# Monkeypox in South Asia: a systematic review

## TL;DR

This paper reviews monkeypox cases in South Asia, highlighting travel-related transmission and the need for better surveillance and diagnostics.

## Contribution

The study provides a systematic review of monkeypox epidemiology and mitigation strategies in South Asia.

## Key findings

- Most monkeypox cases in South Asia were linked to recent travel, especially to UAE and Saudi Arabia.
- Common symptoms included skin lesions, fever, and lymphadenopathy, with diagnostic challenges due to co-infections.
- India had the highest number of cases, and public health responses varied with limited vaccine availability.

## Abstract

Monkeypox (Mpox) has emerged as a significant public health concern globally and in South Asia. Therefore, this systematic review aimed to provide a synthesis of the epidemiological pattern, clinical features, disease severity, and mitigation strategies in the region. A systematic review was conducted across four databases including PubMed, Scopus, Web of Science, and Ovid from inception to August 2024. Out of 2,430 studies, only 19 met the inclusion criteria with 111 confirmed Mpox cases. Forty percent (44) of patients were males and 45.9% (51) did not specify their sex. Young to middle-aged adults were most affected, with rare cases in a neonate. Around two-thirds (73.0%, 81) of Mpox patients were from India, followed by Pakistan (16.2%, 18) and Nigeria (resident in India) (9.9%, 11). Sixty-eight percent (76) of Mpox patients reported recent travel, particularly to UAE (27%, 21) and Saudi Arabia (26.3%, 20). Common signs and symptoms among cases were skin lesion (92.8%, 103), fever (82.0%, 91), lymphadenopathy (65.8%, 73), muscle ache (27.0%, 30), and genital and perianal lesions (17.1%, 19). Co-infection with herpes simplex virus and varicella zoster virus led to difficulty in diagnosis. Nearly all the studies used polymerase chain reaction for diagnosis. Public health responses varied across countries, including enhanced surveillance, contact tracing, and awareness campaigns, but vaccine availability remained limited. Mpox in South Asia was largely linked to travel-related transmission and primarily affected younger adults. Strengthening surveillance systems, a syndemic approach, diagnostic capacity, and targeted interventions are crucial to controlling its spread.