The Director-General of the World Health Organization (WHO) is hereby transmitting the report of the fourth meeting of the International Health Regulations (2005) (IHR) Emergency Committee (Committee) regarding the upsurge of mpox 2024, held on Thursday, 5 June 2025, from 12:00 to 17:00 CEST.
Concurring with the advice unanimously expressed by the Committee during the meeting, the WHO Director-General determined that the upsurge of mpox 2024 continues to meet the criteria of a public health emergency of international concern (PHEIC) and, accordingly, on 9 June 2025, issued temporary recommendations to States Parties, available here.
The WHO Director-General expresses his most sincere gratitude to the Chair, Members, and Advisors of the Committee.
===
Proceedings of the meeting
Sixteen (16) Members of, and two Advisors to, the International Health Regulations (2005) (IHR) Emergency Committee (Committee) were convened by teleconference, via Zoom, on Thursday, 5 June 2025, from 12:00 to 17:00 CEST. Fourteen (14) of the 16 Committee Members, and the two Advisors to the Committee participated in the meeting.
The Director-General of the World Health Organization (WHO) joined in person and welcomed the participants, including Government Officials designated to present their views to the Committee on behalf of the two invited States Parties – Burundi and the Democratic Republic of the Congo (DRC). The opening remarks by the Director-General are available here.
The Representative of the Office of Legal Counsel then briefed the Members and Advisors on their roles and responsibilities and identified the mandate of the Committee under the relevant articles of the IHR. The Ethics Officer from the Department of Compliance, Risk Management, and Ethics provided the Members and Advisors with an overview of the WHO Declaration of Interests process. The Members and Advisors were made aware of their individual responsibility to disclose to WHO, in a timely manner, any interests of a personal, professional, financial, intellectual or commercial nature that may give rise to a perceived or actual conflict of interest. They were additionally reminded of their duty to maintain the confidentiality of the meeting discussions and the work of the Committee. Each Member and Advisor was surveyed, with no conflicts of interest identified.
The meeting was handed over to the Chair who introduced the objectives of the meeting, which were to provide views to the WHO Director-General on whether the event continues to constitute a PHEIC, and if so, to provide views on the potential proposed temporary recommendations.
Session open to representatives of States Parties invited to present their views
The WHO Secretariat presented an overview of the global epidemiological situation of mpox, including all circulating clades of monkeypox virus (MPXV). Over the past 12 months, the majority of mpox cases have continued to be reported from the African continent, largely driven by outbreaks of MPXV clade Ib in East African countries, including the DRC, where clade Ia is co-circulating. Sierra Leone however is experiencing a rapidly evolving outbreak, which based on available genomic sequencing results, appears to be driven by MPXV clade IIb. Outside of the African region, there continues to be a steady report of monthly cases (between about 500 – 1000 monthly), from all regions, mostly reflecting ongoing circulation of MPXV clade IIb among men who have sex with men (MSM).
In the DRC, while surveillance- and access to healthcare-related challenges persist, particularly in the eastern part of the country, trends in most Provinces where MPXV clade Ib is circulating, including those of North Kivu and South Kivu, are now appearing to stabilize or decline. Similar trends are also observed in areas endemic for MPXV clade Ia. In the capital Kinshasa, where the upsurge is driven by a co-circulation of MPXV clades Ia and Ib, the disease appears to be clustered geographically and in specific demographic groups, with incidence disproportionately higher among young adults, reflecting dynamics of transmission sustained by sexual networks in key areas of the city.
In Burundi, a steady decline in incidence of mpox cases has been observed since late 2024. Initially concentrated in and around Bujumbura and later spreading to the administrative capital Gitega, with at its peak cases reported in most districts, the upsurge appears to now be concentrated only in a few hotspots.
In Uganda, although national trends indicate a decrease in mpox cases since mid-February 2025, including a clear downward trend in the capital Kampala, limitations in testing capacity warrant cautious interpretation. Clusters are concentrated in urban settings, with transmission primarily among young adults, consistent with sexual contact transmission dynamics.
In Kenya, although the number of mpox cases remains low, recent data suggest an upward trend. Surveillance is likely underestimating the actual incidence of mpox cases. Transmission has been associated with mobile populations, including truck drivers and sex workers.
Sierra Leone has recently faced a significant upsurge of MPXV clade IIb, with a peak reproduction number in the capital Freetown, exceeding that observed in the past in Kinshasa, DRC, or Kampala, Uganda. Over the past three weeks, the number of observed mpox cases has been declining, possibly due to a combination of, increased natural immunity in high-risk groups and public health interventions. Transmission remains concentrated in urban areas and among young adults, likely to be associated with sexual contact.
Travel-associated cases are declining but remain a concern. Notably, recent diagnoses of MPXV clade Ib infection in Australia – linked to exposure in Thailand – highlight the risk of undetected transmission in countries or areas with underperforming surveillance. The majority of secondary transmission resulting from imported mpox cases occurs through close, intimate, or sexual contact.
MPXV clade Ia continues to show higher mortality, especially in children the DRC with a case fatality rate of 2-3%, although data should be interpreted considering, inter alia, the limitation of syndromic surveillance. Across all clades, individuals with underlying immunosuppression, particularly those with HIV infection, remain at greatest risk of severe outcomes and death. The overall case fatality rate for MPXV clade Ib and clade IIb remains around 0.5%.
The WHO Secretariat presented the assessed risk by MPXV clades and further expressed in terms of overall public health risk where any given clade/s is/are circulating, as: Clade Ib – high public health risk in the DRC and neighbouring countries; Clade Ia – moderate public health risk in the DRC; Clade II – moderate public health risk in Nigeria and countries of West and Central Africa where mpox is endemic; and clade IIb – moderate public health risk globally. It was noted that the above risk assessment corresponds to the one presented during the third meeting of the Committee on 25 February 2025.
The WHO Secretariat subsequently underscored progress in mpox control efforts, attributing gains to partnerships among national governments, communities, and WHO. However, these are now at risk due to a worsening funding shortfall, not only for the response but for global health programs that support mpox prevention and control activities.
An updated WHO Mpox Strategic Preparedness and Response Plan (SPRP, available here), covering the period May-August 2025 and integrating lessons from operational reviews conducted in early 2025, was issued in April 2025. While the strategy remains fit for purpose, the funding environment has deteriorated. Despite a $145 million funding requirement to support all partners involved in mpox response efforts, including $47 million for WHO, the Organization has received no new financial commitments since the issuance of the new SPRP, and resource constraints now threaten the sustainability of operations – personnel levels have dropped, and essential supplies, including vaccines, cannot be deployed efficiently.
WHO has issued updated clinical care and infection prevention and control (IPC) guidance, emphasizing the importance of integrating mpox-related interventions into broader health programs and health services delivery. However, the effective implementation of the guidance remains limited by logistical and financial barriers, and its application at local level requires intensified support. Community-centered care strategies, such as home-based care with IPC integration and linkage to primary care, have been endorsed to alleviate pressure on health facilities.
Seven countries have initiated mpox vaccination (Central African Republic, DRC, Liberia, Nigeria, Rwanda, Sierra Leone, and Uganda), with four additional countries (Angola, Cote d’Ivoire, Kenya, and South Africa) poised to begin. Vaccine supply exists with 2.9 million vaccine doses in countries, but resource limitations hamper distribution and administration, with only approximately 724,000 doses administered to date. Strengthened coordination is essential to ensure equitable and timely delivery to high-risk populations.
While recent progress in controlling and responding to the spread of mpox are encouraging, sustainability hinges on urgent and sustained resource mobilization, greater integration within health systems, and continued prioritization of community engagement. Without this, current gains risk being reversed.
Representatives of Burundi and the DRC updated the Committee on the mpox epidemiological situation in their countries and their current control and response efforts, needs and challenges, and plans in the medium term.
In Burundi, since the mpox upsurge started in July 2024, cumulatively, approximately 4,000 confirmed cases of mpox, including one death, were observed. The number of cases has been subsiding and, as of 25 May 2025, mpox cases are occurring in 9 districts, including two hotspots. The response in Burundi is focusing on rapid response to alerts and contract tracing. Among the challenges in responding to mpox are insufficient resources to provide food for cases, lack of clean water in some of the hotspots, and the absence of a functional multisectoral One Health platform.
In the DRC, the number of mpox cases is plateauing, with a significant decrease in positivity rate, further corroborating the declining trends. Outside areas considered to be endemic, adults account for the majority of cases, with sexual contact being the most frequent mode of transmission. Overall, as a result of contact tracing activities, 83,000 contacts were identified, with a median of 5 contacts per case. More than two million mpox vaccine doses were received, with approximately 600,000 people vaccinated to date. Efforts are ongoing to make triage more efficient and effective, and improve diagnostics for mpox, including transport of samples from the affected communities. National authorities have developed a plan to intensify the response to the mpox outbreak, focusing on surveillance, contact tracing, risk communication, and vaccination. However, the funding gap is again impacting response activities, particularly in remote areas.
Members of, and Advisors to, the Committee then engaged in questions and answers with the presenters from States Parties and the WHO Secretariat, revolving around the issues and challenges enumerated below.
Global epidemiology, clade distribution, and risk assessment – The global epidemiological risk has remained largely unchanged since the Committee last met on 25 February 2025. However, 17 countries in Africa are currently reporting mpox outbreaks (i.e. one case or more in the last six weeks). MPXV clade Ib continues to spread in high-risk groups and has been newly detected in countries including Ethiopia, Malawi, South Sudan, and Zambia. Sierra Leone is experiencing a distinct outbreak, likely due to MPXV clade IIb according to initial evidence. This outbreak poses a specific local and regional risk and is a reminder of the ongoing risk of mpox outbreaks in specific contexts. The Committee asked about progress made towards the elimination of mpox in the WHO European Region. In that respect, the WHO Secretariat indicated that MPXV clade IIb continues to circulate at low levels, predominantly among MSM. Despite the reduced number of cases, elimination has not been achieved, with persistent transmission linked to gaps in immunity, behavioral risk factors, and communication barriers. Given the patterns of international travel, the risk of reintroduction in the WHO European Region persists.
Surveillance, laboratory testing, and confidence in data – On the specific question of confidence in trends in the DRC, while there remain many specific challenges to surveillance, stable or decreasing trends observed in syndromic surveillance, epidemiological case-based surveillance and laboratory-based surveillance, coupled with decreases in test positivity, bring some confidence in the robustness of the assessment. Caution is warranted particularly when interpreting current trends in some areas of the Eastern Provinces of the DRC where access remains constrained, although, overall, Eastern DRC had been seeing a sustained decline in reported cases before the more recent security constraints. Concerns were expressed about the possibility of undetected transmission of MPXV in West Africa, including in Ghana and Togo in relation to MPXV clade Ib, as well as in Sierra Leone, in relation to MPXV clade IIb, despite of the declining trajectory of the number of cases after it peaked in early 2025. Concerns were also expressed regarding the need for enhanced genomic sequencing capacity. Burundi was commended for its strong surveillance performance, including its high testing rate and contact follow-up capacity. National laboratory diagnostic approaches generally report adhering to WHO protocols. However, in Sierra Leone, due to the burden of response activities, only 2% of samples positive for MPXV infection (prior to early May 2025) underwent genomic sequencing.he WHO Secretariat continues to support countries experiencing upsurges of mpox cases by providing technical assistance, including facilitating shipment of specimens to national or international laboratories.
Patterns of transmission – The Committee highlighted that, unlike in most other areas experiencing the MPXV clade Ib outbreaks, an increased number of paediatric mpox cases is observed in the Provinces of North and South Kivu, DRC. While detailed epidemiological data are limited, this age pattern could potentially be explained, inter alia, by the build-up of immunity among adults following sexual exposure, leading to infections due to non-sexual exposure withing households. There have been anecdotical reports of exposure in paediatric healthcare facilities. It was noted that outbreaks of mpox have not otherwise been reported in educational or other settings where children are congregating.
Contact tracing – Approaches to contact tracing differ across countries. In some settings the absence of systematic tracing and access to diagnostics reduces the effectiveness of overall control actions. The need to optimize public health resource allocation was underscored. This would entail reassessing the feasibility of traditional contact tracing in certain settings, as well as the use of mpox vaccine among identified contacts to reduce secondary transmission.
Vaccination – As of June 2025, approximately 2.9 million mpox vaccine doses have been distributed across the African continent, the majority to the DRC, which has received about 2.5 million doses. Of these, approximately 600,000 doses have been administered. The remaining 1.9 million doses comprise 1.5 million LC16m8 vaccine doses donated by Japan (not yet deployed as training of health workers is underway) and 367,000 MVA-BN doses. A further 349,000 doses secured by the United Nations Children’s Fund (UNICEF) remain undeployed due to funding shortages. An additional 219,000 MVA-BN doses have been pledged by the Government of the United States of America, pending approval for deployment. Strategies for the use of mpox vaccine have evolved in response to supply constraints and emerging epidemiological trends. In the DRC, since February 2025, approximately105,000 doses have been administered to children under 12 and approximately 56,000 doses to adolescents aged 12 to 18. Additional groups targeted by vaccination efforts in the DRC include healthcare workers, individuals at risk of severe disease – such as people living with HIV – and, in more recent phases, key populations in transmission hotspots, including sex workers, and MSM. In Sierra Leone, the vaccination strategy was initially focused on healthcare and frontline workers and people living with HIV. The focus of vaccination efforts then shifted to hotspots and contacts, sex workers, and MSM within those hotspots. Initially, most countries began with a two-dose regimen; however, the majority have now transitioned to a single-dose approach or are preparing to shift toward intradermal fractional dosing. These dose-sparing strategies were endorsed in the WHO position paper, if vaccine resources were limited, published on 23 August 2024, available here.[1] It was noted that intradermal fractional dosing, where each vial can yield four to five doses, is applicable only to the MVA-BN vaccine and has already been employed in some settings. Overall, the uptake of available vaccines has remained lower than anticipated due to logistical, operational, and financial barriers. Further efforts are needed to optimize the strategic use of available mpox vaccine and maximize its public health impact.
Mpox and HIV infections and integration of health services – Coinfection with HIV presents significant challenges for health services in the management of mpox, especially in countries with high HIV prevalence. In Kinshasa, DRC, 9.3% of mpox cases are reported to be HIV-positive, though this figure likely underrepresents the true burden due to limited HIV testing and integration of health services. In Uganda, 55% of deaths associated with MPXV infection have occurred among people living with HIV. The importance of co-located testing services and data systems was underscored to capture the dual burden of HIV and mpox more effectively. Reference to WHO technical guidance was made in relation to the use of rapid tests for HIV diagnosis, immediate linkage to care for those who test positive, and protocols for clinical management of coinfected individuals. The needs for improving triage systems and refining clinical diagnostic criteria for mpox were highlighted, with emphasis on the misclassification of dermatological conditions, such as chickenpox. Overall, the integration of health care delivery remains uneven across countries.
Funding – Funding gaps remain one of the most critical threats to the mpox response. It was noted that, since the launch of the updated SPRP in April 2025, WHO has not received any additional earmarked contributions, resulting in the scaling back of operations, including surveillance, laboratory support, community outreach, and vaccine-related logistics. Serious concerns were expressed regarding the sustainability of key control interventions, including HIV-related, the interruption of which could lead to the intensification of transmission and, hence, limit the ability of public health systems to adapt and respond to changing transmission patterns. However, it was emphasized that lessons should be learned from the experience of Burundi that, despite operating with limited resources, has made substantial progress in controlling the upsurge of mpox, thanks largely to non-pharmaceutical interventions – a combination of sensitive surveillance, effective contact tracing, strong laboratory testing capacity, and decentralized district-level interventions leveraging on community engagement.
Anticipated scenarios for controlling and responding to mpox – The Committee expressed concerns about the current epidemiological trajectory suggesting that mpox may be moving toward endemicity in some countries, or areas thereof, in the African continent. Although some countries are seeing sustained declining trends, MPXV transmission persists. This is consistent with preliminary modelling work suggesting that the actual case counts may be higher than reported due to diagnostic and surveillance gaps. Such scenario raises concern in terms of future interspersed surges of cases in countries in the African continent, as well as exportation of cases within and beyond the continent. Therefore, the observed epidemiological evolution of mpox since the public health emergency of international concern (PHEIC) was determined in August 2024, requires the development of adequate definitions to describe the pattern of mpox transmission experienced by countries, or areas thereof, and, consequently, assist in setting the goals for control, and guide control and response interventions accordingly.
Deliberative session
Following the session open to invited States Parties, the Committee reconvened in a closed session to examine the questions in relation to whether the event constitutes a PHEIC or not, and if so, to consider the temporary recommendations drafted by the WHO Secretariat in accordance with IHR provisions.
The Chair reminded the Committee Members of their mandate and recalled that a PHEIC is defined in the IHR as an “extraordinary event, which constitutes a public health risk to other States through the international spread of disease, and potentially requires a coordinated international response”.
The Committee was unanimous in expressing the views that the ongoing upsurge of mpox still meets the criteria of a PHEIC and that the Director-General be advised accordingly.
The overarching considerations underpinning the advice of the Committee are determined by (a) challenges in accurately describing the multi-faceted epidemiological patterns and profiles associated with multiple circulating MPXV clades, observed and markedly differing from historical experience with the disease; (b) uncertainties related to funding availability in the immediate and medium term, both, domestically and internationally; and (c) the subsequent challenges in defining public health strategic approaches for controlling and responding to the spread of mpox.
On that basis, the Committee considered that:
The event is “extraordinary” because of (i) the emergence and spread of MPXV clade 1b has introduced new uncertainties regarding virus evolution, and the current and foreseeable dynamics of mpox spread; (ii) the establishment of sustained community transmission of MPXV clade I in additional countries in the African continent, without a full appreciation of the factors driving the rapid evolution of the surge of mpox cases; (iii) the disproportionate burden of mpox cases among children, especially in the Eastern Provinces of the DRC, with not yet fully explained dynamics of transmission; and (iv) the persistent challenges integrating health service delivery to mpox patients, due to the likelihood of comorbidities and heightened vulnerability.
The event “constitutes a public health risk to other States through the international spread of disease” because of (i) sub-optimal surveillance systems in many countries and regions, likely leading to undetected transmission and subsequent spread of MPXV clade I into additional countries in the African continent. Such consideration applies to both countries in West Africa, where MPXV clade I had not previously been identified, but are experiencing significant population movement with central and east African countries where that virus is spreading, as well as to countries outside the African continent (e.g. exported case of MPXV clade Ib infection from Thailand to Australia); and (ii) the continuous exportation of MPXV clade I mpox cases from Africa to other continents, some of which resulting in secondary transmission.
The event “requires a coordinated international response” because (i) there is a need for concerted efforts by the international community to supplement domestic funding for mpox control and response activities, as well as those of United Agencies, other international institutions and partnerships operational in the field and/or involved in vaccine procurement and related logistics; (ii) access to vaccine, even when available, remains challenging in terms of delivery capacity at the local level; (iii) in the context of limited funding, there is a need to facilitate the exchange of experience between countries, in particular those of countries like Burundi, that despite operating with limited resources, has made substantial progress in controlling the upsurge of mpox through the implementation of non-pharmaceutical interventions; and (iv) there is a need to monitor the spread and phylogenetic evolution of MPXV clades through genetic sequencing, not always available or optimally performing, in countries experiencing upsurges of mpox.
The Committee subsequently considered the draft of the temporary recommendations proposed by the WHO Secretariat.
Anticipating the possibility that the WHO Director-General may determine that the event continues to constitute a PHEIC, the Committee had received a proposed set of revised temporary recommendations ahead of the meeting. This reflected the proposal to extend most of the temporary recommendations issued on 27 February 2025. While acknowledging that the standing recommendations for mpox are approaching their expiration (20 August 2025) and could potentially benefit from extension or revision, the Committee reiterated the relevance of the proposed temporary recommendations. However, the Committee emphasized the needs (i) to prioritize temporary recommendations related to non-pharmaceutical interventions, taking into account implementation challenges and successful experiences on the ground; and (ii) to anchor vaccine deployment in evidence-based approaches.
Conclusions
Considering the complexity of the epidemiological evolution of the spread of mpox, of the distribution of the MPXV clades, the challenges in implementing efficient and effective control and response interventions, as well as issues raised by the Committee in occasion of their previous meetings, the Committee welcomed the proposal by the WHO Secretariat to hold an informal technical meeting aimed at assisting countries to prioritise response measures adapted to the varied epidemiological contexts, ahead of its next formal meeting should the WHO Director-General determine that the event continues to constitute a PHEIC.
The Committee agreed to provide its feedback to the WHO Secretariat on the proposed set of temporary recommendations the day after the meeting (i.e. 6 June 2025), and to finalize the report of the meeting during the week of 9 June 2025.
The Acting Director of the Department of Epidemic and Pandemic Threat Management at WHO headquarters, on behalf of the WHO Deputy Director-General, expressed her gratitude to the Committee’s Officers, its Members and Advisors and closed the meeting.
References:
[1] On 6 June 2025, after the fourth meeting of the Committee, WHO published the Meeting of the Strategic Advisory Group of Experts on Immunization (SAGE), 10-13 March 2025, including a section on mpox vaccine. The report is available here.
