Three years ago, there was surprise – even shock – in the WHO European Region at the emergence and rapid spread of a viral disease, usually only ever found in a number of countries on the African continent.
Mpox, the disease in question, skyrocketed to a peak of around 9000 cases in the Region in July 2022, only 3 months after the first case was detected in the United Kingdom in a person with no history of travel to an endemic area.
The rapid spread of mpox clade II, mainly among gay, bisexual and other men who have sex with men (GBMSM) as a result of sexual activity, was initially concentrated in Europe before cases were reported in other regions. This prompted the WHO Director-General to formally declare it a public health emergency of international concern (PHEIC) for the first time ever.
Although this PHEIC was lifted in May 2023 following a significant decline in global case numbers, mpox has not gone away. Indeed, the concerning rise of another strain of the virus, clade I, in the Democratic Republic of the Congo and its neighbouring countries led the WHO Director-General to declare a second mpox PHEIC in August 2024, which is still ongoing.
Since that time, countries in Europe have continued to report sporadic mpox clade II cases at low levels, with very occasional and often isolated imported cases of clade I mpox. In the last 6 months or so, however, we have seen an increase in clade II case numbers, with the Region now averaging around 200 cases a month, spread across 23 Member States.
The mpox situation in Berlin, Germany
Between January and April 2025, 70 cases of mpox were reported to the Berlin health authorities – more than in the entire year of 2024.
As in previous years, the majority of those affected have been GBMSM, with an average age of 35.
However, this year, there has been a noticeable increase in the proportion that have not been vaccinated with at least one dose of mpox vaccine – 53% of those infected this year, compared to only around 35% in 2024 and 2023.
Although the exact cause of this case cluster is unknown, the State Office for Health and Social Affairs is working closely with nongovernmental organizations (NGOs) representing affected communities to develop responses to this latest outbreak and to bring it to an end as soon as possible.
“Given the current increase in the number of cases, combined with major events in Berlin over Easter and into the summer, providing information and education to affected risk groups is vital,” says Dr Claudia Ruscher, an infection epidemiologist at the Berlin State Office for Health and Social Affairs. “We know from our experience in 2022 that working with affected communities is key to controlling the spread of mpox. That’s why we are collaborating with the city’s gay counselling service Schwulenberatung Berlin and its prevention team sidekicks.berlin to ensure that materials about mpox and the vaccination options available are readily accessible to those who need them.”
A joint effort
In March 2025, the State Office, Schwulenberatung Berlin and sidekicks.berlin issued a joint press statement that was widely picked up by the city’s media outlets, including the lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual and other identities (LGBTQI+) press and websites. In it, they transparently acknowledged the seriousness of the current mpox situation and emphasized the importance of vaccination.
Although the mpox vaccine is not a silver bullet for completely preventing infection from mpox, it has proved to be an effective tool for reducing the chances of infection or reinfection and the severity of symptoms.
“Our assumption is that the recent uptick of cases has occurred because of a shift in the at-risk population who have not yet been reached by our vaccination and information campaigns.” says Dr Ruscher. “Working together, we are determined to change that, to ensure that as many people as possible know about the mpox risks and can take steps to protect themselves.”
Access and barriers to getting the mpox vaccine
Stephan Jäkel from Schwulenberatung Berlin is also committed to this goal and highlights areas that he believes need working on to ensure that vaccines can be quickly and easily accessed by all those GBMSM who need them.
“In Germany, most people access the health system through statutory health insurance, which means that they can choose the clinics they want to go to. As a result, most GBMSM and transgender people in Berlin have been able to visit specialist gay and HIV clinics to get their mpox vaccine.”
However, for those who are not insured through the state system – and this can include foreign students, migrants, refugees, sex workers and others who perhaps cannot afford insurance – vaccines have not always been so easy to access, as Jäkel explains:
“Although these uninsured groups were eligible for vaccines during the 2022 outbreak and again more recently, at times they have been unable to get them. In the case of refugees, they have first had to register for health-care access – a bureaucratic process that can take several months – leaving them vulnerable to mpox infection in the meantime.”
Another barrier that could be preventing some of these uninsured people from getting vaccinated is the cost of the jab itself.
“Foreign students, for example, could in theory pay for the vaccine, in which case not having state insurance wouldn’t be a problem,” says Jäkel. “But, at €200 a shot that’s too much for many students on tight budgets, and something unlikely to be covered by their own travel or health insurances.”
Reaching the unvaccinated
Since January, sidekicks.berlin has been focussing on distributing flyers on the importance of mpox vaccination and where to get it to Berlin’s GBMSM community. As well as conducting outreach work targeting clubs and sex venues, they are also drawing attention to the availability of vaccination services to visitors of Checkpoint BLN – a joint project of Schwulenberatung Berlin, Berliner Aidshilfe and Berlin HIV clinics – which offers HIV and sexually transmitted infections (STI) counselling, testing and treatment services.
Online too, Schwulenberatung Berlin and sidekicks.berlin have been developing informative webpages, as well as a series of engaging posts and reels for social media. These highlight the recent increase in mpox circulation and ways that GBMSM can protect themselves.
They have also been working closely with event organizers in the run-up to some of the city’s fetish parties and in preparation for large mass gatherings over the summer, such as the popular Christopher Street Day (CSD Berlin/Pride). Practically, this involves having awareness raising stands at events, as well as volunteer social workers on hand to provide advice.
“I believe our 20+ years of representing the interests of the queer community makes us a trusted voice when it comes to delivering messages on mpox to the community,” says Jäkel. “It has also enabled us to build good partnerships with state authorities, event organizers, venue owners and others in tackling mpox – in the same way as we have with other health threats to our community.”
Signs the campaign is making a difference
Checkpoint BLN, as the only NGO offering the mpox vaccine to the city’s GBMSM community through its specially organized vaccination days, has already seen more people coming forward to get vaccinated, as its medical director Christoph Weber explains:
“Since January, we have seen a fourfold increase in demand for the mpox vaccine compared to last year and are stepping up our efforts accordingly.... So far this year, we have vaccinated around 100 people, most of them in the last 2 months. Of these, around a third have no or inadequate health insurance.”
Checkpoint BLN does not charge for the vaccine, something that Weber believes is crucial:
“Sexual health risks do not discriminate based on insurance coverage, and neither should our response. We firmly believe that cost should never be a barrier to accessing health care, especially when it comes to public health and community well-being. Offering free vaccines is not only the right thing to do but is also cost-effective.”
Lessons for the WHO European Region
The rapid response to the current mpox situation in Berlin emphasizes the importance of collaboration between multiple stakeholders, including health authorities, civil society, event organizers and affected communities. As trusted voices, NGOs in particular, with their close connections to affected communities are vital partners for ensuring that information on mpox and other health threats can reach those most at risk, through the communication channels and venues that these people use.
WHO/Europe encourages all public health authorities to consider making access to mpox vaccination as easy as possible for the individuals and communities that need it, including rolling out vaccination programmes in settings such as sexual health clinics, HIV centres, pharmacies, community-based organizations and sex-on-premises venues, and at large mass gathering events.
Beyond vaccination, people should also be made aware of the protective measures they can take to lower their chances of infection or reinfection. These include:
- avoiding close contact with anyone with blister-like lesions or a rash;
- practicing safer sex, such as using a condom or talking with partners about symptoms;
- avoiding contact with the objects and materials, such as bedding, used by someone with mpox; and
- keeping your hands clean.
Using communication channels that people at most risk use, like dating apps, or sharing information in STI clinics and travel clinics remains important to inform people that the outbreak is not over, as well as directing people to accurate sources of information.
“While mpox case numbers may be nothing like those at the start of the 2022 outbreak, the threat of a larger mpox outbreak happening again is very real,” says Tran Minh Nhu Nguyen, Manager of WHO/Europe’s Infectious Hazards Management team, part of the WHO Health Emergencies Programme. “This is particularly the case with the emergence of new strains of the virus that could spread beyond the GBMSM community to the general population. We have to remain vigilant.”