Summary

• An International outbreak of Monkeypox was confirmed in Europe on 19th May 2022.
• This is the first outbreak without a clear connection to the regions where Monkeypox is endemic.
• The illness has been spread in mass gatherings in Europe.
• Human to human transmission occurs through large respiratory droplets (coughing, sneezing) or direct contact with skin lesions or bodily fluids.
• No travel restrictions have been implemented as of 26th May 2022.

Situation

During May 2022 Monkeypox spread quickly outside the regions where the illness is endemic. Since the discovery of the illness in 1958, there have been several instances where Monkeypox has been detected in Europe and North America, the first instance was reported in 2003.

The difference between the current outbreak and previous outbreaks is not only the regional aspect but the number of patients and the pattern of spreading. Whereas the previous outbreaks have been directly linked to West or Central Africa, the outbreak in May 2022 appears to have been spread from person to person in Europe, by individuals without a known travel history to Africa.

On 7th May 2022 the UK Health Security Agency (UKHSA) reported the first active case of the illness. This was followed by two more cases on 14th May, although these cases did not appear to be connected. On 16th May, UKHSA reported four new infections, however these were not connected to the previous four cases but connected to each other. On 18th May Portugal confirmed five infected patients, with several additional suspected cases, and at the same time Spain was said to be investigating possible infections.

By 19th May The European Centre for Disease Prevention and Control (ECDC) reported 38 cases internationally, with 26 of these within the European Union (EU). The outbreak was linked to several mass gatherings in Spain and Belgium, and most of the patients were young males, the majority self-identifying as being part of the LGBTQ community. None of the individuals had recent travel history to the regions where Monkeypox is endemic.

On 25th May, ECDC reported 219 confirmed cases globally, and 112 active cases within the European Economic Area, however there were no recorded fatalities. This outbreak is the first time the transmissions have been confirmed outside of the endemic regions, and there is a clear human to human transmission chain.

Monkeypox is a viral zoonosis illness. This means that the infection can be passed from infected animals to humans. It is caused by a virus belonging to the Orthopoxvirus genus. The majority of cases occur in West and Central Africa, where several thousand infections are reported every year. Since 2003 there has been a dramatic increase in the infection rate, and it is now considered endemic to Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Ghana, Ivory Coast, Liberia, Nigeria, the Republic of the Congo, Sierra Leone, and South Sudan. A large proportion of cases are reported in the Democratic Republic of the Congo.

Most infections occur because of contact between humans and wild animals. The transmission can occur by bite or scratch, bushmeat preparation, direct contact with body fluids or lesion material, or indirect contact with lesion material, such as through contaminated bedding. The source of bushmeat is wild animals, and among these are rodents such as squirrels, rats and mice which are known as carriers of the virus.

Transmission between humans is thought to occur primarily through large respiratory droplets. Respiratory droplets usually can’t travel more than a few feet, so prolonged face-to-face contact is required. Alternative human transmission includes direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linen.

The most common symptoms of the illness are fever, intense headaches, swelling of lymph glands, muscle aches, and fatigue. The symptoms will usually occur between 6 to 13 days following the infection. After 1-3 days after the onset of fever, skin eruptions can begin. The rash starts as raised red spots, which turn into small blisters filled with fluid, usually on the face, groin, hands and feet. The blisters eventually form scabs, which later fall off. In endemic countries without a developed healthcare system Monkeypox has a mortality rate between 3 and 6%.

Analysis and Implications

The International Monkeypox outbreak in May 2022 has been linked to several mass gatherings in Europe following the end of the Covid-19 restrictions. The outbreak differs from previous outbreaks as it is not a result of contact between the patients and wild animals but between humans, and the transmission has occurred in a region where the virus is not endemic.

European and International Health organizations have issued warnings and provided advice that infected individuals should report their situation to health professionals and self-isolate.

Authorities are monitoring the situation but have so far expressed that they do not think this will result in an international crisis, as the virus does not spread easily.

Travellers are still advised to be cautious and follow good hygienic practices when travelling to areas where Monkeypox is endemic.

Individual countries are also taking precautions and vaccines have been bought by several states with the possibility to distribute to vulnerable groups.

The implications of the outbreak are still not clear. No travel restrictions have been issued as a result of Monkeypox, but as Europe is moving into the summer season with a large number of mass gatherings and festivals, the World Health Organization has warned there might be an increase in the number of infections.

If there is a steep infection rate during the summer season, health authorities can be expected to take further steps to contain the spreading.