THE modern world is getting increasingly smaller and interconnected. Whether a newsbreak or a viral outbreak, it travels across continents in the blink of an eye. Just as we were beginning to breathe easier after Covid-19, another virus has silently made its way across our border and made its presence felt. Mpox, once considered as confined to the remotest regions of a few countries of the African continent, has now found its way to Pakistan, proving that in our interconnected world, no place is truly free from risk.

The recent confirmation of two mpox cases in KP has brought this disease to our doorstep. For a country already grappling with numerous public health challenges, the arrival of mpox is an unwelcome addition to a growing list of concerns.

The World Health Organisation has announced mpox to be a Public Health Emergency of International Concern (PHEIC). Beyond just another public health scare, mpox may be a new crisis that could threaten our children, including Pakistan.

The virus, carried by animals and transmitted through close contact, broke free from its geographical and non-human confines, and circulating largely in the African continent, has spread to Europe, North America, and beyond. This is largely due to the appearance of a more virulent (aka damaging) strain, ‘clade 1a’ that emerged in the Democratic Republic of the Congo in 2023, claiming the lives of over 500 people, most of them children. For many, including myself, this evolution of the virus to a more severe form was only a matter of time. As the virus is freely transmitting between people it is changing to affect younger people and households in the affected areas.

The strain of mpox now circulating has shown an ability to affect children more severely than adults.

Pakistan is now part of that reality. How did a virus from the heart of Africa find its way here? And what does its presence mean for our children? As a country where the health of most remains fragile, our children are at a greater risk.

Pakistan has a predominantly younger population, where 45 per cent of its over 200 million people are children. Young children’s immune systems are not as fully developed as those of adults. This means that they might have a harder time fighting off the virus, leading to more severe symptoms and complications.

The symptoms of mpox in children, such as fever, rash, and fatigue, can be easily confused with other common childhood illnesses like chickenpox or measles. This can lead to delays in diagnosis and treatment, increasing the risk of severe outcomes, and unsuspected spreading of the virus. As a corollary, chickenpox which is far more common and causes frequent outbreaks, can also lead to unnecessary fear of mpox.

Malnutrition is another risk. One in four children in Pakistan have some form of nutritional deficiency. Mpox in such children can lead to complications such as secondary bacterial infections like sepsis, bacterial skin infections, and respiratory issues including pneumonia.

An inadequate healthcare infrastructure and a pre-existing burden of infectious diseases continue to cast a long shadow over the future of our children. We are already battling polio that is resurfacing, and have not recovered from the decline in vaccination following Covid-19. In this situation, the arrival of mpox could be catastrophic.

The virus, which spreads through close contact, thrives in conditions where access to medical care is limited and where a child with mpox might not see a doctor until late, increasing the risk of further infections and complications.

Children often spend a lot of time in close contact with others in settings like schools, daycare centres, and households. This close contact can facilitate the rapid spread of the virus among children, leading to outbreaks that can be difficult to control.

The strain of mpox now circulating has shown a concerning ability to affect children more severely than adults. In the Congo, approximately 70pc of those affected are children and they are four times more likely to die than adults.

This is not a time for complacency. The arrival of mpox in Pakistan should be a wake-up call for all — policymakers, healthcare providers, and citizens alike. Increased index of suspicion, detection and diagnosis through our surveillance systems is necessary. Early detection is key to preventing the spread of mpox, particularly in vulnerable populations.

We need an organised public campaign to educate communities about the symptoms of the infection and the importance of seeking medical care at the first sign of illness, just as we did for Covid. While no treatment is available, early case-finding, diagnosis, supportive care, isolation and contact-tracing can help limit disease. Paediatric-specific guidelines should be developed in this regard.

Vaccination with the newer second- and third-generation vaccines must be prioritised. It is important to note that while Pakistan may have maintained strategic supplies of older smallpox vaccines from the Smallpox Eradication Programme (concluded in 1980) these first-generation vaccines are not recommended for mpox at this time, as they do not meet current safety and manufacturing standards. The supply of newer vaccines must be ensured, and access strategies must be prioritised in children by our international and local partners.

Child health groups such as Unicef, the Pakistan Paediatric Association and academic bodies advocating for children’s health must join hands to develop educational material for both the public and healthcare workers and train appropriately.

There is a silver lining. Mpox was declared a PHEIC as recently as 2022, and it is highly likely that it may not spread further. The story of mpox in Pakistan is still in its early stages and could inspire new public health vigilance and global solidarity. The choice is ours.

The writer is a paediatric infectious disease specialist and an epidemiologist. She heads Paediatrics & Child Health at the Aga Khan University.

Published in Dawn, August 26th, 2024