Kerala samples confirm global Clade Ib mpox strain, exposing India’s surveillance gaps

The recent identification of the Clade Ib mpox strain in Kerala, with cases linked to international travel and one instance of local transmission, serves as a critical wake-up call for India's public health surveillance system. Mpox, formerly known as monkeypox, is a viral zoonotic disease caused by the mpox virus, belonging to the Orthopoxvirus genus. Historically endemic to parts of Central and West Africa, it gained global attention during the 2022 outbreak, which led the World Health Organization (WHO) to declare it a Public Health Emergency of International Concern (PHEIC) on July 23, 2022. The outbreak primarily involved Clade IIb, a less severe variant, which also accounted for India's previous mpox cases. The PHEIC was eventually terminated in May 2023. What happened in Kerala is distinct and significant: ten mpox samples were confirmed as Clade Ib. This is crucial because Clade I (Congo Basin clade) is generally associated with more severe disease and higher mortality rates compared to Clade II (West African clade), which includes Clade IIb. While nine of these cases were directly linked to international travel, the detection of one case indicating local transmission within Kerala is particularly concerning. It suggests that the virus has managed to establish a foothold beyond imported cases, indicating potential undetected chains of transmission and highlighting potential gaps in entry-point screening and community-level surveillance. Several key stakeholders are involved in managing such public health challenges. At the central level, the **Ministry of Health and Family Welfare (MoHFW)** is the apex body responsible for policy formulation, national surveillance programs, and emergency response coordination. The **Indian Council of Medical Research (ICMR)**, through its network of laboratories like the **National Institute of Virology (NIV), Pune**, plays a pivotal role in diagnostics, viral sequencing, and research. NIV's ability to identify and differentiate between mpox clades is critical for understanding the epidemiological landscape. At the state level, the **Kerala Health Department** is on the front lines, responsible for contact tracing, isolation, treatment, and implementing local surveillance measures. Internationally, the **World Health Organization (WHO)** provides global guidelines, technical support, and facilitates information exchange among member states, which is vital for understanding global disease patterns and responding effectively. This development matters immensely for India. Firstly, it exposes potential **surveillance gaps** not just at international ports of entry but also within communities. The presence of local transmission suggests that infected individuals might have entered the country undetected, or their contacts were not adequately traced and isolated. This could lead to wider community spread if not addressed promptly. Secondly, the identification of Clade Ib, a more virulent strain, necessitates heightened public health preparedness, including adequate diagnostic facilities, trained healthcare personnel, and potentially, access to specific antiviral treatments or vaccines. Economically, uncontrolled outbreaks can strain healthcare resources, disrupt daily life, and potentially impact tourism and trade, as seen during the COVID-19 pandemic. Socially, it can lead to public anxiety, stigma, and misinformation, requiring robust public communication strategies. From a global health security perspective, India's ability to swiftly detect and contain such outbreaks is crucial, aligning with its commitments under the **International Health Regulations (IHR 2005)**. Historically, India has faced numerous outbreaks of infectious diseases, from Nipah in Kerala to the devastating waves of COVID-19. Each incident has underscored the need for resilient public health infrastructure, rapid diagnostic capabilities, and effective inter-sectoral coordination. The lessons from these past events, particularly the genomic surveillance network established during COVID-19 (INSACOG), should be leveraged to strengthen surveillance for mpox and other emerging pathogens. Looking ahead, the future implications are clear. India needs to strengthen its **genomic surveillance capabilities**, potentially expanding the INSACOG model to include a broader range of pathogens at key locations. Improving **port health screening** and implementing stringent follow-up protocols for international travelers from affected regions are essential. Enhanced **public awareness campaigns** are needed to educate citizens about mpox symptoms, transmission, and prevention, reducing stigma and encouraging early reporting. Furthermore, the incident highlights the need for a comprehensive **public health law** to replace the outdated **Epidemic Diseases Act, 1897**. While the 1897 Act provides powers for containment, it lacks provisions for modern disease surveillance, data sharing, and public health infrastructure development. Efforts to enact a new Public Health (Prevention, Control and Management of Epidemics, Bioterrorism and Disasters) Bill, 2017/2020 are crucial. The **Seventh Schedule of the Constitution** places 'Public health and sanitation' primarily in the State List (Entry 6), while 'Prevention of the extension from one State to another of infectious or contagious diseases or pests affecting men, animals or plants' is in the Concurrent List (Entry 29). This federal structure necessitates robust coordination between central and state governments. The **Disaster Management Act, 2005**, could also be invoked during severe health emergencies to streamline response efforts. Ultimately, this Clade Ib detection underscores the continuous need for investment in public health, a 'One Health' approach recognizing the interconnectedness of human, animal, and environmental health, and agile policy responses to safeguard the nation's well-being.