The 2022 mpox outbreak in Asia is a part of the ongoing outbreak of human mpox caused by the West African clade of the monkeypox virus. The outbreak was reported in Asia on 20 May 2022 when Israel reported a suspected case of mpox, which was confirmed on 21 May. seven West Asian, three Southeast Asian, three East Asian and one South Asian country, along with Russia, have reported confirmed cases.

a total of 162 cases were confirmed. Most of them were concentrated in the region of West Asia, with 141 of the total 156 cases (≈90.38%) being reported in the region. Israel alone has reported 114 cases (≈73.07%). Israel reported the first community transmission of the disease on 21 June 2022.

Background

Transmission

A large portion of those infected were believed to have not recently traveled to areas of Africa where mpox is normally found, such as Nigeria, the Democratic Republic of the Congo as well as central and western Africa. It is believed to be transmitted by close contact with sick people, with extra caution for those individuals with lesions on their skin or genitals, along with their bedding and clothing. The CDC has also stated that individuals should avoid contact and consumption of dead animals such as rats, squirrels, monkeys and apes along with wild game or lotions derived from animals in Africa.

In addition to more common symptoms, such as fever, headache, swollen lymph nodes, and rashes or lesions, some patients have also experienced proctitis, an inflammation of the rectum lining. CDC has also warned clinicians to not rule out mpox in patients with sexually transmitted infections since there have been reports of co-infections with syphilis, gonorrhea, chlamydia, and herpes.

History Imported cases before the outbreak According to the World Health Organization, imported cases of mpox from Nigeria was detected in Israel and Singapore in September 2018 and May 2019, respectively.

In 2018, an imported case was detected in Israel. A 38-year-old man came from Rivers State, Nigeria in late September. He showed the symptoms of the disease on that month. Later on October the patient sought medical attention at Shaare-Zedek Medical Center in Jerusalem. He was confirmed to be infected with the West African Clade of monkeypox virus that month. All of the patient's contacts were traced and followed up but no virus transmission were detected.

Arrival

As the outbreak was spreading in Europe in the middle of May 2022, the Israeli Health Ministry reported a suspected mpox case in the country on 20 May. The case was confirmed by testing on 21 May, becoming the first case in Israel during the outbreak, which also became the first in Asia.

The 30-year-old man returned from Western Europe and contracted the disease from there. The ministry reported that he was in isolation in the Ichilov General Hospital in Tel Aviv.

Cases transited through Asia In May and June 2022, two Australians tested positive for mpox in Australia, but before that they stayed in transit in airports for some hours in Southeast Asia.

On 30 May, Thai health authorities confirmed that an Australian who stayed in transit in Suvarnabhumi Airport for two hours that week had tested positive for mpox in Australia.

On 6 June, the Singaporean Ministry of Health announced that a mpox case in New South Wales in Australia stayed in transit in Singapore on 2 June. 13 people who had casual contact were isolated.

Wastewater surveillance A study from the Faculty of Medicine, Chulalongkorn University, Thailand led by Dr Dhammika Leshan Wannigama reported Multiple traces of monkeypox virus were detected in non-sewered wastewater with sparse sampling collected from both the Bangkok, Thailand with increasing concentrations from June to August 2022. This is the first dataset related to monkeypox viral DNA in wastewater in Bangkok. Monkeypox viral DNA was first detected in wastewater in the second week of June 2022. From the first week of July, the number of viral DNA copies increased. Sanger sequencing confirmed the identification of the monkeypox virus and its relation to the 2022–2023 mpox outbreak. The same group later released findings from wastewater surveillance in six Southeast Asian countries (Thailand, Lao PDR, Myanmar, Cambodia, Vietnam, and Indonesia), which showed the presence of Monkeypox virus (MPXV) DNA, suggesting local transmission. This information aids in the distribution of resources such as testing, vaccines, and treatments in regions with limited resources.

Timeline of cases by country Timeline of first confirmed cases by country or territory +First confirmed mpox cases by country or territory Date Countries / Territories • • • •

Timeline of suspected cases by country or territory Countries listed below had only suspected cases at the time of reporting. Some countries reported confirmed cases after reporting suspected cases (i.e. Turkey). Countries listed several times reported suspected cases again after they discarded suspected cases before. +Timeline of suspected mpox cases by country or territory Date Countries / Territories (confirmed on 21 May) (discounted on 4 June) (discounted on 31 May) (discounted between 30 May and 5 June) (discounted on 2 June) (discounted on 7 June) (discounted on 5 June) (confirmed on 15 June) (discounted on 9 June) (discounted on 12 June) (discounted on 17 June) (confirmed on 22 June) (discounted on 9 July) (confirmed on 14 July)

Responses Several countries have responded to the outbreak. The responses of some of them are listed below. : On 22 May, the Directorate General of Health Services (DGHS) issued warnings at every port in the country to prevent the spread of mpox. The Directorate spokesperson Nazmul Islam said that the DGHS has asked all air, land and sea ports to be alert. Suspected cases are instructed to be sent to an infectious disease hospital and kept in isolation. : On 2 June, the Chinese CDC issued a notice quoting the WHO's document with a translation of the original, "Stigmatising people because of a disease is never okay. Anyone can get or pass on mpox, regardless of their sexuality." : On 21 May, Union Health Minister Mansukh Mandaviya directed the National Centre for Disease Control and the ICMR to keep a close watch and monitor the situation. The Union Health Ministry has also directed airport and port health officers to be vigilant, according to official sources. They have been instructed to isolate and send samples to the National Institute of Virology of any sick passenger with a travel history to infected countries. : Indonesian health authorities were put on alert when cases of mpox were reported in Australia in May 2022. Mohammad Syahril, ministry spokesperson, urged medical personnel and the country's population to be alert and aware of the symptoms of the disease. : On 27 May 2022, the Malaysian Ministry of Health reactivated the MySejahtera app to provide information and surveillance on mpox. : Health Secretary Francisco Duque III said that the Philippines was intensifying its border control measures amid the threat of mpox. The health department stated it is exploring potential sources of mpox vaccines and antivirals. : On May 21, the Saudi Ministry of Health stated that they are ready to monitor and investigate cases of mpox, if any occurs. They added that it also has an integrated preventive plan to deal with such cases if they appear, including identifying suspected and confirmed cases. : On 30 May, the Taiwan Centers for Disease Control officially listed mpox as a notifiable infectious disease, and on June 23, mpox was officially upgraded to a second-class notifiable infectious disease, which means that confirmed cases must be notified within 24 hours, and if necessary, isolation treatment may be implemented in designated isolation treatment institutions. : On 24 May 2022, the Department of Disease Control (DDC) started screening all overseas passengers from Central African countries and other outbreak countries at international airports. On 26 May 2022, the DDC set up an emergency operations center to monitor the outbreak situation and plan for a possible outbreak in the kingdom. Anutin Charnvirakul, Minister of Public Health, said that the government is seeking a smallpox vaccine from the WHO to bolster the public's immunity in case of a viral outbreak. On 30 May 2022, The local news reported the first case of mpox in the country. The patient was a passenger who was transiting from Europe to Australia via Bangkok. However, the patient's symptoms developed and were diagnosed in Australia. There have been no local cases discovered as of yet. : On May 24, 2022, Vietnam's Ministry of Health asked border localities to increase surveillance to detect possible cases of mpox.

Outbreak by regions and countries Western Asia Georgia Georgia was the first Caucasian and the third Asian and West Asian country to report confirmed cases of mpox. The first case was reported by the Ministry of Health on 15 June 2022.

Israel

Israel was the first in both Asia and West Asia to report a case.

On 20 May, Israel reported a suspected mpox infected patient who was in isolation in Ichilov Hospital and tested positive on 21 May. On the same day, another suspected case was reported but the case was ruled out the next day, on 22 May.

Israel reported a single case each on 28 May and 7, 9, 15 and 16 June until the authorities reported three cases on 20 June. In a press statement released on 21 June, the ministry stated that one of them was infected locally, confirming community transmission of the disease in Israel. The total reached 9 on that day.

The case figure was updated regularly and press releases were released on the ministry's website whenever cases where reported. But after 21 June, the ministry started to release weekly report of the situation on the website.

On 15 July, Health Minister Nitzan Horowitz announced that 2,000 mpox vaccines will arrive in Israel, adding that he spoke with biotech company Bavarian Nordic CEO Paul Chaplin. He also said that a total of 90 cases were registered till then, and none of them needed hospitalisation.

As of 17 July 2022, 96 confirmed cases were reported in Israel.

Lebanon On 20 June, the first case of mpox in Lebanon was reported by the National News Agency (NNA) stating the Ministry of Health, thus Lebanon became the fourth country in both Asia and West Asia and the third in the Middle East to report a mpox case.

Saudi Arabia On 14 July, the first mpox case was detected in the capital city of Riyadh. The person came from abroad.

Turkey

United Arab Emirates

South Asia Afghanistan

On 29 May, the Islamic Republic News Agency and other news agencies reported two suspected cases of mpox who came back from Iran in Nimruz Province citing local newspapers and the Ministry of Health and provincial health authorities.

On 30 May, one case was reported in Herat Province.

On 31 May, ministry spokesperson Javid Hazhir denied reports of confirmed cases and stated that suspected cases in Nimruz and Kabul provinces tested negative. He also said that Afghanistan has the capability to test mpox cases.

On 5 June, it was reported that the WHO will give test kits to the Taliban-controlled Ministry of Public Health, as they were lacking kits. Ministry spokesperson stated that suspected cases in Herat, Maidan Wardak and Nangarhar provinces along with other provinces which were stated earlier tested negative and the country is free of mpox.

Bangladesh Bangladeshi health authorities declared alert on every ports in the country in mid-May. Shahjalal International Airport in Dhaka was in high alert.