Neonatal mpox in Pakistan: a case study in infection prevention and control gaps and opportunities for improvement

In 2026, a cluster of neonatal deaths from mpox clade Ib was identified in Khairpur, Sindh, marking Pakistan's first pediatric mpox mortality and its first detection of clade Ib. The country had previously recorded only imported clade IIb cases. The cluster mirrors earlier iatrogenic pediatric human immunodeficiency virus (HIV) outbreaks in Ratodero, Mirpur Khas, and Taunsa, and recurrent nosocomial Crimean-Congo hemorrhagic fever (CCHF) outbreaks.

A structured comparative clinical and case review reports analysis of six infectious disease outbreaks in Pakistan (2019-2026) was conducted. Peer-reviewed literature was identified through PubMed, Scopus, and Google Scholar (January 2021-September 2026) using outbreak-specific terms combined with "Pakistan," "iatrogenic," "nosocomial," "infection prevention and control," and "International Health Regulations (IHR)." Gray literature was retrieved from World Health Organization (WHO) country and joint-mission reports, Pakistan's National Institutes of Health advisories, provincial acquired immunodeficiency syndrome control program dashboards, ProMED-mail, and named journalistic investigations where peer-reviewed evidence was not yet available. Outbreaks were compared against IHR 2005 core capacities and the tripartite One Health framework. Infection prevention and control (IPC) failures were assessed by cross-referencing outbreak reports with WHO minimum IPC requirements and the 2025 IPC Assessment Framework assessments in Sindh.

Across the six outbreaks, more than 2050 children were affected between 2019 and 2026. The Khairpur cluster (26 confirmed cases, 50% infants under six months, eight neonates) is consistent with maternal-infant vertical transmission and healthcare-associated amplification, not with adult sexual networks. A separate Karachi cluster (n = 8) demonstrated sustained human-to-human transmission from an index case with recent travel to Central Africa. Points-of-entry syndromic screening missed clade Ib because concealed lesions evade visual assessment. Cross-cutting failures include syringe reuse by unregulated practitioners, driving pediatric HIV; personal protective equipment and isolation shortfalls causing fatal nosocomial CCHF among staff each Eid-ul-Azha; and absent integrated One Health surveillance.

The 2026 neonatal deaths reflect unreformed clinical practice, not a novel pathogen. Priorities include enforceable provincial IPC audits, a ban on unregulated practitioners, molecular-epidemiology-linked points-of-entry surveillance, a clinical pathway for mpox in pregnancy and in neonates, regional-language risk communication, and Modified Vaccinia Ankara - Bavarian Nordic for Mpox and antiviral stockpiling.