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Stockholm – In view of the Mpox outbreak in several African countries, the European Health Authority ECDC expects more people with the virus to come to Europe. This is very likely given the frequent travel connections, the Sweden-based authority announced today after the first Clade I Mpox case outside the African continent was confirmed in the country yesterday. The infected person is a traveler returning from the part of Africa affected by the Mpox outbreak.

However, the likelihood of sustained transmission in Europe is very low, provided imported cases are diagnosed quickly and control measures are implemented, the ECDC said. The new variant of clade I could be more contagious than previous ones and cause more severe disease progression, but experts still see unanswered questions. However, Mpox (formerly known as monkeypox) is generally not so easy to transmit. Direct contact is necessary for this.

The health authority recommends that European countries issue travel advice for people who travel to or return from areas affected by the outbreak. For people who have close contact with people who may or certainly have imported an Mpox infection from Africa, the risk of infection is moderate. The risk level for the general population was raised from “very low” to “low” at the end of July.

This week, the World Health Organization (WHO) declared a public health emergency of international concern, its highest alert level, primarily due to the rapid spread of the virus in several African countries. The aim is in particular to ensure a coordinated international response to stop the spread of the virus.

Mpox has spread particularly strongly in the Democratic Republic of Congo (DRC), with more than 16,000 cases and more than 500 deaths this year, according to the ECDC. Many children are affected.

All provinces of the central African country are now affected by the outbreak, and the infection has spread across national borders. Neighbouring countries where Mpox has not yet been detected are also reporting cases. Experts had warned of this development, the German Medical Journal reported.

According to the Robert Koch Institute (RKI), Clade I infections were previously observed mainly in Central Africa, especially in the DRC. Compared to Clade II, to which the 2022 Mpox outbreak can be traced back, the disease courses in Clade I are generally considered more dangerous.

Mpox was first described in humans in the German Red Cross in 1970.

China strengthens entry controls

Due to the increasing spread of Mpox in some countries, China is increasing its checks at airports over the next six months. Anyone entering from a country where the disease has recently broken out, has had contact with infected people or has symptoms such as a rash must “take the initiative and register with customs upon entry,” the Chinese customs authorities announced today.

Customs officials will then take “medical measures” and conduct samples and tests in accordance with procedures, the statement said. In addition, vehicles, containers and objects from areas with Mpox outbreaks will be disinfected.

“Travel restrictions and border closures do not work and should be avoided,” stressed the WHO. Pakistan also reported its first Mpox case this year today, but it is not yet known whether it is clade I.

Concern about clade Ib

A clade known as Ib was also discovered in the east of the DRC last year, and experts are keeping a close eye on it. Sex is the main route of transmission, the RKI writes on its website. The WHO sees evidence of further adaptation to humans in the pathogen. Sustained human-to-human transmission has probably been occurring since mid-September 2023.

However, what is different from the previous Clade I is that chains of infection apparently no longer break off so quickly on their own. Local experts reported observed transmissions in schools, at work and between people in a household.

When looking at the number of cases from the outbreak region, it is important to note that many undetectable cases are assumed. In addition, in most cases no virus typing/sequencing is carried out, so it is unclear how widespread clade Ib is compared to clade I, as Marion Koopmans, head of the Institute for Virus Research and director of the Pandemic and Disaster Center at Erasmus University Rotterdam, recently told the Science Media Center.

Typical symptoms of an infection with Clade I include skin rashes all over the body, while Clade II mainly affects parts of the body. With Mpox, symptoms such as fever, chills, muscle pain, headaches, fatigue or joint pain can also occur. “There is a risk of infection as long as symptoms persist, usually until the scabs fall off (usually two to four weeks),” writes the RKI.

Appeal to combat outbreaks in African countries

From an expert’s point of view, the priority now should be to support the affected countries in fighting the outbreak. “The virus can be contained with access to diagnostics, vaccines & therapeutics: This must now be quickly available to affected countries,” wrote virologist Isabella Eckerle from the University of Geneva on X (formerly Twitter).

While Mpox vaccinations have been widely used in Western countries to combat the 2022 wave of infections, they are still hardly available in Africa. Vaccine manufacturer Bavarian Nordic says it currently has a stock of 500,000 doses and is ready to produce ten million doses by 2025.

According to its own information today, the company has also applied to the European Medicines Agency (EMA) to authorize the vaccine for use in 12- to 17-year-olds in addition to adults.

The European Commission’s Health Emergency Preparedness and Response Authority (HERA), in cooperation with Bavarian Nordic, has already announced a donation of around 215,000 vaccine doses to the Africa CDC.

The vaccine alliance Gavi also announced that it is in negotiations with manufacturers about the possible direct procurement of Mpox vaccines.

No other measures necessary in Germany for now

The RKI writes on its website that it does not currently believe there is an increased risk from clade I viruses in Germany, but that it continues to monitor the situation very closely and will adapt its recommendations if necessary.

“For medical care and the public health service in Germany, there are initially no other measures that need to be taken,” the RKI continued. Clade I and II have so far been diagnosed and treated in the same way, and the indication for vaccination and other measures to protect against infection do not differ. The available vaccines against Clade I are also assumed to be effective.

Federal Health Minister Karl Lauterbach (SPD) and Charité infectious disease specialist Leif Erik Sander both said that they saw no reason for concern at the moment. Sander said: “We certainly do not need widespread vaccination at the moment for a disease that currently primarily affects people in underprivileged areas of Africa.”

In his opinion, it is not yet possible to say whether the new variant is more dangerous or deadly than the original clade I. According to the Charité expert, however, it is quite likely that variant Ib will reach Germany sooner or later. However, Germany is well prepared just in case. “We have enough vaccines available,” said the doctor.

According to the Federal Ministry of Health, some federal states still have vaccines from 2022 in stock. The federal government also still has around 117,000 vaccine doses. Further central procurement is not currently planned.

By May 2022, clade IIb had spread outside Africa, especially in Europe. It mainly affected men who have sex with men (MSM). The WHO also declared a public health emergency of international concern at that time, which ended in May 2023.

Since then, however, there have still been cases of Clade II in Europe. Berlin, for example, has recorded 33 confirmed cases of Mpox since the beginning of the year, the most in Germany. However, according to the RKI, the course of the disease is not severe, and no deaths have been recorded in Germany.

“In Germany, clade II has spread almost exclusively in the MSM community. That could of course happen again,” said Sander. However, there is a high level of awareness of the disease in this community and there is now good immune protection.

In Germany, vaccination against Mpox is only recommended for certain groups of people. These include MSM who frequently change partners. Two doses are recommended for basic immunization. Sander recommends that people who have only received one vaccination so far get a second dose – also because clade II is still circulating. © dpa/afp/ggr/aerzteblatt.de