The 2026 Ebola outbreak caused by Bundibugyo virus in the Democratic Republic of the Congo and Uganda has prompted European countries and the United States to revise measures for travellers, healthcare workers and humanitarian personnel returning from affected areas. We compare current procedures and protocols with those implemented during the 2013-2016 Ebola outbreak. Despite some national differences, policies have largely converged towards risk-based management, early case detection, rapid isolation, exposure-based monitoring and healthcare preparedness, rather than routine border screening.

BACKGROUND:In 2021, an adult with mpox clade IIb infection was admitted to a UK teaching hospital within the High Consequence Infectious Diseases (HCID) network 14 days after travelling from Nigeria and 12 days after onset of symptoms. Subsequently, two household contacts (one adult and one child) developed confirmed symptomatic mpox infection, and were admitted to the same HCID ward for management. METHODS:Environmental swabs of high-touch and low-touch surfaces were collected, including sampling before and after terminal decontamination. RESULTS:In total, monkeypox virus was detected in 72 of 222 (32.4%) samples collected by quantitative polymerase chain reaction (qPCR). Of samples collected from rooms occupied by cases with active infection, where both pre- and post-decontamination results were available, 65% of samples were positive pre-decontamination and 5% were positive post-decontamination. Environmental sampling was also conducted in a suite occupied by asymptomatic contacts and a recovered case; nine of 43 (20.9%) samples were positive during occupation and pre-decontamination, and one of 27 (3.7%) samples was positive post-decontamination. There was variation in the proportion of positive environmental swabs pre-decontamination (14-100%) and post-decontamination (0-15%) between cases. Post-decontamination, there was a reduction in qPCR-positive samples, and where samples remained positive, the level of nucleic acid detected decreased. Viral isolation was attempted in 13 of 72 qPCR-positive samples, and viable virus was identified in two samples. One of these samples was collected from a suite not occupied by any person with active infection. CONCLUSION:This study establishes the utility of environmental sampling around mpox cases to measure infection prevention and control measures, including the efficacy of cleaning protocols used.

Mpox, a zoonotic orthopoxvirus disease, has transitioned from a rare infection confined to African rainforests to a global public health threat. Originally identified in laboratory monkeys in 1958, the first human case was documented in 1970 in the Democratic Republic of Congo. Following the declaration of smallpox eradication in 1980 and the subsequent cessation of smallpox vaccination, mpox cases persisted at low levels before surging, ultimately leading to the declaration of two Public Health Emergencies of International Concern by the WHO in 2022 and 2024, and the Africa CDC declaration of mpox as a Public Health Emergency of Continental Security in August 2024. Monkeypox virus comprises two major clades: clade I (formerly the Central African clade) subdivided into Ia and emerging Ib variants, and clade II (formerly the West African clade) also subdivided into IIa and the globally circulating IIb subclade. Recent outbreaks demonstrate enhanced human-to-human transmission, particularly through sexual networks, challenging traditional epidemiological patterns. Clinical presentation varies by clade and transmission route, ranging from classical centrifugal rash with high lesion counts to localized anogenital lesions. This Review outlines the emergency, epidemiology, biology, transmission dynamics, risk factors, clinical characteristics, and prevention and control strategies of mpox, and identifies future priorities for addressing this ongoing global issue.

Abstract Increasing human mobility and population connectivity have intensified the risks of global pathogen spread, while concurrent shifts in human demographic patterns, ecological factors, and climatic conditions have altered the global landscape of this risk. Genomic surveillance can serve as a critical tool for early detection of emerging pathogen threats; however, challenges remain in deciding where to monitor, in understanding trade-offs among surveillance modalities, and in translating detections into actionable estimates of importation and local transmission for public health decision-making. Here we develop a computational framework to evaluate strategies for respiratory pathogen detection that integrates an established clinical surveillance modality, intensive care unit (ICU) sampling, with an emerging environmental modality, aircraft wastewater (AWW) sampling. Detections are translated into risk via a multi-scale, stochastic global transmission model that combines international flight data with a detailed agent-based local transmission model. The resulting model-based estimates contrast the time to pathogen detection via AWW at airports with that in the community via realistic healthcare testing pathways. Using real-world data from England and Wales (EW), we find that employing AWW in EW airports can improve first detection times by 12.5-37.7 days for a range of epidemiological parameters under realistic healthcare testing scenarios and random aircraft sampling between 25 and 50%. In particular, for a SARS-CoV-2-like pathogen, we expect AWW to outperform ICU in first detection timing by 22.0-25.6 days, with ∼21.9-42.6 times fewer cases at their respective time of detection. While false detection remains a risk, we show that follow-up confirmatory testing can improve detection confidence substantially. Together our results demonstrate the potential utility of AWW surveillance and how it can reduce detection times and improve global health security.

A 2-dose regimen of the vaccine modified vaccinia Ankara-Bavarian Nordic (MVA-BN) can generate neutralizing antibodies for monkeypox virus clades Ib and IIb. We observed higher response to clade IIb; that result provides evidence that MVA-BN vaccination can induce cross-neutralizing antibodies for monkeypox virus clade Ib as well as for clade IIb.

We designed a multiplex quantitative PCR to differentiate monkeypox virus clades. For clinical samples collected in the United Kingdom and Nigeria, sensitivity was 78% (95% CI 67.67%-86.14%) and specificity 94% (95% CI 80.84%-99.30%); for samples with cycle thresholds <35, sensitivity was 98% (95% CI 91.72%-99.96%) and specificity 94% (95% CI 80.84%-99.30%).

The ongoing 2026 outbreak of Ebola virus disease caused by Bundibugyo virus (BDBV) in the Democratic Republic of the Congo and Uganda has renewed attention to one of the least studied human-pathogenic orthoebolaviruses. Since its discovery in western Uganda in 2007, only two recognised outbreaks of BDBV had been reported, limiting opportunities to define the epidemiology, pathogenesis, diagnosis, clinical spectrum, and optimal management of BDBV or to develop species-specific countermeasures. The current outbreak, declared a Public Health Emergency of International Concern by WHO on May 17, 2026, has also exposed the gap between scientific innovation and operational readiness. Although pan-filovirus diagnostics, investigational vaccines, therapeutics, and adaptive clinical trial platforms are now available, their deployment has been constrained by delayed diagnosis, limited access to species-inclusive diagnostics, insecurity due to conflict, population displacement, and fragile health systems. In this Review, we synthesise evidence on BDBV from its discovery to the current 2026 outbreak, highlighting advances in epidemiology, clinical management, diagnostics, vaccines, therapeutics, and preparedness. More broadly, the outbreak shows that scientific innovation alone is insufficient; its public health impact depends on integrated, species-inclusive systems capable of rapidly detecting, evaluating, and responding to outbreaks caused by any human-pathogenic Orthoebolavirus spp.

OBJECTIVES:This programme primarily aimed to provide access to tecovirimat for patients with suspected mpox. Secondary objectives were to describe the clinical and virological features of Clade Ia mpox and assess the safety of tecovirimat. The programme also supported research capacity strengthening, improved case detection through surveillance engagement, and standardised case management. METHODS:An expanded access programme was implemented at Mbaiki District Hospital and Bangui General Hospital. Consenting patients with suspected mpox received oral tecovirimat for 14 days under a standardised protocol. Follow-up visits occurred at day 21 (if PCR-positive at day 14) and day 28 or later. Blood and lesion samples were collected at each visit. RESULTS:Thirty-one patients were enrolled; 26 (84%) were PCR-positive and 24 (77%) had Clade Ia mpox. Symptoms were heterogeneous, most commonly lymphadenopathy, headache, myalgia, and active lesions. Most symptoms improved by day 14 and the final visit, though lymphadenopathy often persisted. PCR positivity declined over time but remained detectable in some cases. Six serious adverse events occurred in five patients. CONCLUSIONS:While no clear treatment benefit was demonstrated, the programme improved understanding of disease and strengthened clinical and research capacity.

OBJECTIVE:To determine how upper respiratory tract (URT) viral load (VL) kinetics influence the timing, intensity, and duration of symptoms in SARS-CoV-2 community cases. METHODS:Our prospective community cohort provided daily URT swabs for VL quantification for 2 weeks and symptom diaries for 28 days post recruitment. Symptom data were summarized using a composite Symptom Burden Score (SBS) incorporating symptom presence and severity. Only cases who enrolled sufficiently early post exposure to discern peak (p)VL were included (n = 89). Infectious viral shedding was assessed in a subset (n = 37) through quantitative viral culture. RESULTS:The day of pVL correlated with the day of peak symptom burden score (pSBS) (P < 0.001, n = 89). Very high pVL (>170,000,000 RNA copies/ml) was linked to prolonged illness, with a subset experiencing symptoms ≥3 weeks (P < 0.001). Cases reported more symptoms, as well as an increase in URT symptom burden, on the first day of virus cultivability compared to the preceding day (P < 0.001 and P = 0.005, n = 31). Peak systemic symptom score, and specifically muscle aches, significantly associated with prolonged infectious viral shedding (P = 0.012 and P = 0.033, n = 34). URT symptoms such as rhinitis, sore throat, and hoarse voice showed the steepest increase at infectiousness onset. CONCLUSION:The timing of pSBS aligns with pVL, and pVL above 170,000,000 RNA copies/ml predicts prolonged symptom duration. URT symptom escalation often marks the onset of infectiousness, while systemic symptoms, particularly muscle aches, signal prolonged infectiousness. These findings identify symptom-based markers of infectiousness with implications for testing strategies. They also highlight the importance of collecting early, frequent longitudinal symptom and virological data as a core element of the public health response to novel pathogens and future pandemics.

Background SARS-CoV-2 viral load in the upper respiratory tract (URT) typically peaks and declines within days of infection, even in individuals without prior infection or vaccination. Although this implicates the URT innate immune response in effectively restricting viral replication, the nature of the protective responses and how they are affected by demographic factors is poorly defined. Methods We recruited 54 seronegative household contacts of recently diagnosed COVID-19 cases and prospectively collected URT samples during and after exposure. Among the 39 individuals who became infected, we quantified airway mucosal cytokine and chemokine responses and virus-specific nasal IgA using Meso Scale Discovery assays, and assessed associations with demographic factors, viral load, and symptoms. Findings Participants with higher BMI had higher URT viral loads and more marked symptoms. This was significantly associated with delayed induction of protective inflammatory mediators in the airway mucosa but not in blood. Induction of virus-specific nasal IgA at 1-week post-infection also correlated with lower viral load. Interpretation Elevated BMI retards initial airway mucosal innate immune responses to infection, which may partially explain the pronounced adverse impact of higher BMI on clinical and virological outcomes in COVID-19. Funding This work is supported by the NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London in partnership with the UK Health Security Agency (Grant number: NIHR200927; AL) and the Medical Research Council (Grant number: MR/X004058/1). Infrastructure support for this research was provided by the NIHR Imperial Biomedical Research Centre (BRC).

We report two importations of monkeypox virus clade Ib infection to the United Kingdom in 2024. The first was a traveller returning from Tanzania, Rwanda and Uganda, the second from Uganda. Both presented with fever and typical skin lesions; 147 contacts were followed up, 19 vaccinated with MVA-BN. Three household contacts of the first individual, including two children, became infected. These are the first reported autochthonous transmissions of clade Ib in Europe, and first paediatric cases outside the African continent.

A key lesson from the west Africa (2014-16) Ebola disease epidemic was that outbreak responses fail when they respond to patients through a narrow clinical lens without considering the broader community and social context of care. Here, in the second of two Series papers on the modern landscape of Ebola disease, we review progress made in the last decade to improve patient-centred care. Although the biosafety imperatives of treating Ebola disease remain, recent advances show how to mitigate these so that patients are cared for in a safe and dignified manner that encourages early treatment-seeking behaviour and provides support after the return of patients to their communities. We review advances in diagnostics, including faster Ebola disease detection via real-time RT-PCR, and consider design improvements in Ebola disease treatment units that enhance patient safety and dignity. We also review advances in care provision, such as the integration of palliative care and mobile communication into routine care, and address how greater access to research is possible through harmonised clinical trials. Finally, we discuss how strengthened community engagement and psychosocial programmes are addressing stigma and providing holistic support for survivors.

Recently, a novel subclade of mpox virus (MPXV), clade Ib, has emerged in Eastern Democratic Republic of the Congo (DRC). Modified vaccinia Ankara-Bavarian Nordic (MVA-BN) is a third-generation smallpox vaccine that is authorised and in use as a vaccine against mpox. MVA-BN provides approximately 78% protection against disease to Clade IIb MPXV, but there are no data for Clade Ib. We used a plaque reduction neutralisation assay (PRNT) with MPXV clinical isolates from Clade Ib and IIb to investigate immunity in vaccinated health care workers. Here we show that a two-dose regimen of MVA-BN can induce MPXV-neutralising antibodies against both clades, with higher responses to Clade IIb than Clade Ib. KEY POINTS 1. Vaccination with MVA-BN generates antibodies that can neutralise MPXV Clade Ib and IIb. 2. Despite the small sample size paired analysis across the vaccine recipients demonstrate higher neutralisation to Clade IIb than Ib. ### Competing Interest Statement LT has received consulting fees from MHRA and Bavarian Nordic. ### Funding Statement This work was funded by the DECIPHER MPOX consortium (HORIZON-JU-GH-EDCTP3, Grant number 101194676) and The Pandemic Institute (Liverpool). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Research Ethics Committee of University of Liverpool gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

The management of patients with acute infectious diseases can present significant challenges, especially if the causative agent has a propensity for personto- person transmission. In such cases, effective patient management is dependent on both rapid identification of disease and the provision of necessary medical care while adhering to suitable infection prevention and control measures to reduce the potential for onwards transmission. The UK has operated a defined system for managing patients with high consequence infectious diseases (HCIDs) since the 1970s, when protocols were first implemented following the first descriptions of several viral haemorrhagic fever diseases, including Marburg virus disease, Lassa fever and Ebola virus disease (EVD). While more than 200 people with HCIDs have been treated in UK hospitals since the 1970s, most of these patients had COVID-19 or mpox during the early phases of new public health emergencies of international concern (PHEICs), prior to their removal from the UK HCID list in March 2020 and June 2022, respectively. Excluding PHEICs, 26 patients have been treated in HCID treatment centres between 1962 and 2023: 10 patients with Lassa fever, 7 with mpox prior to the 2022 PHEIC, 4 with Middle East respiratory syndrome (MERS), 4 with EVD and 1 with Crimean- Congo haemorrhagic fever (CCHF). In total, 15 additional HCID patients were identified where treatment in a specialist centre did not occur due to retrospective diagnosis (4 patients with Lassa fever), mild or moderate illness [5 patients with avian influenza A(H5N1), 1 with MERS and 1 with CCHF] or death prior to transfer (2 patients with Lassa fever, 1 with CCHF and 1 with pneumonic plague). Here we summarize the UK HCID experience, including details about their detection, patient management and outcomes.

The west Africa Ebola disease epidemic (2014-16) marked a historic change of course for patient care during emerging infectious disease outbreaks. The epidemic response was a failure in many ways-a slow, cumbersome, and disjointed effort by a global architecture that was not fit for purpose for a rapidly spreading outbreak. In the most affected countries, health-care workers and other responders felt helpless-dealing with an overwhelming number of patients but with few, if any, tools at their disposal to provide high-quality care. These inadequacies, however, led to attention and innovation. The decade since then has seen remarkable achievements in clinical care for Ebola disease, including the approval of the first vaccines and treatments. In this paper, the first in a two-part Series, we reflect on this progress and provide expert summary of the modern landscape of Ebola disease, highlighting the priorities and ongoing activities aimed at further improving patient survival and wellbeing in the years ahead.

Air and surface sampling was performed in isolation rooms of seven patients with clade Ib mpox admitted to high consequence infectious disease centres in the United Kingdom. We detected monkeypox virus (MPXV) DNA in 66/90 surfaces samples and 1/14 air samples; replication competent MPXV was identified in 4/21 surface samples selected for viral isolation. These findings demonstrate that viable clade Ib MPXV contamination can occur during treatment of clade Ib mpox patients reinforcing the importance of infection prevention and control measures.

Reducing stigma during infectious disease outbreaks is crucial for delivering an effective response. However, no validated stigma scales exist for use across outbreaks, and outbreak-specific scales are developed too slowly to guide timely interventions. To enable more real-time monitoring and mitigation of stigma across outbreak contexts, we developed and validated the (Re)-emerging and ePidemic Infectious Diseases (RAPID) Stigma Scales. Field testing and psychometric validation were conducted in communities affected by Ebola disease in Uganda, mpox in the UK, and Nipah virus disease in Bangladesh. Content validity was established through cognitive interviews and expert Delphi scoring. 1008 respondents were included across the three countries. The final RAPID Community Stigma Scale (12 items) captures initial social stigma, provider or authority-related stigma, structural stigma, and enduring social stigma. The RAPID Self Stigma Scale (4 items) is unidimensional. Both scales were found to have robust psychometric properties, including content validity, structural validity (factor loadings ≥0·6), and reliability (ordinal alphas 0·79-0·92). High scores on both scales predicted an increased hesitancy to report symptoms and seek care. The RAPID Stigma Scales are validated tools for real-time assessment of stigma across outbreak settings, enabling responders to design targeted interventions to improve health outcomes and promote equitable care.

Background. The global mpox outbreak that started in May 2022 was caused by a novel clade IIb variant of the mpox virus (Orthopoxvirus monkeypox, MPXV). It differed from the traditional Western and Central Africa disease in transmission patterns and clinical presentation. Methods. To address the need for detailed clinical and virologic data, we conducted an observational cohort study (MOSAIC) during May 2022-July 2023 in individuals with confirmed MPXV infection enrolled in 6 European countries. Case management decisions were left to the attending physician. Participants were monitored for up to 6 months for clinical signs/symptoms and clinical and virologic outcomes through hospital visits, phone interviews, and self-administered questionnaires. Outcomes included time to lesion resolution, clinical status, and virus clearance. Results. The 518 participants not receiving any specific treatment ("untreated") were diagnosed a median 5 days from symptom onset; 90% were managed as outpatients. Lesions were mostly cutaneous (88%) and perigenital (74%). By day 14 from the first polymerase chain reaction (PCR)-positive sample, 39% had resolved lesions. Time to 95% unculturable virus was longest in cutaneous lesions (52 days). A putative systemic antiviral was available for 57 participants, 44% as inpatients; 34% and 58% had resolved lesions by day 14 from the first PCR-positive sample and from treatment start, respectively. Time to 95% unculturable virus was 60 days in skin and oropharynx. No death or recrudescence occurred by day 180. Conclusions. MOSAIC provides comprehensive insights into the clinical and virologic characteristics of mpox caused by the clade IIb variant. The study forms the basis of clinical characterization for ongoing mpox outbreaks.