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Three people have died of monkeypox in Brazil and Spain, marking the first known fatalities outside Africa in the current outbreak.

In Brazil, a 41-year-old man with lymphoma and weakened immunity died in the southeastern city of Belo Horizonte, health officials said Friday. The country has confirmed at least 1,259 cases.

Hours later, Spain announced the first death in Europe, although no information about the individual has been released. The health ministry confirmed a second death Saturday. Spain has been one of the worst-affected countries, with 4,298 confirmed cases and at least 120 patients hospitalized.

At least five people have died in Africa.

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On July 23, the World Health Organization declared monkeypox a global health emergency, its highest-level warning. Globally 22,485 cases have been confirmed, according to the Centers for Disease Control and Prevention (CDC), the overwhelming majority outside of countries in central and western Africa where the virus is normally found.

The WHO says the risk from the virus is high in Europe and moderate elsewhere. Cases normally begin with flu-like symptoms, and a rash that appears days later, according to the CDC. Infections usually last between two and four weeks.

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Most cases have so far been reported among men who have sex with men, with WHO Director General Tedros Adhanom Ghebreyesus suggesting earlier this week that they should consider temporarily reducing sexual partners as cases rise. Global health authorities have grappled with the risk of stigmatizing members of the community or downplaying the risk to the wider population.