Brazil reported the first monkeypox-related death outside the African continent on Friday, with Spain later confirming Europe's first known deaths.

The current outbreak started in May, with 20 cases recorded in the United Kingdom. Since then it has grown to more than 20,000 cases in 78 countries.

Last Saturday, the World Health Organization (WHO) declared the monkeypox outbreak a "public health emergency of international concern," its highest level of threat.

It has been endemic for decades in West and Central African countries, but 70% of the current infections are in Europe and 25% in the Americas.

What do we know about the fatalities?

According to the state health ministry of Minas Gerais, the Brazilian victim was a 41-year-old man who also suffered from lymphoma and a weakened immune system.

"The comorbidities aggravated his condition," the ministry said.

He died from septic shock after being taken to the intensive care unit.

Spain's first death was recorded Friday in the Valencia region, the second reported Saturday in the southern province of Andalusia.

Both victims had been hospitalized with infections that attacked the brain in the days before their deaths. It is possible the deaths are linked to pre-existing conditions.

Spain is one of the world's worst-hit countries, and 4,298 people have been infected with the virus, according to the Spanish health ministry's emergency and alert coordination center.

"Of the 3,750 [monkeypox] patients with available information, 120 cases were hospitalized [3.2%], and one case has died," the center said.

The WHO said around 8% of the monkeypox cases in Europe have required hospitalization.

The global health body has so far reported five confirmed monkeypox deaths in countries in Africa.

New WHO monkeypox advice

WHO Director-General Tedros Adhanom Ghebreyesus said on Wednesday that 98% of monkeypox cases had been identified in men who have sex with men.

He urged them to limit their number of sexual partners while monkeypox cases increase within their community and to swap contact details with any new partners.

"This is an outbreak that can be stopped... The best way to do that is to reduce the risk of exposure," Tedros told a news conference from Geneva. "That means making safe choices for yourself and others."

Vaccines are available to help protect against the virus but there's a limited supply.

Monkeypox is not as transmissible or fatal as smallpox.

The WHO says the type of monkeypox currently spreading outside Africa has a fatality rate of between 1%.

Symptoms of monkeypox infection include fever, muscle pain and a rash that forms blisters.

mm, lo/wd (AFP, Reuters)