Monkeypox – answers to the most important questions

Monkeypox is a rare viral disease caused by the monkeypox virus. Monkeypox is related to the classic smallpox and cowpox viruses. The monkeypox virus is widespread in countries in west and central Africa. In these regions, the virus is most common among rodents. Despite its name, monkeypox rarely occurs in monkeys. The virus can also infect humans and make them ill.

In regions where the monkeypox vaccine is widespread (endemic), humans can contract the virus as a result of contact with animals who are carriers.
Animal-to-human transmission is possible, for example, through

• animal bites
• animal body fluids and excretions
• touching dead animals, e.g., when hunting
• eating meat that hasn’t been heated to a sufficient temperature during cooking

Human-to-human transmission of monkeypox is only possible with close physical contact, such as

• contact with the fluid in or scabs formed by sores (known as lesions) that typically occur on the skin
• contact with ulcers or wounds in the mouth
• contact with body fluids (e.g., saliva)
• contact with respiratory droplets that are expelled when breathing and talking
• contact with the clothing, bed linen, towels or dishes used by a person infected with monkeypox

The viral load in the lesions is particularly high. The risk of contracting monkeypox is especially high if a person touches the lesions or comes into contact with the fluid inside the lesions. However, monkeypox can also be transmitted before any skin changes become visible. For example, it can be spread in respiratory droplets that are expelled during face-to-face contact.  
Pregnant women who have contracted monkeypox can pass the virus on to their unborn child. The baby may also contract the virus during the birth.

Can monkeypox be spread through sexual contact?

Monkeypox can spread from person to person during close physical contact. This includes sexual contact. For example, a person could contract the virus due to direct contact with skin lesions during sexual activity.
The virus is spread when viral particles come into contact with the mucus membranes lining the eyes, mouth, nose, penis, anus or vagina. However, the virus can also enter the body through tiny cuts or wounds on the skin.

It is not yet entirely clear whether monkeypox is transmitted by semen or vaginal fluids during sex but it appears that this is a possibility. However, a person can become infected by having direct contact with injured areas of skin during sexual activity. The rash caused by monkeypox can also occur on the genitals and in the mouth. In such cases, there is an increased risk of viral transmission during sexual contact.

People who are infected with monkeypox can pass on the virus to others for as long as they have symptoms. This period generally lasts between two and four weeks.
However, the risk of catching monkeypox is not restricted to people who are sexually active. Anyone who has close physical contact with an infected person can contract the virus. For this reason, it's important to avoid close physical contact with a person showing symptoms of monkeypox and to immediately seek medical advice.

The incubation period, i.e., the time between getting infected and the first symptoms of the illness appearing, is around 5 to 21 days. The latest data suggests that shorter incubation periods of 2 to 4 days can also occur in individual cases. People who contract the virus remain infectious as long as they have symptoms. This period usually lasts between two and four weeks.

Monkeypox produces symptoms similar to those of smallpox, which was eradicated in 1980, although these are usually much milder. However, severe and fatal outcomes are possible.

The main symptoms are fever, headache, muscle aches and back pain, as swollen lymph nodes. People typically develop a rash of flat sores that fill with pus and, over time, crust over and fall off.

The rash generally appears on the face, palms of the hands and soles of the feet. However, changes may also be found on the skin and mucus membranes of the mouth, genitals, anus and eyes. A rash on the genitals and anus has frequently been observed in recent cases.

Symptoms usually last between two and four weeks and, in most cases, clear up on their own without treatment.

If you suspect that you may have a monkeypox infection, you can get advice on what to do in a matter of minutes from the PoxApp available at: www.poxapp.charite.de.

People who are diagnosed with monkeypox are normally instructed to self-isolate. Please follow the advice of your local health authority. There are a number of precautions to take during isolation at home, including the following:

• Avoid all types of close contact – especially sexual contact – with other people until the rash has cleared and the last scab and fallen off. This period may last between two and four weeks.
• Where possible, you should not share a household with people who are in at-risk groups. These include people with immune deficiency, pregnant women, children under the age of 12 and older people.
• If you live with other people, you should remain in a separate room as far as possible while you have the rash and you should ideally have access to your own bathroom.
• Avoid sharing bed linen, towels and other items such as dishes with others. Don’t shake out bed linen, as this could release virus particles into the air. When doing laundry, wash at a temperature of at least 60°C and use heavy duty detergent.
• Ensure good hand hygiene. Wash your hands thoroughly with soap and water.
• Frequently touched surfaces, such as bedside tables, smartphones or tablets, should be cleaned carefully at least once a day.
• Bath and toilet surfaces should be cleaned after each use.
• Avoid direct contact with pets to prevent human-to-animal transmission.
• If your health deteriorates at any time, immediately contact your doctor so that supportive treatments can be started if necessary. The drug tecovirimat is approved for the targeted treatment of monkeypox.

More information and recommendations are provided in the leaflet published by the RKI that deals with self-isolation at home for confirmed cases of monkeypox.

If you have had close contact with a person infected with monkeypox, you should seek advice from your local health authority.

It is possible to get vaccinated against monkeypox.

If signs of infection occur – including non-specific symptoms – avoid contact with other people and contact a medical practice. Before visiting a doctor in person, you should notify the team at the practice that you have a suspected case of monkeypox to discuss precautions for protecting other patients and staff. If you are unable to contact the practice by phone, you should inform those working there as soon as you arrive that you have a suspected case of monkeypox.

Most people who contract monkeypox recover themselves without treatment within a few weeks.

Treatment relieves symptoms in severe cases. It is also essential to prevent a severe bacterial infection from occurring alongside the viral infection. The drug tecovirimat is approved for the treatment of monkeypox.

Doctors will decide which treatment makes sense on a case by case basis.

In the European Union (EU), a vaccine called Imvanex® has been approved for smallpox since 2013. This vaccine is less likely to cause side-effects than older smallpox vaccines. It can also be used to protect against smallpox in people aged 18 and older.

The Standing Committee on Vaccination in Germany (STIKO) recommends vaccination in cases where there is an increased risk of infection for up to 14 after contact with infected persons, as for people who are at an increased risk of coming into contact with the virus in their private or professional sphere. General vaccination is not recommended.

Clear, reliable and up-to-date answers to frequently asked questions are available on the website www.infektionsschutz.de.

Information and advice are available from your local health authority. As monkeypox is a notifiable disease, health authorities will have access to the latest information about the situation and experience in dealing with the illness.

Robert Koch Institute (RKI)

See www.rki.de/affenpocken for all recommendations by the RKI, including those on hygiene measures, managing contacts and isolation, as well as prevention, diagnosis and treatment.

The RKI also provides an assessment of the current situation in Germany.

For further information and recommendations, refer to the monkeypox fact sheet published by the Robert Koch Institute (RKI) and the Federal Center for Health Education (“Bundeszentrale für gesundheitliche Aufklärung”, BZgA) (also available in English) and to the leaflet published by the RKI about isolation at home following a confirmed infection with monkeypox.

Information about the treatment of monkeypox is provided at www.rki.de/stakob by the Permanent Working Group of Competence and Treatment Centers for High Consequence Infectious Diseases (“Ständige Arbeitskreis der Kompetenz- und Behandlungszentren für Krankheiten durch hochpathogene Erreger”, STAKOB). STAKOB is also available to advise on clinical management and treatment.

For details relating to immunization, see the decision of the STIKO to recommend vaccination against monkeypox with Imvanex (MVA vaccine).

Important information about vaccination, how it is administered and which side-effects may occur is provided in the information leaflet that accompanies the IMVANEX/JYNNEOS monkeypox vaccine.

Deutsche Aidshilfe

More information is provided by the “Deutsche Aidshilfe” organization, which represents those with HIV/AIDs, at www.aidshilfe.de/affenpocken. Deutsche Aidshilfe also provides information about the transmission of monkeypox, protection against the virus and vaccination.

Friedrich-Loeffler Institute (FLI)

Information about monkeypox and about other types of pox occurring in animals, including pets and farm animals, is available on the website of the Friedrich-Loeffler Institute.