Mpox containment strategies in China, 2022-2023: from preparedness to legal management.

WHO declared mpox a Public Health Emergency of International Concern on 23 July 2022. China experienced the first imported case in September 2022, the first local case in May 2023, indigenous clustered outbreaks in June to August 2023 and finally has achieved routine management since September 2023. We designed a conceptual framework through literature review and theoretical underpinnings according to the risk management theory and Chinese mpox control practice, with the strategy and measures evolution of the mpox control in China over time from the stages of risk preparedness, emergency response and management, to routine report and management. Overall, China proactively takes strategies and measures ranging from risk preparedness to emergency response of imported cases, and finally controls the cross-border importation and local outbreaks of mpox. Notably, risk management was performed in the whole process of mpox response through HIV/AIDS service system. The imported case in September 2022 did not cause local transmission or aggregated outbreaks. The indigenous cases and clustered outbreaks in June 2023 did not result in three-generation transmission. Since September 2023, less than 100 cases per month and zero aggregated outbreaks were reported nationwide. As of 31 December 2023, the cumulative incidence per million population in China (1.202) was much lower than that in some European and American countries, such as Spain (161.780), Germany (45.633) and the USA (93.340). China has maintained a low mpox incidence rate through early surveillance, mandatory case reporting and prompt treatment. These measures effectively curbed large-scale transmission among high-risk groups. Additionally, the country's vast population size creates a larger denominator, which may further contribute to the lower observed prevalence. However, China still faces challenges, including low case linkage (<15%), under-reporting due to privacy concerns and unclear infection sources in 94 of 99 aggregated outbreaks. Thus, how to accurately trace infection sources and manage close contacts is a significant obstacle in China. Additionally, how to address stigmatisation and rapidly develop vaccines and medicines remains a problem to be solved in China. In summary, China demonstrates a practical example of mpox risk management, which may provide valuable experience for the other countries and regions with mpox epidemics.