The number of monkeypox cases reported globally dropped by 21% in the last week, reversing a month-long trend of rising infections and a possible signal the outbreak in Europe may be starting to decline, according to a World Health Organization report issued Thursday. The U.N. health agency reported 5,907 new weekly cases and said two countries, Iran and Indonesia, reported their first cases. To date, more than 45,000 cases have been reported in 98 countries since late April. Cases in the Americas accounted for 60% of cases in the past month, WHO said, while cases in Europe comprised about 38%. It said infections in the Americas showed “a continuing steep rise.” The Africa Centers for Disease Control and Prevention said Thursday the continent had 219 new cases reported in the past week, a jump of 54%. Most were in Nigeria and Congo, the agency said. Also read: Public health emergency declared over monkeypox in WA county In early July, just weeks before the agency declared the international spread of the disease to be a global emergency, WHO’s Europe director said countries in the region were responsible for 90% of all laboratory confirmed cases of monkeypox. British health authorities said last week after seeing a decline in the number of new cases getting reported daily that there were “early signs” the country’s monkeypox outbreak was slowing. The U.K.’s Health Security Agency downgraded the country’s monkeypox outbreak last month, saying there was no evidence the once rare disease was spreading beyond men who were gay, bisexual or had sex with other men. Since monkeypox outbreaks in Europe and North America were identified in May, WHO and other health agencies have noted that its spread was almost exclusively in men who have sex with men. Also read: Monkeypox cases cross 35,000: WHO Monkeypox has been endemic in parts of Africa for decades and experts suspect the outbreaks in Europe and North America were triggered after the disease started spreading via sex at two raves in Spain and Belgium. WHO’s latest report said 98% of cases are in men and of those who reported sexual orientation, 96% are in men who have sex with men. “Of all reported types of transmission, a sexual encounter was reported most commonly,” WHO said. “The majority of cases were likely exposed in a party with sexual contacts,” the agency said. Among the monkeypox cases in which the HIV status of patients was known, 45% were infected with HIV. WHO has recommended that men at high risk of the disease temporarily consider reducing their number of sex partners or refrain from group or anonymous sex. Monkeypox typically requires skin-to-skin or skin-to-mouth contact with an infected patient’s lesions to spread. People can also become infected through contact with the clothing or bedsheets of someone who has monkeypox lesions. With globally limited vaccine supplies, authorities in the U.S., Europe and the U.K. have all begun rationing doses to stretch supplies by up to five times. WHO has advised countries that have vaccines to prioritize immunization for those at high risk of the disease, including gay and bisexual men with multiple sex partners, and for health workers, laboratory staff and outbreak responders. While Africa has reported the most suspected deaths from monkeypox, the continent has no vaccine supplies apart from a very small stock being tested in a research study in Congo. “As we know, the situation with monkeypox vaccine access is very topical, but there are not enough doses of vaccines," Nigeria Center for Disease Control Director-General Ifedayo Adetifa said this week. Potentially, a lot more more doses will become available, but because of challenges with manufacturing factories and unexpected uptick in monkeypox cases, the vaccine may actually not be available until 2023.”

The World Health Organization’s Europe chief warned Friday that monkeypox cases in the region have tripled in the last two weeks and urged countries to do more to ensure the previously rare disease does not become entrenched on the continent. And African health authorities said they are treating the expanding monkeypox outbreak as an emergency, calling on rich countries to share limited supplies of vaccines to avoid equity problems seen during the COVID-19 pandemic. WHO Europe chief Dr. Hans Kluge said in a statement that increased efforts were needed despite the U.N. health agency’s decision last week that the escalating outbreak did not yet warrant being declared a global health emergency. “Urgent and coordinated action is imperative if we are to turn a corner in the race to reverse the ongoing spread of this disease,” Kluge said. To date, more than 5,000 monkeypox cases have been reported from 51 countries worldwide that don’t normally report the disease, according to the U.S. Centers for Disease Control and Prevention. Kluge said the number of infections in Europe represents about 90% of the global total, with 31 countries in the WHO’s European region having identified cases. Kluge said data reported to the WHO show that 99% of cases have been in men — the majority in men that have sex with men. But he said there were now “small numbers” of cases among household contacts, including children. Most people reported symptoms including a rash, fever, fatigue, muscle pain, vomiting and chills. Scientists warn anyone who is in close physical contact with someone who has monkeypox or their clothing or bedsheets is at risk of infection. Vulnerable populations like children and pregnant women are thought more likely to suffer severe disease. About 10% of patients were hospitalized for treatment or to be isolated, and one person was admitted to an intensive care unit. No deaths have been reported. Kluge said the problem of stigmatization in some countries might make some people wary of seeking health care and said the WHO was working with partners including organizers of gay pride events. In the U.K., which has the biggest monkeypox outbreak beyond Africa, officials have noted the disease is spreading in “defined sexual networks of gay, bisexual, or men who have sex with men.” British health authorities said there were no signs suggesting sustained transmission beyond those populations. A leading WHO adviser said in May that the spike in cases in Europe was likely tied to sexual activity by men at two rave parties in Spain and Belgium. Ahead of gay pride events in the U.K. this weekend, London’s top public health doctor asked people with symptoms of monkeypox, like swollen glands or blisters, to stay home. Nevertheless in Africa the WHO says that according to detailed data from Ghana monkeypox cases were almost evenly split between men and women, and no spread has been detected among men who have sex with men. WHO Europe director Kluge also said the procurement of vaccines “must apply the principles of equity.” The main vaccine being used against monkeypox was originally developed for smallpox and the European Medicines Agency said this week it was beginning to evaluate whether it should be authorized for monkeypox. The WHO has said supplies of the vaccine, made by Bavarian Nordic, are extremely limited. Countries including the U.K. and Germany have already begun vaccinating people at high risk of monkeypox; the U.K. recently widened its immunization program to mostly gay and bisexual men who have multiple sexual partners and are thought to be most vulnerable. Read: No monkeypox case detected yet in Bangladesh: Health Ministry Until May, monkeypox had never been known to cause large outbreaks beyond parts of central and west Africa, where it’s been sickening people for decades, is endemic in several countries and mostly causes limited outbreaks when it jumps to people from infected wild animals. To date, there have been about 1,800 suspected monkeypox cases in Africa, including more than 70 deaths, but only 109 have been lab-confirmed. The lack of laboratory diagnosis and weak surveillance means many cases are going undetected. “This particular outbreak for us means an emergency,” said Ahmed Ogwell, the acting director of the Africa Centers for Disease Control. The WHO says monkeypox has spread to African countries where it hasn’t previously been seen, including South Africa, Ghana and Morocco. But more than 90% of the continent’s infections are in Congo and Nigeria, according to WHO Africa director, Dr. Moeti Matshidiso. Vaccines have never been used to stop monkeypox outbreaks in Africa; officials have relied mostly on contact tracing and isolation. The WHO noted that similar to the scramble last year for COVID-19 vaccines, countries with supplies of vaccines for monkeypox are not yet sharing them with Africa. “We do not have any donations that have been offered to (poorer) countries,” said Fiona Braka, who heads the WHO emergency response team in Africa. “We know that those countries that have some stocks, they are mainly reserving them for their own populations.” Matshidiso said the WHO was in talks with manufacturers and countries with stockpiles to see if they might be shared. “We would like to see the global spotlight on monkeypox act as a catalyst to beat this disease once and for all in Africa,” she said Thursday.

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. There are about 80 confirmed cases worldwide and 50 more suspected ones, the World Health Organization said. France, Germany, Belgium and Australia reported 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 WHO 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, 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 disease’s appearance 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 “a notable proportion” of the infections in the U.K. and Europe have been in young men with no history of travel to Africa and 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. Also Read: US case of monkeypox reported in Massachusetts man 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.” Also read: North Korea’s suspected COVID-19 caseload nears 2 million 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.”