Mpox response in urban informal settlements

The World Health Organization declared the second mpox public health emergency of international concern (PHEIC) in August 2024. Cases of mpox have been reported in both endemic and non-endemic countries in diverse settings in Central and East Africa. In urban areas, there is sustained human-to-human spread of mpox via close physical contact including sexual contact. Of particular concern are urban informal settlements that often face high population densities, overcrowded dwellings and inadequate infrastructure. It is important that the mpox response is adapted to these unique contexts. The mpox response should build upon an array of local capacities and knowledge, including the strategies that these communities have used during previous disease outbreaks.

The brief highlights key issues and good practices that can be carried into the design and delivery of mpox response activities. This brief is based on a rapid review of published and grey literature, drawing on social science evidence on health emergencies in urban informal settlements in sub-Saharan Africa.

This brief complements the collection of SSHAP resources on mpox.

Key considerations

Urban informal settlement context and local adaptation of mpox response

• Urban informal settlements are vibrant, dynamic and heterogeneous spaces, and residents may face several disadvantages at once. Informal settlements may face multiple challenges, such as population density and overcrowding; inadequate access to water, sanitation and hygiene (WASH); and political, economic and social inequalities rooted in issues of governance and public authority. These challenges are experienced in locally specific ways. ‘Informal settlements’ is an overarching category that captures a variety of contexts with internal diversity: informal settlements are home to residents who may vary in age, gender, ethnicity, disability and tenure status (amongst other differences). These intersecting challenges will strongly influence a person’s vulnerability to mpox, making it crucial to understand local contexts.
• In many informal settlements, cultures of caring and intimacy – within the family and between neighbours and sexual partners – shape both vulnerability to mpox and possibilities for response. Communities have valuable experience in responding to health emergencies, as illustrated by Ebola disease, HIV/AIDS and COVID-19. Although Ebola disease has a higher case fatality ratio than mpox, an understanding of cultures of caregiving, domestic lives, shared spaces and shared responsibilities will again be relevant as both diseases are transmitted via intimate contacts. Tailoring mpox response activities to this context, rather than seeking to stop or prevent cultures of caring and intimacy, may be more locally appropriate. This might mean supporting home-based isolation for mild cases of mpox and providing guidance to potential caregivers – though these individuals may not necessarily be within the same household.
• Response efforts should focus on context-specific factors or behaviours that shape risk and vulnerability in informal settlements and avoid focusing solely on risk groups. Behaviours are shaped by structural inequities, including criminalisation, and there is likely less capacity to change behaviour in these settings. Focusing on risk groups (e.g., sex workers and men who have sex with men) may inadvertently increase stigma and discrimination and may not recognise the cross-cutting factors (e.g., caregiving) that might still place people at risk of mpox. As was the case with Ebola disease and HIV, people may experience stigma after recovering from mpox as well, and so many people do not want to be known as an mpox patient.
• People living with HIV/AIDS who are immunocompromised are more vulnerable to severe mpox and death. In the context of declining U.S. foreign aid for HIV services, access to much-needed antiretroviral therapy may have deteriorated, which in turn may worsen immune Special attention is needed to this group of people. The full extent of U.S. foreign aid cuts remains unclear, and local responses might include integrating mpox screening questions and risk communication efforts into HIV services (e.g., routine counselling).
• Given health access issues in urban informal settlements, many people with mpox may not receive an official diagnosis, although this is context dependent. Past research has found that mpox may be mistaken for chickenpox or measles. People experiencing severe symptoms are more likely to go to hospitals.
• If the World Health Organization declares an end to the mpox PHEIC, mpox control and monitoring will remain important in the longer term, and ongoing attention will be required for vulnerable settings such as urban informal settlements. It will be important to strengthen and invest in long-term and integrated strategies for mpox, such as community-based surveillance or training (and support for) community health workers.

Isolation and quarantine

• As with past health emergencies, residents of informal settlements face significant constraints in isolating and quarantining due to structural and environmental factors. Residents may be less able to isolate or quarantine in isolation centres because of livelihood constraints (e.g., precarious livelihoods in the informal economy, which usually depend upon daily earnings and face-to-face interactions). With most cases of mild mpox, isolation at home may be possible, but this will be difficult in informal settlements where many people may share crowded homes.
• Practical and contextually specific guidance is needed for isolation or quarantine. Protocols for isolation and quarantine that support people to stay within their communities, when appropriate according to disease severity, can be co-designed with local leaders.

Home-based care

• Home-based care of mpox will be an important strategy for people with mild cases of the disease, but actionable guidance is needed on how to prevent transmission within the (See recent SSHAP brief on home-based care). People living in multigenerational or multi-family households, or even in one-room quarters close to other families, will find it difficult to isolate a person with mpox within the home. The ‘household’ is not a fixed unit within urban informal settlements – people move, stay with other friends or family, and people may also spend considerable time outside their actual home.
• People may also decide to care for their symptoms at home rather than going to a health facility not out of choice, but out of necessity. People may not have access to health facilities, which can be costly or far away from urban informal settlements. Out of fear of being identified as a person with mpox, people from stigmatised groups may also choose to stay home rather than seek care.
• People living in urban or informal settlements rely on a range of healthcare providers, including traditional healers, herbalists and pharmacists. Engaging with the full range of health providers is vital as treatments from these providers may be helpful in managing In informal settlements, antibiotic use is widespread, without any official diagnosis of a disease. Contextually specific guidance can discourage the use of antibiotics for mild cases with no secondary infection and if a person has no other underlying vulnerabilities.

Contact tracing

• Standard contact tracing guidance will need to be adapted for urban informal settlements. Population mobility is a major challenge for surveillance efforts. In cases of secondary infection, such as via respiratory droplets, people may not know where or how they were infected with mpox, given the often-crowded conditions of informal settlements. Asking an individual to share contact information for close contacts will be difficult with marginalised residents, such as sex workers or men who have sex with men, particularly in settings where sex work or same-sex relations are criminalised. It will be crucial to focus contact tracing efforts on specific questions that are the most important based on context and purpose. Contact tracing can be conducted by trusted community health workers, peer leaders or local community-based organisations.

Community engagement

• Work with local organisations and clinics, including those that provide services for HIV/AIDS and sexually transmitted infections, to reach populations who live in urban informal settlements and that may be more vulnerable to severe mpox. However, given cuts to global development funding and foreign aid, many organisations that are vital in the HIV response may have limited or no capacity to engage in activities beyond their current scope. Some organisations have had to close or limit their activities due to funding shortfalls. Therefore, whilst it is important to consult with and engage organisations that are run by peer leaders – particularly for sex workers and for gay, bisexual and other men who have sex with men (GBMSM) – it is also important to facilitate their participation.
• Build on successful programmes that train community health workers to engage in health emergency response. However, it is also necessary to recognise community health workers’ limitations in terms of their time, competing priorities and limited resources. Any programme engaging community health workers would also require adequate resourcing and personal protective equipment. Supervision, mental health support and clear referral pathways – in addition to compensation and transportation – remain essential to ensure that community health workers can do their work well.
• Engage with local leaders – both formal and informal – and local decision-making processes to explore where the mpox response can be adapted or co-designed. This might include attending community meetings or engaging with local neighbourhood groups such as business associations or savings and loans groups.
• Community-based surveillance, which relies on communities to report public health information, can be an important part of mpox response in urban informal settlements. However, it is important to pay attention to inequitable or exclusionary local power dynamics and politics, which can affect the effectiveness of interventions. See recent SSHAP guidance on community-based surveillance.

Risk communication

• Design risk communication guidance that is feasible within the context of urban informal settlements. The guidance should recognise the structural factors that limit residents’ abilities to undertake preventative actions: for instance, regular handwashing may not be feasible due to inadequate or unaffordable WASH provision. Similarly, recommendations around ‘safe sex’ and condom use in the context of other sexually transmitted illnesses have limited effectiveness in the case of mpox. Abstinence may not be feasible for many people with mpox, particularly those who rely on sex for material support.
• Work through existing infrastructures to identify trusted peer influencers to be trained to co-design and deliver messaging around mpox prevention and response. Informal settlements have a range of formal and informal leaders and individuals who may be able and trusted to share information with others. This includes local business leaders, but also people who make announcements like ‘town criers’. Peer influencers may include community health workers, traditional healers, herbalists or HIV/AIDS outreach workers. In the context of sex work, peer leaders and brothel or lodge managers are often key sources of information.

Vaccination

• Mpox vaccines are new to most people, and so there is a potential for low vaccine confidence. In places where vaccines are available, targeted vaccination is a vital part of mpox response, especially in informal settlements where other forms of action may be limited. It is therefore important that vaccine roll-out is preceded by careful, inclusive co-design of such interventions with robust community engagement efforts.
• Ensure information about mpox vaccines is clear and repeated often. Include information about vaccine effectiveness, the need for two doses in the case of the MVA-BN vaccine and any potential adverse effects. See SSHAP guidance on the use of vaccines during health emergencies.

Mpox in urban areas

The epidemiological diversity, evolving nature and uncertainties of mpox have created challenges for mpox response activities. A clearer picture of mpox transmission has emerged due to increasing attention to mpox in recent years.^1–4

Mpox caused by clades I and II of the monkeypox virus (MPXV) have spread in different regions of sub-Saharan Africa: clade I in Central and East Africa, and clade II in West Africa.¹ Clade II spread during the period of the first mpox PHEIC declared in 2022. In the current outbreak, clade Ia has spread largely in rural areas via zoonotic transmission, and clade Ib has spread in predominantly urban areas and mining communities of eastern Democratic Republic of the Congo (DRC) via human-to-human transmission, including through intimate contact.¹ Mpox has since spread to neighbouring countries along trade, travel and migration routes as well as to urban centres. Cases of mpox caused by clade IIb have been reported in West Africa, including in urban areas of Nigeria.⁵ The extent of spread amongst some of the vulnerable populations within urban contexts is likely underestimated; these populations include people living with HIV/AIDS, children and women engaged in transactional and commercial sex work (female sex workers), and GBMSM and their intimate partners.^1,6 Box 1 provides information about cases of mpox in an informal settlement in DRC.

For the purposes of this brief, we will focus on human-to-human mpox transmission in urban areas, which has been seen with both MPXV clades Ib and IIb. These clades have spread via close physical contact, including sexual contact and aerosol vehicle.^1,4 There is some evidence that mpox can be transmitted via respiratory droplets (and possibly short-range aerosols requiring prolonged close contact), though more research is needed on this.⁷ Mpox can present as a mild illness, but severe forms of the disease can be fatal.

Given health access issues in urban informal settlements, many people with mpox may not receive an official diagnosis, though this is context-dependent as attention to mpox is high in places like Kinshasa, DRC.⁸ (See Box 1). Social science research on mpox in urban Nigeria found that many people described their mpox symptoms as ‘chickenpox’ or possibly ‘measles’.^8–10 People with severe mpox were more likely to go to hospitals, where they were officially diagnosed and treated in isolation. However, seeking hospital care was expensive. GBMSM with mpox were also more likely to isolate at home due to stigma and fears of being identified as an mpox patient.¹⁰

Box 1. Mpox in Pakadjuma, an informal settlement in Kinshasa, DRC

Source: Authors’ own.

Urban informal settlements: Context and definitions

Urban growth is happening extremely rapidly in Africa, and projections suggest that the urban population will double by 2050 to reach 1.4 billion people.¹⁴ Most of this urban growth is unplanned and has led to a proliferation of ‘informal settlements’, sometimes called ‘slums’ (a derogatory term which is sometimes reclaimed by residents). In most African cities, more than half the population currently live in informal settlements.¹⁵ These communities are extremely diverse and complex, but in-depth data on informal settlements are usually scarce.

Many households identified in the international statistics as ‘slum’ households (based on crowding in the home, lack of on-site access to water or sanitation, or poor shelter construction) do not live in settlements identified locally as informal settlements or ‘slums’, and vice versa.¹⁶ Household level indicators, favoured by the UN, can often obscure community-level disease risks stemming from inadequate infrastructure, services, hazardous sites (e.g., waste dumps) and other neighbourhood-wide challenges.¹⁷ Claims to land ownership are often contested at the settlement level.¹⁸ Settlement developments are unplanned, often building on precarious lands that are highly exposed to floods or other disasters.

Informal settlements are often home to socially, economically or politically marginalised residents. For instance, internal migrants, refugees and internally displaced people often first settle and live in informal settlements.¹⁹ These areas are typically where urban poverty is usually most concentrated, but they are also where burgeoning local livelihoods (e.g., food vendors) can provide crucial goods and services for their fellow residents.^20,21

The informal, poorly planned nature of these settlements may strongly influence how diseases spread and can be controlled. Since these areas exist outside of formal planning and face political exclusions, they face major shortfalls in service delivery. For diseases spread through fluids and close contact, the lack of accessible, affordable or reliable WASH at household and community levels, as well as inadequate rubbish collection, may all undermine residents’ efforts to decontaminate themselves and their belongings. Residents also face stigmatising narratives about hygiene and being amplifiers of disease.

Relatedly, many informal settlements face severe official neglect and may have contested relations with formal authorities or other government agencies. City and national authorities can be unwilling to recognise residents’ claims to land and housing rights, omitting them from policy frameworks or development plans, withholding investments in basic services or threatening to bulldoze and evict homes. Some city governments have taken more progressive stances towards informal settlements, working with residents and grassroots groups to upgrade settlements.²² Some settlements have lengthy histories, well-established services and more collaborative local governance relationships. These local histories will inform residents’ levels of trust and engagement with formal authorities during disease outbreaks.

Popular images of ‘slums’ depict them as uniformly chaotic, dirty and disease-ridden, and as a social, environmental and developmental threat to the rest of the city. However, as noted above, these areas are heterogeneous with stark variations between and within informal settlements. While there is poverty, there can also be wealth and therefore extreme inequality in some places.²³ These neighbourhoods can be dense and overcrowded, or sprawling but poorly provided with infrastructure (e.g., in peri-urban areas), depending on the location of settlement. Contrary to definitions based on material deficits, there is an enormous amount of social capacity and social capital, as well as economic activity within informal settlements.

These areas should not be seen as separate from the wealthier and planned areas of a city. Indeed, many urban sectors and services – including health, hospitality, manufacturing and transport – will be heavily dependent on informal workers and economies based in informal settlements.²⁴

Learning from past outbreaks in urban informal settlements

The history of urban planning has often been entwined with controlling infectious diseases. During the late 20th century, however, this was less of a concern, and there was a greater focus on medical technologies, personal behaviour and targeted interventions.^25,26 In recent years, major disease outbreaks have overwhelmingly affected urban areas, with residents of informal settlements especially vulnerable (e.g., to Ebola disease, Zika virus disease, COVID-19).^27,28

Lessons learnt for community-centred response

There is vast learning about how a community-centred response to health emergencies is vital. A systematic review of community-based interventions to prevent and control infectious disease in informal settlements found evidence that community-based education, community-based screening, community-based vector control, community health worker capacity building, behaviour change communication, and electronic and mobile health interventions were all effective.²⁹ However, the outcome measures usually reported behavioural impacts rather than strong evidence of impacts on disease spread. While these findings are helpful, the research misses crucial contextual factors relevant to how and why interventions do (or do not) work in informal settlements.

Lessons from previous humanitarian and health crises in informal urban settlements, as well as non-urban settings, highlight that locally led and contextually adapted responses are important for their effectiveness.^28,30–32 Local ownership enables response approaches to be better attuned to the diversity and complexity of urban settings.

There is evidence of significant local organisation and collective action that can support inclusive, contextually appropriate interventions during health crises. Lessons learnt from past outbreaks in urban informal settlements highlight the need for locally led and adapted response.²⁸ Urban informal settlements can have a range of active local organisations – including complex care and support networks, formal and informal leaders, business leaders, security patrols and groups, spiritual or religious leaders, and youth groups – who often fill the gaps in state provision or welfare and participate in community health and development programmes. There are also organisations that represent and advocate for people living in informal settlements, such as Slum Dwellers International with affiliate organisations in many African nations. During crises such as mpox, it will be essential to co-produce locally appropriate solutions in collaboration with local organisations.

There are also examples of local and collective action from other disease outbreaks. For Ebola disease in West Africa, this included bye-laws for community surveillance and movement control.^31,32 For COVID-19, there were local peer support networks. Such efforts can be especially effective when done in collaboration with authorities, either with resources or other forms of support.³³ This echoes findings from non-urban settings where control operations were most effective when they merged epidemiological and community priorities.^32,34,35

Community health workers are also active in many urban informal settlements and play an important role in the disease surveillance and notification system. Community health workers are often on the ‘frontlines’ of epidemic response, but they are not always adequately supported or equipped to conduct their work. Community health workers must also be adequately supported with compensation and personal protective equipment. Community health workers are also overwhelmingly female and face limited recognition. Recent work in urban Nigeria demonstrated how frontline health workers often have to make difficult decisions in prioritising different disease responses (based on limited time and resources).⁹ Adding further work to already overburdened staff is often problematic, as it can negatively affect health workers’ well-being. There are opportunities for training initiatives for community health workers, as shown in Box 2.

Box 2. Training community health workers to support outbreak response in Pakadjuma, an informal settlement in Kinshasa, DRC

Source: Authors’ own.

In most informal settlements, there are formal and informal decision-making structures as well as consultative processes (e.g., open community meetings). There might also be community networks, committees and groups that were established in previous outbreaks such as cholera. These are existing spaces where the mpox response can be co-designed, adapted and conducted. As was the case during the West African Ebola epidemic, local ‘task forces’ can form to support mpox case identification, support isolation and home-based care (where possible), and refer severe cases to hospital care.

More information may help to spread awareness of how mpox is (and is not) spread. The AIDS Support Organisation, amongst other organisations and activists, played a critical role in raising awareness in the early days of HIV. Lessons learnt from HIV in Uganda, for example, showed that bringing the disease into the public sphere, via political and civil society efforts, contributed to greater awareness of the disease.^37,38 Box 3 highlights an initiative to engage community health workers and sex workers to raise awareness of mpox symptoms and transmission routes. HIV stigma persists, however, particularly for those from marginalised groups.

Box 3. Training community health workers and sex workers for mpox response in Kawempe Division in Kampala, Uganda

Source: Authors’ own.

Care infrastructures and epidemic response

Settlements are often characterised by their material deficits, but this perspective overlooks the profound and diverse sources of social capital in these areas. Ali and colleagues call this ‘social infrastructure’,³¹ similar to Simone’s concepts of ‘people as infrastructure’.⁴⁰ Ali and colleagues make the point that informal networks and capacity are strong because of, not in spite of, the lack of other services.³¹ When developing community engagement strategies, it will be vital to recognise and work through these assets, as well as to consider their historical roots and complex relations with official actors. For example, the use of formal, top-down interventions and rules may backfire where there have been histories of state neglect or absence.

Literature on Ebola disease and COVID-19 has valuable lessons about local action and co-produced responses in informal settlements. It is important, however, to acknowledge where mpox is distinct and what that means for local organisation. The response will also be influenced by the speed and severity of an outbreak. States of emergency and ‘emergency thinking’ can preclude the bottom-up approaches that will be essential, as the West African Ebola epidemic showed. However, the acute nature of (some) outbreaks is also what stimulates a strong local response. During times of crisis, results have been obtained more quickly than for chronic, everyday risks (e.g., long-standing sanitation deficits are ignored until cholera outbreaks).⁴¹ Mpox may not carry the same sense of urgency and sense of people being ‘all in this together’. Expectations of local action during mpox should, in turn, be more limited.

Experiences with Ebola disease contain poignant lessons for mpox about outbreaks where transmission takes primarily in domestic and intimate spheres. Ebola disease has been described as a ‘disease of love’: ‘This virus preys on care and love, piggybacking on the deepest, most distinctively human virtues.’⁴² Control of Ebola in the West Africa outbreak, as in subsequent outbreaks, involved intervening in areas of social and reproductive life, including caregiving, informal and traditional healthcare provision, public and private distributions of labour, cleaning, food preparation and consumption, funerary practices, and mobility and transportation.³⁵

Although anthropologists have tried to point out that local ‘culture’ was not the problem, there were occasions when local social and cultural obligations and priorities outweighed biomedical disease control imperatives. But just as importantly, people’s social circumstances sometimes would simply not allow for people to follow public health advice. For example, home care was an inevitability when hospitals were too far away, full or unsafe. Breaking quarantine was unavoidable if there was no food to eat.

The major lesson from the West African Ebola epidemic was that, to have locally acceptable and feasible control strategies, it was essential to align them with local priorities and contexts, and crucially to provide resources which enabled people to adhere to infection control advice. The same mistakes were repeated with COVID-19 in urban informal settlements when residents were initially told to wash hands and maintain social distance, which was impossible in places where there was no private running water and homes were crowded.²⁸ The response to Ebola disease and COVID-19 did eventually formulate more context-specific messages and interventions; for example, providing food, disinfectants, simple personal protective equipment and psychosocial support was pivotal in enabling people to comply with public health and social measures.

Although Ebola disease has a higher case fatality ratio than mpox, an understanding of cultures of caregiving, domestic lives and shared spaces and responsibilities will be just as relevant as both are diseases transmitted through intimate contacts. Homes became frontiers during the Ebola response in Freetown: they became places of safety and sanctuary, but also places carrying risks of transmission or being reported for breaking rules.⁴³

Where resources are scarce, then ‘kinship’ networks of family and friends become the sources of work and opportunities, so building relationships is essential.^31,43 Disease transmission may take place through behaviours associated with these networks, and any interventions which aim to interrupt them will need to be sensitive to these social logics. This is not unique to urban informal settlements, but outsiders often have perceptions of informal settlements as places where there is chaos and weaker social bonds. In a similar vein, the concept of urban kinship focuses on the micropolitics of proximity and relatedness in African cities.⁴⁴ This concept challenges traditional atomised views of urban life by emphasising the importance of everyday social interactions and relationships in densely populated urban areas.

Structural drivers of HIV vulnerability in urban informal settlements

Mpox is a heterogeneous health emergency and not solely a disease related to sexual contact (or sexual transmission). There are risks of framing it as such, especially in contexts where same-sex relations are criminalised or highly stigmatised (see this SSHAP brief). Close physical contact is the overarching way in which mpox spreads via human-to-human transmission, and children constitute a vulnerable group. Sexual transmission is one part of the story in this PHEIC.

Mpox is ‘new’ in many urban settings, but the underlying drivers of sexual transmission of infectious diseases have long existed. Social scientists, community activists and others have extensively documented and argued for a recognition of the structural drivers of sexual transmission in urban contexts.^45–49 Urban informal settlements have long been home to new migrants, including rural-to-urban migrants who come to the city in search of work.⁴⁵ For some people, these spaces are ‘transitory’, meaning people may come for a short period of time and move on when work is no longer available. Informal settlements are also home to circular migrants, temporary visitors and long-standing residents including intergenerational families.

The mpox response can learn important lessons from past work on the structural drivers of HIV/AIDS in urban informal settlements. Urban spaces have seen shifting patterns in marriage and intimate relationships in addition to the social complexity and vibrant social life in urban informal settlements. With this change, there have been shifting risks and vulnerabilities to diseases such as HIV/AIDS rooted in structural inequalities.⁴⁵ Social science research in South Africa, for example, has shown how structural violence as well as gender-based violence, rising unemployment and social inequalities leave some groups (especially women in urban informal settlements) vulnerable to HIV/AIDS.^{45,46,50–52} Transactional sex is one way in which women meet their basic needs, improve social status or receive material expressions of love like money or gifts, but it is also linked to an increased risk of HIV infection.⁵³

Other significant research on HIV/AIDS has shown how the vulnerability of female sex workers is clearly linked to structural drivers of risk, such as police and client violence and the criminalisation of sex work, which push female sex workers to marginal positions in urban spaces.^54,55 GBMSM face increasing stigma and discrimination linked to shifting criminal laws around same-sex relations, as discussed in in the SSHAP brief ‘Supporting the mpox response for people with diverse sexual orientation, gender identity and/or gender expression in contexts where their rights are restricted’. Stigma is an important driver of delayed care seeking, as discussed in the SSHAP report on mpox and discrimination.

Structural drivers of HIV vulnerability also mean that vulnerable groups (e.g., female sex workers and GBMSM) are less able to access high-quality health information, attend a health centre or health facility, and continue with medical treatments once prescribed. Local and trusted clinics, and organisations welcoming to female sex workers and GBMSM, have historically stepped in to provide services. Cuts to development and foreign aid funding mean, however, that these organisations are likely facing deficits and may close down.⁵⁶ The full extent of these cuts remains to be seen.

Structural and social drivers of human-to-human transmission of mpox in urban informal settlements

Epidemiological vulnerability

Vulnerability to mpox depends on local epidemiology and drivers of transmission.¹ In urban informal settlements, transmission risk is likely highest within households (especially for children) and also between sexual partners.⁵⁷ Immunosuppressed people are at a higher risk of developing severe mpox or dying from the disease. People living with HIV/AIDS, particularly those with a low CD4 count, are at elevated risk of death from severe mpox.⁵⁷ With the end of U.S. foreign aid for the HIV response, countries with a high burden of HIV in sub-Saharan Africa will be particularly affected if antiretrovirals are less available. People living with HIV/AIDS who cannot access treatment will experience declining health and are likely to become more vulnerable to co-infections and severe mpox.

Children are at high risk of mpox given their close proximity to caregivers, who are typically women.² In many urban informal settlements, children are cared for by multiple caregivers including women, extended family and neighbours. Children often play together across multiple households.

There is also evidence of mpox vertical transmission, including stillbirth and miscarriage, and so pregnant women must be closely monitored if mpox is contracted at any point.³

Where mpox is spread via sexual contact, it is important to highlight the structural drivers of infectious disease transmission and learn from the HIV/AIDS epidemic (see above). Social and behavioural science evidence has shown that behaviour change efforts in relation to sex are not uniformly effective. Many people do not have the ability to change behaviour, such as avoiding sex, on account of gender and power dynamics as well as other structural inequalities. Condom use in the context of mpox prevention is not fully effective,⁵⁸ and research has shown the ineffectiveness of abstinence-only approaches.

Human-to-human transmission via close physical contact

Informal settlements are highly diverse, heterogeneous contexts, but there may be specific concerns related to mpox human-to-human transmission in these areas. These include:

• Density and overcrowding: In some urban informal settlements, elevated levels of crowding may be the greatest concern in terms of mpox transmission. Homes may range from a separate standing structure to single, highly crowded rooms. Occupants may lease their rooms, sometimes daily. People who live in insecure housing may move frequently. In these contexts, there are additional opportunities for mixing and more limited options for isolation within the home.
• Household structures: Household structures are often very flexible, with people moving between homes and sharing food or sleeping space as needed. Children may often move between homes in urban informal settlements and in rural areas, and they may be cared for by extended family or friends.
• Sexual contact: Urban informal settlements are often sites where low-wage sex work takes place, though people who engage in sex work may not identify as sex workers. Sex work includes a wide range of practices such as home-based sex work or transactional sex, street-based sex work, or lodge- or brothel-based sex work. Given the nature of mpox transmission via intimate contact, those who have denser sexual networks (including sex workers and their partners) may be more vulnerable to mpox. Sex workers are also less likely to be able to abstain from sex as an mpox preventative measure.
• Mobility: Movement between and within urban areas is frequent, including people who come to informal settlements for short periods of time (e.g., farmers who come to sell in the city) or longer periods of time with regular trips back to a rural area. People often also travel when sick, and, in many places, must return the deceased to their ancestral home for burial. The reasons for mobility and the implications of urban-urban and urban-rural linkages are important for an mpox response.
• Informal livelihoods: People living and working in urban informal settlements often engage in a wide range of informal livelihood strategies, including wage work, temporary work on construction sites or factories, and operating small businesses. These are often precarious, poorly paid or seasonal livelihoods, and people may engage in multiple income-generating strategies to support themselves and their families. Furthermore, informal workers typically lack access to social protections such as sick pay, health insurance or other measures to deal with shocks (including COVID-19 or mpox), and they may have few or readily depleted savings and other assets.⁵⁹ In turn, this makes it extremely difficult to stop working, particularly to isolate with mpox. People may avoid detection or reporting mpox symptoms if it might mean mandatory isolation.
• Ventilation: Whilst the relative contribution of the respiratory route to mpox transmission is unclear, animal studies and other lab-based research has demonstrated its feasibility.⁷ In the absence of more definitive information, public health guidance on respiratory transmission reduction strategies is important. In the context of urban informal settlements, this becomes difficult in unventilated and confined spaces. Informal settlements may have open-air areas, but this depends on the context.
• WASH: Access to WASH is a major challenge in informal settlements, and the burdens of inadequate provision often disproportionately affect women and girls.⁶⁰ Water points are typically shared and in public spaces, often with lengthy queues or prohibitive costs. Mpox is not a waterborne disease. However, bedding and items of clothing that have been in contact with a person infected with mpox must be regularly washed until the infectious period has passed. People who wash clothes (typically women or girls) may be vulnerable to mpox in informal settlements.¹² Hand hygiene is an important preventative measure, but it is compromised by a lack of water and soap.

Health system vulnerability

Health systems in urban informal settlements are pluralistic, and access to government-run healthcare facilities is uneven. Urban informal settlements are home to a range of providers, formal and informal, including small drug shops, pharmacies, private doctor- or nurse-run clinics, traditional healers and herbalists.

People living in informal settlements typically select the most convenient provider based upon cost or location, and this may include visiting a herbalist or drug shop where treatments can be quickly purchased. Box 4 provides an example of herbal treatments and home remedies used to manage mpox. People trust some providers more than others, depending on the type and severity of disease. Language barriers, discriminatory attitudes and other negative experiences of health services affect when and how people seek care. People may also seek care in hospitals when the symptoms of a disease are more severe, but there are usually major cost barriers (alongside issues of medicine stock-outs, healthcare provider motivation or lengthy waiting times).

Engaging with the full range of health providers is also vital. Contextually specific guidance can also help to guide people away from dangerous treatments. Although some vulnerable groups will need access to antibiotics, guidance can also help avoid the routine use of antibiotics for mild cases with no secondary infection.

Guidance on home-based care and isolation is critical in these settings. People from stigmatised groups may also choose to stay home rather than seek care, out of fear of being identified as a person with mpox. Reports from Bujumbura, Burundi, have shown that stigma can follow people back home, with individuals reporting that they were sent away from their home after recovering from mpox due to a landlord’s fear of the disease.⁶¹

Box 4. Management of mpox via herbal treatments and home remedies in south-west Nigeria

Source: Authors’ own.

References

1. Ndembi, N., Folayan, M. O., Komakech, A., Mercy, K., Tessema, S., Mbala-Kingebeni, P., Ngandu, C., Ngongo, N., Kaseya, J., & Karim, S. S. A. (2025). Evolving epidemiology of mpox in Africa in 2024. New England Journal of Medicine, 392(7), 666–676. https://doi.org/10.1056/NEJMoa2411368
2. Nachega, J. B., Sam-Agudu, N. A., Ogoina, D., Mbala-Kingebeni, P., Ntoumi, F., Nakouné, E., Njouom, R., Lewis, R. F., Gandhi, M., & Rosenthal, P. J. (2024). The surge of mpox in Africa: A call for action. The Lancet Global Health, 12(7), e1086–e1088.
3. Beiras, C. G., Malembi, E., Escrig-Sarreta, R., Ahuka, S., Mbala, P., Mavoko, H. M., Subissi, L., Abecasis, A. B., Marks, M., & Mitjà, O. (2025). Concurrent outbreaks of mpox in Africa—An update. The Lancet, 405(10472), 86–96. https://doi.org/10.1016/S0140-6736(24)02353-5
4. Van Dijck, C., Hoff, N. A., Mbala-Kingebeni, P., Low, N., Cevik, M., Rimoin, A. W., Kindrachuk, J., & Liesenborghs, L. (2023). Emergence of mpox in the post-smallpox era—A narrative review on mpox epidemiology. Clinical Microbiology and Infection, 29(12), 1487–1492.
5. Ogoina, D., Dalhat, M. M., Denue, B. A., Okowa, M., Chika-Igwenyi, N. M., Oiwoh, S. O., Tobin, E. A., Yusuff, H. A., Ojimba, A. O., Christian, U. C., Aremu, J.-T. A., Gomerep, S. S., Habila, K. L., Awang, S. K., Adekanmbi, O., Iroezindu, M., Onukak, A., Falodun, O., Sunday, M., … on behalf of Nigerian Infectious Diseases Society (NIDS) mpox study group. (2024). Mpox epidemiology and risk factors, Nigeria, 2022. Emerging Infectious Diseases, 30(9), 1799–1808. https://doi.org/10.3201/eid3009.240135
6. Kuppalli, K., Dunning, J., Damon, I., Mukadi-Bamuleka, D., Mbala, P., & Ogoina, D. (2024). The worsening mpox outbreak in Africa: A call to action. The Lancet Infectious Diseases, 24(11), 1190–1192. https://doi.org/10.1016/S1473-3099(24)00577-2
7. Beeson, A., Styczynski, A., Hutson, C. L., Whitehill, F., Angelo, K. M., Minhaj, F. S., Morgan, C., Ciampaglio, K., Reynolds, M. G., McCollum, A. M., & Guagliardo, S. A. J. (2023). Mpox respiratory transmission: The state of the evidence. The Lancet Microbe, 4(4), e277–e283. https://doi.org/10.1016/S2666-5247(23)00034-4
8. Adegoke, O., Schmidt-Sane, M., Kunnuji, M., Abbas, S., Lawanson, A., Jegede, A., & MacGregor, H. (2025). Diagnosis, treatment, and management of Mpox in urban informal settlements in Southwestern Nigeria: An ethnographic approach. BMC Public Health, 25(1), 115. https://doi.org/10.1186/s12889-024-21267-1
9. Schmidt-Sane, M., Adegoke, O., Abbas, S., Lawanson, A. O., Kunnuji, M., Jegede, A., & MacGregor, H. (2024). Infrastructures of epidemic response: Mpox and everyday repair work in southwestern Nigeria. Social Science & Medicine, 358, 117246. https://doi.org/10.1016/j.socscimed.2024.117246
10. Kunnuji, M., Schmidt-Sane, M., Adegoke, O., Abbas, S., Shoyemi, E., Lawanson, A., Jegede, A., & MacGregor, H. (forthcoming). Mpox and the MSM community in Nigeria: Exploratory insights from gay men and persons providing healthcare services to them.
11. Mpox in the DRC: Residents of the slum at the centre of Kinshasa’s epidemic have little chance of avoiding this major health crisis. (n.d.). Retrieved 12 May 2025, from https://www.gavi.org/vaccineswork/mpox-drc-residents-slum-centre-kinshasas-epidemic-have-little-chance-avoiding-major
12. Boum, Y. (2025, January 24). Mpox in the DRC: Residents of the slum at the centre of Kinshasa’s epidemic have little chance of avoiding this major health crisis. The Conversation. http://theconversation.com/mpox-in-the-drc-residents-of-the-slum-at-the-centre-of-kinshasas-epidemic-have-little-chance-of-avoiding-this-major-health-crisis-247809
13. WHO guideline on contact tracing. (n.d.). Retrieved 22 May 2025, from https://www.who.int/publications/i/item/9789240102965
14. Organisation for Economic Co-operation and Development (OECD), African Development Bank (AfDB), UNOPS‐Cities Alliance, & United Cities and Local Governments of Africa (UCLG Africa). (2025). Africa’s urbanisation dynamics 2025: Planning for urban expansion (West African Studies). OECD Publishing. https://doi.org/10.1787/2a47845c-en
15. Chitekwe-Biti, B., Dodman, D., Mitlin, D., & Ouma, S. (2022, March 24). Upgrading informal settlements in African cities. African Cities Research Consortium. https://www.african-cities.org/upgrading-informal-settlements-in-african-cities/
16. UN Habitat. (2024). Housing, Slums and Informal Settlements. https://data.unhabitat.org/pages/housing-slums-and-informal-settlements
17. Satterthwaite, D. (2016). Missing the Millennium Development Goal targets for water and sanitation in urban areas. Environment & Urbanization, 28(1), 99–118. https://doi.org/10.1177/0956247816628435
18. UN-Habitat helps in solving land disputes | UN-Habitat. (n.d.). Retrieved 22 May 2025, from https://unhabitat.org/un-habitat-helps-in-solving-land-disputes
19. Earle, L., & Brown, A. (2024). Realigning responses to protracted displacement: Putting “urban first” in a “world without camps”. Environment and Urbanization, 36(2), 233–248. https://doi.org/10.1177/09562478241283868
20. Mitlin, D., & Satterthwaite, D. (2013). Urban poverty in the global South: Scale and nature. Routledge.
21. Githiri, G., Ngugi, R., Njoroge, P., & Sverdlik, A. (2016). Nourishing livelihoods: Recognising and supporting food vendors in Nairobi’s informal settlements (IIED Working Paper). IIED. https://www.iied.org/10762iied
22. Ouma, S. (2023). Participation as ‘city-making’: A critical assessment of participatory planning in the Mukuru Special Planning Area in Nairobi, Kenya. Environment and Urbanization, 35(2), 470–489. https://doi.org/10.1177/09562478231175031
23. Mwau, B., Sverdlik, A., & Makau, J. (2020). Urban transformation and the politics of shelter: Understanding Nairobi’s housing markets (IIED Working Paper). IIED. https://www.iied.org/10876iied
24. Chen, M. A., & Carré, F. J. (Eds.). (2020). The informal economy revisited: Examining the past, envisioning the future. Routledge.
25. Corburn, J. (2004). Confronting the challenges in reconnecting urban planning and public health. American Journal of Public Health, 94(4), 541–546. https://doi.org/10.2105/AJPH.94.4.541
26. Ahmed, S., Dávila, J. D., Allen, A., Haklay, M. (Muki), Tacoli, C., & Fèvre, E. M. (2019). Does urbanization make emergence of zoonosis more likely? Evidence, myths and gaps. Environment and Urbanization, 31(2), 443–460. https://doi.org/10.1177/0956247819866124
27. Snyder, R. E., Boone, C. E., Cardoso, C. A. A., Aguiar-Alves, F., Neves, F. P. G., & Riley, L. W. (2017). Zika: A scourge in urban slums. PLOS Neglected Tropical Diseases, 11(3), e0005287. https://doi.org/10.1371/journal.pntd.0005287
28. Wilkinson, A. (2020). Local response in health emergencies: Key considerations for addressing the COVID-19 pandemic in informal urban settlements. Environment & Urbanization, 32(2), 503–522. https://doi.org/10.1177/0956247820922843
29. Shafique, S., Bhattacharyya, D. S., Nowrin, I., Sultana, F., Islam, M. R., Dutta, G. K., Del Barrio, M. O., & Reidpath, D. D. (2024). Effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low- and middle-income countries: A systematic review. Systematic Reviews, 13(1), 253. https://doi.org/10.1186/s13643-024-02651-9
30. Campbell, L. (2017). Learning from the Ebola response in cities: Population movement (ALNAP Working Paper). ALNAP/ODI. https://alnap.org/help-library/resources/learning-from-the-ebola-response-in-cities-population-movement/
31. Ali, S. H., Fallah, M. P., McCarthy, J. M., Keil, R., & Connolly, C. (2022). Mobilizing the social infrastructure of informal settlements in infectious disease response – The case of Ebola virus disease in West Africa. Landscape and Urban Planning, 217, 104256. https://doi.org/10.1016/j.landurbplan.2021.104256
32. Richards, P. (2016). Ebola: How a people’s science helped end an epidemic. Zed Books.
33. Loewenson, R., Colvin, C. J., Szabzon, F., Das, S., Khanna, R., Coelho, V. S. P., Gansane, Z., Yao, S., Asibu, W. D., Rome, N., & Nolan, E. (2021). Beyond command and control: A rapid review of meaningful community-engaged responses to COVID-19. Global Public Health, 16(8–9), 1439–1453. https://doi.org/10.1080/17441692.2021.1900316
34. Abramowitz, S. A., McLean, K. E., McKune, S. L., Bardosh, K. L., Fallah, M., Monger, J., Tehoungue, K., & Omidian, P. A. (2015). Community-centered responses to Ebola in urban Liberia: The view from below. PLOS Neglected Tropical Diseases, 9(4), e0003706. https://doi.org/10.1371/journal.pntd.0003706
35. Abramowitz, S. (2017). Epidemics (especially Ebola). Annual Review of Anthropology, 46(1), 421–445. https://doi.org/10.1146/annurev-anthro-102116-041616
36. World Health Organization. (2025, April 30). WHO EPI-WIN Webinar: Empowering community health workers (CHWs) through capacity strengthening for outbreak detection and response: lessons from the field. https://www.who.int/news-room/events/detail/2025/04/30/default-calendar/who-epi-win-webinar-empowering-community-health-workers-(chws)-through-capacity-strengthening-for-outbreak-detection-and-response-lessons-from-the-field
37. Grebe, E. (2016). The ambiguities of the ‘partnership’ between civil society and the state in Uganda’s AIDS response during the 1990s and 2000s as demonstrated in the development of TASO. Global Public Health, 11(4), 496–512. https://doi.org/10.1080/17441692.2015.1062121
38. Kuhanen, J. (2008). The historiography of HIV and AIDS in Uganda. History in Africa, 35, 301–325. https://doi.org/10.1353/hia.0.0009
39. Baylor College of Medicine Children’s Foundation-Uganda. (2025, March 27). From crisis to safety: How sex workers are championing action against mpox in Kampala’s slums. https://www.baylorfoundationuganda.org/news/from-crisis-to-safety-how-sex-workers-are-championing-action-against-mpox-in-kampalas-slums/
40. Simone, A. (2021). Ritornello: “People as infrastructure”. Urban Geography, 42(9), 1341–1348. https://doi.org/10.1080/02723638.2021.1894397
41. McFarlane, C. (2023). Waste and the city: The crisis of sanitation and the right to citylife. Verso.
42. Hale, B. (2014, September 19). The most terrifying thing about Ebola. Slate. https://slate.com/technology/2014/09/why-ebola-is-terrifying-and-dangerous-it-preys-on-family-caregiving-and-human-bonds.html
43. Lipton, J. (2017). Family business: Work, neighbourhood life, coming of age, and death in the time of Ebola in Freetown, Sierra Leone [PhD thesis, London School of Economics and Political Science]. http://dx.doi.org/10.21953/lse.jpzeph36am68
44. Bjarnesen, J., & Utas, M. (2018). Introduction Urban kinship: The micro-politics of proximity and relatedness in African cities. Africa, 88(S1), S1–S11. https://doi.org/10.1017/S0001972017001115
45. Hunter, M. (2007). The changing political economy of sex in South Africa: The significance of unemployment and inequalities to the scale of the AIDS pandemic. Social Science & Medicine, 64(3), 689–700. https://doi.org/10.1016/j.socscimed.2006.09.015
46. Hunter, M. (2010). Love in the time of AIDS: Inequality, gender, and rights in South Africa. Indiana University Press.
47. Parikh, S. A. (2007). The political economy of marriage and HIV: The ABC approach, “safe” infidelity, and managing moral risk in Uganda. American Journal of Public Health, 97(7), 1198–1208. https://doi.org/10.2105/AJPH.2006.088682
48. Smith, D. J. (2007). Modern marriage, men’s extramarital sex, and HIV risk in Southeastern Nigeria. American Journal of Public Health, 97(6), 997–1005. https://doi.org/10.2105/AJPH.2006.088583
49. Hirsch, J. S., Wardlow, H., Smith, D. J., Phinney, H. M., Parikh, S., & Nathanson, C. A. (2009). The secret: Love, marriage, and HIV. Vanderbilt University Press.
50. Hunter, M. (n.d.). Beyond the male-migrant: South Africa’s long history of health geography and the contemporary AIDS pandemic. Health and Place, 16, 25–33.
51. Saleem, H. T., Zhang, L., Silberg, C., Latkin, C., & Likindikoki, S. (2021). Structural, everyday, and symbolic violence and the heightened vulnerability to HIV of women who use drugs in Tanzania. SSM – Qualitative Research in Health, 1, 100010. https://doi.org/10.1016/j.ssmqr.2021.100010
52. Mills, E. (2016). “When the skies fight”: HIV, violence and pathways of precarity in South Africa. Reproductive Health Matters, 24(47), 85–95. https://doi.org/10.1016/j.rhm.2016.04.006
53. Stoebenau, K., Heise, L., Wamoyi, J., & Bobrova, N. (2016). Revisiting the understanding of “transactional sex” in sub-Saharan Africa: A review and synthesis of the literature. Social Science & Medicine, 168, 186–197. https://doi.org/10.1016/j.socscimed.2016.09.023
54. Beyrer, C., Crago, A.-L., Bekker, L.-G., Butler, J., Shannon, K., Kerrigan, D., Decker, M. R., Baral, S. D., Poteat, T., Wirtz, A. L., Weir, B. W., Barré-Sinoussi, F., Kazatchkine, M., Sidibé, M., Dehne, K.-L., Boily, M.-C., & Strathdee, S. A. (2015). An action agenda for HIV and sex workers. The Lancet, 385(9964), 287–301. https://doi.org/10.1016/S0140-6736(14)60933-8
55. Shannon, K., Strathdee, S. A., Goldenberg, S. M., Duff, P., Mwangi, P., Rusakova, M., Reza-Paul, S., Lau, J., Deering, K., Pickles, M. R., & Boily, M.-C. (2015). Global epidemiology of HIV among female sex workers: Influence of structural determinants. Lancet (London, England), 385(9962), 55–71. https://doi.org/10.1016/S0140-6736(14)60931-4
56. Friedman, E., Gostin, L. O., & Wetter, S. (2025, March 4). Pepfar funding to fight HIV/Aids has saved 26 million lives since 2003: How cutting it will hurt Africa. The Conversation. http://theconversation.com/pepfar-funding-to-fight-hiv-aids-has-saved-26-million-lives-since-2003-how-cutting-it-will-hurt-africa-250413
57. Akingbola, A., Adegbesan, C. A., Adewole, O., Idahor, C., Odukoya, T., Nwaeze, E., Mayowa, S., Abdullahi, O., & Mariaria, P. K. (2025). Understanding the resurgence of mpox: Key drivers and lessons from recent outbreaks in Africa. Tropical Medicine and Health, 53(1), 47. https://doi.org/10.1186/s41182-024-00678-1
58. World Health Organization. (2024, October 16). Mpox. https://www.who.int/news-room/questions-and-answers/item/mpox
59. Alfers, L., Lund, F., & Moussié, R. (2017). Approaches to social protection for informal workers: Aligning productivist and human rights‐based approaches. International Social Security Review, 70(4), 67–85. https://doi.org/10.1111/issr.12153
60. Ray, I. (2007). Women, water, and development. Annual Review of Environment and Resources, 32(1), 421–449. https://doi.org/10.1146/annurev.energy.32.041806.143704
61. Manirabarusha, C. (2024, October 9). Stigma adds to Burundi’s challenges in mpox fight. Reuters. https://www.reuters.com/business/healthcare-pharmaceuticals/stigma-adds-burundis-challenges-mpox-fight-2024-10-09/

Authors: Megan Schmidt-Sane (IDS) et Annie Wilkinson (IDS).

Acknowledgements: This brief was reviewed by Hayley MacGregor (IDS), Eva Niederberger (WHO), Alice Sverdlik (University of Manchester) and Michael Kunnuji (University of Lagos). Editorial support was provided by Harriet MacLehose. This brief is the responsibility of SSHAP.

Suggested citation: Schmidt-Sane, M. and Wilkinson, A. (2025). Key considerations: Mpox response in urban informal settlements. Social Science in Humanitarian Action Platform (SSHAP). www.doi/org/10.19088/SSHAP.2025.025

Published by the Institute of Development Studies: May 2025.

Copyright: © Institute of Development Studies 2025. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.

Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).

About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.

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