ECDC Situation risk assessment
A total of 22363 cases of monkeypox have been identified through IHR mechanisms and official public sources up to 30 August 2022, 14:00, from 43 countries and areas throughout the European region. Case-based data were reported for 22050 cases from 36 countries and areas to ECDC and the WHO Regional Office for Europe through The European Surveillance System (TESSy), up to 30 August 2022, 10:00.
Of the 22050 cases reported in TESSy, 21902 were laboratory confirmed. Furthermore, where sequencing was available, 353 were confirmed to belong to Clade II, formerly known as the West African clade. The earliest known case has a specimen date of 07 March 2022 and was identified through retrospective testing of a residual sample.The earliest date of symptom onset was reported as 03 April 2022. The majority of cases were between 31 and 40 years-old (8746/21998 - 40%) and male (21710/21994 - 98.7%). Out of the 9053 male cases with known sexual orientation, 97% self-identified as men who have sex with men. Among cases with known HIV status, 37% (3304/8964) were HIV-positive. The majority of cases presented with a rash (10470/13685 - 76.5%) and systemic symptoms such as fever, fatigue, muscle pain, chills, or headache (9294/13685 - 68%). 607 cases were hospitalised (5.9%), of which 206 cases required clinical care. Three cases were admitted to ICU, and three were reported to have died of monkeypox. To date, WHO and ECDC have been informed of 84 cases of MPX infection among health workers, including three cases of occupational exposure. In all three cases of occupational exposure, health workers were wearing recommended personal protective equipment but were exposed to body fluid while collecting samples. The WHO interim guidance on clinical management and infection prevention and control for monkeypox remains valid and is available at https://apps.who.int/iris/handle/10665/355798.
This report provides an overview of the total number of cases of monkeypox identified by ECDC and the WHO Regional Office for Europe through IHR mechanisms and official public resources and case-based data through The European Surveillance System (TESSy) up to 30 August 2022.
The first summary table and maps (first two tabs) describe the number of cases identified through the different platforms. The following figures and tables describe national case-based data for surveillance of monkeypox reported in TESSy from all the countries and areas of the WHO European Region, including the 27 countries of the European Union (EU) and the additional three countries of the European Economic Area (EEA).
Case Report Form Data are submitted through the case-based record type MPX to The European Surveillance System (TESSy) database hosted at ECDC.
As of 25 August 2022
Cases of monkeypox should be reported to TESSy if they meet any of the WHO, ECDC or national case definitions.
AND One or more of the following:
OR:
AND for which the following common causes of acute rash or skin lesions do not fully explain the clinical picture:
N.B. It is not necessary to obtain negative laboratory results for listed common causes of rash illness in order to classify a case as suspected. Further, if suspicion of monkeypox infection is high due to either history and/or clinical presentation or possible exposure to a case, the identification of an alternate pathogen which causes rash illness should not preclude testing for MPXV, as coinfections have been identified.
The person has been exposed to a probable or confirmed monkeypox case.
Serology can be used for retrospective case classification for a probable case in specific circumstances such as when diagnostic testing through PCR of skin lesion specimens has not been possible, or in the context of research with standardized data collection. The primary diagnostic test for monkeypox diagnosis is PCR of skin lesion material or other specimen such as an oral or nasopharygeal swab as appropriate.Serology should not be used as a first line diagnostic test
PCR on a blood specimen may be unreliable and should also not be used alone as a first line diagnostic test. If blood PCR is negative and was the only test done, this is not sufficient to discard a case that otherwise meets the definition of a suspected for probable case. This applies regardless of whether the blood PCR was for OPXV or MPXV specific.
Cases of monkeypox should be reported to TESSy if they meet any of the WHO, ECDC or national case definitions.
AND one of the following:
OR
Since EU/EEA countries are just starting to identify cases and if testing capacity is sufficient, the above more sensitive case definition can be used. In countries with limited testing capacity for orthopoxviruses, the following description can be added to characterize the rash: ‘unexplained localized or generalized maculopapular or vesiculopustular rash potentially with umbilication or scabbing’.
Fever (usually higher >38.5°C), headache, back ache, fatigue, lymphadenopathy (localized or generalized).
Summary of number of cases of monkeypox identified through IHR mechanisms and official public resources and reported to TESSy, European Region, 2022
Overall number of cases of monkeypox, per date of notification, European Region, TESSy, 2022
Date of notification is defined as the date when the case report is notified for the first time to the place of notification, date of diagnosis is defined as the first date of clinical or laboratory diagnosis, and date of onset as the date of onset of any symptoms.
Overall number of cases of monkeypox, per date of notification, EU/EEA countries, TESSy, 2022
Date of notification is defined as the date when the case report is notified for the first time to the place of notification, date of diagnosis is defined as the first date of clinical or laboratory diagnosis, and date of onset as the date of onset of any symptoms.
Overall number of cases of monkeypox, per date of symptom onset, European Region, TESSy, 2022
Date of notification is defined as the date when the case report is notified for the first time to the place of notification, date of diagnosis is defined as the first date of clinical or laboratory diagnosis, and date of onset as the date of onset of any symptoms.
Overall number of cases of monkeypox, per date of symptom onset, EU/EEA countries, TESSy, 2022
Date of notification is defined as the date when the case report is notified for the first time to the place of notification, date of diagnosis is defined as the first date of clinical or laboratory diagnosis, and date of onset as the date of onset of any symptoms.
Number of cases of monkeypox, per day and per country/area of notification, European Region, TESSy, 2022
Date of notification is defined as the date when the case report is notified for the first time to the place of notification, date of diagnosis is defined as the first date of clinical or laboratory diagnosis, and date of onset as the date of onset of any symptoms.
Number of cases of monkeypox, per day and per country/area of notification, EU/EEA countries, TESSy, 2022
Date of notification is defined as the date when the case report is notified for the first time to the place of notification, date of diagnosis is defined as the first date of clinical or laboratory diagnosis, and date of onset as the date of onset of any symptoms.
Number of cases of monkeypox, per day and per country/area of notification, European Region, TESSy, 2022
*Day of symptom onset or earliest of day of diagnosis or notification if missing
Summary of number of probable and confirmed cases of monkeypox by reporting country/area, European Region, TESSy, 2022
Summary of number of probable and confirmed cases of monkeypox by reporting country/area, EU/EEA countries, TESSy, 2022
Age and gender distribution of cases of monkeypox, European Region, TESSy, 2022
Gender from 17 cases is reported as Other and these cases are not depicted on this graph. Information on gender is missing for 39 cases and information on age is missing for 52 cases.
Data on gender is collected as Female, Male, Other (e.g., transgender man, transgender woman and collected as free text), or Unknown.
Age and gender distribution of cases of monkeypox, EU/EEA countries, TESSy, 2022
Gender from 15 cases is reported as Other and these cases are not depicted on this graph. Information on gender is missing for 14 cases and information on age is missing for 46 cases.
Distribution of symptoms among those reporting at least one type of symptom (N=13685), European Region, TESSy, 2022
The median time between symptom onset and diagnosis was 7 days.
Distribution of rash and systemic symptoms among those reporting at least one type of symptom (N=13685), European Region, TESSy, 2022
*Fever, fatigue, muscle pain, chills, headache
Detection of asymptomatic cases is dependent on testing guidelines which currently do not recommend testing of asymptomatic persons
Distribution of symptoms among those reporting at least one type of symptom (N=13404), EU/EEA countries, TESSy, 2022
The median time between symptom onset and diagnosis was 7 days.
Distribution of rash and systemic symptoms among those reporting at least one type of symptom (N=13404), EU/EEA countries, TESSy, 2022
*Fever, fatigue, muscle pain, chills, headache
Detection of asymptomatic cases is dependent on testing guidelines which currently do not recommend testing of asymptomatic persons
Summary of outcome, HIV status of cases, and cases of monkeypox among health workers, European Region, TESSy, 2022
*Includes cases hospitalized for isolation or treatment (137 cases were hospitalized for isolation purposes,206 required clinical care and 264 were hospitalized for unknown reasons).
Summary of outcome, HIV status of cases, and cases of monkeypox among health workers, EU/EEA countries, TESSy, 2022
*Includes cases hospitalized for isolation or treatment (134 cases were hospitalized for isolation purposes,199 required clinical care and 263 were hospitalized for unknown reasons).
Summary of reported sexual orientations among male cases of monkeypox, European Region, TESSy, 2022
Sexual orientation in TESSy is defined according to the following non-mutually exclusive categories:
Sexual orientation is not necessarily representative of the gender of the person the case had sex with in the past 21 days nor does it imply sexual contact and sexual transmission.
We summarize here the sexual orientation that male cases identified with.
Summary of reported sexual orientations among male cases of monkeypox, EU/EEA countries, TESSy, 2022
Sexual orientation in TESSy is defined according to the following non-mutually exclusive categories:
Sexual orientation is not necessarily representative of the gender of the person the case had sex with in the past 21 days nor does it imply sexual contact and sexual transmission.
We summarize here the sexual orientation that male cases identified with.
Summary of specimen types with positive test result used for diagnosis of monkeypox, European Region, TESSy, 2022
Summary of specimen types with positive test result used for diagnosis of monkeypox, EU/EEA countries, TESSy, 2022
Phylogenetics of monkeypox virus
Genome sequences of MPXV were extracted from GISAID EpiPox and NCBI GenBank on 29 August 2022. NextClade [1] was used to assess the quality and poor-quality sequences were excluded. Identical sequences were identified using SeqKit [2] and submissions identified in both databases were flagged as duplicates. The phylogenetic analysis was performed using ParSNP [3] with fasttree with MT903344.1 as reference and visualized using MicroReact [4].
There are two genetically distinct clades described for MPXV: Clade I, formerly called the Central African (Congo Basin) clade, and Clade II with sub-clades IIa and IIb, formerly called the West African clade [5, 6] (Figure A). The current outbreak belongs to Clade II. Figure B shows a phylogeny based on available sequences from Clade II. Sequences from 2022 are indicated with coloured circles and the binary heatmap shows sequences uploaded to sequence databases after 22 August 2022. Following the nomenclature used in Nextstrain, the outbreak sequences belong to lineage B.1 [6,7].
The 2022 outbreak sequences from Europe (Austria (9), Belgium (10), Czechia (1), Finland (3), France (6), Georgia (1), Germany (347), Hungary (1), Israel (1), Italy (7), Luxembourg (1), Netherlands (14), Portugal (60), Slovakia (10), Slovenia (7), Spain (20), Switzerland (4), and the United Kingdom (81)) cluster together with 2022 MPXV sequences from Australia (1), Brazil (56), Canada (101), Chile (1), Ecuador (1), Indonesia (1), Japan (1), Mexico (3), Peru (98), South Africa (2), South Korea (1), Taiwan (1), Thailand (1), and the United States (132) (lineage B.1, Figure B).
A few 2022 sequences from cases in India [8], Thailand, and United States [9] do not cluster with the outbreak sequences but fall into lineage A.2 (Figure B). In addition, United Kingdom Health Security Agency reported two 2022 MPXV sequences designated as lineage A.2 [10]. Additional data and investigations are needed for further characterization of lineage A.2.
Figure A. Phylogenetic tree of monkeypox virus sequences as
of 29 August 2022. 
Figure B. Phylogenetic tree of monkeypox virus sequences of
Clade II as of 29 August 2022. 
[1] Aksamentov I, Roemer C, Hodcroft EB, & Neher RA. (2021). Nextclade: clade assignment, mutation calling and quality control for viral genomes. Journal of Open Source Software, 6(67), 3773, https://doi.org/10.21105/joss.03773
[2] Shen W, Le S, Li Y, Hu F. (2016). SeqKit: A Cross-Platform and Ultrafast Toolkit for FASTA/Q File Manipulation. PLoS One 5;11(10):e0163962. Available at: https://doi.org/10.1371/journal.pone.0163962
[3] Treangen TJ, Ondov BD, Koren S, Phillippy AM. The Harvest suite for rapid core-genome alignment and visualization of thousands of intraspecific microbial genomes. Genome Biology. 2014;15(524). Available at: https://genomebiology.biomedcentral.com/articles/10.1186/s13059-014-0524-x
[4] Argimón S, et al. Microreact: visualizing and sharing data for genomic epidemiology and phylogeography. Microbial Genomics. 2016;2(11). Available at: https://www.microbiologyresearch.org/content/journal/mgen/10.1099/mgen.0.000093
[5] World Health Organization. Available at: https://www.who.int/news/item/12-08-2022-monkeypox--experts-give-virus-variants-new-names
[6] Happi C, et al. Urgent need for a non-discriminatory and non-stigmatizing nomenclature for monkeypox virus. Virological. Available at: https://virological.org/t/urgent-need-for-a-non-discriminatory-and-non-stigmatizing-nomenclature-for-monkeypox-virus/853
[7] Nextstrain Genomic epidemiology of monkeypox virus. Available at: https://nextstrain.org/monkeypox/hmpxv1
[8] Yadav PD, Reghukumar A, Rima R, Sahay RR, et al. First two cases of Monkeypox virus infection in a traveller returned from UAE to India, July 2022, Journal of Infection, 2022. Available at: https://doi.org/10.1016/j.jinf.2022.08.007
[9] Crystal M, et al. Multiple lineages of Monkeypox virus detected in the United States, 2021- 2022. bioRxiv 2022.06.10.495526 PREPRINT. Available at: https://www.biorxiv.org/content/10.1101/2022.06.10.495526v1
[10] The UK Health Security Agency. Investigation into monkeypox outbreak in England: technical briefing 6, 19 August 2022. Available at: https://www.gov.uk/government/publications/monkeypox-outbreak-technical-briefings/investigation-into-monkeypox-outbreak-in-england-technical-briefing-6
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Suggested citation: European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Monkeypox, Joint Epidemiological overview, 31 August, 2022.
Tables and figures should be referenced: European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Monkeypox, Joint Epidemiological overview, 31 August, 2022.
© World Health Organization 2022.
© European Centre for Disease Prevention and Control 2022.
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We gratefully acknowledge the input of national public health staff involved in surveillance activities and data submission to TESSy, as well as the following authors from the originating laboratories responsible for obtaining the specimens, as well as the submitting laboratories where the genome data were generated and shared via GISAID, on which this research is based.
