# Operationalizing a Hub‐and‐Spoke Telemedicine Model for Mpox Surveillance in a High‐Alert, Zero‐Prevalence Setting: An Observational Study, Real‐World Experience From Iran

## TL;DR

A telemedicine model helped manage suspected Mpox cases in Iran, reducing unnecessary referrals and saving costs without confirming any Mpox cases.

## Contribution

A tiered telemedicine model was operationalized and evaluated for Mpox surveillance in a zero-prevalence region.

## Key findings

- The model prevented 81.3% of unnecessary specialist referrals.
- The telemedicine approach saved an estimated 76% in direct costs.
- Most cases were diagnosed as varicella or herpes zoster, not Mpox.

## Abstract

The global monkeypox (Mpox) outbreak prompted heightened surveillance in regions with significant travel links. Fars Province, Iran, implemented a structured telemedicine response to manage patients presenting with Mpox‐like symptoms.

This study aimed to describe and evaluate the impact of a tiered, hub‐and‐spoke telemedicine model on the triage, differential diagnosis, and cost efficiency of managing suspected Mpox cases in a setting with no confirmed Mpox.

In this observational study conducted from August 27 to September 22, 2024, 150 patients presenting with fever and vesiculopustular rash across Fars Province were managed via a mandated protocol. Cases unresolved by local physicians were escalated via asynchronous (store‐and‐forward) WhatsApp consultations to a central specialist hub. Diagnostic testing, including Orthopoxvirus (Mpox) PCR, varicella zoster virus PCR, and herpes simplex virus testing, was performed based on telemedicine triage. A cost–consequence analysis compared the implemented pathway to a hypothetical standard referral scenario.

Among 150 teleconsultations, 28 patients (18.7%) were triaged as high suspicion for Mpox; three had relevant international travel history. No Mpox cases were confirmed. Final diagnoses were varicella (56.7%), herpes zoster (27.3%), herpes simplex (8.0%), and other conditions (8.0%). The telemedicine model prevented 122 (81.3%) unnecessary in‐person specialist referrals. The median consultation response time was 95 min. The cost analysis showed a 76% reduction in direct costs, saving an estimated 1,087,500,000 Iranian Rials compared to standard care.

A tiered telemedicine model proved effective for outbreak preparedness, enabling rapid expert triage, accurate differential diagnosis, and significant resource savings in a high‐alert, zero‐prevalence setting. This approach might yield a scalable blueprint for managing future alerts of emerging infectious diseases with cutaneous manifestations.