Policy paper

Mpox control: UK strategy 2025 to 2026

Published 17 April 2025

This document sets out an overarching public health strategy for controlling and eliminating mpox (previously referred to as monkeypox) across the UK, focusing on the next 12-month period. It serves as a statement of intent to work towards achieving elimination of mpox transmission.

This strategy has been agreed between the UK’s 4 public health agencies with a commitment to continue to work closely together in a collegiate approach towards its implementation. However, each agency is accountable for delivering its own national response. The UK Health Security Agency (UKHSA) continues to take a lead role across government in mpox response and preparedness whilst facilitating regular inter-agency discussion and coordination on key health risks. UKHSA also leads procurement of vaccines and therapeutics, on behalf of other nations by mutual consent.

Progress towards implementation of this strategy will be monitored initially by the incident management team, transitioning to the UK’s 4 public health agencies if the incident is de-escalated to business as usual, as per the UKHSA Incident Response Plan.

Levels of mpox transmission

The UK’s public health agencies have agreed the following framework for measuring the level of transmission of mpox within the UK at any particular moment in time. The levels are:

• level 1: incursions from the rest of the world – small numbers of imported or import-related cases or clusters
• level 2: transmission within a defined population group
• level 3: transmission with multiple or larger population groups
• level 4: wider significant community transmission – with potential for endemic or epi-zoonotic disease

The World Health Organization (WHO) European Region defines national elimination of mpox disease as a country detecting only imported or import-related cases or clusters with onset in the previous 3 months and no local animal reservoir, in the presence of a well-performing surveillance system.

Epidemiological overview

There are 2 major genetic groups (clades) of monkeypox virus (MPXV), clade I and clade II. Clade I is split into clade Ia and clade Ib. Clade II is split into clade IIa and clade IIb, with subgroup clusters called lineages.

A global outbreak of clade IIb, lineage B.1, began in 2022 and continues to this day. Over 4,000 cases have been confirmed in the UK since May 2022. Transmission within the UK has mainly been reported within networks of gay, bisexual, and other men who have sex with men (GBMSM) without a documented history of travel to endemic countries, with limited onward transmission outside of sexual networks.

There are also growing outbreaks of clades Ia and Ib in the Central African Region affecting men and women through close, often sexual, contact and children through household transmission. As of August 2024, clade Ib has also been detected beyond the African Region, mainly associated with travel to an affected country, including a small number of cases and household clusters within the UK. See the countries affected by clade I mpox.

See the mpox clade Ib and clade IIb outbreak: epidemiological overview and the mpox clade Ib data dashboard for more information.

People and settings with the highest risk

There are several population groups and settings observed to be at a higher risk of exposure to, and poor outcomes from, mpox infection.

These groups are highly diverse and include:

• those at risk of sexual exposure due to the known establishment of mpox within certain networks, such as GBMSM (clade II) and sex workers globally (clade I)
• those at risk of overseas travel-associated exposure, such as people visiting endemic or outbreak-affected countries
• those at risk of poor outcomes due to their immune status, such as people with immunosuppression, pregnant women, and children under 5 years of age
• people who attend communal accommodation settings, such as adult social care, prisons and prescribed places of detention, asylum seeker accommodation, and other communal settings used to house individuals for emergency or temporary accommodation

Strategic aims of the UK response

Our long-term goal is to eliminate person-to-person mpox transmission in the UK. This is the equivalent to maintaining Level 1 transmission (small numbers of imported or import-related cases/clusters) over a period of 3 months for both mpox clade I and clade II.

Therefore, over the next 12 months the strategic aims of all 4 UK public health agencies are to:

• reduce harm (hospitalisation, complications, severe illness, and stigma) and health inequalities from mpox
• reduce the impact of the introduction of clade I mpox by preventing sustained transmission, particularly within sexual networks, in the UK
• achieve and maintain elimination of sustained transmission of clade II mpox in the UK
• contribute to the reduction in global burden via collaboration through sharing knowledge, data, and information

Public health interventions to meet our aims

Achieving the aims set out above depends on 9 broad categories of interventions:

1. Risk communication and community engagement

Alongside providing general information for the public, including on effective public health and social measures, specific communications and engagement will be focused on the people and settings with the highest risk (discussed above). The latest evidence and guidance will be highlighted to support informed decision-making and harm reduction among all relevant groups and settings.

Pre-travel advice, based on the most up-to-date epidemiology and risk assessments, will be provided to people intending to travel to countries with ongoing transmission of mpox (Clade I mpox: affected countries), including people travelling to visit friends and relatives. Post-travel advice and information will also be provided at ports of entry to the UK while imported cases of clade Ib mpox remain a concern.

Communications will aim to avoid stigma and reduce inequalities, including reaching communities who experience barriers to accessing services with tailored support and advice. Emerging evidence, community engagement and co-production will be used where possible to develop materials, content, videos and outreach strategies, and to refine messaging to encourage preventive behaviours, including vaccine uptake for those who are eligible.

Positive outcomes will include:

• people at higher risk of acquiring mpox receiving tailored, evidence-based communications and support from trusted sources to enable informed decision-making about infection prevention, vaccination, and how and when to seek clinical support
• health system and government partners providing a coordinated approach that supports engagement and co-production where appropriate, particularly with groups who experience barriers to accessing services

2. Vaccination

Vaccination will be focussed on those most at risk of mpox. We will ensure that vaccination strategies are optimal, guided by the latest evidence and expert assessment, including from the Joint Committee on Vaccination and Immunisation (JCVI). 

A UK-wide vaccination programme is already in place to offer pre-exposure vaccination to those who are most at risk of clade II mpox (namely GBMSM). UKHSA has expanded access to this geographically within England. Details of mpox vaccination sites in each of the 4 nations can be found at:

• England: Find an mpox vaccination site - NHS
• Northern Ireland: Vaccination - Sexual Health NI
• Scotland: Vaccination to help protect against mpox - NHS inform
• Wales: Mpox - Public Health Wales

High-risk contacts of cases will be offered post-exposure vaccination. We will use ring vaccination where indicated, particularly in clinically vulnerable and other high-risk groups and settings (discussed above).

We will continue to assess vaccine interest, communications, and outreach strategies in order to monitor and improve vaccine uptake. We will also monitor vaccine effectiveness and duration of protection to assess the need for reinforcing (booster) doses or revaccination strategies.

We will review and expand the eligibility for vaccination in response to any changes in epidemiology that indicate an emerging risk in wider or different population groups.

Positive outcomes will include:

• offering pre- and post-exposure vaccination to those at increased risk of mpox, in line with UK public health agency expert recommendations, and JCVI advice or recommendations
• delivering vaccination rollout as efficiently as possible, considerate of impact on wider NHS service delivery
• continually reviewing vaccination programme, drawing on the best available evidence and latest epidemiology, including lessons learnt from previous vaccination programmes

3. Rapid and accurate case finding

Early diagnosis and management are paramount to protecting population health. We will further develop clinical pathways for diagnosis and management for people with symptoms of mpox and ensure that those entering services are brought into existing clinical and diagnostic pathways wherever they present.

We will continue to support the rollout of mpox testing and clade differentiation capacity in NHS and local authority commissioned services and laboratories, whilst monitoring the epidemiology and risk factors so if there is a change, testing can be scaled up rapidly.

We will continue to work with primary health care, emergency departments, sexual and reproductive health, and travel health clinics in order to increase professional and public awareness of mpox, ensure effective and efficient use of testing and clinical pathways, and thus prevention and detection.

Sexual health, HIV/STI and travel health programmes and services should integrate mpox prevention and care into their work. We will work with the NHS, local authorities, and the British Association for Sexual Health and HIV (BASHH) to increase testing for mpox in sexual health services (SHSs), and work to identify cases and improve access for groups who experience barriers to accessing services.

We will engage with relevant wider health system partners to improve case finding as dictated by any changes to the epidemiology of mpox in the UK.

Positive outcomes will include:

• integrating mpox testing and management within existing services where possible, ensuring individuals on mpox clinical pathways are appropriately integrated into other population health programmes
• ensuring suspected cases are identified rapidly and offered appropriate testing, support and treatment
• working with partners to try to ensure there is sufficient capacity within relevant services, including laboratories

4. Clinical management of cases and therapeutics

Integrated care boards, and corresponding structures and services in the devolved nations, will ensure there is sufficient clinical capacity to identify and manage cases in both in-patient and out-patient settings. This includes the provision of specialist infectious diseases advice to support the management of severe and complicated disease and the identification of rare or severe complications. Given the limited experience we have with mpox in children and pregnant women, paediatric and maternal cases should be discussed with appropriate specialists, including paediatric infectious diseases and obstetrics.

Each organisation in health, care and other services will ensure robust infection prevention and control (IPC) arrangements are in place to prevent transmission.

Positive outcomes will include:

• cases being managed using agreed evidence-based protocols in the most appropriate setting
• no transmission occuring in healthcare settings
• clinical services contributing to the evidence base
• access to appropriate evidence-based therapeutics for severe cases being admitted to hospitals

5. Public health case and contact management

We will continue follow-up of cases for surveillance (including to monitor progress against elimination), contact tracing, and to provide guidance and support to reduce transmission. This may include advising and enabling cases to take effective public health and social measures to reduce transmission, including isolation and avoidance of close or sexual contact when required, access to statutory sick pay and other forms of support, appropriate confidentiality safeguards, information, and additional resources.

Contact tracing will be performed by health protection teams, IPC teams, occupational health teams, and sexual health services. It will follow the standardised contact classification and management matrix. Outcomes of contact tracing will be accurately recorded to add to the evidence base regarding transmission dynamics.

Contact tracing will include an offer of post-exposure vaccination and provision of guidance to reduce transmission. We will review the contact classification and advice given to contacts to ensure it is proportionate to the level of risk, mindful of barriers to isolation, and as effective and efficient as practicable.

Positive outcomes will include:

• cases receiving information and advice that enables them to reduce onwards transmission
• contact tracing being conducted in line with best available evidence and appropriate confidentiality safeguards in place, with methods and guidance continuously reviewed

6. Infection prevention and control

Infection prevention and control (IPC) is crucial in mitigating and containing the spread of mpox. If appropriate IPC measures are not used, transmission can be amplified which can result in further spread, resulting in increased morbidity. We will work with partners to ensure that IPC measures are evidence-based and implemented reliably in order to minimise the risk of secondary infections in healthcare settings and other higher risk settings (described above).

Safe systems of work informed by local risk assessment and the application of the hierarchy of controls will ensure that IPC measures are appropriate and proportionate to different settings. Control measures include engineering, administrative and work practice controls, the use of personal protective equipment, and cleaning and decontamination. The latter are highly relevant to mpox given the propensity of pox viruses to survive in the environment.

Positive outcomes will include:

• secondary infections and associated complications being prevented/minimised
• those attending cases of mpox working in a safe environment
• cases of mpox being safely managed at home if clinically appropriate

7. Population-level surveillance

We will ensure testing and surveillance arrangements are in place to rapidly identify cases and clusters, detect changes in epidemiology, and inform control measures. Information will be analysed at a national level to understand whether cases have been acquired in, or imported to, the UK; understand epidemiology and transmission patterns to effectively target interventions; and to identify changes in the populations at-risk by capturing important  health inequalities information where possible.

We will maintain proportionate genomic surveillance of UK mpox to inform understanding of domestic epidemiology (for example, contribution of different clades) and to contribute to the global understanding of mpox evolution.

Positive outcomes will include:

• surveillance enabling monitoring of progress towards elimination
• changes in transmission and epidemiology being rapidly detected, in particular to distinguish between travel and endemic exposures
• surveillance enabling control efforts to be appropriately targeted
• genomic sequencing of isolates as appropriate and sharing on international platforms

8. Research and evaluation

Research and scientific evaluation activities will focus resources on identifying, prioritising, and co-ordinating studies to address evidence gaps that will meet the needs of the response. To do this, we will work with relevant experts across UKHSA, devolved nations, and academic partners.  

Prioritised evidence gaps include:

• clinical presentation of all clades, including incubation, transmissibility, asymptomatic and pre-symptomatic transmission, and severity
• presentation and transmission in different groups, for example vaccinated individuals, pregnant individuals
• optimisation of serological assays and point-of-care diagnostics
• effectiveness of infection controls measures in healthcare settings
• effectiveness and cost-effectiveness of public health intervention measures, for example self-isolation
• identification and evaluation of available therapeutics
• barriers and facilitators for behavioural public health interventions, for example testing, vaccination
• tracking public awareness and risk perception over time
• relative efficacy and feasibility of different vaccination strategies
• impact of mpox outbreaks and mitigation measures on health inequalities

The above has informed communications with UK research funding bodies and National Institute for Health and Care Research (NIHR) Health Protection Research Units (HPRUs), as well as engagement with relevant ongoing and planned research activity within UKHSA and academic partners.

Positive outcomes will include:

• a registry of research and scientific evaluation gaps, subject to systematic refinement and prioritisation, being maintained
• research and scientific evaluation questions being prioritised and addressed in a co-ordinated approach
• research and scientific evaluation studies being undertaken and knowledge mobilisation activities deliver impact, directly informing the incident response

9. Global collaboration

Knowledge of the current epidemiological situation, technical support, response measures, and public health management interventions will be shared by engagement with international organisations including:

• WHO
• Africa Centres for Disease Control and Prevention (Africa CDC)
• European Centre for Disease Prevention and Control (ECDC)
• Centers for Disease Control and Prevention (CDC)

and other global partners in order to improve knowledge and understanding, and reduce the global burden.

Positive outcomes will include:

• mpox communications being received through the UK International Health Regulations national focal point are rapidly disseminated to inform ongoing response activities
• guidance on travel restrictions for cases and contacts, and international contact tracing, being supported by international collaboration and epidemic intelligence activities
• regular liaison with international organisations and other public health agencies being undertaken to share knowledge and best practice

Scientific uncertainties

There remain some uncertainties in the underpinning science that guides the response to the mpox outbreak. Many of these will be, at least partially, resolved over the coming months through planned studies and ongoing surveillance. If the evidence suggests more challenging viral or immunological characteristics than currently expected, or if there are changes to the pattern of transmission, these may affect the trajectory of the UK outbreak and timelines of elimination.

Current uncertainties include:

• the at-risk population for clade I mpox in the UK
• vaccine effectiveness against clade-specific infection and impact on transmission
• the characteristics of asymptomatic infection or transmission
• the potential for viral evolution and adaptation for increased transmission between humans
• the risk of infection from the environment and contaminated surfaces
• duration of natural and vaccine-derived immunity, including those vaccinated against smallpox in childhood
• effectiveness of tecovirimat and other therapeutics in reducing onwards transmission
• duration of transmission risk through semen and other bodily fluids after the resolution of skin lesions
• the global trajectory of the epidemic