Previous Mpox Risk Assessment - July 2024

As of July 8, 2024

CDC assessed the overall risk to the United States posed by the clade I mpox outbreak in the Democratic Republic of Congo (DRC) for two populations.

1. The risk to the general population is assessed as VERY LOW.A
2. The risk to gay, bisexual, and other men who have sex with men (MSM) who have more than one sexual partner and people who have sex with MSM, regardless of gender, is assessed as LOW to MODERATE.

The purpose of this assessment is to provide time-sensitive health information about the ongoing clade I outbreak of mpox in the DRC for public health agencies.

We have moderate confidence in this qualitative assessment. The assessment relies on subject-matter experts evaluating a range of evidence related to risk, including limited epidemiologic data from the DRC outbreak, historical data on clade I mpox epidemiology and clinical severity, and extrapolations based on the ongoing clade IIb mpox outbreak in the United States. We will review available evidence every two weeks, or if the situation changes significantly, and update this assessment as warranted.

This assessment is an update to the previously published risk assessment on May 10, 2024. This update includes new evidence, but there are no changes to the overall risk assessment. We do not anticipate producing additional updates to this risk assessment. We continue to monitor the outbreak of clade I mpox in DRC, and will update this risk assessment if the risk to the United States changes.

Risk assessment for general population in the United States

Overall Risk

We assess the overall risk to the general U.S. population as very low, with moderate confidence. Overall risk is assessed by considering the likelihood and impact of infection across the population (see Methods section). This assessment may change as new evidence becomes available.

Likelihood

We assess the likelihood of infection for the general population as extremely low. Factors that informed our assessment of likelihood included the following:

There are no known cases of clade I mpox in the U.S. or any other country outside of endemic areas, although the virus could potentially spread from DRC to the United States or other countries through infected travelers from the DRC.

While the DRC outbreak has resulted in more than 7,000 confirmed or suspected cases so far in 2024, we assess that similar levels of transmission are unlikely in the United States.

• Experts do not believe that a similar scenario of transmission is likely in the United States for several reasons, including smaller average household sizes, increased access to improved sanitation and healthcare, and the lack of zoonotic reservoirs of disease.
• CDC modeling suggests close-contact transmission within and between households is unlikely to result in a large number of mpox clade I cases in the United States.
• The DRC outbreak represents multiple, ongoing provincial-level outbreaks in 25 of 26 provinces. Data suggest that cases have stemmed from many separate zoonotic introductions and subsequent chains of household transmission, with the exception of one outbreak in Kamituga, described below.

Although there is evidence of sexual transmission in some localities in the DRC, widespread sexual transmission in the U.S. general population is unlikely.

• A recent outbreak in the Kamituga mining region in DRC has been associated with sexual transmission, with 29% of confirmed cases identifying as sex workers. One recent cohort study of 371 Kamituga hospital patients with suspected mpox found that 88% of patients reported recent transactional sex.
• There is no current confirmed evidence of widespread heterosexual transmission in other DRC provinces, and it is unclear what proportion of cases elsewhere may be linked to sexual transmission. However, the high number of cases in children ≤ 15 years old is similar to historical trends in DRC and suggests that factors outside of sexual transmission have important roles. In general, epidemiologic data are limited for mpox patients, and we do not know the true number of cases nor how each case acquired infection.
• The potential for sustained heterosexual transmission of clade I mpox is likely to be low in the United States based on lack of widespread transmission in heterosexual networks during the 2022 global clade IIb mpox outbreak and insights from modeling studies.
  • Modeling work from the United Kingdom related to the 2022 outbreak indicated that lower partnership formation rates among heterosexuals prevented sustained transmission within these networks.
  • CDC modeling has shown similar results for heterosexual networks in the U.S.1
• The likelihood of infection among gay, bisexual, and other men who have sex with men (MSM) is assessed separately in the risk assessment for MSM in the United States, reported below.

As of June 2, 2024 , there are 109 reported cases (confirmed, probable, or suspected) in the Republic of Congo, which borders DRC to the west. As of November 2023, WHO indicated it is unknown whether there are links between the Republic of Congo outbreak and DRC's outbreak. Clade I is endemic in Republic of Congo; these cases may have resulted from zoonotic introductions or spread across the border in a relatively localized area and as such, do not yet suggest wider regional spread.

Impact

We assess the impact of infection for the general population as low to moderate. Factors that informed our assessment of impact included the following:

• Most of the United States population has no immunity to mpox.
  • Acquired immunity from previous infection with the mpox virus is extremely low for the general population (see separate analysis for MSM, who were disproportionately affected by mpox during the 2022 outbreak).
  • Vaccine-induced immunity from mpox vaccination during the 2022 outbreak is also very low across the general population. During the 2022 outbreak, vaccination was targeted to those at highest risk of infection, including MSM and their partners.
  • Prior smallpox vaccination, which can offer some protection against mpox, has declined substantially in the United States since the 1970s, when population-wide smallpox vaccination ceased.

• Morbidity and mortality from clade I mpox are likely lower in the United States, compared to DRC, because of the availability of high-quality supportive care and access to medical countermeasures.
  • DRC health authorities reported the case fatality rate (CFR) from suspected clade I mpox in 2023 was 4.6% and rose to 6.7% throughout early 2024; however, this may be an overestimation because of challenges in completeness of case reporting. In a study of 216 mpox patients from one DRC hospital from 2007-2011, investigators found a CFR of 1.4% among 216 patients who received limited supportive care and no mpox therapeutics.
  • In the United States, the CFR would likely be lower, given better access to high-quality supportive medical care and therapeutics.

Confidence

We have moderate confidence in this assessment.

We note uncertainties around epidemiologic and genomic data in DRC, including transmission dynamics in children and non-MSM sexual networks.

Risk assessment for MSM in the United States

Overall risk for this population

We assess the overall risk for gay, bisexual, and other men who have sex with men (MSM) in the United States, who have more than one sexual partner, and their sexual partners, regardless of gender as low to moderate, with moderate confidence. Overall risk is assessed by considering the likelihood and impact of infection across the population (see Methods section). This assessment may change as new evidence becomes available.

Likelihood

We assess the likelihood of infection for MSM as low to moderate. Factors that informed our assessment of likelihood included the following:

• There are no known cases of clade I mpox in the United States or any other country outside of endemic areas, although the virus could potentially spread from DRC to the United States or from other countries through infected travelers who expose others at their destinations.

• Health authorities have documented sexually transmitted clade I mpox in DRC in MSM in six cases during 2023, indicating the virus could spread among these sexual networks in the United States if cases were imported.

• During the ongoing 2022 global mpox outbreak, most U.S. cases were among MSM and their sexual partners, suggesting this population could be at increased risk for clade I mpox infection if the clade I mpox virus were to spread to the United States. Furthermore, only a minority of MSM who CDC has estimated would benefit from vaccination have been fully vaccinated, though rates vary widely by jurisdiction.

• There is some level of population immunity among MSM and their sexual partners following the 2022 outbreak of clade IIb mpox, which might reduce the risk of infection if clade I mpox were imported to the United States. In addition, during the 2022 global mpox outbreak in the U.S., MSM reported behavior adaptations that likely contributed to declines in mpox incidence, indicating that similar changes might be expected in response to future outbreaks.
  • A 2023 modeling study estimated that depending on population mpox immunity levels, jurisdictions face varying degrees of risk for sustained mpox recurrence, indicating that many jurisdictions may have a high likelihood of sustained transmission.
  • More recent CDC modeling found that as population-level immunity increased, the chances of a prolonged or large outbreak decreased. The study also found that if clade I mpox were to be introduced to MSM sexual networks in the United States, counties with greater than 50% population-level immunity would have smaller outbreaks on average (fewer than 100 infections).

Impact

We assess the impact of infection for this population as low to moderate. Factors that informed our assessment of impact included the following:

• Like the general population, we expect that the impacts of clade I mpox among MSM are likely lower in the United States, compared to DRC, because of the availability of high-quality supportive care and access to medical countermeasures.

• Population immunity among MSM and their sexual partners is likely to additionally reduce the severity of infection.

Confidence

We have moderate confidence in this assessment.

Given uncertainties around the level of prior immunity and the extent to which behavior adaptations initiated during the 2022 outbreak have continued or could recur, we have moderate confidence in this assessment.

Factors that could change our assessment

Geographic and population spread

• Detection of clade I mpox cases in the United States, particularly if there is domestic person-to-person transmission in jurisdictions with low estimated population immunity.

• Clade I mpox spreads outside sub-Saharan Africa, including among people attending mass gatherings or among other highly mobile populations.

• The outbreak in DRC intensifies or spreads to countries where mpox is not endemic, in the region or globally.

Transmission dynamics

• Evidence of person-to-person spread among children in DRC, outside of already recognized high-risk activities, such as exposure to animals or close contact with mpox patients.

• Evidence of widespread, prolonged chains of sexual transmission in DRC.

Natural history and medical countermeasures

• Additional data to suggest an increased or decreased illness severity of clade I mpox infection.

• Increased mpox vaccination coverage among high-risk groups in United States.

Background

Descriptive Epidemiology

There is an ongoing outbreak of mpox in DRC caused by the clade I mpox virus, which is distinct from the clade IIb mpox virus that caused the 2022 global outbreak. As of June 2, 2024, DRC reported 7,281 confirmed or suspected cases of mpox in 2024. In previous outbreaks, clade I has caused more severe disease and has been more transmissible than clade II within close-contact settings, typically in a household. Although clade I mpox is endemic in DRC, in 2023, health authorities reported a higher number of suspect cases and deaths across a wider geographic area that in some provinces affected atypical demographic groups. Approximately 70% of suspected mpox cases in DRC in 2024 were in children under age 15, similar to historical observations. However, adults were disproportionately affected in South Kivu province, where sexual transmission was predominant.

CDC has not detected any cases of clade I mpox in the United States, despite testing a high proportion of presumed mpox specimens—those positive for non-variola orthopoxvirus (NVO)—with tests that can identify mpox by clade. In addition, several commercial and other non-CDC laboratories perform clade II testing in addition to NVO tests, and all specimens tested to date have been clade II. If these laboratories see anything unusual—for example, an NVO positive but clade II negative result—they would alert CDC immediately to ensure additional genotyping is conducted to determine if they are clade I. CDC continues to work, including with other U.S. government agencies, on multiple approaches to expand clade-specific testing domestically. Several public health laboratories (PHLs) have begun or are working to begin clade-specific testing.

Transmission

The DRC outbreak of clade I mpox has likely resulted from transmission through several modes and in different settings. Most cases in 2023 were in children, and in past outbreaks, children have been more likely to acquire infection through contact with infected animals. Transmission caused by close contact within households has occurred in past clade I mpox outbreaks. Household transmission chains have typically been small, although occasionally have involved up to six generations of transmission. Transmission risk is highest among unvaccinated contacts; children and young adults are less likely to have vaccine-induced orthopoxvirus immunity since smallpox vaccination programs ended in 1980 in DRC. Sexual transmission has also been recently reported in Kamituga, South Kivu province in Eastern DRC, primarily among female sex workers, and in a small outbreak affecting MSM and women in Kenge, Kwango Province in March 2023.

Importation risk

In 2023, outbreaks were reported in urban areas of DRC, including Kinshasa and less-populated regions of DRC, such as Équateur and South Kivu Provinces, where cross-border movement elevates the risk of spread of the disease outside of the country. As of June 2, 2024, there are 109 clade I mpox cases (confirmed, probable, and suspected) in the neighboring Republic of Congo, where clade I mpox is endemic, likely representing localized transmission in a region with frequent cross-border movement. There are no direct commercial air passenger flights arriving from DRC and its neighboring countries into the United States.

Methods

CDC subject-matter experts specializing in risk assessment methods, infectious disease modeling, global health, and mpox and other orthopoxviruses collaborated to develop this rapid assessment. Experts initially convened in February 2024 to discuss the need for an assessment examining the risks posed by the DRC outbreak to the United States, key evidence related to the DRC outbreak, and specific populations to include in the assessment. To conduct this assessment, experts considered evidence including epidemiologic data from DRC, data from the ongoing mpox outbreak in the United States caused by clade IIb, and historical data on clade I mpox outbreaks in DRC. After the initial assessment was finalized in February, experts subsequently re-reviewed evidence and updated this assessment in early March, mid-March, and mid-April.

Overall risk was estimated by combining the likelihood of infection and the impact of the disease. For example, low likelihood of infection combined with high impact of disease would result in moderate risk. The likelihood of infection refers to the probability that members of the general U.S. population or MSM acquire mpox throughout 2024, which in turn depends on the likelihood of exposure, infectiousness of the disease, and susceptibility of the population. The impact of infection considers several factors affecting the consequences of infection, including the severity of disease, level of population immunity, availability of treatments, and necessary public health response resources. A degree of confidence was assigned to each level of the assessment, taking into account evidence quality, extent, and corroboration of information.

For more details on our methods, please see our rapid risk assessment methods webpage.

Previous Updates

See the previous updates of the Mpox Rapid Risk Assessment.