Perspectives on wastewater surveillance of mpox: Current methods and future needs

The global resurgence of mpox (monkeypox) underscores the need for rapid detection of the mpox virus (MPXV). Clinical surveillance underreports cases because of the self-limiting nature of MPXV and social stigma. Wastewater-based surveillance (WBS) offers a complementary tool for population-level monitoring and overcomes individual testing barriers. However, the detection of MPXV in wastewater is hindered by low viral loads, complex sample matrix, and a lack of standardized methods. This review summarizes recent advances and challenges in WBS of MPXV, including sampling, sample treatment, nucleic acid amplification and detection, and data interpretation. We emphasize the efficient recovery of viral components (virions and nucleic acids), removal of inhibitors, and use of appropriate controls for method validation. We describe an analytical framework combining composite sampling, viral release and concentration, nucleic acid extraction, isothermal amplification, and molecular detection. Developing robust, field-deployable methods remains a key priority.