Epidemiological Trends of Human Monkeypox Cases in Northern, Southern, Western, and Eastern Regions in Europe: A Cross-Sectional Study

Background The growing amount of monkeypox cases in non-endemic regions raises concerns in societies as a potential pandemic. This study highlights the prevalence and epidemiological trends of a human monkeypox outbreak in various regions in Europe. Methods This cross-sectional study was conducted in the Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia. The data about the monkeypox outbreak in European countries were recorded by the World Health Organization (WHO), and Centers for Disease Control and Prevention (CDC) reports. The period prevalence-based data were recorded from Jan 1, 2022, to July 7, 2022, and analyzed, and epidemiological trends were established in different European regions and countries. Results In Europe, the human monkeypox rapidly spread in all the four subregions and involved 30 European countries, infecting 6077 people. The rising number of monkeypox cases is identified in Western Europe, 2599 (42.76%); Southern Europe, 1932 (31.79%); Northern Europe, 1487 (24.46%); and Eastern Europe, 59 (0.97%). In Western Europe, significant cases are found in Germany (1304), France (604), the Netherlands (352), Belgium (168), and Switzerland (131). In Northern Europe, it is found in the United Kingdom (1351), Ireland (44), Sweden (28), and Denmark (26); in Southern Europe, it is found in Spain (1256), Portugal (415), and Italy (233). However, a smaller number of cases are found in Eastern European states, Hungary (22), Poland (13), and Romania (12). The results further revealed that the number of monkeypox cases per million people in Northern Europe was 14.40%; Southern Europe, 13.49%; Western Europe, 13.26%; and Eastern Europe, 0.70%. The highest monkeypox cases per million population are found in Portugal, 40.70; Gibraltar, 29.68; Spain, 26.86; the United Kingdom, 19.90; Malta, 18.12; the Netherlands, 20.54; Germany, 15.56; Switzerland, 15.14; Belgium, 14.50; France, 9.27; and Ireland, 8.90. Conclusions In a short period, the monkeypox cases swiftly spread in 30 non-endemic European countries and involved all four European regions. The healthcare authorities must take timely decisions to control the outbreak of human monkeypox disease, as the world cannot afford the global burden of human monkeypox outbreak as another potential pandemic.


Introduction
Monkeypox (MPX) is an emerging zoonotic disease, caused by the monkeypox virus (MPXV). e swift spread of the disease has caused an alarming situation globally [1]. e MPXV is an enveloped double-stranded DNA virus, genus Orthopoxvirus, subfamily Chordopoxvirinae, and family poxviridae [2]. Monkeypox virus belongs to the same family as smallpox, although it has a milder disease impact. e monkeypox virus is brick-shaped, with a moderately large size of about 200-250 nm, encircled by a lipoprotein [2][3][4][5].
In 1958, monkeypox was first identified as a pox-like disease in monkeys, and the disease acquired the term monkeypox.
e first case of human monkeypox was reported in 1970 in the Democratic Republic of the Congo [2]. Afterward, the virus has been identified in other African countries [2,3]. Since May 2022, monkeypox cases have been identified in many non-endemic states in European countries, the United States, Australia, Asia, and the Middle East [6]. e monkeypox disease transmits from animal to human, through direct contact with the bodily fluids, blood, or cutaneous lesions of infected animals [2]. e human-to-human transmission can result from close contact with respiratory secretions, skin lesions of an infected person, or contaminated stuff. e transmission of disease can occur via the placenta, mother to fetus, and close contact during and after birth [2]. e spread of the disease also occurs through the sexual routes [7], mainly among men who have sex with men [8,9]; in some cases, the seminal fluid samples were positive for monkeypox viral DNA [10]. e incubation period of monkeypox is 6 to 13 days, ranging from 5 to 21 days [2]. e clinical symptoms of monkeypox disease are fever, headache, body ache, swollen lymph nodes, chills, fatigue, sore throat, nasal congestion, cough [2], and diarrhea [9]. Moreover, skin rashes, pimples, or blisters appear on the face, mouth, chest, hands, feet, and other parts of the body. e disease lasts for about 2-4 weeks. e case mortality ratio of monkeypox is 0 to 11% in the general population and higher among young children. In recent times, the mortality rate due to monkeypox disease is approximately 3-6% [2].
Since May 2022, an increasing number of human monkeypox cases are found in different countries in Europe [6]. Europe has four major topographical regions: Western Europe, Eastern Europe, Northern Europe, and Southern Europe [11]. e sudden spread of the monkeypox disease in European regions has developed a threatening and challenging situation [1].
is study aimed to highlight the prevalence of human monkeypox outbreaks, and better understand the spread of diseases in different European countries.

Materials and Methods
is cross-sectional study was performed in the Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
is study explored the epidemiological trends of human monkeypox viral disease in various countries in different European regions.

Data Collections.
After the study concept, one investigator was assigned to review the international websites and literature on monkeypox cases. For quality assurance, another team member was assigned to recheck the entire data for any error. Initially, two international health organizations, the World Health Organization (WHO) [12] and Centers for Disease Control and Prevention (CDC) [6], and 6 documents from PubMed [13] and Web of Science [14] were selected. However, after reviewing the detailed reports and articles, the required information about the period prevalence-based data was gathered from the World Health Organization [12] and the Centers for Disease Control and Prevention [6].
e European subregions and the population of various countries were recorded from the Worldometer [11]. e documents in PubMed [13] and Web of Science [14] were based mainly on brief reports and editorials; hence, their data and findings were not included in the analysis. e relevant literature was explored through keyword searches, including monkeypox, epidemiology, incidence, prevalence, Europe, and European countries. After the literature had been shortlisted, the appropriate period prevalence-based data were recorded and analyzed, and interpreted.

Ethical Statement and Statistical Analysis.
e information on the monkeypox outbreak was recorded from publicly available data; hence, ethical approval was not required. In this study, the data were documented and analyzed, and the findings were expressed in numbers and percentages. e number of cases per million population was calculated by using ratios, dividing the total cases by the total population, and then multiplying it by 1,000,000. e normality of the data was assessed using the Shapiro-Wilk test. As data were not normally distributed, the Kruskal-Wallis test was used to compare the average number of cases per million among the four regions of Europe. As the Kruskal-Wallis test was significant, so pairwise comparison was performed by alpha family correction using the Bonferroni method. A p value ≤0.05 is considered significant.

Results
e data were recorded from Jan 1, 2022, to July 7, 2022. In Europe, the human monkeypox rapidly spread in all the four subregions, and involved 30 European countries, infecting 6077 people. e rising number of monkeypox cases is reported in Western Europe, 2599 (42.76%); Southern Europe, 1932 (31.79%); Northern Europe, 1487 (24.46%); and Eastern Europe, 59 (0.97%) (  Table 3 shows the sample average rank with standard test statistics and significance level between the different regions in the European countries.

Discussion
Still, the COVID-19 pandemic continues, and the world is facing another public health threat of a global outbreak of monkeypox disease [15]. e number of monkeypox cases in non-endemic regions raises concerns in societies as a potential pandemic [1]. e monkeypox outbreak in non-  Netherland, Italy, Belgium, and Switzerland. In a short period, the monkeypox cases swiftly spread in 30 non-endemic European countries and involved all four European regions.
Since 1970, the human monkeypox virus has been causing regular outbreaks in Central and West African nations [5]. Presently, the geographical dispersal pattern is bigger than the previous outbreaks which were more localized and occurred in under-resourced African societies [5]. e topographical dispersal of human monkeypox virus infection has been speedily shifting from endemic regions to non-endemic regions. MPXV can spread from animal to person or person to person, once an individual has close contact with the virus from an infected animal, person, or virus-contaminated materials such as clothing or linens [16]. Presently, in 2022, the human monkeypox virus swiftly spread in non-endemic regions and has knocked on the doors of developed nations in Europe, the USA, Australia, Asia, and the Middle East [6,12]. e current volume of the outbreak is rapidly growing day-today, as the ecological spread continues across the world mainly the Europe [1].
Today, the world is witnessing that monkeypox cases are rapidly increasing both in endemic and non-endemic regions [17]. e World Health Organization (WHO) African regional reported that Africa has about 1821 cases in 13 countries [18]. However, in non-endemic regions of Europe, these cases are over 6000, mainly during the period from early May 2022 to July 7, 2022. e geographic spread of monkeypox to non-endemic countries in Europe is an alarming sign as in these nations, no case has ever been identified before.
ere are chances of local community spread of the virus in the European countries; hence, the number of cases is rapidly increasing in various states in Europe.  Over the past 5 decades, monkeypox outbreaks have occurred in various African countries, but this is the first time the disease has swiftly crossed the various continental borders and infected a large population worldwide mainly in the European countries. is is a time to learn why the disease was ignored once its cases were regularly detected in African nations. e virus has been ignored in Africa for several decades, and now, the disease is approaching the level of a potential pandemic in Europe and other parts of the globe.

Study Strengths and Limitations.
is study highlights the epidemiological trends of the prevalence of human monkeypox virus disease in all the European regions and countries. e epidemiological data are based on the period from Jan 1, 2022, to July 7, 2022. is study attempts to harmonize the information across the regions and countries and provide a piece of additional information to highlight the epidemiological trends of the prevalence of the monkeypox outbreak in non-endemic European regions. e limitation of this study is that PubMed-and Web of Sciencebased literatures consist of mainly brief communication and editorials, and are hence unable to provide more detailed analyses and conclusions.

Conclusions
e human monkeypox cases rapidly spread in all the four European subregions, involving 30 European counties, infecting 6077 people from early May 2022 to July 7, 2022. A higher number of monkeypox cases is identified in Western Europe, Southern Europe, and Northern Europe; however, minimum cases are identified from Eastern Europe. A significant number of cases are found in the United Kingdom, Germany, Spain, France, Portugal, the Netherlands, Italy, Belgium, and Switzerland. e results further revealed that the number of monkeypox cases per million people was identified in Northern Europe, Southern Europe, Western Europe, and the minimum cases per million population were found in Eastern Europe. e highest number of monkeypox cases per million population is observed in Portugal, Gibraltar, Spain, the United Kingdom, Malta, the Netherlands, Germany, Switzerland, Belgium, France, and Ireland. In a short period, the monkeypox cases swiftly spread in nonendemic European countries and involved all four European regions. e healthcare authorities must take timely decisions to control the outbreak of human monkeypox disease, as the world cannot afford the global burden of human monkeypox outbreak as another potential pandemic.
Data Availability e data may be provided on reasonable request to the corresponding author.
Ethical Approval e information on the monkeypox outbreak was recorded from publicly available data, hence ethical approval was not required.

Conflicts of Interest
e authors declare no conflicts of interest.