Policy paper

UK strategy for mpox control, 2022 to 2023

Published 8 December 2022

This document sets out an overarching public health strategy for controlling mpox (previously referred to as monkeypox) across the UK, focused on the next 6- to 12-month period.

Despite a rapid increase in cases from May 2022, the effectiveness of the UK response has meant that cases have been in decline across all 4 nations of the UK since July. This means the emergency phase of outbreak management has passed.

This strategy reflects a move into the second phase of our outbreak management strategy. In this phase, although new case numbers are low, given the status of the global outbreak it is likely we will continue to see low levels of cases driven by importations as well as short chains of domestic transmission.

This strategy has been agreed between the UK’s 4 public health agencies. Each public health agency has delivered their own national response. A UK Strategic Response Group has been formed by the agencies to provide UK level co-ordination, and the UK Health Security Agency (UKHSA) has taken a lead role by mutual agreement on some issues including on procurement of vaccines and therapeutics on behalf of other nations.

Levels of mpox transmission

The UK’s public health agencies have agreed a framework for measuring the level of transmission of mpox at a particular moment in time.

Level 1

Incursions from rest of the world – small numbers of imported cases with limited onward transmission.

Level 2

Transmission within a defined population group.

Level 3

Transmission within multiple populations or larger population groups.

Level 4

Wider significant community transmission – with potential for endemic and local epi-zoonotic disease.

Bringing together data and intelligence from all UK public health agencies and academia, UKHSA regularly publishes mpox technical briefings, which outline the current transmission level in the UK and include the assessments of disease epidemiology used to determine this, such as:

• the trajectory and geographic spread of cases
• how likely a case is to be identified (that is, the likelihood of ascertainment)
• the primary route or routes of transmission
• the observed clinical severity of cases
• virological characterisation (that is, genomic data) of cases
• the primary route or routes of transmission in other non-endemic countries and endemic countries

Where we are now

Prior to the 2022 global outbreak of mpox, the UK was in Level 1, experiencing only very occasional case importation from endemic regions with limited onward transmission. Between 2018 and 2021, there had been 7 cases of mpox in the UK. Of these, 4 were imported, 2 were cases in household contacts, and one was a case in a health care worker involved in the care of an imported case. There was no evidence of community transmission.

Cases in this current outbreak were first detected in the UK on 6 May 2022 (though we have since identified a case dating from March) and domestic community transmission confirmed later in May (when further cases with no travel history or link to the initial cases were identified).

Cases were also found in several other countries from May onwards. On 23 July 2022 the World Health Organization (WHO) declared the escalating global mpox outbreak a Public Health Emergency of International Concern (PHEIC).

To date, almost all cases have been in networks of gay, bisexual, and other men who have sex with men (GBMSM), but there have been a small number of cases in women (predominantly still a result of sexual contact).

As of 30 November 2022, 3,725 confirmed and highly probable mpox cases have been identified in the UK.

The number of new cases per day peaked at 350 per week in July and has now reduced significantly to 5 per week as of 6 December.

As of 23 September 2022, the UK is at Level 2 (transmission within a defined population group) with flat or negative growth.

Strategic aims of the UK response

Our long-term goal is to eliminate person-to-person mpox transmission in the UK. Although this is achievable, until the global outbreak is under better control, we will continue to import cases at a rate which makes complete elimination unlikely for the UK as a whole.

Disease elimination is defined by the WHO European Region as the absence of indigenously acquired cases for a period of at least 3 months, in the presence of a well-performing surveillance system.

Elimination is the equivalent of establishing Level 1 (minimal transmission of mpox within the UK) over a period of 3 months.

Over the next 6 to 12 months, the strategic aims of all 4 UK public health agencies are therefore to:

• reduce harm (hospitalisation, complications, severe illness, and stigma) from mpox
• suppress current UK transmission
• minimise transmission of mpox within the UK from imported cases
• contribute to 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 8 broad categories of interventions:

1. Community engagement and risk communication
2. Vaccination
3. Rapid and accurate case finding
4. Clinical management of cases and therapeutics (that is, knowing how best to treat patients)
5. Public health case and contact management
6. Population-level surveillance
7. Research and evaluation
8. Global collaboration to decrease the global burden and minimise the number of imported cases

1. Community engagement and risk communication

Communications and engagement should be focused on those who face the highest risk of exposure to mpox. Vaccine uptake is encouraged for those who are eligible, and the latest evidence and guidance will be highlighted to support informed decision-making and harm reduction among all relevant groups.

Communications will aim to avoid stigma and reduce inequalities, including targeting people who are underserved, especially those not routinely engaging with health or sexual health services (SHSs). Engagement with LGBT and sexual health organisations will also continue to help refine messaging and activity.

Positive outcomes:

• people at higher risk of acquiring mpox receive targeted, evidence-based, communications, guidance, and support from trusted sources that enables informed decision-making about prevention, vaccination and how and when to seek clinical support
• health system partners provide a coordinated approach that supports engagement, particularly with marginalised groups among the affected populations

2. Vaccination

Maintain a vaccination programme as part of outbreak response that is targeted to those most at risk of mpox (including both pre- and post-exposure vaccination). We will keep the programme under close review, drawing on the best available evidence, including use of all UK public health agencies experts to provide advice on eligibility and determine cost-effectiveness for any longer term public health vaccine programme. The Joint Committee on Vaccination and Immunisation (JCVI) may also consider outbreak control proposals.

Positive outcomes:

• offer pre- and post-exposure vaccination to those at increased risk of mpox, in line with UK public health agency expert recommendations, and JCVI considerations
• deliver vaccination rollout as efficiently as possible, considerate of impact on wider NHS service delivery
• continually review vaccination programme as part of the incident response, drawing on the best available evidence globally, including lessons learnt from previous vaccination programmes

3. Rapid and accurate case finding

Support the establishment of, and further develop, clinical pathways to testing for those with symptoms of mpox and ensure that individuals entering services are brought into existing clinical and diagnostic pathways wherever they present in order to improve population health. Furthermore, establish sufficient sampling and testing capacity in NHS services and laboratories; this includes simultaneously monitoring the epidemiology and risk factors so if there is a change, testing can be rapidly scaled up.

Consider the introduction of asymptomatic testing of those at highest risk, depending on available evidence and epidemiology.

Positive outcomes:

• be ready to adapt services in response to changes in epidemiology (most testing occurs in SHSs because of current epidemiology, but if the population group changes access may also need to change)
• integrate mpox testing and management within existing services where possible, ensuring individuals on mpox clinical pathways are appropriately integrated into other population health programmes
• ensure suspect cases are identified rapidly and offered appropriate testing, support and treatment
• work with others to try to ensure there is sufficient capacity within relevant services, including SHSs, to manage levels of demand

4. Clinical management of cases and therapeutics

Facilitate infection prevention and control (IPC) arrangements to prevent transmission in healthcare settings, including the development and dissemination of relevant guidance. Promote the establishment and maintenance of sufficient clinical capacity to identify and manage cases in both in-patient and out-patient settings in line with current evidence. This includes supporting the management of severe and complicated disease through pain management, and the identification of rare or severe complications such as encephalitis.

Research impact of antivirals on clinical outcomes and transmission through trials as well as observational studies of compassionate use in severe disease, supported by robust governance processes.

Positive outcomes:

• cases are managed using agreed evidence-based protocols in most appropriate setting
• no transmission occurs in healthcare settings
• clinical services contribute to evidence base
• access to tecovirimat for severe cases admitted to hospital
• clinical trials to assess the impact of tecovirimat in cases managed in the community

5. Public health case and contact management

Continue case follow-up for surveillance (including to monitor progress against elimination), contact tracing and to provide guidance and support to reduce transmission. This could include advising and enabling cases to take measures to reduce transmission, including isolation when required, access to statutory sick pay, appropriate confidentiality safeguards, information, and additional resources.

Contact tracing should also include use of post-exposure vaccination and provision of guidance to reduce transmission. The methods used for contact tracing should be reviewed to ensure they are as effective and efficient as practically achievable.

Positive outcomes:

• cases receive information and support that allows them to reduce onwards transmission
• contact tracing is conducted in line with best available evidence and appropriate confidentiality safeguards in place, with methods and guidance continuously reviewed

6. Surveillance

Ensure testing and surveillance arrangements are in place to rapidly identify cases and clusters, to detect changes in epidemiology and inform control measures. Effectively follow up and collate information at national level for cases to understand whether cases have been acquired in the UK or are imported cases; understand epidemiology and transmission patterns to effectively target interventions; and detect changes in epidemiology including communities affected. Meanwhile, undertake genomic surveillance to detect changes within the outbreak clade.

Positive outcomes:

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

7. Research and evaluation

Focus resources on answering questions that will directly affect the response using rapid surveillance and public health investigation:

• prevalence changes over time
• presence and nature of new symptoms and/or asymptomatic infection and transmission
• presentation and transmission in those vaccinated
• protective effects of past smallpox vaccination
• relative contributions of behaviours to transmission
• virological characteristics of the outbreak clade

Establish evaluation framework to understand effectiveness of interventions.

Positive outcome:

• research directly impacts the response, supporting all other aims

8. Decreasing the global burden and minimising imported cases

Engagement with international organisations – including WHO, the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC) – and other global partners in order to share knowledge including on UK case numbers, the current epidemiological situation, technical support, response measures and public health management interventions.

Positive outcomes:

• mpox communications 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, is supported by international epidemic intelligence activities and collaboration
• regular liaison with WHO, ECDC, CDC and other public health agencies 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 surveillance, which are reported on regularly through technical briefing notes. 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:

• vaccine effectiveness against disease and impact on transmission
• asymptomatic infection and potential for asymptomatic transmission
• the potential of the virus to adapt for better transmission between humans or to evolve in other ways
• duration of natural and vaccine-derived immunity
• effectiveness of tecovirimat in reducing onwards transmission
• duration of transmission through semen after the resolution of visible infection
• importation or development of a zoonotic reservoir within the UK
• global trajectory of the epidemic