Decoding the data of the Chinese mpox outbreak

This story first appeared in China Report, MIT Technology Review’s newsletter about technology developments in China. Sign up to receive it in your inbox every Tuesday.

Almost exactly a year after the World Health Organization declared mpox (formerly known as monkeypox) a public health emergency, the hot spot for the outbreak has quietly moved from the US and Europe to Asia. China in particular is experiencing a concerning increase in mpox cases right now.

This morning, I published a story on the developing mpox situation there and the government’s response so far. While Beijing did recently issue a guidance on mpox prevention, the country hasn’t taken a very proactive approach to containing the outbreak—a stark contrast from its strict covid policies (which I wrote about extensively last year).

It’s particularly worrying that the government hasn’t talked at all about using mpox vaccines, though there are three options available globally and they have proved to be effective at containing the mpox spread in countries including the United States. 

Beijing’s omission may be a result of “technology nationalism,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. But delaying the approval of effective foreign vaccines could stymie prevention and result in more dangerous outcomes, Huang warns—the same thing that happened with covid.

You can read more about the difficulties in containing the mpox spread in China in the story today. But in this newsletter, I want to highlight a different challenge: because of the way Beijing has so far reported mpox data and the way the WHO publishes it, it’s quite difficult to understand the exact scale of mpox in the country.

When I started reporting this story, I found that the only available mpox case count China has published is a one-time report tallying cases from June 2 to June 30. No information on weekly developments or cases from before or after June has been made public, even though other Asian countries, including Japan, started to see cases rise back in March. 

But when I looked up the WHO dashboard on the global mpox outbreak, with data starting in January 2022, I was surprised to find a consistent stream of new cases being reported by China several times a week, as recently as July 20.

For some time I thought this meant Chinese health authorities or researchers had been quietly reporting more timely data to the WHO while keeping the information inaccessible to the public. After all, something similar has happened before with covid data. 

Honestly, I found this data surprising and alarming. News about mpox in China has been mostly under the radar, but as the WHO overview explains: “In the most recent week of full reporting, 7 countries reported an increase in the weekly number of cases, with the highest increase reported in China.” The WHO data shows that from May to July, China reported 315 mpox cases, the most around the world in this time frame.

Sounds quite bad, right? 

It turns out the reality is a tad more complicated. On the WHO website, the recent mpox data listed under China is the sum of cases reported in China, Taiwan, and Hong Kong. 

The lack of data separation is significant here for a few reasons. First, while case counts have indeed risen in China, we don’t know by how much and over what time frame. China reported 106 cases in June alone, and it’s safe to assume there were additional cases in May and July. But there’s no information there to help us understand the exact urgency and severity of the outbreak, which can lead to panic and uninformed interventions. What’s more, as its handling of covid shows, the Chinese government may be holding onto data to serve its own interests. 

Beyond that, this combined data reporting obscures the fact that Taiwan and China, with their different governing bodies, have responded to public health emergencies in very different ways. 

While China has not signaled any interest in using mpox vaccines, Taiwan, which has its own CDC, has already administered over 72,000 shots so far. While China has only issued a one-month report of case counts, Taiwan has a public database showing how many new cases are reported each week, making it easy to see that the outbreak is on the decline there, six months after local transmission started. 

So aggregating very different sources of data creates a confusing landscape and makes it hard to follow the impact of public health measures.

This means that when the WHO data shows a 550% increase in weekly new cases in China between July 10 and July 17, the jump means little. It doesn’t reveal the direction of the mpox outbreak; it only emphasizes the broken, irregular pattern of case reporting from China. 

This is not to say the outbreak in China is insignificant, but that the data on the WHO website can easily mislead observers. 

It’s important to realize that despite how authoritative they may sound, international organizations like the WHO don’t have a magic source of data that overcomes the limited public health information coming out of China. It can only rely on individual countries to voluntarily report such data. (The WHO didn’t immediately respond to questions about its data aggregation practices; today is a public holiday in Switzerland, where it’s headquartered.)

Unfortunately, as the status of Taiwan remains one of the most sensitive security topics to Beijing, even the act of singling out the island’s public health data can be seen as a political move. That is larger than any technical obstacle. At a crucial time like this, transparent and timely case counting is one of the most important public health tools against infectious diseases. It’s too bad that politics is getting in the way of that. 

Do you think WHO should disaggregate the mpox data of China and Taiwan? What are your reasons? Tell me at zeyi@technologyreview.com.

Catch up with China

1. Chinese feminists are rushing out to support the Barbie movie. (But you can’t do a “Barbenheimer” double feature yet, since Oppenheimer isn’t arriving in China until August 30.) (Financial Times $)

2. The US government believes Chinese hackers have inserted malware into the communications, logistics, and supply networks of US military bases. (New York Times $)

3. A former party official in the city of Hangzhou, who oversaw the rise of tech giant Alibaba, was imprisoned for life for taking $25 million in bribes. (Bloomberg $)

4. Volkswagen bought a 5% stake in the Chinese electric vehicle company Xpeng, and the companies will jointly develop two EV models under the Volkswagen brand. (Wall Street Journal $)

5. TikTok’s newly launched ad library in Europe shows that Chinese major state media have run over 1,000 ads on the platform, even though TikTok’s policy forbids political ads. (Forbes)

6. Shein spent $600,000 on lobbying activities between April 1 and June 30, nearly three times its lobbying spending in the first quarter. (Business of Fashion)

7. China will restrict the export of long-range civilian drones, citing concerns that they might be converted to military use. (Associated Press)

8. A Taiwanese businessman accused of espionage and stealing state secrets was freed after two years in a Chinese jail. (BBC)

Lost in translation

A new AI photo generator app called 妙鸭相机 (Miaoya Camera), developed with support from a Alibaba-owned company, is all the rage in China right now. Users can upload 21 photos with their faces to create personalized portraits that look as if they were created by a professional. It’s priced at just 9.9 RMB ($1.38), a tiny fraction of what chain photography studios often charge. (These studios have become a popular business in recent years.)

Experts told Chinese publication Southern Metropolis Daily that the technology Miaoya Camera uses—mostly the open-source model Stable Diffusion and a technique called “low-rank adaptation of large language models” to improve the result—is nothing groundbreaking but just well packaged for the user experience. Expectedly, a controversy then arose about the broad data use permissions in the app’s user agreement; the app apologized and promised it will use personal data only to generate profile photos.

One more thing

These Barbies and Kens are from Dongbei, the northeastern region of China, where food portions are gigantic and people are often stereotyped as being straightforward and tough. (Sort of like the Texas of China, you know.) But really, these are created by an AI artist, Kim Wang, through Midjourney. I talked to Wang in a story earlier this year about using Midjourney to reimagine Chinese history.

China is suddenly dealing with another public health crisis: mpox

Hazmat suits, PCR tests, quarantines, and contact tracing—it was hard not to feel déjà vu last week when China’s Center for Disease Control and Prevention published new guidance on how to contain a disease outbreak. 

But what was happening was not another covid wave. Rather, the Chinese government was addressing a potentially significant new public health concern: mpox. The World Health Organization reports China is currently experiencing the world’s fastest increase in cases of mpox (formerly known as monkeypox), and the country needs to act fast to contain the spread.

While the Americas and Europe have mostly contained the mpox outbreak that started in mid-2022, Asia has emerged as the disease’s new hot spot. Japan, South Korea, and Thailand, which all saw sporadic imported cases last year, have reported weekly new case numbers in the double digits in 2023, meaning the virus has been spreading in the domestic population. But according to the latest data reported to the WHO, China has surpassed all other countries in the world, with 315 confirmed cases in just the past three months—though irregular case reporting from Beijing means it’s impossible to know the true scale of the disease at this point.  

Mpox is less contagious than covid, but since 2022, more than 88,000 people have contracted the disease, which can be painful and even debilitating for some. More than 150 people have died. Some countries have been more successful than others at containing domestic mpox outbreaks—and much of their success is arguably a result of proactive measures like vaccination campaigns.

But the Chinese government has barely started to take action. 

“Compared with the response to covid-19 … the [Chinese] response is certainly dramatically different,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. “Even though [mpox] is less likely to develop into a large outbreak in the country, the Pollyanna attitude may encourage the spread of the disease among the at-risk population—unless they take a more active campaign against the disease.”

How it’s spreading now

In May, the WHO declared that mpox was no longer a public health emergency of international concern (PHEIC) because cases had gone down significantly in countries that had seen large outbreaks last year, mostly in the Americas and Europe. (Mpox has been endemic in West and Central Africa for decades and remains so.) 

“Overall, compared to where we were last year, we’re definitely in a different place,” says Krutika Kuppalli, an infectious-disease physician and chair of the Infectious Disease Society of America’s Global Health Committee. “We have much fewer cases, but we are seeing sporadic outbreaks in different parts of the world.” 

Indeed, by the time the WHO rescinded the PHEIC declaration, many Asian countries were already starting to see an uptick. Japan was the first Asian country to report a significant increase in mpox cases, in March. In May, a report by researchers in the country warned that the disease could surge across Asia, owing to the connectedness between Japan and other Asian countries and the low mpox vaccination rate in the region. If the outbreak grows to the level that it did in the West, the researchers noted, over 10,000 cases might be expected in Japan alone before mpox is successfully contained.

It’s less clear what exactly is happening in China. According to data collected by the WHO, China reported 315 new mpox cases from May to July. A case count this high suggests that not all cases were travel related.

But—in another situation reminiscent of its covid response—China isn’t as forthcoming as other countries with its disease data; it doesn’t publish weekly reports of new cases. Rather, it has released a one-time report of the number of mpox cases recorded in June: 106. The Chinese government didn’t release data from May, and hasn’t released any data about July cases yet. 

The WHO, though, lumps together the case counts from Taiwan, which has its own government and CDC, and Hong Kong under the name of China. And there’s no way for the public to separate the data. So the 315 number includes the 106 cases Beijing says it identified in July, plus the number of infections in Taiwan and Hong Kong over May, June, and July. 

This all further obscures the true toll of mpox in China—even though it’s critical during an infectious-disease outbreak to be on top of things as soon as possible. 

“We also need to understand more about the people that have been infected,” Kuppalli says, “such as … the demographics, the clinical presentation, their immune status, and about how they’ve been presenting to care. I think that type of information is important.”

A muddled response that makes LGBTQ communities a target

The lack of clarity on how the disease has spread has caused some Chinese people to panic. The news that mpox cases have started to appear in the country has been circulating for weeks. But not until July 26 did China’s CDC and health ministry co-publish a new guidance on how to prevent its spread, and even that left unanswered questions. 

The directive asked that all confirmed mpox patients transfer to a medical facility for quarantine unless they have only mild symptoms. It said contact tracing going back three weeks would be conducted for every patient, and their close contacts would be asked to self-quarantine for three weeks. It also recommended that local authorities monitor the mpox virus level in wastewater around certain areas.

What makes monitoring the outbreak more difficult in China is that, as in the West, the current mpox spread has been seen mostly among communities of men who have sex with men (MSM). And similar to what happened in the US and Europe, that association is consistently misinterpreted in China to suggest that mpox is only an STD spread by gay men through sexual activities—a particularly dangerous connection, as the LGBTQ community is increasingly targeted in the country. 

Many Chinese social media users who have spotted men with skin lesions in public have been posting their photos to ask whether it’s an mpox symptom. And the Chinese name for mpox—猴痘, or houdou—has also been thrown around casually as a slur against gay men.

To efficiently stop the spread of mpox, public health officials need to strike a delicate balance between destigmatizing the disease by dispelling the idea that it affects only gay men and prioritizing the MSM communities that are most vulnerable to it. 

“Working with the people that are affected, helping to have non-stigmatizing language and communication, has been hugely effective in helping to curb the outbreak” in the West, Kuppalli says. 

So far, some local LGBTQ communities in China feel they’re on their own. 

M, who works for a queer rights organization in Guangzhou and asked to be identified only by his first initial given the sensitivity of his work, points out that the CDC recommended wastewater monitoring specifically near venues that MSM communities frequent, including bars, clubs, and saunas. He says this has become controversial within the Chinese LGBTQ community, and that some organizers feel this puts a target on their backs. 

Another LGBTQ organizer, Suihou, who works in the central province of Hubei and asked to be identified by a pseudonym, tells MIT Technology Review that even though contact tracing information is supposed to be strictly confidential, he has seen one example in which an mpox patient’s private information, including phone number, national ID, address, and HIV status, was leaked and passed around on social media.

Organizers like M and Suihou are doing their own work to mobilize a disease response. To spread information about mpox prevention, M has recently sent text messages to 700 people and hosted in-person lectures that reached over 900 people.

And Suihou has worked with one mpox patient closely, helping him get testing and treatment. Not all the medical workers they’ve encountered have been trained on how to handle the sensitivity of these cases, he says; during the contact tracing process, the doctor told the patient that this disease is a problem for “your kind of people.”

Suihou warns that some people may avoid seeking medical help altogether, particularly given the lack of state support for mandatory quarantine and contact tracing. 

“From the individual cases that I have heard of, everyone who has a confirmed case is being asked to go to a quarantine facility,” Suihou says. But, he explains, since the government has not provided a budget to help cover the quarantine, as it did with covid, patients have no choice but to pay for the hospital stay and all medical tests out of their own pockets. Many marginalized individuals, who are also more vulnerable in an infectious-disease outbreak, may not be able to afford that.

“With the slowdown of the [Chinese] economy, local governments don’t have the physical capacity or even the willingness to invest more in public health,” Huang explains. Even the WHO doesn’t have funding specifically earmarked for mpox prevention; it has been using its emergency fund to cover mpox-related work. 

A lot of the financial burden will again fall on local organizers. M tells me that his organization is using funds intended for HIV prevention to conduct mpox outreach work.

All of this could further disincentivize people who get infected from seeking medical tests and treatment. This in turn would make the community spread of mpox even harder to track—and could undermine prevention efforts taken so far.

A lack of available vaccines

Much as with covid, vaccination is one of the best ways to get mpox under control. Worldwide, three vaccines are currently being used for mpox prevention: ACAM2000, MVA-BN (also known as JYNNEOS in the US), and Lc16m8. All these vaccines were originally designed for protection against smallpox but have been found effective against mpox. 

The US has administered more than 1.2 million JYNNEOS and ACAM2000 shots. And in Asia, South Korea imported 10,000 JYNNEOS shots last year and is planning to procure another 20,000 this year, while Taiwan, despite its small size, has procured and administered over 72,000 JYNNEOS shots so far. Japan, meanwhile, has relied on a Japanese company to produce its own Lc16m8, while also donating doses of the vaccine to countries including Colombia.

But none of these vaccines have been approved for use in China. The situation recalls how China refused to import any mRNA covid vaccines, instead relying on a few homegrown vaccines that were shown to be less effective. In this case, though, the country doesn’t currently produce any of its own smallpox vaccines; production was terminated after smallpox was eradicated globally in 1980. 

Bavarian Nordic, the Danish company that produces the JYNNEOS vaccine, tells MIT Technology Review that it can’t disclose client information unless requested by the government and can’t confirm whether China has procured any JYNNEOS shots. But it says the company is not in the process of applying to register the vaccine in China.

The WHO also has a sharing mechanism in place that allows member states to receive vaccines if needed. But it’s unclear whether China has applied for mpox vaccines. The organization did not immediately respond to an inquiry about whether there are plans to send vaccines to China.

The new Chinese CDC guidance on mpox made no mention of any vaccine as part of its outbreak response. “It’s quite unlikely that China will focus on procuring vaccines at this moment, since there’s no precedent and [no] emergency approval of the vaccines. Rather, there seems to be a focus on surveillance, monitoring, quarantine, contact tracing, etc.,” says Zoe Leung, a senior associate at Bridge Consulting, a Beijing-based communication consultancy specializing in public health.

It may not be this way forever: Sinopharm, a Chinese state-owned pharmaceutical company, announced last November that it had developed the world’s first mRNA vaccine against mpox, and it has been found effective in preclinical studies. On July 13, Sinopharm officially applied for clinical trial approval for a “replication-defective mpox vaccine,” though it’s unclear whether these are the same products. Sinopharm did not immediately reply to questions about its mpox vaccine development.

“There is domestic research [on a mpox vaccine], but we don’t know when it can be commercially available. It will take a long time,” says M, the organizer in Guangzhou. “I have some friends who have already traveled to Hong Kong or Macau to get vaccinated for mpox.” 

But for Chinese people to get vaccinations outside mainland China, there is often a high cost, a long wait time, and layers of bureaucracy to wade through. It’s again similar to trends seen earlier in the pandemic, when Chinese people with means traveled to Hong Kong to get mRNA covid vaccines.

“It doesn’t necessarily mean [Beijing is] not interested in vaccines,” says Huang, “but there’s this technology nationalism that discouraged them from rapid approval of the use of foreign vaccines.” And that, he warns, “certainly contributed to the rapid increase in covid-related mortalities.”