India reports first virulent Clade 1b strain of mpox: Is the country prepared?

India has recorded its first case of mpox (monkeypox), caused by the virulent Clade 1b strain, which has been dominant in the current global outbreak. The infection was detected in a 38-year-old man from Malappuram, Kerala, who had recently returned from the United Arab Emirates, said the central government officials, adding that the patient is stable and remains under observation.

In response, Kerala has increased its surveillance systems and is preparing to release updated prevention guidelines. Isolation facilities have been established across the state, and additional testing centres are being considered to accommodate a potential increase in cases. The Kerala health department is currently monitoring over 70 individuals who were in close contact with the infected person; none have shown symptoms thus far, state health officials said.

“This is India’s second case of mpox, but this is the first involving the new Clade 1b strain known for its increased virulence. Although the likelihood of a large-scale outbreak in India is slim, states are well-prepared to handle any situation. The public should not panic,” a senior official at Union health ministry said. The patient’s contacts have been traced, and none have tested positive for the virus, said the official.

Earlier this month, India reported its first mpox case in a 26-year-old man from Hisar, Haryana, who had a travel history to an affected African country. He was isolated at Delhi’s Lok Nayak Hospital, where the strain identified was linked to the previous 2022 outbreak in India.

On August 14, 2024, WHO Director-General Dr. Tedros Adhanom Ghebreyesus declared mpox a Public Health Emergency of International Concern (PHEIC), following a similar declaration made in May 2022.

The monkeypox virus comprises two clades: Clade 1 and Clade 2. Clade 1, formerly known as the Congo Basin clade, is more severe and has been reported outside Africa only in Sweden and Thailand. In contrast, Clade 2, previously the West African clade, is milder and less infectious, responsible for the majority of global monkeypox cases in 2022 and 2023.

In light of the WHO’s declaration, the Indian government started taking steps to prepare for a potential outbreak since August 2024, when there were no cases.

The Union Health Ministry said that central government hospitals, including Safdarjung and the All India Institute of Medical Sciences (AIIMS), are ready with isolation wards. Lok Nayak Hospital has been designated as the nodal treatment centre, equipped with 20 isolation rooms—10 for suspected cases and 10 for confirmed ones. Also, Guru Teg Bahadur (GTB) and Baba Saheb Ambedkar hospitals each have five rooms allocated for both suspected and confirmed mpox cases.

Key measures that have been in place include enhanced surveillance at airports, seaports, and land crossings, along with readiness in 32 laboratories for early diagnosis. “Hospitals have been instructed to prepare for the isolation and treatment of cases. While the overall risk of a large-scale outbreak is considered low, health authorities continue to monitor the situation closely to ensure a swift response if needed,” said the official.

Union Health Secretary Apurva Chandra recently advised states and Union territories, through a letter, to prevent undue panic while ensuring community screening and isolation measures are in place.

“India has made significant strides in preparing for the ongoing cases of mpox, building on its experience with public health crises like Covid-19. Early detection, surveillance, and rapid response protocols have been strengthened and healthcare institutions across the country are equipped to handle potential outbreaks. The availability of vaccines and the strategic use of antiviral treatments are crucial components of the nation’s readiness,” said Dr. Manisha Arora, Director of Internal Medicine at CK Birla Hospital, Delhi, adding that awareness campaigns about prevention and hygiene have been actively promoted to curb the spread of the virus.

The WHO has also recently called on manufacturers of mpox vaccines and diagnostic tools to submit Expressions of Interest (EOI) for Emergency Use Listing (EUL) due to the escalating situation. The EUL process enables the rapid review and recommendation of unlicenced medical products based on a risk-benefit assessment, boosting demand for vaccines and diagnostic tools and creating opportunities for Indian companies.

The private sector has also offered help, indicating that it will be a part of the government’s efforts in handling the disease. Adar Poonawalla, CEO of Serum Institute of India (SII), has advanced efforts to develop a vaccine for monkeypox. “Given the global health emergency, Serum Institute of India is working on a vaccine to address the needs of those at risk,” Poonawalla said, highlighting the importance of prompt diagnostic solutions.

On August 18, 2024, Prime Minister Narendra Modi also chaired a meeting to review India’s readiness for monkeypox. The disease, a zoonotic viral infection, spreads through close contact with infected individuals or contaminated materials. It typically resolves within 2 to 4 weeks, with symptoms including fever, rash, and swollen lymph nodes. Treatment is primarily supportive, focusing on managing symptoms, while various therapeutics are currently under development.

“With the ongoing global outbreak of mpox, our focus is on being prepared to support the government's efforts. As one of India’s leading diagnostic chains, we are fully equipped with the necessary testing capabilities to initiate nationwide testing. Drawing on our experience in handling other outbreaks, such as Covid-19, we are confident in our ability to respond swiftly and effectively to the needs of the public health system,” said Ameera Shah, Executive Chairperson and Whole Time Director, Metropolis Healthcare Limited.

“In addition, Metropolis Healthcare has taken proactive measures, including the procurement of essential testing kits and the implementation of comprehensive preparations, such as personal protective equipment (PPE), transportation logistics, and standard operating procedures (SOPs) for sample collection and disposal,” she added.

In a recent review published in the Medical Letter, Assistant Professors Amit Sachdeva and Nasim Ahmed from the Department of Community Medicine at Indira Gandhi Medical College in Shimla, Himachal Pradesh, analysed India’s comprehensive approach to managing monkeypox.

“India’s response has emphasised early detection, equitable vaccine distribution, and the fortification of healthcare systems, playing a crucial role in preventing widespread transmission of the virus,” stated Sachdeva and Ahmed. They highlighted that India’s preparedness reflects a well-rounded approach balancing immediate actions with long-term strategies.

However, the review noted that several challenges persist. Ensuring equitable access to vaccines and treatments remains a critical issue. Maintaining public awareness without causing unnecessary panic and strengthening healthcare infrastructure in underserved regions are also vital for future outbreak management.

Similarly, Dr Arora said that challenges remain, particularly in rural areas where access to healthcare and awareness of mpox is limited. “Vigilance, continuous monitoring, and ensuring that healthcare infrastructure reaches the most vulnerable populations will be key to containing the virus. India’s proactive approach, combined with global collaborations, places it on a solid path to manage and mitigate the impact of mpox, but sustained efforts will be necessary to fully address this evolving threat,” Dr Arora added.

To address these challenges effectively, the authors recommended ongoing vigilance and continued investment in healthcare systems. They emphasise the importance of enhanced international partnerships and adaptable response strategies. “Lessons learned from the mpox outbreaks of 2022 and 2024 will be invaluable in shaping future approaches, ensuring that India is better equipped to confront not only mpox but also other emerging infectious diseases,” they advised.
 
Nationally, India has reported a total of 32 mpox cases since the WHO declared it a public health emergency. Since January 2022, over 103,000 monkeypox cases and 229 deaths have been reported across 121 countries. In India, 32 cases have been recorded since the WHO’s 2022 declaration.