vaccination for unexposed veterinarians, veterinary staff, or animal control officers, unless such persons are involved in field investigations. no smallpox or mpox vaccine has been approved for use during pregnancy. the cdc recommends that healthcare providers don a full set of personal protective equipment (ppe) before caring for an infected person. this includes a gown, mask, goggles, and a disposable filtering respirator (such as an n95). an infected person should be isolated in preferably a negative air pressure room or at least a private exam room to keep others from possible contact. mpox prevention cannot be simplified to just providing a vaccine. there are more pressing challenges to address, such as access to treatment, veracity and availability of information, and quality of health care. public health messaging is perhaps the most important challenge. the multiple levels of interconnectivity and negotiated social meanings inherent to the disease require cooperation between medical professionals and patients to achieve correct public health communication. therefore, the university of london lecturer marco scalvini argues in the bmj that it is necessary to establish a "new ethic of shared responsibility" to educate people about dangers and give people from underprivileged groups the tools they need to make better decisions. treatment in the european union and the united states, tecovirimat is approved for the treatment of several poxvirus infections, including mpox. bmj best practice recommends tecovirimat or the smallpox treatment brincidofovir as the first line antiviral treatment if required, alongside supportive care (including antipyretic, fluid balance and oxygenation). empirical antibiotic therapy or aciclovir may be used if secondary bacterial or varicella zoster infection is suspected, respectively. outcome after healing, the scabs may leave pale marks before becoming darker scars. the risk of death in those infected ranges from 0% to 11%, depending on the type of monkeypox virus and location in the world. fatality rates have been reported as around 3.6% in west africa and 10.6% in central africa. most reported deaths have occurred in young children and people with hiv infection. epidemiology a map of the spread of the monkeypox virus globally. endemic clade i endemic clade ii both clades recorded clade ii outbreak in 2022 suspected cases in 1970, monkeypox virus was first associated with an illness as a disease in humans in the democratic republic of the congo (formerly zaire), in the town of basankusu, équateur province. although it was once thought to be uncommon in humans, cases increased since the 1980s, possibly as a result of waning immunity since the stopping of routine smallpox vaccination. between 1981 and 1986 who surveillance in drc/zaire recorded 338 confirmed cases and 33 deaths (cfr 9.8%). in 1996–1997, a second outbreak of human illness was identified in drc/zaire and between 1991 and 1999, 511 cases were reported in drc/zaire. clade i of disease remains endemic in drc and has a higher cfr than the other genetic clade in western africa. by may 2022, the case fatality rate (cfr) of past outbreaks was around 3%–6%, while the cfr of the 2022 outbreak remains below 1%. no human-to-human transmission was documented until the 2022 mpox outbreak in europe. clade ii had an outbreak – the first outbreak of mpox outside africa – in midwestern united states among owners of pet prairie dogs in 2003. seventy-one people were reportedly infected, of whom none died. as of 2018, mpox was traditionally restricted to the ecology of tropical rainforests. although the pattern was broken in 2005, when 49 cases were reported in sudan (areas now south sudan), with no fatalities. the genetic analysis suggested that the virus did not originate in sudan but was imported, most likely from drc. many more mpox cases have been reported in central and west africa, and in the democratic republic of congo in particular: 2000 cases per year are known between 2011 and 2014. the collected data is often incomplete and unconfirmed, which hinders realistic estimations of the number of cases of mpox over time. nevertheless, it was suggested that the number of reported mpox cases had increased and the geographical occurrence broadened as of 2018. 2003 u.s. outbreak mpox in a gambian pouched rat main article: 2003 midwest monkeypox outbreak in may 2003, a young child became ill with fever and rash after being bitten by a prairie dog purchased at a local swap meet near milwaukee, wisconsin. in total, 71 cases of mpox were reported through 20 june 2003. all cases were traced to gambian pouched rats imported from accra, ghana, in april 2003 by a texas exotic animal distributor. no deaths resulted. electron microscopy and serologic studies were used to confirm that the disease was human mpox. people with mpox typically experienced prodromal symptoms of fever, headaches, muscle aches, chills, and drenching sweats. roughly one-third of infected people had nonproductive coughs. this prodromal phase was followed 1–10 days later by the development of a papular rash that typically progressed through stages of vesiculation, pustulation, umbilication, and crusting. in some people, early lesions had become ulcerated. rash distribution and lesions occurred on head, trunk, and extremities. many of the people had initial and satellite lesions on palms, soles, and extremities. rashes were generalized in some people. after onset of the rash, people generally manifested rash lesions in different stages. everyone affected reported direct or close contact with prairie dogs, later found to be infected with the monkeypox virus. 2017–2019 nigeria outbreak main article: mpox in nigeria according to the nigeria centre for disease control (ncdc), between 1971 and 1978, only 10 human mpox infections were reported in the country. in september 2017, monkeypox virus infecting humans re-emerged in nigeria, 39 years since it had been last reported. the subsequent 2017–18 nigerian human mpox outbreak was, at that time, the largest ever outbreak of clade ii of the virus, with 118 confirmed cases. unlike previous outbreaks of this clade, infection was predominantly among young male adults and human-to-human transmission appears to have readily occurred. seven deaths (5 male, 2 female, case fatality rate of 6%) were reported, including a baby and four hiv/aids patients. additionally, a pregnant woman in her second trimester had a spontaneous miscarriage due to monkeypox virus infection. the niger delta university teaching hospital reported that a substantial number of its young adult cases had concomitant genital ulcers, syphilis and hiv infection. mpox spread around southeast and south nigeria with some states and the federal government of nigeria seeking ways to contain it. by december 2017 it spread to akwa ibom, abia, bayelsa, benue, cross river, delta, edo, ekiti, enugu, imo, lagos, nasarawa, oyo, plateau, rivers and federal capital territory. the outbreak started in september 2017 and remained ongoing across multiple states as of may 2019. confirmed cases of mpox by state in nigeria state sep 2017 – dec 2019 jan 2020 – feb 2022 abia 3 0 adamawa 0 1 akwa ibom 7 0 anambra 2 0 bayelsa 37 6 benue 2 0 cross river 13 1 delta 19 10 ebonyi 0 1 edo 6 4 ekiti 2 0 enugu 4 0 federal capital territory 5 2 imo 8 1 lagos 20 11 nasarawa 2 0 niger 0 1 ogun 0 1 oyo 6 0 plateau 2 1 rivers 46 6 totals 184 46 the us centers for disease control and prevention reported cases of american travelers contracting mpox upon return from lagos and ibadan. agam rao, a medical officer in the division of pathogens and high consequence pathology at the cdc, said that since 2018 all cases reported outside africa have come from nigeria. in a 2021 article oyewale tomori pointed out that the number of mpox cases in nigeria through 2021 was likely to be under-represented, because much of the nigerian population had been avoiding healthcare facilities due to fear of contracting covid-19. in may 2022, the nigerian government released a report stating that between 2017 and 2022, 558 cases were confirmed across 32 states and the federal capital territory. the rivers state was the most affected by mpox followed by bayelsa and lagos. there were 8 deaths reported, making for a 3.5% case fatality ratio. in 2022, ncdc implemented a national technical working group for reporting and monitoring infections, strengthening response capacity. 2018 and 2019 united kingdom cases in september 2018, the united kingdom's first case of mpox was recorded. the person, a nigerian national, is believed to have contracted mpox in nigeria before travelling to the united kingdom. according to public health england, the person was staying in a naval base in cornwall before being moved to the royal free hospital's specialised infectious disease unit. people who had been in contact with the person since he contracted the disease were contacted. a second case was confirmed in the town of blackpool, with a further case that of a medical worker who cared for the case from blackpool. a fourth case occurred on 3 december 2019, when mpox was diagnosed in a person in south west england. they were travelling to the uk from nigeria. 2019 singapore case in may 2019, a 38-year-old man who travelled from nigeria was hospitalised in an isolation ward at the national centre for infectious diseases in singapore, after being confirmed as the country's first case of mpox. as a result, 22 people were quarantined. the case may have been linked to a simultaneous outbreak in nigeria. 2021 cases in united kingdom, united states in may 2021, in the uk, three cases of mpox from a single household were identified by public health wales. the cases were also announced by health secretary matt hancock while addressing mps. the index case was diagnosed on 24 may after traveling from nigeria. the second case was reported on 2 june, and the third on 24 june. one of the three patients, an adult female, was treated with tecovirimat. on day 7 of tecovirimat, she was discharged from hospital to complete her second week of treatment at home. in july 2021, in the us, an american returning from a trip in nigeria was diagnosed with mpox. subsequent testing identified the virus as belonging to clade ii. the patient was hospitalized and treated with tecovirimat and was discharged after 32 days, at which time monkeypox virus dna could no longer be detected in residual skin lesions. 2022–2023 outbreak main article: 2022–2023 mpox outbreak an outbreak of mpox was confirmed in may 2022. the initial cluster of cases was found in the united kingdom, where the first case was detected in london on 6 may 2022 in a patient with a recent travel history from nigeria (where the disease is endemic). on 16 may, the uk health security agency (ukhsa) confirmed four new cases with no link to travel to a country where mpox is endemic. all four cases appeared to have been infected in london. from 18 may onwards, cases were reported from an increasing number of countries and regions, predominantly in europe and in the americas but also in asia, in africa, and in oceania. in may 2023, the world health organization declared an end to the global health emergency declared in response to the worldwide outbreak of mpox virus. history mpox was first identified as a distinct illness in 1958 among laboratory monkeys in copenhagen, denmark. the first documented cases in humans was in 1970, in six unvaccinated children during the smallpox eradication efforts; the first being a 9-month-old boy in the democratic republic of the congo (formerly zaire). the others, including three who were playmates, were in liberia and sierra leone. it was noted to be less easily transmissible than smallpox. from 1981 to 1986, over 300 cases of human mpox were reported in the drc, the majority being due to contact with animals. in 1996, the disease reemerged in the drc with 88% of cases resulting from human-to-human transmission. small viral outbreaks with a death rate in the range of 10% and a secondary human-to-human infection rate of about the same amount occur routinely in equatorial central and west africa. in humans, the disease remained confined to the rain forests of western and central africa until 2003, when an outbreak of mpox occurred in the us. all cases were traced to sick rodents imported from ghana. local prairie dogs caught the infection and passed it onto their owners. the disease was found to