{Summary}
° Date and version of current assessment: 18 August 2026, v7
° Overal Global Risk statement:
§ This global rapid risk assessment (RRA) assessesthe current public health risk associated with the 2024 upsurge of mpox in Africa, in the context of the continuing global occurrence of mpox in all regions since 2022, with a focus on updates since the previous RRA in February 2026.
§ The overall public health risk posed by mpox remains unchanged from the last RRA.
Global overview
As of 30 June 2026, the monkeypox virus (MPXV) continues to spread globally, causing both localized and extended mpox outbreaks driven by multiple MPXV clades (Ia, Ib, IIa, and IIb) in diverse settings. The recombination of MPXV clades has also been documented, with the two previously reported cases of a recombinant clade Ib/IIb MPXV strain detected in the United Kingdom of Great Britain and Northern Ireland in late 2025 and India in January 2026, and one additional case reported in Qatar since the last RRA.
Globally, from 1 January 2022 to 30 June 2026, 145 countries and territories across all WHO regions reported 188 847 confirmed cases of mpox, with 521 deaths [case fatality ratio (CFR) – 0.3%] and including two additional countries: Comoros and Guinea-Bissau.
Since the last RRA, an additional 10 908 confirmed cases, 44 deaths, and an average of 420 new confirmed mpox cases per week have been reported across all affected countries.
As with the previous version, this RRA assesses the risk for three population groups;
i) global risk for individuals with multiple sexual partners,
ii) risk for children in mpox historically endemic areas where risk of zoonotic transmission continues, and
iii) global risk for all other individuals. Updates in understanding of mpox epidemiology within these groups are described herein.
Individuals with multiple sexual partners – global risk
Since the start of the global mpox 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. The major and predominant contribution of sexual transmission, whether linked to heterosexual or same-sex contact, to the introduction, spread and establishment of mpox in communities has been recognized across all affected settings.
Outside the WHO African Region, over 87% of reported cases have been among men who have sex with men (MSM), with transmission driven by spread among individuals with multiple sexual partners in a short time span and/or frequent partner change.
Outbreaks are commonly linked to a sex-on-premises location or event. In Africa, transmission has often been reported to involve sex workers and their clients, long-distance drivers and other sexual networks where people have multiple partners and/or frequent partner change. In Africa, most transmission appears to be heterosexual.
In networks characterized by multiple partners and/or frequent partner change over short periods (days to a few weeks), the secondary attack rate for sexual contact may be high (estimated at 73% in some settings), facilitating epidemic spread. This pattern was observed during the initial spread of clade IIb MPXV among MSM communities and more recently clade Ib and IIb MPXV outbreaks in Africa and elsewhere, with amplification in key populations such as female sex workers and their clients as well as others with multiple partners, often in different locations. The recently identified recombinant clade Ib/IIb strain of MPXV has also been identified in this group with similar risk factors related to sexual contact. This risk group therefore includes people with multiple or frequently changing sex partners, including those with higher-risk sexual behaviours.
Sexual contact transmission likely occurs during various stages of infection, including pre-symptomatic or less apparent stages, the duration of which can vary between individuals. People with few or mild genital lesions might not recognise the infection. 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 suggests 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 encountered in interrupting human-tohuman transmission, while the contribution of asymptomatic viral carriage to transmission remains unclear.
In most healthy adults of this group, mpox is often self-limiting. However, severe disease, including disabling complications, secondary infections, long-term sequelae and death, continues to occur most particularly but not exclusively in people living with advanced HIV disease or uncontrolled HIV infection, as well as other immunocompromising conditions. While overall case fatality has remained below 1% in most settings, up to 15-fold or higher fatality has been observed among individuals with immunosuppression, as well as in vulnerable infants, and particularly neonates in some settings. Notably, recent data from the African setting support observations elsewhere that people living with HIV who have suppressed viral loads and preserved CD4 counts experience mortality equivalent to HIV-negative individuals, indicating that the HIV-associated mortality risk is largely modifiable and deaths are preventable through sustained viral suppression and immune reconstitution. Although most people living with HIV globally are on antiretroviral therapy, significant and growing gaps in diagnosis and treatment persist in several lowand middle-income settings, with 26.3 million people estimated to be living with HIV in Africa in 2025, of which over 20% either do not know their status, are not on antiretroviral therapy or are not successfully virally suppressed, a situation exacerbated by recent funding cuts to HIV control programmes in many countries. In many contexts, over half of mpox cases are reported among people living with HIV, adding more complexity to the convergence of risks faced by this group (risk of infection, risk of severe disease, and risk of poorer health service access).
Most countries globally have activated outbreak responses, including surveillance, case investigation, contact tracing, case management, and infection prevention and control. However, control efforts have been impeded when sexual contact transmission or other risk factors are not adequately recognized, or when risk communication and community engagement do not effectively reach key populations and other individuals within sexual networks. Furthermore, countries are increasingly tasking HIV/STI control programmes – themselves heavily constrained by recent funding cuts – with participating in or leading the response, as well as activating immunization policies and programme capacity.
While targeted mpox vaccination has been implemented for groups at higher risk of mpox exposure in many countries in high and low-income settings, including administration of more than two million doses in Africa, coverage remains uneven or partial and most individuals in this group remain susceptible to MPXV infection, particularly in countries outside Europe and North America. In addition, younger cohorts are continually entering sexually active age groups.
The duration and level of protection conferred by prior infection and/or vaccination remains uncertain.
Overall, transmission in these groups at higher risk is ongoing and likely to continue to spread geographically, which can be expected to lead to severe outcomes among immunocompromised individuals, thus focusing risk of spread among individuals with multiple partners in interconnected sexual networks who may not be aware of risk, and the risk of complications and death among vulnerable individuals.
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 West and Central African countries, where viruses continue to circulate in animal hosts and zoonotic spillover continues to occur, particularly in the Democratic Republic of the Congo, the highest number of mpox cases and incidence of deaths has been documented among young children (<5 years). Surveillance and diagnostic capacities in these settings remain suboptimal and have continued to decline in 2026, making the interpretation of available data challenging.
Among individuals younger than 50 years in the Democratic Republic of the Congo, age-specific mpox incidence appears broadly comparable across age groups, largely reflecting the underlying age distribution of the population. However, case fatality among suspected mpox cases in children under five years of age (CFR 3.0%) is higher than that observed among individuals aged five to 15 years (CFR 1.9%), and almost twice that observed among individuals aged 15 years and older (1.7%). Of note, the case fatality ratio in historically endemic areas of the Democratic Republic of the Congo remains much higher across all age groups than elsewhere (about 7 to 20-fold higher). This may arise from specific vulnerabilitiesincluding delayed or limited access to appropriate health care, compounded by concomitant health risks, such as malaria, varicella, measles, malnutrition, and complications of mpox such as dehydration and secondary infections. This higher fatality is particularly observed in infants and young children, who are largely immunologically naïve. At present, mortality data from this setting are largely drawn from syndromic surveillance and multiple studies are underway to better describe the risks associated with mpox in these settings.
While targeted vaccination has supported outbreak response, in the absence of established vaccination programmes against mpox and limited access to early and appropriate healthcare, children and pregnant women in the affected settings are likely to continue experiencing elevated health risks from mpox and MPXV infection.
The risk of geographic spread associated with non-sexual contact transmission is predominantly local. Available data indicate secondary attack rates of less than 20% following non-sexual household contact, suggesting that while children are vulnerable to more severe disease, and outbreaks in schools have been documented , children generally appear to have a limited role in driving viral spread. In addition, children have not often been reported as a source of introduction of mpox 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, particularly now as countries transition from an acute outbreak response approach to a longerterm disease control programme. Mpox programmes in these settings have previously been greatly under-resourced and will increasingly need to rely on preventive strategies and routine care capacity.
Overall, in the absence of vaccination programmes for mpox in historically endemic areas, and resources for national programmes conducting outbreak response activities, the virus will likely continue to circulate, disproportionately affecting younger children.
The overall public health risk for children in historically endemic areas is, therefore, assessed as moderate.
All other individuals – global risk
For individuals outside the above two risk groups, the overall risk of acquiring mpox is lower. While illness in the general population is typically mild and self-limiting, with most cases requiring only supportive care and no hospitalization, severe disease and death can also occur, albeit less commonly. While the risk of severe outcomes is much higher among individuals with underlying immunocompromising conditions, these persons generally represent a small proportion of cases reported in recent outbreaks, and thus the majority of cases with complications or deaths may actually occur in persons without immune suppression in some settings. As noted above, case fatality in historically endemic areas of the Democratic Republic of the Congo remains much higher across all age groups than elsewhere (about 7 to 20-fold higher). More research is needed to characterise less studied risk factors for severe disease.
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 with lower disease severity.
While breakthrough cases of mpox have been documented in some older previously vaccinated persons, epidemiological data indicate that few mpox deaths have been reported in this group. New cases of mpox with clade Ib MPXV in various regions have predominantly been associated with sexual contact in people with a history of travel to outbreak-affected areas who developed symptoms just prior to or upon return. Spread through sexual networks from some cases has ultimately led to the establishment of community transmission of clade Ib MPXV in several countries outside Africa.
Overall, the spread of clade Ib MPXV in newly affected areas has remained largely confined to groups at risk. Since the start of the global outbreak in 2022, the general population has not been widely affected by ongoing circulation of clade IIb MPXV in high income settings, nor has it been implicated in mpox introduction or establishment in new geographic areas. Secondary transmission to non-sexual contacts has remained limited. Thus, individuals in this risk group (“all other individuals”) affected by clade IIb have mainly been infected through household or occupational contact, characterized by low secondary attack rates and limited onward transmission. Nonetheless, explosive outbreaks in West Africa have demonstrated that all age groups can be significantly affected such that continued vigilance is required for all mpox clade outbreaks in different settings. Within this broad group which includes most people, there are also other individuals in settings where there is a higher risk of onward mpox transmission, such as those in internally displaced person (IDP) and refugee camps and other congregate, overcrowded settings. Furthermore, some more vulnerable individuals are considered to face a higher risk of severe disease and poorer disease outcomes if they fall ill, particularly pregnant individuals, neonates, and infants. Poor outcomes have been documented among pregnant individuals and their unborn children, including spontaneous abortions, missed abortions, still births, congenital mpox and early neonatal death, with recent studies reporting these adverse outcomes in about half of pregnant individuals followed up. The healthcare-associated clade Ib mpox outbreak among neonates and infants in Pakistan in early 2026 which resulted in a CFR higher than 20% also demonstrated that mpox transmission can lead to severe consequences in highly vulnerable populations. In this instance, mpox in a neonatal intensive care setting resulted in rapid amplification and disproportionate impact in neonates and infants.
Public health control measures such as laboratory confirmation, rapid contact tracing and isolation have generally been sufficient to manage mpox in the general population, notably in high-income settings. Nonetheless, partner notification strategies should supplement classic contact-tracing to reach non- disclosed sexual partners. Vaccination has been prioritized for groups at higher risk of exposure with the intent to prevent and stop transmission. Where vaccines have, in some settings, been mainly offered to health workers for their individual protection, this strategy builds confidence and quality of care but cannot be expected to play a major role in stopping outbreaks.
In all settings therefore, the general population largely remains immunologically naïve to mpox, while the risk to health, contribution to international spread and burden of insufficient response capacities, remains low. Exceptions to this include where mpox is inadvertently introduced into high-risk settings, such as newborn and infant care units.
The overall public health risk for all other individuals without multiple sexual partners 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, as well as recurrent outbreaks in countries where zoonotic transmission occurs. While all countries remain at risk of importation and limited local transmission, recent outbreaks (starting from 2022- 2023) have confirmed observations that sustained transmission and geographic spread are largely driven by sexual contact in specific population groups and network dynamics, rather than in the general population, with some notable exceptions such as health facility-based outbreaks.
While most countries have established outbreak response mechanisms, such as early detection and contact tracing that help in controlling viral spread, the effectiveness of classic contact-tracing for a sexually transmissible infection remains very limited. Other countries are less prepared and at a higher risk of missing chains of local transmission, especially where low index of suspicion, stigma, and discrimination create barriers to access diagnostic testing, clinical care services and implementation of infection prevention and control measures, and where political and socio-cultural contexts or other circumstances preclude timely information-sharing with communities, health sector partners and timely and complete reporting to WHO.
While improvements in understanding mpox transmission and risk have improved since the first mpox public health emergency of international concern (PHEIC) was declared in 2022, 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 (e.g., for immunocompromised individuals), 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. The lack of reporting by some countries further limits overall community awareness, appreciation of risk, and visibility on continuing evolution of the epidemic.
Several cases and larger outbreaks have been reported in humanitarian emergency settings such as IDP and refugee camps and other congregate, overcrowded settings, but the risk of spread and modes of transmission in these settings, including the role of living conditions among other factors, are still poorly understood. Additionally, transmission between children outside of the household setting is not fully understood, and its potential to sustain spread of the virus in the community context has not been quantified.
In recent years, access to diagnostics, vaccines, and response tools has improved through coordinated efforts by WHO and partners, and 19 countries in Africa 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 reduce the potential impact of vaccination, underscoring the importance of prioritization and timely vaccine deployment. In addition, data on the effectiveness of available therapeutics for mpox remain 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, one additional case has been detected since the last RRA, bringing the cumulative case count to three. The geographic areas where the recombination event first occurred remain unknown. While the public health risk associated with this recombinant strain is currently considered low, ongoing genomic surveillance is essential given uncertainties related to viral evolution and recombination.
Overall, MPXV continues to circulate in all WHO regions and pose distinct risks across different population groups and settings. Sustained transmission of this still emerging and evolving orthopoxvirus continues, posing health risks for vulnerable individuals of all ages and in all settings. While response capacity continued to improve during the second PHEIC, it remains uneven with suboptimal reporting practices, and highly dependent on dwindling or non-existent resources as priorities shift. Transition to longer term disease prevention and control programmes and strategies is still in early stages in most settings and resources remain extremely limited as interest in mpox response wanes. Taken together, this context creates additional risk that the gains made over the past few years may erode.
Thus, the overall public health risk at the global level is assessed as moderate.
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Source:
Link: https://www.who.int/publications/m/item/who-rapid-risk-assessment-mpox--global-v.7
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