For how long can monkeypox reach the Balkan region?

In April this year, some countries around the world have experienced an unexpected raise in acute hepatitis of an unknown origin in young children and since May 7, 2022, we have also seen an unprecedented and unexpected outbreak of human monkeypox cases and clusters, across Europe, the Americas, and Australia. Monkeypox is a zoonotic disease, caused by the monkeypox virus, which belongs to the Poxviridae family [[1], [2], [3]] – a known member of the genus is Variola virus, which caused smallpox. Monkeypox is fast becoming an emergence disease in some countries. In endemic areas, monkeypox virus is transmitted to humans through a bite or direct contact with an infected animal's blood, meat, bodily fluids or cutaneous/mucosal lesions. The human infection cases have been isolated in some West and Central African countries [2]. The last naturally occurring case was diagnosed in October 1977, and the World Health Organization (WHO) certified the global eradication of the disease in 1980, making it the only human disease to be eradicated [4]. In the beginning of this century limited cases started to report outside of Africa, but during the last months the disease is spreading more widely as the list of countries reporting infected cases is growing. The disease is now reaching a number of European countries as well as Latin America [1,5].

As the world recovers from the shock of the COVID-19 pandemic and reflects on lessons learnt from failure of global public health systems to contain the global outbreak of SARS-CoV-2, new infectious disease threats caused by movement of people globally, remain omnipresent and repeated calls for more proactive action go unheeded which yet again, have taken many public authorities by surprise.

It's been over three weeks since public-health authorities confirmed a case of monkeypox in the United Kingdom. Since then, more than 500 confirmed or suspected cases have emerged in at least 20 non-African nations, including Canada, Portugal, Spain and the United Kingdom - the largest outbreak ever seen outside Africa [[1], [2], [3],[5], [6], [7]]. The situation is unprecedented and the scientific community is on alert due to the monkeypox virus spread across multiple countries, with no obvious link between many of the clusters, raising the possibility of undetected local transmission of the virus. The situation is evolving and WHO expects there will be more cases of monkeypox identified elsewhere in the world as surveillance expands in such non-endemic countries.

Fortunately, the Balkan countries are yet to report any confirmed or suspected cases of monkeypox, expect of Greece (with a suspected case) [5], but there are no warranties this will remain the case in the future. The main cause of concern is the wide spread of the disease in non-endemic countries, but luckily it's a condition that requires prolonged face-to-face or close contact with an infected person. Although the extent to which asymptomatic infection may occur in unknown, there is a possibility of transmission by those infected that can spread the disease without clear clinical symptoms. It is not easy to differentiate from smallpox or varicella but the presence of fever and cutaneous lesions can assist the identification of a suspicion case. Immediate actions require a focused awareness campaign on informing those who may be most at risk from monkeypox infection, in order to stop further spread. Current available evidence suggests that those who are most at risk are those who have had close physical contact with someone with monkeypox. The incubation period varies (5–21 days) and the possibility for human-to-human transmission is a concern not just among household members, but also among travelers (flying or moving across countries), care providers (such as sexual health clinic or primary care staff) and other professionals in contact with an infected individual. Consequently, we are drawing attention at this stage, at reinforcing all measures of control and surveillance knowing that some close Balkan countries such as Italy and Slovenia have already reported monkeypox cases and also aware that Balkan counties will attract a lot of tourism as part of this year's summer holidays. The Balkans is made up of the following countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Kosovo, Republic of North Macedonia, Montenegro, Serbia, Romania, Greece and part of Turkey. The number of tourists is expected to be very high in particular as the covid-19 cases are steadily decreasing at their lowest levels, due to removal of contact tracing and with as a set of other pandemic measures relaxed. Most of Balkan countries are coastal countries. The interest to visit these countries is growing, and often they are often overpopulated by tourists, which usually travel from Europe and UK, because they are attractive and beautiful places and food. On the other side Turkey and Greece often serve as first gate from African and non-African emigrants. The war in Ukraine can serve as another factor that can add number the uncontrolled people travelling to this region. The lessons learned during the Covid-19 pandemic suggest that a strong surveillance and effective preventative system is required to control the spread of this disease – even so, we may see some imported monkeypox cases over the summer. The data collected and analyses of current outbreaks demand that we all need to act quickly and decisively to contain the spread of the disease any further.

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