2022–2023 mpox outbreak

2022 monkeypox outbreak
Spread of disease as of 2 August 2022   Endemic West African clade   Endemic Congo Basin (Central African) clade   Both clades recorded   West African clade outbreak in 2022   Suspected cases
Disease	Human monkeypox
Virus strain	Monkeypox virus (MPV), West African clade, 2017–2019 outbreak subclade
Source	Travel from Nigeria (presumed/hypothesis)
Location	82 countries and territories (see § Cases per country and territory) (80 have confirmed cases while 2 have only suspected cases)
First outbreak	London, United Kingdom (first outside West Africa)
Date	4 May 2022 – present
Confirmed cases	25,480
Suspected cases‡	1,138
Deaths	11 (Nigeria (3), Central African Republic (2), Spain (2), Brazil (1), Ghana (1), India (1), Peru (1)
‡Suspected cases have not been confirmed by laboratory tests as being due to this strain, although some other strains may have been ruled out.

An ongoing outbreak of monkeypox, a viral disease, was confirmed in May 2022. The initial cluster of cases was found in the United Kingdom, where the first case was detected on 6 May 2022 in an individual with travel links to Nigeria (where the disease is endemic). The outbreak marked the first time monkeypox has spread widely outside Central and West Africa. From 18 May onwards, cases were reported from an increasing number of countries and regions, predominantly in Europe but also in North and South America, in Asia, in Africa, and in Oceania. On 23 July, the World Health Organization (WHO) declared the outbreak a public health emergency of international concern (PHEIC), raising the status of the outbreak to a global health emergency. As of 2 August, there were a total of 25,436 confirmed cases in nearly 80 countries that do not typically see cases.

Monkeypox is a viral infection that manifests a week or two after exposure with fever and other non-specific symptoms, and then produces a rash with lesions that usually last for 2–4 weeks before drying up, crusting and falling off. While monkeypox can cause large numbers of lesions, in the current outbreak, some patients experience only a single lesion in the mouth or on the genitals, making it more difficult to differentiate from other infections. In infections before the current outbreak, 1–3 percent of people with known infections have died (without treatment). Cases in children and immunocompromised people are more likely to be severe.

Monkeypox spreads through close, personal, often skin-to-skin contact. The disease can spread through direct contact with rashes, or body fluids from an infected person, by touching objects and fabrics that have been used by someone with monkeypox or through respiratory secretions. An infected person can spread it to others from the time symptoms start until the rash has fully healed. As of 21 July, 98% of reported cases outside endemic regions in Africa occurred in the community of men who have sex with men, particularly those with multiple sexual partners, 75% occurred in white people, and 41% in people with HIV/AIDS. The Centers for Disease Control and Prevention has emphasized the importance of reducing stigma in communicating about the demographic aspects of monkeypox, specifically with regards to gay and bisexual men.

Background

These paragraphs are an excerpt from Mpox.[edit]

Emergency preparedness

In March 2021, the Nuclear Threat Initiative led a tabletop exercise at the Munich Security Conference simulating hypothetical public health responses to the release of a genetically manipulated strain of monkeypox.

On 23 July 2022, the World Health Organization (WHO) declared the monkeypox outbreak as a global health emergency as the number of infected cases rose above 17,000 people.

Cases and deaths in endemic African countries

The Africa Centres for Disease Control and Prevention has alerted several members of the African Union in May 2022 about cases of monkeypox. The director of the Africa CDC, Ahmed Ogwell, said that Cameroon, Central African Republic, the Democratic Republic of Congo and Nigeria have reported 1,405 endemic cases with 62 deaths during the first five months of 2022. The case fatality rate in these four African countries combined is 4.4%.

In an article in The Conversation, Oyewale Tomori pointed out that the number of monkeypox infections in Nigeria through 2021 is likely to be under-reported because much of the Nigerian population has been avoiding healthcare facilities due to fear of contracting COVID-19. Nigeria's surveillance of various diseases, including monkeypox, had to focus on the global COVID-19 pandemic in 2020 and 2021, missing many cases and resulting in a drop in official statistics. As British health authorities reported the first case of monkeypox in the UK in May 2022, the Nigerian government has released to the public information and statistics on reported cases and deaths in the country. In the report of 9 May 2022, the NCDC stated that 230 cases were confirmed across 20 states and the Federal Capital Territory between 2017 and 2022. Rivers State was the most affected, followed by Bayelsa and Lagos. In the span from 2017 to 2022, the NCDC reported six deaths in six different states, making for a 3.3% case fatality ratio. On 30 May, the first death from monkeypox was reported in Nigeria during 2022; the last time a death was reported in the country from this disease was in 2019. On 20 July 2022, the World Health Organization reported that there had been 5 deaths in endemic African nations during the outbreak.

The following table shows 2022 cases in countries which experienced endemic monkeypox before the current outbreak, as of 17 June according to the WHO:

Cases per country (endemic African countries)

Country	Confirmed	Probable	Suspected	Total	Data taken	Clade	Deaths
Benin	3	0	0	3	1 June 2022 – 26 June 2022	West
Cameroon	Total: 3 Centre: 1 Southwest: 2	0	28	31	1 January 2022 – 2 June 2022	West & Central
Central African Republic	Total: 8 Alindao: 1 Bimbo: 1 Mbaïki: 6	0	17	25	4 March 2022 – 23 May 2022	Central	2
Republic of the Congo	Total: 2 Likouala 2	0	7	9	1 January 2022 – 30 May 2022	Central
Democratic Republic of the Congo	107	0	Total: 1476 Maniema: 182 Sankuru: 525 Sud-Ubangi: 111 Tshopo: 198 Tshuapa: 123 Rest of Provinces: 309	1583	1 January 2022 – 26 June 2022	Central
Liberia	1	0	4	5	23 July 2022	West
Nigeria	Total: 62 Adamawa: 5 Bayelsa: 4 Cross River: 2 Delta: 3 FCT: 2 Imo: 2 Kano: 2 Lagos: 8 Nasarawa: 1 Plateau: 2 Niger: 1 Ogun: 1 Osun: 1 Oyo 1 Rivers: 3 State not specified: 24	0	207	269	1 January 2022 – 19 June 2022	West	3
Sierra Leone	0	0	2	2	—	West
Total	186	0	1741	1927			5

Deaths outside of endemic Africa

The first death outside of endemic Africa was reported in Brazil on 29 July 2022, in a 41-year-old man with underlying comorbidities. On the same day Spain reported its first death, a 44-year-old man in Alicante, with the cause a death being encephalitis associated with monkeypox infection. Spain reported its second monkeypox-related death on 30 July 2022, in a 31-year-old man in Córdoba, who had also suffered from encephalitis according to reports. On 31 July 2022, a first monkeypox death was reported in Ghana. On 1 August 2022 India confirmed its first monkeypox death, a 22-year-old male who died in Thrissur, Kerala on 30 July. On 1 August 2022 Peru reported the death of a monkeypox affected 45-year-old male, who also had HIV and septic shock.

Outbreak characteristics

See also: Monkeypox § Epidemiology

Monkeypox is endemic to West and Central Africa. Prior to the 2022 outbreak, the United Kingdom had recorded only seven previous cases of monkeypox, all of which were imported cases from Africa or healthcare workers involved in their treatment. The first three such cases were in 2018, followed by a further case in 2019 and three more in 2021. The only major monkeypox outbreak to be recorded in a Western country prior to 2022 was the 2003 Midwest monkeypox outbreak in the United States, which did not feature community transmission.

This outbreak is of the West African clade, which according to the WHO has a reported case fatality rate of 1%. The genomic sequence of the virus associated with this outbreak was first published on 19 May by Portuguese researchers. They confirmed that the monkeypox virus was of the West African clade, related to other previous international outbreaks in 2018–19.

The 2022 outbreak has a different pattern of spread compared to prior monkeypox outbreaks outside Africa. Genetic evidence suggest the outbreak likely started in Nigeria. Given the unusually high frequency of human-to-human transmission observed in this event, and the probable community transmission without history of traveling to endemic areas, spread of the virus through close contact is more likely, with transmission during sexual activities being the most common route. Most cases have been in men. A significant proportion of cases, although not all, are in men who have sex with men (MSM), notably in Canada, Spain, and the UK, with many cases diagnosed in sexual health clinics. Cases are mostly in young and middle-aged men. This points to transmission due to close contact during sex as being one route of transmission. In May 2022, the European Centre for Disease Prevention and Control (ECDC) considered the monkeypox virus to be moderately transmissible among humans. According to the centre, among MSM who contracted the virus, the most common means of transmission is likely through sexual activity due to intimate contact with infectious skin lesions. The ECDC rated likelihood of transmission due to close contact, including sexual contact, as "high", but, without close contact, as low. In Nature, Anne Rimoin and Raina MacIntyre speculate that the higher percentage of MSM affected is a result of coincidental introduction to the community and then sexual activity constituting "close contact" rather than the virus itself becoming sexually transmitted. Monkeypox is not primarily a sexually transmitted disease.

As of 23 July 99% cases outside endemic regions in Africa were in men. In this group, 98% of cases occurred in the community of men who have sex with men, mainly those who have multiple sex partners (median of 5 partners in the previous 3 months). 75% were white, 57% were on pre-exposure prophylaxis, and 41% had HIV/AIDS, of which 96% were on antiretroviral therapy. 29% had another concomitant sexually transmitted infection, and in the previous month, 32% attended a sex on premises venue and 20% engaged in chemsex.

On 23 May, David Heymann, an advisor for the World Health Organization, said that the likely theory of how the outbreak started is transmission during sexual intercourse of gay and bisexual men at two raves in Belgium and Spain. On 25 May, The Guardian stated that many scientists suspect the disease was circulating across Europe before reaching the MSM community, possibly misdiagnosed or detected only in isolated cases; four cases were diagnosed in 2018 and 2019, all in individuals recently arrived from Nigeria.

The UK Human Animal Infections and Risk Surveillance (HAIRS) group warned that the virus could reach wildlife and become endemic as a result.

Initial reported cases in the United Kingdom

Main article: 2022 monkeypox outbreak in the United Kingdom

In the beginning of May 2022, a case of monkeypox in a British resident who had travelled to Lagos and Delta State in Nigeria, in areas where monkeypox is considered to be an endemic disease, was reported. The person developed a rash on 29 April while in Nigeria and flew back to the United Kingdom, arriving on 4 May, and presented to hospital later the same day. Monkeypox infection was immediately suspected, and the patient was hospitalised at a specialist clinical unit of the Guy's and St Thomas' NHS Foundation Trust and isolated, then tested positive for the virus on 6 May. Testing of patient swab samples by polymerase chain reaction revealed the outbreak to be of the West African clade of monkeypox, which is the less deadly of the two known monkeypox variants with a case fatality rate of around 1%.

Extensive contact tracing of people who had been in contact with the index case both on the international flight from Nigeria to the United Kingdom and within the country following their arrival was carried out, with potential contacts advised to remain aware of the symptoms of monkeypox and immediately isolate if any were to develop within 21 days of the contact event. Following this contact tracing effort, the World Health Organization (WHO) considered further transmission of the virus within the United Kingdom to be of "minimal" risk. Contact tracing was extended to Scotland on 14 May according to Public Health Scotland. A "small number" of people in Scotland were ordered to self-isolate following close contact with the person initially reported to have been infected, although overall risk to the general public remained "very low".

On 12 May two new cases of monkeypox were confirmed by the UK Health Security Agency (UKHSA), both in London, living together in the same household, with no known link between either of them and either the index case or travel to endemic regions. One of the new cases was hospitalised at St Mary's Hospital, while the other case with milder symptoms was said to be self-isolating at home. On 17 May, another four cases of monkeypox were confirmed by the UKHSA in three Londoners and a person in North East England who had previously travelled to London.

Unusually, none of these new cases had any known contact history with the previous three confirmed cases, which suggested a kind of transmission that had not been seen before, a wider community transmission of the virus in the London area. The UKHSA stated that the risk to the general public remained "very low". Patients with active monkeypox infection were confirmed to be hospitalised at the Royal Victoria Infirmary in Newcastle upon Tyne and at the Royal Free Hospital and Guy's Hospital in London.

Also on 20 May, UK Health Secretary Sajid Javid reported that another eleven cases had been confirmed, bringing the total in the country to twenty. UKHSA reported on 10 June that 311 of the 314 cases where sex was known were men, and that all of the 151 infected persons who filled out an additional questionnaire and answered questions about sexual practices were men who have sex with men, abbreviated MSM. Dr. Susan Hopkins from the UKHSA urged watchfulness among men who have sex with men. The UK Health Security Agency (UKHSA) advised people who have had close contact with a person infected with monkeypox to self-isolate for 21 days.

Multi-country outbreak

For a chronological guide, see Timeline of the 2022 monkeypox outbreak.

Further cases in multiple countries outside the endemic area were reported through the second half of May 2022. On 18 May, Portugal reported 14 cases of monkeypox. In Spain, there were seven confirmed cases as of 18 May. On the same day, the United States confirmed its first 2022 case of monkeypox and Canada reported 13 suspected cases.

On 19 May, Sweden, Belgium and Italy confirmed their first cases. On 20 May, Australia, Germany, France and the Netherlands confirmed their first cases. In the remainder of May, multiple European countries and Israel confirmed their first cases. The United Arab Emirates and Mexico also confirmed their first cases.

On 23 May, Dr. Sue Hopkins, the chief medical adviser for the UK Health Security Agency, announced that 37 new monkeypox cases had been confirmed, more than doubling the total confirmed in the UK to 57 cases.

Statistics

Total confirmed cases outside of endemic Africa

Total deaths outside of endemic Africa

New cases, per day outside of endemic Africa

New deaths, per day outside of endemic Africa

Vaccination

Smallpox vaccines containing vaccinia such as Imvanex (Jynneos) and ACAM2000 can provide around 85% effectiveness against monkeypox. This protection level is calculated from studies using smallpox vaccines tested in late 1980 in Africa. The UKHSA has begun using Imvanex as post-exposure prophylaxis for close contacts of known cases. According to the CDC the vaccination with Jynneos/Imvanex is "[a]dministered as two subcutaneous injections four weeks apart." while the vaccination with ACAM2000 is "administered as one percutaneous dose via multiple puncture technique with a bifurcated needle." However, ACAM2000 is not recommended for potentially immunocompromised persons due to high replication competency of vaccinia while JYNNEOS is recommended for potentially immunocompromised persons due it containing an attenuated, non-replicating orthopoxvirus, Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN).

On 25 May, disease experts from the NICD in South Africa said they saw no need for mass vaccination, because they believe cases will not explode as they did in the COVID-19 pandemic.

In reaction to the current outbreak of monkeypox, a number of countries have stated they are buying vaccines and/or releasing vaccines from national stockpiles for use in the outbreak. In May 2022, the US, Spain, Germany and the UK all announced purchases of smallpox vaccine.

On 24 May, Centers for Disease Control (CDC) Deputy Director Jennifer McQuiston confirmed the United States is releasing some of their Jynneos vaccine supply from their Strategic National Stockpile for people who are "high-risk".

On 23 June, the New York City Department of Health announced a clinic at the Chelsea Sexual Health Clinic would offer the two-dose Jynneos vaccine to "...all gay, bisexual, and other men who have sex with men (cisgender or transgender) ages 18 and older who have had multiple or anonymous sex partners in the last 14 days." By July 27, the federal government had distributed 300,000 doses to state and local health authorities, with distribution at clinics nation-wide, and was planning to release 786,000 more that week.

Bavarian Nordic is the only manufacturer of Jynneos in the world, and its manufacturing facility closed in spring 2022 to be refitted to make vaccines for other diseases using the MVA-BN technology. The company projects Jynneos manufacturing will restart in 2023, except for 15 million doses that just need final "fit and finish" repackaging. The United States helped fund the development of Jynneos, leading to concerns that existing contracts will lead to vaccine nationalism and hoarding, and prompting calls for allocating doses to lower-income countries via GAVI.

Another monkeypox vaccine, the modern LC16 vaccine was developed in Japan as a national asset, and the manufacturer said it could not assist other countries.

Social aspects

As of May 2022, public health authorities have aimed to target resources and education to affected groups, but avoid stigma which could discourage people with symptoms or who have been exposed from seeking help. LGBTQ+ rights groups have issued statements advising media to avoid stigmatising marginalised groups such as men who have sex with men. On 22 May, UNAIDS urged communicators to avoid stigma by taking an evidence-based approach, reiterated that the disease can affect anyone and that risk is by no means limited to men who have sex with men.

On 24 May, The Washington Post published an article that pointed out the lack of global attention to the disease when it only affected Africans, compared to the attention directed at it when a small number of cases started affecting Western countries. Some also objected to pictures used in media coverage of mild illnesses in Europe that featured severe cases in sub-Saharan Africans.

Misinformation

Misinformation and conspiracy theories spread online in various social media networks. In an article published by the BBC in May 2022 countering misinformation about the monkeypox outbreak, journalist Rachel Schraer noted that social media accounts and news outlets from different countries including China, Russia, Ukraine and the United States have been promoting the idea that the outbreak was caused by a lab leak or that monkeypox is being used as a bioweapon. The Institute for Strategic Dialogue described this as "Reviving the spread of a set of cut-and-paste... conspiracies", referring to conspiracy theories used during the COVID-19 pandemic. The BBC also made it clear that the genetic sequences of the virus, as far as is known, date back to a West African strain.

Responses

World Health Organization

On 20 May, the World Health Organization (WHO) convened an emergency meeting of independent advisers to discuss the outbreak and assess the threat level. Initial assessments expressed the expectation of the outbreak to be contained, and of low impact to the general population in affected countries. Its European chief, Hans Kluge, expressed concern that infections could accelerate in Europe as people gather for parties and festivals over the summer. On 1 June, a WHO statement acknowledged that undetected transmission had occurred for some time, and called for urgent action to reduce transmission. On 14 June, the WHO announced plans to rename the monkeypox virus in order to combat stigma and racism surrounding the disease. A meeting convened on 23 June determined that the outbreak did not constitute a public health emergency of international concern for the time being, but that decision was overturned by a later meeting on 23 July.

Countries

• Algeria: The Pasteur Institute of Algeria issued a communiqué in May, in which the Institute described the origins of Monkeypox in Sub-Saharan Africa, and recommended physical distancing, as well as the use of masks in crowded or enclosed places, in addition to avoiding contact with wild animals that may possess the virus.
• Armenia: On 28 July, Health Minister Anahit Avanesian told reporters that the country had not yet recorded any cases of Monkeypox, but confirmed that the country had received test kits from Russia.
• Australia: On 28 July, the Chief Medical Officer of Australia declared the increasing presence of monkeypox "a communicable disease incident of national significance".
• Bangladesh: On 22 May, the Directorate General of Health Services (DGHS) issued warnings at every port in the country to prevent the spread of monkeypox. The Directorate spokesperson said that they have asked all air, land and sea ports to be alert. Suspected cases are instructed to be sent to an infectious disease hospital and kept in isolation. Bangladesh became the first country bar shore passes, after the Chittagong Seaport barred shore passes for all crew unless in the case of an emergency, while signed-off crew will have to undergo health checks.
• Belgium: The Risk Assessment Group (RAG) and health authorities declared that those infected with monkeypox must self-isolate for 21 days.
• Brazil: The Brazilian Ministry of Health started monitoring the Brazilian patient in Germany, requesting more information from the German Ministry of Health. It also created groups of biologists to monitor monkeys and medical groups to monitor possible cases. The Minister of Health of Brazil, Marcelo Queiroga, and his entourage are in Portugal to reach an agreement on medical exchanges in public health and bioethics. After the trip to Portugal, the minister will participate in the 75th World Health Assembly, thus having his return monitored by the proximity to Europe.
• Botswana: In June, the Ministry of Health advised the population of Botswana to go to the nearest hospital in case of any unusual symptoms. In addition, the ministry advised to avoid close contact with other people.
• Cambodia: In May, Or Vandine, spokeswoman for the Ministry of Health, alerted the citizens of Cambodia that Monkeypox could be lethal due to the lesions caused by this disease, which can lead to complications in the body's organs. In June 2022, the Cambodian government ordered screening under the supervision of health workers of all air, sea and land entry points in the country, in addition to ordering mandatory quarantine of anyone infected or in contact with people with the disease.
• Canada: On 21 April, Public Services and Procurement Canada published a tender request seeking to stockpile doses of smallpox vaccine to be prepared in the event of a future accidental or intentional release of the virus. The contract for 500,000 doses closed on 5 May, and was awarded to Bavarian Nordic. On 24 May, the Public Health Agency of Canada stated that they were in the process of extracting Imvamune vaccines from their National Emergency Strategic Stockpile for deployment across the country, starting with the province of Quebec. On 26 May, Quebec announced that Imvamune vaccines would be made available to those who have been in close contact with confirmed or suspected monkeypox cases. On 7 June, PHAC announced that travellers returning to Canada may be subject to a mandatory quarantine period if they become ill with monkeypox, and warned that quarantined travellers may have restricted access to health care and delays returning home.
• China: On 2 June, the Chinese CDC issued a notice quoting WHO's document with a translation of the original "Stigmatising people because of a disease is never okay. Anyone can get or pass on monkeypox, regardless of their sexuality."
• Colombia: As of May, the Colombian Ministry of Health was taking follow-up and control measures. The Director of Epidemiology and Demography of the Ministry of Health, Claudia Cuellar, informed the Colombian population about how monkeypox is spread through people, and she spoke about the clinical presentation of the virus and international health regulations. Health authorities in the Department of Norte de Santander have been on alert, since the department is a border area where people pass between Colombia and Venezuela.
• Dominican Republic: In May, the Ministry of Public Health of the Dominican Republic issued a preventive epidemiological alert after monkeypox was reported in several countries.
• Egypt: On 24 May, the Egyptian Ministry of Health and Population informed about measures to prevent new Monkeypox infections, among them, was to wash hands with soap or use an alcohol-based hand sanitiser, in addition to using personal protective equipment such as masks. In addition, the Ministry informed that veterinary quarantine procedures should be taken for animals that present the disease.
• Fiji: The country's Centre for Disease Control and Border Health Protection Unit are monitoring the situation. The Ministry of Health has put in place infection prevention protocols at the border. Minister for Health Ifereimi Waqainabete said that the Ministry is on high alert after three suspected cases of Monkeypox returned negative results.
• Germany: Fabian Leendertz of the Robert Koch Institute described the outbreak as an epidemic that will not 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."
• Guatemala: On 26 May, the Minister of Health of Guatemala, Francisco Coma, informed that the Ministry declared an epidemiological alert on the borders of the Central American country, with the objective of detecting possible cases of Monkeypox. The minister also mentioned that one of the main transmissions of Monkeypox is from injuries and body fluids as well as contact with contaminated clothing.
• India: Union Health Minister Mansukh Mandaviya directed the National Centre for Disease Control and the ICMR to keep a close watch and monitor the situation. The Union Health Ministry has also directed airport and port health officers to be vigilant, according to official sources. They have been instructed to isolate and send samples to the National Institute of Virology of any sick passenger with a travel history to infected countries.
• Indonesia: When cases of monkeypox were reported in Australia in May 2022, they triggered the alert of health authorities in Indonesia. Mohammad Syahril, ministry spokesperson, urged medical personnel and the country's population to be alert and aware of the symptoms of the disease.
• Ireland: The Health Service Executive (HSE) has set up a multidisciplinary incident management team to prepare for the possible arrival of monkeypox, and infectious diseases experts are on alert for patients with symptoms of the virus. On 26 July, the Government of Ireland confirmed the issuing of a vaccination for specific groups and to increase awareness.
• Japan: The Japanese health ministry has confirmed its first case of monkeypox on 25 July 2022. It was detected from a male in his 30s residing in the Tokyo area.
• Kosovo: On 23 May, the Ministry of Health and the National Public Health Institute, have drafted a document of recommendations and measures to help prevent the spread of the disease. In a press statement, healthcare authorities have declared that the situation is being closely monitored.
• Luxembourg: On 21 May, the Ministry of Health said that they are monitoring the situation with Europe. The National Infectious Diseases Department of the HLC and refrain from close contact activities until the infection has resolved.
• Malaysia: On 27 May, the Malaysian Ministry of Health reactivated the MySejahtera app to provide information and surveillance on monkeypox.
• Mexico: In May, Mexican health authorities have posted notices in clinics and hospitals for the purpose of identifying suspected cases in the country. In addition, the Ministry of Health has issued an epidemiological alert on 26 May 2022.
• Morocco: In May, several regional directors of the Moroccan Ministry of Health are coordinating a surveillance system for Monkeypox with the Directorate of Epidemiology and Disease Control in order to prevent cases of Monkeypox from European countries from spreading to Morocco, according to the Al Akhbar newspaper. Due to the "Marhaba 2022" operation, an operation that aims to facilitate the travel of Moroccans living abroad by sea when they travel during the summer period, sanitary measures have already been put in place.
• Netherlands: The Netherlands started vaccinating people considered 'at risk' for monkeypox infection at the end of July 2022. This includes people on pre-exposure prophylaxis for HIV prevention.
• Nigeria: The director general of the NCDC, Ifedayo Adetifa, advised the Nigerian population to avoid eating bush meat to prevent new Monkeypox infections, in addition to storing food properly to avoid being contaminated by rodents, as Monkeypox is a viral zoonosis.
• Philippines: Former health secretary Francisco Duque III said that the Philippines was intensifying its border control measures amid the threat of the monkeypox virus. The health department stated it is exploring potential sources of monkeypox vaccines and antivirals.
• Saudi Arabia: On 21 May, the Saudi Ministry of Health stated that they are ready to monitor and investigate cases of monkeypox, if any occurs. They added that it also has an integrated preventive plan to deal with such cases if they appear, including identifying suspected and confirmed cases.
• Senegal: Badara Ly of the Ministry of Health and Social Action, spoke about the creation of a contingency plan in Senegal during an online conference with the WHO in May, in addition the doctor alerted the health system and advised the creation of fact sheets on prevention methods and reinforcement of screening in border areas.
• South Africa: On 26 May, the National Institute for Communicable Diseases (NICD) gave a communiqué on how the virus is transmitted, and the institute stated that the 2022 outbreak is the largest outbreak of Monkeypox outside of endemic regions. In addition, the NICD affirmed that the virus mainly spreads in tropical forest areas in West and Central Africa.
• Taiwan: On 30 May, the Taiwan Centers for Disease Control officially listed monkeypox as a notifiable infectious disease, and on 23 June, monkeypox was officially upgraded to a second-class notifiable infectious disease, which means that confirmed cases must be notified within 24 hours, and if necessary, isolation treatment may be implemented in designated isolation treatment institutions.
• Thailand: On 24 May, the Department of Disease Control (DDC) started screening all overseas passengers from Central African countries and other outbreak countries at international airports. On 26 May 2022, the DDC set up an emergency operations center to monitor the outbreak situation and plan for a possible outbreak in the kingdom. Anutin Charnvirakul, Minister of Public Health, said that the government is seeking a smallpox vaccine from the WHO to bolster the public's immunity in case of a viral outbreak. On 30 May, The local news reported the first case of monkeypox in the country. The patient was a passenger who was transiting from Europe to Australia via Bangkok. However, the patient's symptoms developed and were diagnosed in Australia.
• United Kingdom: On 22 May, Education Secretary Nadhim Zahawi said "we're taking it very, very seriously" and that the UK government had already started purchasing smallpox vaccines. The Terrence Higgins Trust and British Association for Sexual Health and HIV (BASHH) expressed concern about the impact on sexual health services in the United Kingdom.
• United States: On 22 May, President Joe Biden commented "they haven't told me the level of exposure yet but it is something that everybody should be concerned about". National security advisor Jake Sullivan told reporters the US has a vaccine that is relevant to treating monkeypox. On 25 May, the CDC issued an alert for gay and bisexual men to be especially vigilant. In addition, the CDC placed its monkeypox travel alert at "Level 2", following reports of cases in Australia and several countries in Europe. Beginning 18 July 2022, Sonic Healthcare USA started testing for monkeypox using CDC's orthopoxvirus test, which includes monkeypox virus at Sonic Reference Laboratory in Austin, Texas.
• Vietnam: On 24 May, Vietnam's Ministry of Health asked border localities to increase surveillance to detect possible cases of monkeypox.

Dependent territories

• Gibraltar: On 31 May, a Strategic Coordination Group met to discuss Gibraltar's state of preparedness in the eventuality that a case of Monkeypox was confirmed in the territory amid the rapid rise of cases in the United Kingdom and Spain.

Cases per country and territory

This is a table of confirmed and suspected monkeypox cases outside of African countries where the virus is endemic. It does not include countries where suspected cases were reported but later discarded such as Afghanistan, Costa Rica, and Fiji.

Cases per country and territory (outside endemic African countries)

Country	Confirmed	Suspected	Total	Deaths	Last case update	First confirmed case
Andorra	3	—	3		26 July 2022	2 July 2022
Argentina	24	—	24		28 July 2022	27 May 2022
Australia	45	—	45		28 July 2022	20 May 2022
Austria	135	—	135		2 August 2022	22 May 2022
Bahamas	1	—	1		30 June 2022	30 June 2022
Barbados	1	—	1		16 July 2022	16 July 2022
Bermuda	1	—	1		22 July 2022	22 July 2022
Belgium	482	1	483		1 August 2022	19 May 2022
Bolivia	1	4	5		1 August 2022	1 August 2022
Bosnia and Herzegovina	1	—	1		13 July 2022	13 July 2022
Brazil	1,474	846	2,320	1	1 August 2022	9 June 2022
Bulgaria	4	—	4		25 July 2022	23 June 2022
Canada	817	45	862		29 July 2022	19 May 2022
Chile	55	1	56		29 July 2022	17 June 2022
Colombia	20	—	20		31 July 2022	23 June 2022
Costa Rica	3	—	3		26 July 2022	20 July 2022
Croatia	12	—	12		29 July 2022	23 June 2022
Cyprus	1	—	1		2 August 2022	2 August 2022
Czech Republic	25	—	25		2 August 2022	24 May 2022
Denmark	101	—	101		2 August 2022	23 May 2022
Dominican Republic	3	—	3		19 July 2022	6 July 2022
Ecuador	5	—	5		29 July 2022	6 July 2022
Estonia	8	—	8		2 August 2022	28 June 2022
Finland	21	—	21		1 August 2022	27 May 2022
France	2,171	—	2,171		2 August 2022	20 May 2022
Georgia	1	—	1		19 July 2022	15 June 2022
Germany	2,724	—	2,724		2 August 2022	20 May 2022
Ghana	34	159	193	1	27 July 2022	8 June 2022
Gibraltar	5	—	5		19 July 2022	1 June 2022
Greece	33	—	33		2 August 2022	8 June 2022
Hungary	42	—	42		2 August 2022	31 May 2022
India	8	4	12	1	2 August 2022	14 July 2022
Iceland	10	—	10		2 August 2022	9 June 2022
Ireland	97	—	97		2 August 2022	27 May 2022
Israel	153	—	153		2 August 2022	21 May 2022
Italy	505	—	505		2 August 2022	19 May 2022
Jamaica	2	—	2		24 July 2022	6 July 2022
Japan	2	—	2		28 July 2022	25 July 2022
Jersey	1	—	1		23 July 2022	23 July 2022
Latvia	3	—	3		22 July 2022	3 June 2022
Lebanon	4	—	4		22 July 2022	20 June 2022
Luxembourg	30	—	30		1 August 2022	15 June 2022
Martinique	1	—	1		17 July 2022	17 July 2022
Malta	17	—	17		19 July 2022	28 May 2022
Mexico	91	—	91		2 August 2022	28 May 2022
Monaco	1	—	1		22 July 2022	22 July 2022
Montenegro	1	—	1		31 July 2022	31 July 2022
Morocco	1	1	2		14 June 2022	2 June 2022
Netherlands	925	—	925		1 August 2022	20 May 2022
New Caledonia	1	—	1		12 July 2022	12 July 2022
New Zealand	3	—	3		2 August 2022	9 July 2022
Norway	57	—	57		2 August 2022	31 May 2022
Panama	1	—	1		5 July 2022	5 July 2022
Peru	324	10	334	1	2 August 2022	26 June 2022
Philippines	1	—	1		29 July 2022	29 July 2022
Poland	63	—	63		2 August 2022	10 June 2022
Portugal	633	—	633		27 July 2022	18 May 2022
Puerto Rico	21	—	21		29 July 2022	29 June 2022
Qatar	2	—	2		26 July 2022	21 July 2022
Romania	21	—	21		29 July 2022	13 June 2022
Russia	1	—	1		12 July 2022	12 July 2022
Saudi Arabia	4	—	4		2 August 2022	14 July 2022
Serbia	10	—	10		26 July 2022	17 June 2022
Singapore	12	—	12		2 August 2022	20 June 2022
Slovakia	6	—	6		29 July 2022	12 July 2022
Slovenia	37	—	37		2 August 2022	24 May 2022
Somalia	—	4	4		9 June 2022	—
South Africa	3	—	3		11 July 2022	23 June 2022
South Korea	1	—	1		22 June 2022	22 June 2022
Spain	4,748	62	4,810	2	2 August 2022	18 May 2022
Sudan	1	—	1		31 July 2022	31 July 2022
Sweden	102	—	102		2 August 2022	19 May 2022
Switzerland	298	—	298		2 August 2022	21 May 2022
Taiwan	2	—	2		13 July 2022	24 June 2022
Thailand	2	—	2		28 July 2022	21 July 2022
Turkey	5	—	5		2 August 2022	30 June 2022
United Arab Emirates	16	—	16		24 July 2022	24 May 2022
United Kingdom	2,672	—	2,672		1 August 2022	6 May 2022
United States	6,326	—	6,326		2 August 2022	18 May 2022
Uruguay	1	—	1		29 July 2022	29 July 2022
Venezuela	1	—	1		12 June 2022	12 June 2022
Zambia	—	1	1		20 June 2022	—
Total	25,480	1,138	26,618	6	—

Timeline of first confirmed cases by country or territory

First confirmed monkeypox cases by country or territory

Date	Countries / Territories
6 May 2022	United Kingdom
18 May 2022	Portugal • Spain • United States
19 May 2022	Belgium • Canada • Italy • Sweden
20 May 2022	Australia • France • Germany • Netherlands
21 May 2022	Israel • Switzerland
22 May 2022	Austria
23 May 2022	Denmark
24 May 2022	Czech Republic • Slovenia • United Arab Emirates
27 May 2022	Argentina • Finland • Ireland
28 May 2022	Malta • Mexico
31 May 2022	Hungary • Norway
1 June 2022	Gibraltar
2 June 2022	Morocco
3 June 2022	Latvia
8 June 2022	Ghana • Greece
9 June 2022	Brazil • Iceland
10 June 2022	Poland
12 June 2022	Venezuela
13 June 2022	Romania
15 June 2022	Georgia • Luxembourg
17 June 2022	Chile • Serbia
20 June 2022	Lebanon • Singapore
22 June 2022	South Korea
23 June 2022	Bulgaria • Colombia • Croatia • South Africa
24 June 2022	Taiwan
26 June 2022	Peru
28 June 2022	Estonia
29 June 2022	Puerto Rico
30 June 2022	Bahamas • Turkey
2 July 2022	Andorra
5 July 2022	Panama
6 July 2022	Dominican Republic • Ecuador • Jamaica
7 July 2022	Slovakia
9 July 2022	New Zealand
12 July 2022	New Caledonia • Russia
13 July 2022	Bosnia and Herzegovina
14 July 2022	India • Saudi Arabia
16 July 2022	Barbados
17 July 2022	Martinique
20 July 2022	Costa Rica • Qatar
21 July 2022	Thailand
22 July 2022	Monaco • Bermuda
23 July 2022	Jersey
25 July 2022	Japan
29 July 2022	Philippines • Uruguay
31 July 2022	Montenegro • Sudan
1 August 2022	Bolivia
2 August 2022	Cyprus

Timeline of suspected cases by country or territory

Countries listed below had only suspected cases at the time of reporting. Some countries reported confirmed cases after reporting suspected cases (i.e. Greece, Morocco, Turkey, Ecuador, Peru). Countries listed several times reported suspected cases again after they discarded suspected cases before.

Timeline of suspected monkeypox cases by country or territory

Date	Countries / Territories
20 May 2022	Greece (discounted on 22 May) • Israel (confirmed on 21 May)
23 May 2022	French Guiana (discounted on 1 June) • Morocco (discounted on 25 May)
25 May 2022	Bolivia (discounted between 3 and 10 June) • Sudan (discounted on 3 June)
27 May 2022	Ecuador (discounted on 30 May) • Iran (discounted on 4 June) • Malaysia (discounted on 31 May)
29 May 2022	Afghanistan (discounted between 31 May and 5 June)
30 May 2022	Peru (discounted on 2 June) • Brazil (confirmed cases reported on 9 June)
1 June 2022	Costa Rica (discounted on 4 June) • Haiti (discounted on 5 July) • Paraguay (discounted on 7 June)
2 June 2022	Cambodia (discounted on 2 June) • Cayman Islands (discounted on 30 June) • Mauritius (discounted on 10 June) • Uruguay (confirmed cases reported on 29 July)
3 June 2022	India (discounted on 7 June)
4 June 2022	Kosovo (discounted on 15 June) • Turkey (discounted on 5 June)
5 June 2022	Georgia (confirmed on 15 June)
7 June 2022	Bahamas (confirmed cases reported on 30 June) • Bangladesh (discounted on 9 June)
8 June 2022	Uganda (discounted on 1 July)
9 June 2022	Somalia
14 June 2022	Ecuador (discounted on 15 June)
15 June 2022	Libya (discounted on 13 July)
16 June 2022	Nepal (discounted on 17 June)
20 June 2022	Zambia
21 June 2022	South Korea (confirmed on 22 June)
24 June 2022	Fiji (discounted on 28 June)
8 July 2022	India (discounted on 9 July)
14 July 2022	India (confirmed on 14 July)

Timeline of first deaths by country or territory

Timeline of monkeypox deaths by country or territory

Date	Countries / Territories
29 July 2022	Brazil • Spain
31 July 2022	Ghana • India
1 August 2022	Peru

External links

• Monkeypox outbreak – by the World Health Organization
• 2022 Monkeypox and Orthopoxvirus Outbreak Global Map – CDC
• Monkeypox Meter – nice graphs and maps, but no source/reference links
• Monkeypox Tracker by BNO News ("This tracker is no longer being updated. The final update was on 11 June 2022.")
• Monkeypox_Public_www.global.health, a case-tracking spreadsheet maintained by the nonprofit Global.Health