Mpox Singapore

SINGAPORE - On 6 March 1981, relevant sections of the Singapore legislation were amended and smallpox vaccination became no longer compulsory by law.

Most older Singaporeans who were born in or before 1980 and were vaccinated against smallpox in childhood would have fairly good protection against mpox.

As smallpox and mpox are both orthopoxviruses, there is some cross-protection conferred by smallpox vaccination.

In Singapore, vaccination against smallpox was made mandatory in 1869. This was discontinued in 1981, following a 1980 declaration by the World Health Organisation (WHO) that smallpox had been eradicated globally.

The Jynneos vaccine now given for mpox is also a vaccine used to protect against smallpox. This vaccine, third generation for smallpox, is 80 per cent effective in preventing mpox infection.

The earlier, first-generation vaccine is 95 per cent effective in protecting against smallpox, according to the Centres for Disease Control and Prevention (CDC) in the United States. Later-generation vaccines are safer.

Professor Hsu Li Yang, vice-dean for Global Health at the NUS Saw Swee Hock School of Public Health, said that vaccine protection drops over time, although protection against death from smallpox will last for decades.

He said people who have had smallpox vaccination, should they get infected with mpox, are likely to have less severe symptoms.

Mpox is usually a self-limiting disease, with symptoms that include fever, muscle ache, swollen lymph nodes, exhaustion and painful or itchy blisters.

WHO declared mpox a public health emergency of international concern on Aug 14 – the second time it has done so for this disease. The first time was in July 2022, and that lasted until May 2023.

Key facts

• Mpox, previously known as monkeypox, is a viral illness caused by the monkeypox virus, a species of the genus Orthopoxvirus. There are two distinct clades of the virus: clade I (with subclades Ia and Ib) and clade II (with subclades IIa and IIb). In 2022–2023 a global outbreak of mpox was caused by the clade IIb strain. 
• Mpox continues to be a threat today, and an upsurge of cases in the Democratic Republic of the Congo and other countries caused by clades Ia and Ib has raised concern.
• There are vaccines for mpox. Vaccination should be considered along with other public health interventions. 
• Common symptoms of mpox are a skin rash or mucosal lesions which can last 2–4 weeks accompanied by fever, headache, muscle aches, back pain, low energy and swollen lymph nodes. 
• Mpox can be transmitted through close contact with someone who has mpox, with contaminated materials, or with infected animals. During pregnancy, the virus may be passed to the fetus, or to the newborn during or after birth.
• Mpox is treated with supportive care for symptoms such as pain and fever, with close attention to nutrition, hydration, skin care, prevention of secondary infections and treatment of co-infections, including HIV where present.

Overview

Mpox is an infectious disease that can cause a painful rash, enlarged lymph nodes, fever, headache, muscle ache, back pain and low energy. Most people fully recover, but some get very sick. 

Mpox is caused by the monkeypox virus (MPXV). It is an enveloped double-stranded DNA virus of the Orthopoxvirus genus in the Poxviridae family, which includes variola, cowpox, vaccinia and other viruses. There are two distinct clades of the virus: clade I (with subclades Ia and Ib) and clade II (with subclades IIa and IIb).

A global outbreak of clade IIb began in 2022 and continues to this day, including in some African countries. There are also growing outbreaks of clades Ia and Ib affecting the Democratic Republic of the Congo and other countries in Africa. As of August 2024, clade Ib has also been detected beyond Africa.

The natural reservoir of the virus is unknown, but various small mammals such as squirrels and monkeys are susceptible.

Transmission

Mpox spreads from person to person mainly through close contact with someone who has mpox, including members of a household. Close contact includes skin-to-skin (such as touching or sex) and mouth-to-mouth or mouth-to-skin contact (such as kissing), and it can also include being face-to-face with someone who has mpox (such as talking or breathing close to one another, which can generate infectious respiratory particles).

People with multiple sexual partners are at higher risk of acquiring mpox. 

People can also contract mpox from contaminated objects such as clothing or linen, through needle injuries in health care, or in community settings such as tattoo parlours. 

During pregnancy or birth, the virus may be passed to the baby. Contracting mpox during pregnancy can be dangerous for the fetus or newborn infant and can lead to loss of the pregnancy, stillbirth, death of the newborn, or complications for the parent.

 Animal-to-human transmission of mpox occurs from infected animals to humans from bites or scratches, or during activities such as hunting, skinning, trapping, cooking, playing with carcasses or eating animals. The animal reservoir of the monkeypox virus remains unknown and further studies are underway. 

More research is needed on how mpox spreads during outbreaks in different settings and under different conditions.

Signs and symptoms

Mpox causes signs and symptoms which usually begin within a week but can start 1–21 days after exposure. Symptoms typically last 2–4 weeks but may last longer in someone with a weakened immune system. 

Common symptoms of mpox are: 

• rash 
• fever 
• sore throat 
• headache 
• muscle aches 
• back pain 
• low energy 
• swollen lymph nodes.  

For some people, the first symptom of mpox is a rash, while others may have fever, muscle aches or sore throat first.  

The mpox rash often begins on the face and spreads over the body, extending to the palms of the hands and soles of the feet. It can also start on other parts of the body where contact was made, such as the genitals. It starts as a flat sore, which develops into a blister filled with liquid that may be itchy or painful. As the rash heals, the lesions dry up, crust over and fall off. 

Some people may have one or a few skin lesions and others have hundreds or more. These can appear anywhere on the body including: 

• palms of hands and soles of feet 
• face, mouth and throat 
• groin and genital areas 
• anus.

Some people also have painful swelling of their rectum (proctitis) or pain and difficulty when peeing (dysuria) or when swallowing. 

People with mpox can pass the disease on to others until all sores have healed and a new layer of skin has formed. Some people can be infected without developing any symptoms. Although getting mpox from someone who is asymptomatic (not showing symptoms) has been reported, information is still limited on how common it is.  

Children, pregnant people and people with weak immune systems, including people living with HIV that is not well controlled, are at higher risk for serious illness and death due to complications from mpox. 

Some people with mpox become very sick. For example, the skin can become infected with bacteria, leading to abscesses or serious skin damage. Other complications include pneumonia; corneal infection with loss of vision; pain or difficulty swallowing; vomiting and diarrhoea causing dehydration or malnutrition; and infections of the blood (sepsis), brain (encephalitis), heart (myocarditis), rectum (proctitis), genital organs (balanitis) or urinary passages (urethritis). Mpox can be fatal in some cases.

Diagnosis

Identifying mpox can be difficult because other infections and conditions can look similar. It is important to distinguish mpox from chickenpox, measles, bacterial skin infections, scabies, herpes, syphilis, other sexually transmitted infections, and medication-associated allergies. Someone with mpox may also have another sexually transmitted infection at the same time, such as syphilis or herpes. Alternatively, a child with suspected mpox may also have chickenpox. For these reasons, testing is key for people to get care as early as possible and prevent severe illness and further spread.

The preferred laboratory test for mpox is detection of viral DNA by polymerase chain reaction (PCR). The best diagnostic specimens are taken directly from the rash – skin, fluid or crusts – collected by vigorous swabbing. In the absence of skin lesions, testing can be done using swabs or the throat or anus. Testing blood is not recommended. Antibody detection methods may not be useful as they do not distinguish between different orthopoxviruses. 

HIV testing should be offered to adults with mpox, and children as appropriate. Diagnostic tests for other conditions should be considered where feasible, for example, varicella zoster virus (VZV), syphilis and herpes.

Blog

Singapore has reported a small number of imported Mpox cases, primarily linked to travellers returning from affected regions. While the risk of widespread community transmission remains low, Ministry of Health (MOH) continues to monitor the situation closely and take necessary measures to prevent an outbreak.

In light of recent developments, Singapore has also introduced precautionary Mpox screenings at Changi and Seletar airports, as well as at sea checkpoints. Travellers from areas with reported Mpox cases will undergo health screenings, including temperature checks and visual assessments for symptoms. These measures are designed to identify potential cases early and ensure that symptomatic individuals receive proper care and isolation, helping to minimise the risk of community transmission.

MOH has implemented comprehensive protocols to manage potential Mpox cases, including early detection, isolation, and contact tracing to prevent the spread of the virus, and regularly updates the public and healthcare providers to ensure everyone remains informed and prepared. For the latest advisory and detailed guidelines on Mpox, you can refer to MOH’s advisory on Mpox.

What is Mpox?

Mpox is a viral infection caused by the monkeypox virus, which belongs to the same family as the virus that causes smallpox. Although Mpox is generally less severe than smallpox, it can still lead to significant health issues, especially in vulnerable populations such as children and seniors.

Symptoms of Mpox

Mpox typically begins with flu-like symptoms, including fever, headache, muscle aches, and fatigue. Within a few days, a rash develops, usually starting on the face and spreading to other parts of the body. The rash goes through several stages, from red spots to blisters, and eventually forms scabs that fall off.

In addition to the rash, swollen lymph nodes may occur, which can help distinguish Mpox from similar viral infections like chickenpox.

Mpox in Children and Seniors

Children and seniors are particularly vulnerable to Mpox due to their generally weaker immune systems. In children, the infection may lead to more severe symptoms, including dehydration from fever or difficulty managing the rash. Seniors, especially those with underlying health conditions, may also experience more severe complications if infected.

Given their increased vulnerability, it is crucial for parents and caregivers to monitor symptoms closely in these populations and seek medical advice promptly.

How is Mpox Spread?

Mpox spreads through close contact with an infected person, including skin-to-skin contact, bodily fluids, or contaminated materials like bedding. While it is less contagious than some other viral infections, Mpox can spread quickly in environments where close contact occurs, such as within households.

Self-care and Prevention Measures

Most people with mpox will recover within 2–4 weeks. Things to do to help the symptoms and prevent transmitting mpox to others: 

Do 

• contact your health care provider for advice;
• stay at home and in your own, well-ventilated room if possible; 
• wash hands often with soap and water or hand sanitizer, especially before or after touching sores; 
• wear a mask and cover lesions when around other people until your rash heals; 
• keep skin dry and uncovered (unless in a room with someone else); 
• avoid touching items in shared spaces and disinfect shared spaces frequently;  
• use saltwater rinses for sores in the mouth; 
• take warm baths with baking soda or Epsom salts for body sores; and 
• take over-the-counter medications for pain like paracetamol (acetaminophen) or ibuprofen. 

Do not 

• pop blisters or scratch sores, which can slow healing, spread the rash to other parts of the body, and cause sores to become infected; or 
• shave areas with sores until scabs have healed and you have new skin underneath (this can spread the rash to other parts of the body). 

To prevent spread of mpox to others, people with mpox should isolate at home following guidance from their health care provider, or in hospital if needed, for the duration of the infectious period (from onset of symptoms until lesions have healed and scabs fall off). Covering lesions and wearing a well-fitting mask when in the presence of others may help prevent spread. Using condoms during sex will help reduce the risk of getting mpox but will not prevent spread from skin-to-skin or mouth-to-skin contact. If having sex, use condoms as a precaution for 12 weeks (about 3 months) after you have recovered.

Taking a break from sexual activity with new partners during periods of increased transmission can reduce the risk of getting mpox. Those who have had contact with someone with mpox should monitor for signs and symptoms for 21 days (3 weeks) and take precautions such as avoiding sexual activity during this period.

Health workers should follow infection prevention and control measures to protect themselves while caring for patients with mpox by wearing appropriate personal protective equipment (PPE) (i.e. gloves, gown, eye protection and respirator) and adhering to protocol for safely swabbing lesions for diagnostic testing and handling sharp objects such as needles.

To protect yourself and your loved ones from Mpox, consider the following preventive measures:

1. Good Hygiene: Regular hand washing with soap and water is essential, especially after contact with sick individuals or animals. Hand sanitizers with at least 60% alcohol can also be effective.
2. Avoid Close Contact: Stay away from individuals showing symptoms of Mpox. If you need to care for someone who is sick, use protective gear such as gloves and masks.
3. Caution with Animals: Avoid handling wild animals or consuming bushmeat, as Mpox can be transmitted from animals to humans.
4. Stay Informed: Keep up with the latest updates from reliable sources like MOH and World Health Organization (WHO).

What to Do If You Suspect Mpox

If you or someone you know develops symptoms, especially children or seniors, it’s important to seek medical attention immediately. Contact a healthcare provider via telemedicine at the first signs of illness. Early diagnosis and treatment can help manage symptoms and prevent the virus from spreading. Telemedicine offers a safe way to receive timely care without risking further exposure to others.

In addition to seeking medical consultation, over-the-counter (OTC) products like calamine lotion can help soothe itching and discomfort caused by the rash. For children experiencing fever or pain, ibuprofen or paracetamol can be used to manage these symptoms. You can conveniently purchase calamine lotion, ibuprofen, and other children’s OTC products, with free doorstep delivery in Singapore. Shop online a range of hand sanitizers, disinfectant cleaners, and handwash.

Treatment and Vaccination

The goal of treating mpox is to take care of the rash, manage pain and prevent complications. Early and supportive care is important to help manage symptoms and avoid further problems. 

Getting an mpox vaccine can help prevent infection (pre-exposure prophylaxis). It is recommended for people at high-risk of getting mpox, especially during an outbreak.

Groups that may be at high risk of mpox include: 

• health and care workers at risk of exposure; 
• people in the same household or close community as someone who has mpox, including children;
• people who have multiple sex partners, including men who have sex with men; and
• sex workers of any gender and their clients.

The vaccine can also be administered after a person has been in contact with someone who has mpox (post-exposure prophylaxis). In these cases, the vaccine should be given less than 4 days after contact with someone who has mpox. The vaccine can be given for up to 14 days if the person has not developed symptoms.

Some antivirals have received emergency use authorization in some countries and are being evaluated in clinical trials. To date, there is no proven effective antiviral treatment for mpox. It is a priority to continue evaluation of therapeutics in robust clinical trials and to focus on optimizing supportive care for patients.

Individuals with HIV and mpox should continue taking their antiretroviral therapy (ART). ART should be initiated within 7 days of diagnosis of HIV.

There is no specific treatment for Mpox, but symptoms can be managed with supportive care. In some cases, antiviral medications may be prescribed. Additionally, the smallpox vaccine has been shown to be effective in preventing Mpox, and vaccination may be recommended for individuals at higher risk, such as healthcare workers or close contacts of confirmed cases.

While the risk of Mpox in Singapore remains low, it’s crucial to stay vigilant, especially for vulnerable groups like children and seniors. By following preventive measures and seeking timely medical advice, we can protect ourselves and our community. If you experience any symptoms, don’t hesitate — sanitizer and disinfect your environment with ECOSAM.

Outbreaks

The monkeypox virus was discovered in Denmark (1958) in monkeys kept for research. The first reported human case of mpox was a nine-month-old boy in the Democratic Republic of the Congo (1970). Following the eradication of smallpox in 1980 and the end of smallpox vaccination worldwide, mpox steadily emerged in central, east and west Africa. Since then, mpox has been reported sporadically in central and east Africa (clade I) and west Africa (clade II). In 2003, an outbreak in the United States of America was linked to imported wild animals (clade II). Since 2005, thousands of cases are reported in the Democratic Republic of the Congo every year. In 2017, mpox re-emerged in Nigeria and continues to spread between people across the country and in travellers to other destinations.

Data on suspected and confirmed cases reported up to 2021 are available here and data on laboratory confirmed cases from 2022 until today are available here.

In May 2022, an outbreak of mpox appeared suddenly and rapidly spread across Europe, the Americas and then all six WHO regions. The global outbreak has affected primarily (but not only) gay, bisexual, and other men who have sex with men and has spread person-to-person through sexual networks. More information on the global outbreak is available here, including information on community responses to control the outbreak.

In 2022, outbreaks of mpox due to clade I occurred in refugee camps in the Republic of the Sudan.

Since 2022, there has also been an upsurge in mpox cases and deaths in the Democratic Republic of the Congo. In some areas of the country, a new offshoot of clade I, called clade Ib, has been spreading person-to-person. As of mid-2024, the clade has also been reported in other countries.

Over 120 countries have reported mpox between Jan 2022 – Aug 2024, with over 100 000 laboratory-confirmed cases reported and over 220 deaths among confirmed cases.

Stigma and discrimination

Stigma and discrimination for any disease are never acceptable. Stigma linked to mpox can undermine public health efforts or prolong a disease outbreak, as people may be more reluctant to come forward and seek care and treatment. For mpox, stigma, discrimination and racism have been particularly directed against communities initially most affected by the disease, namely men who have sex with men, trans people and gender diverse communities.