not treated as unpaid channels for messaging. Stigma linked to sex work can discourage testing, contact disclosure and vaccination. Community-led groups often reach affected populations more effectively than formal institutions.

Most importantly, mpox cannot be managed solely inside clinics. Clade Ib now spreads efficiently between people, but other transmission chains continue to arise through zoonotic spillover. Deforestation, forest encroachment, artisanal mining settlements, wildlife trade, reliance on wild animal protein and declining orthopoxvirus immunity all increase risk.

This makes One Health governance crucial. Veterinary services, wildlife authorities, environment ministries, mining agencies and local governments need formal roles in surveillance, outbreak investigation, land-use planning and risk communication. Shared laboratories and genomic data could connect human and animal cases and identify emerging transmission chains earlier.