Monkeypox: how dangerous is the virus?

Monkeypox: how dangerous is the virus?

Monkeypox (Mpox) is currently spreading in Europe and many other countries. At the beginning of May, the UK Health Security Agency (UKHSA), i.e. the English health authority, registered the first case of monkeypox. The sick person is said to have contracted it in Nigeria and then travelled to the UK. Only a few days later, further cases became known – first in England, then other countries on different continents and Germany. What kind of virus is this, and how dangerous is the disease? What are the symptoms, and how is the infection transmitted? Information about the virus, the vaccination and an overview of the cases in Germany and other countries can be found here.

What is monkeypox?

Monkeypox is a sporadic smallpox-like disease caused by a virus. The pathogen is known as monkeypox (MPXV) or monkeypox virus (Orthopoxvirus simiae) and is found primarily in West and Central Africa. The virus is closely related to the variola virus, the causative agent of smallpox.

The virus was discovered in monkeys in 1958 – hence the name. In 1970, an infection with the pathogen was first detected in humans. The World Health Organization (WHO) has given the disease and its virus variants a new name to avoid misunderstandings or stigmatization. This designation is Mpox.

 

How dangerous is monkeypox?

In contrast to smallpox, infection with monkeypox is much less likely to be fatal. Mortality is one to eleven per cent (depending on the source and virus variant). The WHO speaks of three to six per cent, although the actual numbers are probably lower due to the poorer diagnostic options in the regions usually affected. Children and people with immunodeficiency are particularly at risk of dying from the infection.

In pregnant women, the disease can lead to complications or miscarriage. There is also a risk of conjunctivitis or corneal inflammation and even blindness. Other possible complications are pneumonia, meningitis or bacterial skin infections. In addition, scars may remain after the rash has healed.

The current outbreak is the West African variant, which is milder and less contagious than the Central African variant. Therefore, most of those affected do not become seriously ill. Nevertheless, some deaths have already been registered – in Europe, the first deaths occurred in Spain.

Monkeypox: how to recognize the symptoms?

The disease usually causes mild symptoms; sometimes, cases can go undetected. However, serious courses are also possible.

The incubation period, i.e. the period between infection and the onset of symptoms, is usually five to 13 days, a maximum of three weeks. Rarely, incubation times of two to four days have been observed.

Symptoms  of the disease include:

A smallpox-like rash appears about one to three days later, usually starting on the face and spreading to other body areas. It can also often be observed in the anal and genital area or on the hands, feet or chest. In addition, it can affect, for example, the mucous membranes of the oral cavity or the conjunctiva.

This rash changes throughout the disease – from patches to papules to pustules – and scabs over before the scabs finally fall off and heal (possibly with scarring). The lesions can be itchy or very painful. A first case report also indicates that skin blisters in the corners of the mouth (corner of the mouth) could also be the first early sign of an infection.

If an infection with Mpox is suspected, a swab can be taken from the throat or, for example, from open skin lesions to confirm the diagnosis. Other skin diseases such as chickenpoxherpes simplex, herpes zoster (shingles) or syphilis should be ruled out, as well as tropical diseases such as malaria or leptospirosis after a corresponding trip.

 

Mpox: How is the treatment done?

The disease usually heals without treatment within two to four weeks without any consequences. A specific treatment does not currently exist. Therefore, the therapy’s focus is treating the symptoms and preventing an additional bacterial infection, which can result in pneumonia or meningitis, for example.

However, early vaccination against smallpox or administering antibody preparations can help mitigate the course. In the European Union, the antiviral drug Tecovirimat has also been approved for therapy since January 2022.

How do you get infected with monkeypox?

It is a zoonosis, i.e. a disease that spreads from animals to humans. Possible sources of infection are the meat of African wild animals (“bush meat”) or close contact with infected animals – the pathogen can be transmitted through bites, scratches or secretions, for example. Possible carriers include primates, especially rodents like African wild squirrels or rats. Monkeys are merely false hosts of the virus. In Africa, children are particularly affected by the disease, as they are more likely to become infected while playing with infected animals.

Monkeypox is not considered to be very contagious because transmission from person to person only occurs through close contact (e.g. when touching the pustules that break open or via droplet infection, i.e. inhaling droplets with excreted respiratory secretions that are released into the air when speaking), the saliva can also be infectious. The disease is not formally classified as a sexually transmitted disease, but transmission through direct contact with the skin and mucous membranes can also occur during sex. The pathogen was also found in semen. Infected people are contagious for the entire disease duration (even before the rash appears), usually for about two to four weeks.

However, transmission is also possible via objects, for example, shared towels, that have come into contact with bodily fluids. According to the Robert Koch Institute (RKI), the virus can survive on surfaces for days to months.

How do we prevent contagion and spread?

To protect against monkeypox, keep your distance from infected people, avoid close skin contact and do not share objects. According to the World Health Organization, the hygiene measures that have become a matter of course for most people during the coronavirus pandemic – such as thoroughly washing hands with soap and water and using disinfectants – are also suitable for protection against monkeypox infections.

Infected people should go into isolation in Germany for at least 21 days. This can only be ended when the symptoms have healed. Appropriate quarantine is also recommended for contact persons of infected people.

To be safe, infected people should also stay away from their pets, warn the EU health authority ECDC and the Friedrich Loeffler Institute to avoid infecting them. There has already been a corresponding case in Paris with an infected dog. It is also essential that infected people protect household waste from rodents and other animals. This precaution prevents the virus from spreading to animals and local populations and becoming endemic here.

In principle, you can reduce your risk of infection by keeping the number of sexual partners as low as possible. Condoms only provide limited protection against infection since transmission can also take place via skin contact. However, it is recommended to continue using condoms for eight weeks after healing, as the pathogen could still be present in the semen for that long.

According to the WHO, whether a previous infection results in lifelong immunity has not been fully clarified. There have been cases in Africa of people re-infecting themselves with monkeypox after recovering.

 

How many cases are known so far?

 

 

According to the US disease control agency CDC, 80,215 monkeypox infections (as of November 29, 2022) have been reported worldwide in previously hardly affected countries – new cases are becoming known every dayResearch indicates that the eruption could have started as early as mid-April and initially went unnoticed.

The first case was recorded in Great Britain: On May 7, the British health authority reported the infection of a scientist who had returned from a trip to Nigeria. Shortly after that, two other cases became known – both members of a household – who are said to have been infected independently of the first person. More cases soon emerged – almost all had been infected in London. Affected persons were isolated, and contact persons were informed in all cases. The WHO stressed the importance of accurate contact tracing to avoid further spread.

Soon, authorities in other countries in Europe and other continents were also reporting cases of monkeypox infections. In Germany, the first infection was detected in a man who had previously travelled from Portugal via Spain. Since then, more and more cases have been detected – now in all federal states. So far, 3,672 cases have been registered in Germany (as of November 22, 2022).

Since many of those infected are men who have previously had sexual contact with other men (MSM), bisexual and homosexual men, in particular with changing sexual partners, are asked to look out for unusual rashes on their bodies. People returning from trips abroad should also be particularly aware of possible symptoms. In principle, however, the infection can affect everyone – sexual orientation plays no role.

Is there a risk of an epidemic or pandemic?

Monkeypox is not as contagious as smallpox or COVID-19, for example. Symptomatic infected people can only transmit the disease if they encounter close contact. In previous cases, it was observed that chains of infection from person to person were limited. Therefore, experts currently consider the general population’s risk to be low.

There have also been individual cases of monkeypox in the past without a significant epidemic having occurred. Since 2017, cases of monkeypox infection in humans have been reported in Nigeria. According to the WHO, there were more than 1,400 cases of infection in Africa this year alone, 72 of which were fatal. There have also been isolated cases outside of Africa but not in Germany.

Studies have shown that the virus mutates quite quickly. It is assumed that enzymes in our immune system trigger these changes in the virus. These mutations could mean that the monkeypox virus is better adapted to humans. Whether this is the case and what effects the changes in the virus have remains to be researched – it is currently assumed that the mutations have no severe effects.

Experts hope to contain the outbreak of the disease through vaccination and contact tracing. Nevertheless, the WHO warns that festivals and large celebrations in summer, in particular, could contribute to the spread of the disease. On July 23, 2022, the WHO declared an international health emergency as the virus spread. A health emergency has also been declared in the United States.

How is the vaccination against monkeypox done?

Anyone who has been vaccinated against smallpox is also considered to be protected against monkeypox – the WHO reports an effectiveness of 85 per cent in this regard. However, global vaccination protection against smallpox in the population has been declining since the disease was eradicated in 1980, and the vaccination campaign ended.

Further development of the smallpox vaccine called Imvanex® from Bavarian Nordic (known as Jynneos® in the USA) can offer protection. This vaccine has been approved in the EU as a vaccine against smallpox since 2013. An official extension of approval as a vaccine against monkeypox in the EU was confirmed by the European Medicines Agency (EMA) on July 25, 2022.

Two doses of vaccine spaced at least 28 days apart are recommended. A single dose is considered sufficient as a booster dose of smallpox vaccination. According to statements by the British health authority in November 2022, the first vaccine dose already offers robust protection with an effectiveness of around 78 per cent.

To make better use of the available vaccine quantities and to be able to distribute them to more people, on August 19, the EMA temporarily approved a new vaccination procedure in which the vaccine is not entirely under the skin (subcutaneous) as before but only under the top layer of skin (intradermal). Is administered. The advantage of this method is that only one-fifth of the amount of vaccine is needed, so five times as many people can be vaccinated with the existing doses. The effectiveness of this procedure was proven in a study in 2015.

Side effects are relatively mild and include headaches, muscle aches, pain at the injection site, and fatigue. If the vaccination is given in the skin instead of under the skin, the risk of local vaccination reactions, such as reddening or thickening of the affected skin area, increases.

 

Who is the vaccine recommended for?

On June 9, the Standing Committee on Vaccination (STIKO) made a recommendation for specific risk groups (from the age of 18):

  • People with close physical contact with infected people should be vaccinated against monkeypox as soon as possible (preferably within four days) but no later than after 14 days.
  • This also applies to medical or laboratory staff after unprotected contact with infected people, infectious laboratory samples, or contaminated materials.
  • Men who have alternating sexual contact with other men should be vaccinated as a preventive measure because the disease is currently spreading in Germany, particularly in this community.
  • People with an increased risk of infection should also be vaccinated as a preventive measure because they work in special laboratories (after an individual risk assessment).

Since only limited quantities of the vaccine are available so far, the RKI recommends making an initial vaccination available to as many people as possible and catching up on the second vaccination dose at a later date, as this is primarily needed to maintain vaccination protection for a more extended period.

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