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Berlin Against the background of the Mpox outbreak in several African countries, a network of experts at the Robert Koch Institute (RKI) has updated the treatment instructions for the viral disease in Germany.

According to the guidelines for action published today by the Standing Working Group of the Competence and Treatment Centers for Diseases Caused by Highly Pathogenic Agents (STAKOB), adjustments will be made to patient care.

The reasons for this are the declaration of a health emergency of international concern by the World Health Organization (WHO) at the end of August and the newly discovered virus clade Ib, which has not yet been detected in Germany. The previous Mpox cases in this country from 2022 were caused by clade II viruses.

What is new about clade Ib is that, in addition to sexual contact, it also increasingly leads to infections through very close physical contact, for example in families or refugee camps under poor hygienic conditions, as the STAKOB notes.

Isolation in case of suspicion or confirmation of clade I infection

According to the document, it is currently not certain whether clade I infections in Europe behave like the already known clade II infections in terms of clinical symptoms and transmissibility.

Therefore, if an infection with clade I is suspected or confirmed, those affected should be isolated regardless of the location of the lesions, writes the STAKOB. Isolation lasts until general symptoms have subsided and scabs and crusts have completely healed or fallen off.

The instructions for dealing with patients who are suspected or proven to be affected by clade II viruses have remained unchanged. Isolation is recommended as long as the lesions are detectable on parts of the body that cannot be covered with clothing or protective bandages in everyday life and as long as symptoms of illness such as fever are present.

Contact with particularly vulnerable groups such as pregnant women, immunocompromised people, children and the very elderly should be avoided until the lesions have healed.

Only medicine against Mpox limited available

Regarding the treatment of those affected, the group notes that the only Mpox therapeutic agent approved in Europe, tecovirimat, is currently only available in limited quantities in Germany.

In the case of an infection with a high probability of a serious course of the disease, the urgent advice is to contact the regionally responsible STAKOB treatment center in the current epidemiological situation.

Initial, as yet unpublished, results from a study in the Democratic Republic of Congo recently showed that the antiviral drug had no effect on the time it took for lesions to heal in those infected with clade I. The German Medical Journal reported.

However, the Standing Working Group is still very cautious in its assessment of this: From the perspective of STAKOB, no definitive statement can be made on the effectiveness of tecovirimat based on the published topline results. Important details for the interpretation have therefore not yet been published.

In general, however, it is also noted that there are currently no major clinical studies that could provide reliable evidence of the effectiveness of tecovirimat.

In addition, due to indications of a possible rapid development of resistance, the indication for tecovirimat therapy should be strict and the drug should be offered primarily to people at risk of a serious course of the disease, stressed the STAKOB.

The indication is most likely in cases of relevant immunodeficiency, such as organ or stem cell transplantation. However, the therapy may also be indicated in immunocompetent patients, for example depending on the type and location of the lesions, the clinical picture and the social situation, it said.

In the paper, the STAKOB also discusses other substances that could be considered. However, it says that these are currently only available to a very limited extent or not at all.

Vaccine probably effective regardless of clade

With regard to the Imvanex vaccine, the experts write that, given the cross-immunity shown to Mpox, it is assumed that it is effective regardless of the virus clade present. In contrast to the treatment options, there is no mention of availability problems: Imvanex is regularly available through wholesalers.

The vaccination recommendation of the Standing Committee on Vaccination (STIKO) has not changed since the current MPox outbreak in African countries. It is aimed at people with an increased risk of exposure and infection. These are in particular men who have same-sex sex (MSM) and frequently change partners, as well as staff in special laboratories.

The epidemiological development is continuously monitored and if the risk constellations or the population groups affected change, the recommendation will be adjusted if necessary, writes the group.

What applies to travelers in Mpox outbreak areas

In addition to the risk groups, the question of an Mpox vaccination is also relevant for people who travel to the outbreak areas for professional reasons, such as humanitarian workers. The Democratic Republic of Congo is currently particularly affected, but several neighboring countries have already recorded cases of clade Ib.

However, as the RKI writes in an online FAQ, there is currently no recommendation for travel vaccination against Mpox: neither from the STIKO, nor from the German Society for Tropical Medicine, Travel Medicine and Global Health, nor from the Foreign Office. Nevertheless, the lack of a STIKO recommendation is no obstacle to a justified vaccination. This means that a decision about vaccination can be made on an individual basis after weighing up the benefits and risks.

In view of the current outbreak with Clade I, the following relevant vaccination indications are seen: Exposure due to occupational activities and associated close/sustained contact with the local population in the affected areas, for example people working as disaster relief workers or emergency medical workers.

It is the responsibility of doctors to assess the individual situation with patients and to point out this protective option, writes the RKI. © ggr/aerzteblatt.de