International emergency: Infectiologist Clemens Wendtner: "There will be no pandemic 2.0 due to monkeypox"

Do you share the assessment and concerns of the WHO? And what does it mean for the situation in Germany?

Clemens Wendtner: We are a long way from the fact that these are just isolated cases. We also have four-digit numbers in Germany. The Robert Koch Institute reported 2,410 cases (as of July 26, 2022). I assume that the number of cases will continue to rise in the coming weeks and months. In calculation models, it is assumed that the number could increase to 10,000 cases in Germany. However, the outbreak of monkeypox will not result in a Pandemic 2.0. That is the unanimous opinion of experts in the field.

How likely is a further spread of monkeypox in Germany?

Nobody would wish for monkeypox to become endemic in Germany. The risk increases with the number of cases. The monkeypox outbreak still affects one group in particular, namely men who have sex with men, namely sexual intercourse with many different partners. But if the virus jumps to other groups, if more women are affected and children are added, the risk of an endemic increases. So far, five cases of monkeypox in women are known in Germany. So far, children have not been affected in the Federal Republic. It would also be problematic if the monkeypox virus were also to circulate in rodents, including squirrels, in Germany, as we know it from endemic areas on the African continent. Such a situation that the virus keeps multiplying and persisting in the animal reservoir – this must be prevented.

What must be considered in Germany so that monkeypox does not spread further?

First and foremost, changing behavior helps. One measure, for example, can be caution in the case of frequently changing sexual contacts with close physical contact. There is also the possibility of ring vaccination to vaccinate risk groups or contact persons. In this way, the occurrence of infection can be contained.

Do Germans know enough about the virus to protect themselves?

The population may not yet have enough knowledge about monkeypox. There is also not as much media coverage of monkeypox as in the case of the Covid 19 infection. There are still knowledge deficits among the Germans – for example about the transmission path of monkeypox.

Can you explain again how monkeypox is transmitted?

Close physical contact with an infected person is enough to become infected. Lesions on the skin caused by the virus are highly contagious. Skin contact is crucial for infection. It is a smear infection. This means that you can also become infected with monkeypox via contaminated surfaces. An example: You can get infected through bed linen that an infected person has used. Even the smallpox scabs, if they fall off and are in the bedding, can be contagious.

For a long time, human-to-human transmission was considered unlikely. What do you know so far, why there are now more than 17,000 infections worldwide?

There is still no evidence that the current monkeypox virus has mutated and is therefore easier to transmit. A mutation is very rare in a DNA virus anyway. In addition, the immunity situation has changed, there is increasingly a generation that is not protected from smallpox or even from monkeypox. We commonly see monkeypox in people under the age of 40 who have never had a smallpox vaccine.

We have to recognize that zoonoses – i.e. infections that spread from animals to humans – will increase. The reason for this is that the living space for animals is becoming smaller, for example due to deforestation, and animals are getting closer to humans.

We live in a globalized world where traveling from London to Australia, China or Nigeria is no longer an issue, and as a result such germs are spreading faster than we saw 20 or 30 years ago. It was the same with monkeypox – the first case in London had contact in Nigeria, where monkeypox is endemic, then the virus circulated in London and there was a big festival in Spain, which fueled the infection process.

So there are situations in which the risk of infection is increased?

Large events from Christopher Street Day to huge music festivals draw large crowds. There is an increased risk of infection. Since such events are booming in summer, the virus does not take a break. The densely packed people in a large crowd make it easier for infections to occur.

The second aspect is: It is a disease that is transmitted through (unprotected) sex with many different partners. One precaution against infection is safe sex. However, the condom is no guarantee that you will not be infected during sex.

Monkey pox isn’t a sexually transmitted disease in the classic sense, is it? According to the current state of knowledge, they are mainly transmitted through close physical contact – and that doesn’t just happen during sex.

Monkey pox or its genetic material (DNA) can also be detected in semen. However, we cannot yet prove whether they are capable of reproduction. We can also detect the virus in the blood. We see that the concentration in the semen and blood is lower than in the skin lesions. Means: Smallpox on the skin is the classic transmission route for monkeypox, i.e. through close physical contact. Of course, there is close physical contact during sex, but even at a music festival I can get infected from people close to me if they have smallpox on their skin.

Can there be asymptomatic cases of monkeypox?

The monkeypox that we experience here in the clinic is rather weaker. One counts the blisters on the body of the patients for the treatment – most have less than 50 smallpox. If a patient only has 20 blisters on the body, the risk of infection is also lower than with a larger number of skin lesions. We have not had a completely asymptomatic case here. A so-called selection bias can also occur here: In the inpatient environment, we only see cases that have also become symptomatic. So I cannot rule out that there are also more or less asymptomatic cases in which patients only have one or two lesions. These can also occur in the mouth, for example, so that those affected cannot see them at all.

When is a person who has contracted monkeypox contagious?

There is also a risk of infection if patients only have mild symptoms – i.e. before the smallpox stage. The skin lesions only appear a few days after fever, muscle aches and headaches. Anyone who notices such symptoms and skin lesions should have this checked out by a doctor.

You treated the first monkeypox case in Germany. What can you report about the monkeypox cases from everyday life in the clinic?

The good news is that no one has died from monkeypox at our clinic. Five people worldwide lost their lives in the current outbreak due to this infection. In our clinic, no patient had to be treated in the intensive care unit. Monkeypox can be a condition associated with severe pain. We see this especially in patients who have anal intercourse, that sometimes very painful ulcers form that can only be treated with painkillers administered intravenously. Severe itching or abscesses can also occur in monkeypox patients. These are details from everyday medical practice that show that monkeypox should be avoided.