Mpox (Clade I and II)

A confirmed MPXV inter-clade recombinant strain (Ia/Ib or Ib/IIb genomic elements) will be reported in a peer-reviewed publication or WHO/Africa CDC bulletin within 180 days, arising from DRC tri-clade co-circulation confirmed Apr 3 2026.

California CDPH will issue a formal mpox Clade I cluster alert or public health emergency with ≥10 confirmed cases by 2026-07-19, based on CDPH messaging shift to statewide surge framing within 72h of the Apr 16 SF index case.

Clade Ib non-sexual community or healthcare-associated transmission documented in at least one high-income non-African country within 120 days, based on CIDRAP/EurekAlert Dec 2025 evidence of shifting transmission pathways in DRC and Ireland, extended incubation periods, and Spain's ongoing surge driven by vaccination gaps.

At least one confirmed Clade Ib case in the United States linked to the Mexico-US border corridor (distinct from the San Francisco Clade I case) within 90 days, based on Mexico's confirmed Clade Ib Jan 2026, high-volume cross-border movement, and CDC diagnostic pause creating federal detection gaps.

India will confirm sustained domestic Clade Ib community transmission (≥3 epidemiologically linked locally-acquired cases without direct foreign travel history) within 90 days, based on: Kerala confirmed Clade Ib Jan 2026 with scientists warning of sustained spread; India surveillance gaps noted by Down To Earth; Pakistan Sindh multi-district Clade Ib on India's western border (25 cases, 9 deaths).

At least one MPXV Clade I or Clade Ib case in the California cluster (or a direct epidemiological contact) will demonstrate tecovirimat treatment failure — defined as progressive or non-resolving lesions after ≥14 days of standard-dose therapy — documented by CDC, CDPH, or peer-reviewed source by 2026-07-19. F13L mutation conferring phenotypic resistance is already documented in Clade IIb (Contag et al., EID Dec 2023, PMC10683816); if the SF/California Clade I exposure is reaching immunocompromised hosts (HIV/AIDS, oncology patients) — the highest-risk population for resistance selection — ...

A locally-acquired Clade I mpox transmission chain (≥2 epidemiologically linked cases without African travel history) will be confirmed in North America within 90 days of the San Francisco Clade I detection (Apr 19 2026).

Pakistan (Khairpur/Sindh) mpox cases will be genomically confirmed as Clade Ib by WHO DON or Pakistan MoH by June 2026, representing the third non-African Clade Ib community transmission geography after Spain (Dec 2025) and Singapore (Apr 2026), based on infant mortality in Khairpur district (7 infants dead/positive, Apr 2026) and demographic severity patterns consistent with Clade Ib rather than Clade IIb.

At least one confirmed mpox Clade Ib case with travel linkage to Singapore will be detected in Japan, South Korea, or Australia by October 2026, given Singapore's confirmed local Clade Ib transmission (2 cases, CDA Apr 4 2026) and Singapore's role as the primary aviation hub for East Asia–Pacific travel.

At least one confirmed mpox Clade IIb case linked to Singapore will be detected in Japan, South Korea, or Australia by October 2026, given Singapore's confirmation of local Clade IIb transmission (Apr 14 2026) and its role as the primary aviation hub for East Asia–Pacific travel.

Mpox clade Ib will be confirmed in at least 2 East African countries outside the DRC by April 2026.

California will confirm at least 2 additional Clade I mpox cases (beyond the San Francisco Apr 16 index) within 60 days of Apr 20 2026, with at least one in Los Angeles County or adjacent counties — indicating multi-focus Clade I circulation rather than isolated importation.

WHO will issue a Disease Outbreak News (DON) specifically addressing Clade Ib community transmission outside Africa (Spain Dec 2025, Singapore Apr 2026, Pakistan unconfirmed Apr 2026) as a distinct non-African Clade Ib spread pattern by June 30, 2026, given that the existing global PHEIC DONs have not yet characterized the non-African Ib pattern as a separate epidemiological entity.

At least one confirmed mpox Clade Ib case imported to the US will be significantly delayed in diagnosis (>7 days from symptom onset to laboratory confirmation) or go initially undetected due to CDC diagnostic capacity gaps, by October 2026, given that CDC paused mpox and rabies diagnostic testing capability (Apr 1–2 2026) during an active global PHEIC with confirmed Clade Ib community transmission outside Africa.

Pakistan Khairpur Sindh Clade Ib cluster (Apr 2026) will trigger WHO or Pakistan MoH-coordinated enhanced surveillance in Afghanistan and/or Iran within 90 days, resulting in at least one MPXV case detected in either country by July 14 2026, based on cross-border population movement patterns in the Balochistan/Sindh/Afghanistan corridor and the unprecedented pediatric severity profile indicating likely Clade Ib circulation at a regional rather than isolated scale.

At least one Asian country outside Africa will report sustained community Clade Ib transmission (≥3 locally acquired cases in ≥2 distinct chains) confirmed by WHO DON or national health authority by end of 2027, based on the documented non-African Clade Ib emergence pattern: Spain Dec 2025, Singapore Apr 2026, Pakistan cluster under investigation Apr 2026 — three geographies in 5 months demonstrating Clade Ib fitness outside its endemic African zone.

At least one confirmed mpox case (clade unspecified) will be detected in India within 90 days of the Pakistan Khairpur Sindh infant deaths cluster (by July 14 2026), given Pakistan-India cross-border movement in the Punjab/Rajasthan/Gujarat corridor and the unprecedented pediatric severity profile suggesting Clade Ib circulation in an adjacent geography.

Mpox Clade Ib will establish at least one additional documented sustained community transmission chain outside the African continent by July 2026.