Already 21 cases in Germany: Much of the monkeypox outbreak remains a mystery

The number of monkeypox cases outside of Africa is increasing.

Already 21 cases in Germany: Much of the monkeypox outbreak remains a mystery

The number of monkeypox cases outside of Africa is increasing. So far there are more than 400 worldwide. The sudden appearance continues to puzzle researchers. German professional associations are now urging quick action – before the virus can no longer be got rid of.

The monkeypox virus seems to appear out of nowhere in many countries, although for years it was only native to West and Central Africa. According to the Global Health research network, there are now more than 430 confirmed cases in non-endemic countries, according to the Robert Koch Institute (RKI) there are so far 21 infected people in six federal states in Germany. Many questions are still open - including whether the pathogen can ever be contained again.

"The current infection process is dynamic with an increasing number of cases," write several medical and scientific professional associations in Germany in a joint statement. It is "challenging" to assess the extent of the outbreak, the same applies to tracking contact chains because of the long incubation period of one to three weeks. The professional associations urge "rapid and consistent action" - such as target group-specific education, isolation of cases of infection and quarantine for close contacts and suspected cases.

What's new about the global monkeypox outbreak: Most cases outside of Africa have no direct travel link to an endemic area. The virus is native to West and Central Africa. According to the WHO, there have been more than 1,200 reported cases in the Democratic Republic of the Congo alone since the beginning of the year, and 58 infected people have died. In Nigeria, from where the virus may have entered the UK a few weeks ago, it is already circulating in an outbreak that has been ongoing since 2017. Various animal species are known to be infected with monkeypox, but it is unknown which animal exactly triggered the outbreak in Nigeria.

Researchers around the world are also concerned about why the virus behaves so differently from previous outbreaks. "As far as I know, we have so far had no evidence that genetic changes have occurred in the virus that suggest adaptation to humans," said virologist Thomas Mettenleiter, President of the Friedrich Loeffler Institute, in an interview with ntv .de. Other experts point out that the monkeypox genome is not as easy to analyze as that of Sars-CoV-2, for example, because it is about six times larger. Smallpox virus genomes are full of mysteries, Elliot Lefkowitz, a computer virologist at the University of Alabama, told Nature.

It's also unclear whether the current cases outside of Africa are due to a single returnee from Africa, which researchers think is the most likely -- or whether they also stem from previous records. The World Health Organization (WHO) is currently assuming undetected transmission over a longer period of time due to the simultaneous, sudden appearance of the virus in several countries.

But there are still many unanswered questions about the transmission route. So far, contact with the lesions - blisters and pustules - as well as body fluids and droplets from the breath of infected people or animals were considered possible transmission routes. However, since the virus has apparently recently spread mainly among men who have had sex with other men, an adaptation of monkeypox to sexual transmission is also considered possible.

In the currently known non-endemic cases, men are predominantly affected, but women are also occasionally affected, according to data from Global Health. The German professional associations emphasize that there have already been "intrafamilial transmissions". They also warn against an "entry into the animal kingdom". Because a big concern is that the monkeypox virus also nests in animals outside of Africa, from where it could trigger new outbreaks in humans again and again. "There will definitely not be a new pandemic. But I'm afraid that the monkeypox virus could settle here," said smallpox expert Gerd Sutter to the "Spiegel".

Lucky in disguise: According to current knowledge, the international cases of monkeypox are the West African variant of the virus, which is considered to be milder. According to the RKI, the symptoms, which include the prominent skin rash, usually disappear on their own within a few weeks, but can lead to medical complications and, in very rare cases, death in some people. So far, however, no deaths from the virus have been reported outside of Africa.

For the West African variant, a case mortality of about one percent is assumed, according to other sources three to four percent. However, the data comes from Africa, where the population is significantly younger. According to the WHO, the few deaths in West Africa since 2017 are mainly associated with young age or untreated HIV infection. The Central African variant of monkeypox is more dangerous, with a mortality rate of around ten percent. Most recently, however, according to the WHO, the Democratic Republic of the Congo reported a case mortality rate of just three percent.

Most experts currently assume that the current monkeypox outbreak can be contained. Virologist Mettenleiter also referred to on existing drugs and vaccines - so in an emergency a "ring vaccination" is possible to curb the transmission. The federal government has already ordered vaccine doses against monkeypox. According to Health Minister Karl Lauterbach, around 40,000 doses could be delivered in June, and another 200,000 later in the year.

The intended vaccine, Imvanex, is a vaccine developed against human smallpox, which, according to the WHO, is also 85 percent effective against monkeypox. The United States began distributing the vaccine on Monday last week. So far, the WHO sees no need for mass vaccinations.

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