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Disease experts offer early ideas about why Europe's monkeypox outbreak has swelled

In a matter of weeks, around 80 new cases of monkeypox have been reported across eight European countries, an unprecedented outbreak of a disease that rarely spreads outside central and western Africa. A handful of additional cases have been reported in the U.S., Canada and Australia since Wednesday.

The growing case tally has raised questions among disease experts about the nature of monkeypox's transmission, since many of the patients have no history of travel to Africa or known exposure to an infected person.

"How they initially got infected and why it's all over the place is still a mystery," said Dr. Stuart Isaacs, an associate professor of medicine at the University of Pennsylvania.

Monkeypox doesn't easily jump from person to person. Until now, most infections occurred among people who'd been exposed to an infected animal through bites, scratches or the preparation of meat from wild game, experts said. The most notable outbreak in the Western Hemisphere occurred in 2003, when pet prairie dogs infected 47 people in the U.S.

From past instances of human-to-human transmission, scientists have learned that the virus spreads through the exchange of large respiratory droplets or via direct contact with bodily fluids, lesions that form during infection, or contaminated items like clothing or bedding. Monkeypox isn't considered a sexually transmitted infection, but it could be passed during sexual encounters, experts said.

Many of the recent cases in Europe are among men who have sex with men, and a Friday alert from the Centers for Disease Control and Prevention suggested that some recent cases started out with lesions around the anus and genitals.

"I'm guessing that sexual transmission will be high on the list of potential culprits," said Dr. Grant McFadden, director of the Biodesign Center for Immunotherapy, Vaccines and Virotherapy at Arizona State University.

McFadden, Isaacs and several other experts offered their early ideas about to how and why the new outbreak has swelled.

McFadden said the genetic sequence of the monkeypox virus that has infected people in Europe looks relatively run-of-the-mill. That's a clue that human behavior, rather than inherent changes in the virus itself, might be driving the new cases.

"It could be just a simple, accidental chain, for example, into the gay community," McFadden said.

Viruses often transmit more easily within tight-knit groups of people. According to, a group that gathers infectious disease data, all of the recent monkeypox cases for which gender has been reported have been male.

"You could imagine one person had it and, if they’re part of a small, intimate group of people, could have spread it amongst those connections," said Dr. David Evans, a virologist at the University of Alberta.

But that doesn’t explain why the cases are so geographically dispersed. And the experts also agreed that it's premature to suggest monkeypox is solely spreading within any one community. It will be important to pinpoint the first case of human-to-human transmission and study it, they said, to determine how the outbreak started.

Some experts hypothesized that the loosening of international travel restrictions may have contributed to the spread.

"It kind of looks like the virus always had this potential capacity" for human-to-human transmission, McFadden said. "It just never had the opportunity in the past — or if it did, it quickly petered out and we never really saw it as an event. Whereas now with people being able to travel all over the world, it's entirely possible we're actually seeing it for the first time in a larger context."

Most people who get monkeypox make full recoveries. In the past, just 1 percent of people who've gotten the West African strain responsible for the new outbreak have died. But a different lineage of the virus, the Congo Basin clade, has killed closer to 10 percent, according to the World Health Organization.

Monkeypox belongs to the poxvirus family, which includes smallpox. Smallpox vaccines are around 85 percent effective at preventing monkeypox, the WHO estimates. But the U.S. stopped vaccinating the public for smallpox in 1972, and global vaccination ceased around 1980, when smallpox was eradicated worldwide.

So people have less immunity to poxviruses overall than in decades past.

"We no longer have immunity and therefore we're going to continue to see cases emerge — and more of them over time," said Anne Rimoin, an epidemiology professor at the University of California, Los Angeles Fielding School of Public Health.

Isaac said diminished population immunity could also explain why Africa has recorded more monkeypox cases in recent years. The Democratic Republic of the Congo reported up to 18,000 confirmed or suspected monkeypox cases from 2010 to 2019, but fewer than 10,000 between 2000 and 2009. In 2020 alone, the country reported more than 6,000 suspected cases, according to the WHO.

Monkeypox may have started spreading in Europe a while before it landed on scientists' radars, several experts suggested.

"Because of the geographically dispersed nature of the cases across Europe and beyond, this suggests that transmission may have been ongoing for some time," Dr. Hans Kluge, WHO Regional Director for Europe, said in a statement on Friday.

Isaacs said doctors can sometimes miss a monkeypox case because the rash looks similar to chickenpox, syphilis or herpes.

"Most doctors and clinics are not thinking about monkeypox," he said. "It may have been brewing over time and just no one thought to identify or think about this."

That's especially likely if a patient has mild disease, McFadden said. So far, that's been the case among most of the new infections, according to reports from the U.S., Belgium, Canada, Germany and Portugal. No recent deaths have been reported.

"If it was particularly mild, someone may not really have really noticed much and didn't think much of what was going on and then spread it amongst their their social group," Evans said.

Source: Disease experts offer early ideas about why Europe's monkeypox outbreak has swelled

WHO calls emergency meeting as monkeypox cases top 100 in Europe

  • Cases in nine European countries, North America, Australia
  • Cause still unclear
  • WHO holds emergency meeting to discuss cases
  • Germany says biggest outbreak ever in Europe
  • LONDON, May 20 (Reuters) - The World Health Organization was holding an emergency meeting on Friday to discuss the recent outbreak of monkeypox, a viral infection more common to west and central Africa, after over 100 cases were confirmed or suspected in Europe.

    In what Germany described as the largest outbreak in Europe ever, cases have been reported in at least nine countries – Belgium, France, Germany, Italy, the Netherlands, Portugal, Spain, Sweden and the United Kingdom - as well as the United States, Canada and Australia.

    Spain reported 24 new cases on Friday, mainly in the Madrid region where the regional government closed a sauna linked to the majority of infections. read more

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    A hospital in Israel was treating a man in his 30s who is displaying symptoms consistent with the disease after recently arriving from Western Europe.

    First identified in monkeys, the disease typically spreads through close contact and has rarely spread outside Africa, so this series of cases has triggered concern.

    However, scientists do not expect the outbreak to evolve into a pandemic like COVID-19, given the virus does not spread as easily as SARS-COV-2.

    Monkeypox is usually a mild viral illness, characterised by symptoms of fever as well as a distinctive bumpy rash.

    "This is the largest and most widespread outbreak of monkeypox ever seen in Europe," said Germany's armed forces' medical service, which detected its first case in the country on Friday.

    The World Health Organisation (WHO) committee meeting to discuss the issue is the Strategic and Technical Advisory Group on Infectious Hazards with Pandemic and Epidemic Potential (STAG-IH), which advises on infection risks that could pose a global health threat.

    It would not be responsible for deciding whether the outbreak should be declared a public health emergency of international concern, WHO's highest form of alert, which is currently applied to the COVID-19 pandemic.

    "There appears to be a low risk to the general public at this time," a senior U.S. administration official said. read more


    Fabian Leendertz, from the Robert Koch Institute, described the outbreak as an epidemic.

    "However, it is very unlikely that this epidemic will last long. The cases can be well isolated via contact tracing and there are also drugs and effective vaccines that can be used if necessary," he said.

    Still, the WHO's European chief said he was concerned that infections could accelerate in the region as people gather for parties and festivals over the summer months. read more

    A section of skin tissue, harvested from a lesion on the skin of a monkey, that had been infected with monkeypox virusA section of skin tissue, harvested from a lesion on the skin of a monkey, that had been infected with monkeypox virus, is seen at 50X magnification on day four of rash development in 1968. CDC/Handout via REUTERS

    There is no specific vaccine for monkeypox, but data shows that the vaccines used to eradicate smallpox are up to 85% effective against monkeypox, according to the WHO.

    British authorities said they have offered a smallpox vaccine to some healthcare workers and others who may have been exposed to monkeypox. read more

    Since 1970, monkeypox cases have been reported in 11 African countries. Nigeria has had a large ongoing outbreak since 2017. So far this year, there have been 46 suspected cases, of which 15 have since been confirmed, according to the WHO.

    The first European case was confirmed on May 7 in an individual who returned to England from Nigeria.

    Since then, over 100 cases have been confirmed outside Africa, according to a tracker by a University of Oxford academic.

    Many of the cases are not linked to travel to the continent. As a result, the cause of this outbreak is unclear, although health authorities have said that there is potentially some degree of community spread.


    The WHO said the early cases were unusual for three reasons: All but one have no relevant travel history to areas where monkeypox is endemic; most are being detected through sexual health services and among men who have sex with men, and the wide geographic spread across Europe and beyond suggests that transmission may have been going on for some time.

    In Britain, where 20 cases have been now confirmed, the UK Health Security Agency said the recent cases in the country were predominantly among men who self-identified as gay, bisexual or men who have sex with men.

    Portugal detected nine more cases on Friday, taking its total to 23.

    The previous tally of 14 cases were all detected in sexual health clinics and were men aged between 20 and 40 years old who self-identified as gay, bisexual or men who have sex with men.

    It was too early to say if the illness has morphed into a sexually transmitted disease, said Alessio D'Amato, health commissioner of the Lazio region in Italy. Three cases have been reported so far in the country. read more

    "The idea that there's some sort of sexual transmission in this, I think, is a little bit of a stretch," said Stuart Neil, professor of virology at Kings College London.

    Scientists are sequencing the virus from different cases to see if they are linked, the WHO has said. The agency is expected to provide an update soon.

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    Reporting by Jennifer Rigby and Natalie Grover in London; additional reporting by Emma Pinedo Gonzalez, Emma Farge, Catriona Demony, Patricia Weiss, Eric Beech, Dan Williams and Michael Erman; Writing by Josephine Mason and Costas Pitas; Editing by Nick Macfie, David Clarke and Bill Berkrot

    Our Standards: The Thomson Reuters Trust Principles.

    Source: WHO calls emergency meeting as monkeypox cases top 100 in Europe

    African Scientists Baffled By Monkeypox Cases In Europe, US

    LONDON (AP) — Scientists who have monitored numerous outbreaks of monkeypox in Africa say they are baffled by the disease’s recent spread in Europe and North America.

    Cases of the smallpox-related disease have previously been seen only among people with links to central and West Africa. But in the past week, Britain, Spain, Portugal, Italy, U.S., Sweden and Canada all reported infections, mostly in young men who hadn’t previously traveled to Africa.

    France, Germany, Belgium and Australia confirmed their first cases Friday.

    “I’m stunned by this. Every day I wake up and there are more countries infected,” said Oyewale Tomori, a virologist who formerly headed the Nigerian Academy of Science and who sits on several World Health Organization advisory boards.

    “This is not the kind of spread we’ve seen in West Africa, so there may be something new happening in the West,” he said.

    To date, no one has died in the outbreak. Monkeypox typically causes fever, chills, a rash and lesions on the face or genitals. WHO estimates the disease is fatal for up to one in 10 people, but smallpox vaccines are protective and some antiviral drugs are being developed.

    British health officials are exploring whether the disease is being sexually transmitted. Health officials have asked doctors and nurses to be on alert for potential cases, but said the risk to the general population is low. The European Center for Disease Control and Prevention recommended all suspected cases be isolated and that high-risk contacts be offered smallpox vaccine.

    Nigeria reports about 3,000 monkeypox cases a year, WHO said. Outbreaks are usually in rural areas, when people have close contact with infected rats and squirrels, Tomori said. He said many cases are likely missed.

    Dr. Ifedayo Adetifa, head of the country’s Center for Disease Control, said none of the Nigerian contacts of the British patients have developed symptoms and that investigations were ongoing.

    WHO’s Europe director, Dr. Hans Kluge, described the outbreak as “atypical,” saying the appearance of the disease in so many countries across the continent suggested that “transmission has been ongoing for some time.” He said most of the European cases are mild.

    On Friday, Britain’s Health Security Agency reported 11 new monkeypox cases, saying that “a notable proportion” of the most recent infections in the U.K. and Europe have been in young men with no history of travel to Africa who were gay, bisexual or had sex with men.

    Authorities in Spain and Portugal also said their cases were in young men who mostly had sex with other men and said those cases were picked up when the men turned up with lesions at sexual health clinics.

    Experts have stressed they do not know if the disease is being spread through sex or other close contact related to sex.

    Nigeria hasn’t seen sexual transmission, Tomori said, but he noted that viruses that hadn’t initially been known to transmit via sex, like Ebola, were later proven to do so after bigger epidemics showed different patterns of spread.

    The same could be true of monkeypox, Tomori said.

    In Germany, Health Minister Karl Lauterbach said the government was confident the outbreak could be contained. He said the virus was being sequenced to see if there were any genetic changes that might have made it more infectious.

    Rolf Gustafson, an infectious diseases professor, told Swedish broadcaster SVT that it was “very difficult” to imagine the situation might worsen.

    “We will certainly find some further cases in Sweden, but I do not think there will be an epidemic in any way,” Gustafson said. “There is nothing to suggest that at present.”

    Scientists said that while it’s possible the outbreak’s first patient caught the disease while in Africa, what’s happening now is exceptional.

    “We’ve never seen anything like what’s happening in Europe,” said Christian Happi, director of the African Centre of Excellence for Genomics of Infectious Diseases. “We haven’t seen anything to say that the transmission patterns of monkeypox have been changing in Africa. So if something different is happening in Europe, then Europe needs to investigate that.”

    Happi also pointed out that the suspension of smallpox vaccination campaigns after the disease was eradicated in 1980 might inadvertently be helping monkeypox spread. Smallpox vaccines also protect against monkeypox, but mass immunization was stopped decades ago.

    “Aside from people in west and Central Africa who may have some immunity to monkeypox from past exposure, not having any smallpox vaccination means nobody has any kind of immunity to monkeypox,” Happi said.

    Shabir Mahdi, a professor of vaccinology at the University of Witwatersrand in Johannesburg, said a detailed investigation of the outbreak in Europe, including determining who the first patients were, was now critical.

    “We need to really understand how this first started and why the virus is now gaining traction,” he said. “In Africa, there have been very controlled and infrequent outbreaks of monkeypox. If that’s now changing, we really need to understand why.”

    Geir Moulson in Berlin, Jan M. Olsen in Copenhagen, Chinedu Asadu in Lagos, Nigeria, and AP reporters across Europe contributed to this report.

    The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

    Source: African Scientists Baffled By Monkeypox Cases In Europe, US

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