In three weeks since the first case of monkeypox infection was confirmed on May 7 in the U.K. in a person who had just arrived from Nigeria (where the outbreak has been continuing since September 2017) the virus has spread to at least 21 countries and infected 226 people, mainly in Europe and North America. The U.K., which is the hardest hit, has reported 106 lab-confirmed cases as of May 26. As per WHO, more cases can be expected as surveillance expands; scientists believe the virus has been spreading under the radar for some time. For instance, a person in Canada had symptoms of monkeypox on April 29, though it was not tested at that time.
Similarly, the monkeypox genome sequence first shared by Portugal was from a sample collected on May 4 but was not tested for monkeypox till the U.K. reported the first case. All the 21 countries that have reported at least one case are non-endemic for monkeypox, raising concerns about the fast spread of the virus, by far the largest outbreak in humans outside Africa. Two rave parties in Spain and Belgium have been super-spreader events. Nigeria has reported 231 confirmed cases and eight deaths since 2017, with 15 cases reported this year till April 30. There have been a few instances of exportation to non-endemic countries from Nigeria since 2017, and eight such instances in all from the endemic countries in Central and West Africa. However, human-to-human transmission in non-endemic countries has been very limited, if at all, in the past. Despite the first case in humans being reported in 1970, and the virus becoming endemic in about a dozen countries in Africa, very little attention has been paid to study the virus characteristics, the host animal, and the modes of transmission. However, in September 2019, the FDA approved a vaccine, and two antivirals approved for treating smallpox have shown promise in animal studies. It is unclear how long it would take to contain the outbreak. Meanwhile, there is a potential risk of the virus jumping from humans to animals, which may make it endemic in these countries. While China was rightly criticised for keeping the SARS-CoV-2 outbreak a secret for weeks, the developed countries have paid scant attention to stop the outbreak in Nigeria. The low mortality rate of about 1% for the virus clade now in circulation in Europe and North America, the slow rate of mutation, the relative ease of stopping the virus spread, and the availability of vaccines should not be a reason once more to ignore the virus spread in Nigeria. Instead, it should spur more research on the virus and make vaccines and antivirals available in Nigeria and other endemic countries in Africa.