2022–2023 mpox outbreak in Germany

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(Redirected from
2022 monkeypox outbreak in Germany
)

2022–2023 mpox outbreak in Germany
Disease
Munich, Germany[1][2]
Arrival date19 May 2022 (1 year, 11 months and 5 days ago)
DateAs of 3 January 2023
Confirmed cases3,677[3] (#Cumulative number of cases)

The 2022–2023 mpox outbreak in Germany is part of an ongoing global outbreak of human mpox caused by the West African clade of the monkeypox virus. At the beginning of September 2022, Spain, France, Germany and the United Kingdom are the countries with most cumulative cases (in absolute numbers) in Europe.

Background

The following paragraphs are an excerpt from Mpox.[edit]

Mpox (formerly known as monkeypox)[4] is an infectious viral disease that can occur in humans and other animals.[5] Symptoms include a rash that forms blisters and then crusts over, fever, and swollen lymph nodes.[5] The illness is usually mild and most of those infected will recover within a few weeks without treatment.[6] The time from exposure to onset of symptoms ranges from five to twenty-one days and symptoms typically last from two to four weeks.[7] Cases may be severe, especially in children, pregnant women or people with suppressed immune systems.[8]

The disease is caused by the
variola virus, the causative agent of the disease smallpox, is also in this genus.[5] Human-to-human transmission can occur through direct contact with infected skin or body fluids, including sexual contact.[5] People remain infectious from the onset of symptoms until all the lesions have scabbed and healed.[8] It may spread from infected animals by handling infected meat or via bites or scratches.[8] Diagnosis can be confirmed by PCR testing a lesion for the virus' DNA.[5]

Detection in Europe

The following paragraph is an excerpt from 2022–2023 mpox outbreak in the United Kingdom § Background.[edit]
An ongoing
community transmission taking place in the London area as of mid-May,[10] but it has been suggested that cases were already spreading in Europe in the previous months.[11]

Development potential

German virologist Christian Drosten from the Charité – who was the main medical adviser for the German federal government for measures against the COVID-19 pandemic in Germany[12] and who warned early that the SARS virus potential needed to be investigated[13] – warned in May 2023 that the Mpox disease could aggravate: "Wir wissen aus der Geschichte, dass andere Pockenvirus-Infektionen mit milden Verläufen begannen und sich dann in der Anpassung an den Menschen verstärkt haben" [We know from history that other smallpox virus infections began with mild courses and then intensified as they adapted to humans].[14]

Transmission

The following paragraphs are an excerpt from 2022–2023 mpox outbreak § Transmission.[edit]
A large portion of those infected had not recently travelled to areas of Africa where mpox is endemic, such as Nigeria, the Democratic Republic of the Congo as well as central and western Africa. It is transmitted by close contact with infected people, with extra caution for those individuals with lesions on their skin or genitals, along with their bedding and clothing. The disease can spread via respiratory secretions or by direct contact with rashes, body fluids or by touching objects and fabrics that have been used by someone with mpox. The CDC has also stated that individuals should avoid contact and consumption of dead animals such as rats, squirrels, monkeys and apes along with wild game or lotions derived from animals in Africa.[15]

History

On 20 May 2022, the first case of mpox was serologically detected in a man in Munich, who showed "characteristic skin changes" already the day before.[1][2]

May & June 2022

Until the end of May 2022, 33 cases of mpox were confirmed,[16] on 10 June the (cumulated) number of cases was 165,[17] and as of 5 July the number rose to 1,242.[18]

As of 3 June 2022, the most affected federal state of Germany in terms of reported cases has been the city-state of Berlin − with 39 reported cases in Berlin and 65 in the whole country,[19] and as of 28 June Berlin reported about two thirds of all cases (557 out of 838). The city-state planned to start vaccination during the week of 4 July.[20]

July 2022

As of 1 July 2022 there were 1,054 cases reported for the whole country, albeit the Robert Koch Institute (RKI) expounded that the situation was not worrisome ("nicht beunruhigend") for the general population.[21] As of 5 July 2022 there were 761 reported cases in city-state of Berlin alone; one article criticized that vaccinations had not yet started in Berlin, although 8,000 vaccine doses of

non-replicating smallpox vaccine were already in stock.[22][23] Vaccination in Berlin were going to start in the week of 11 July.[24]

As of 8 July 2022[update] there were 1,490 reported cases in Germany.[24] On 19, 2 July 033 (cumulative) cases were reported,[25] with 1,140 cases in Berlin alone; on 22 July, the state of Berlin was applying for more vaccine allocations due to high demand.[26][27]

On 22 July 2022, the European Medicines Agency recommended the approval of Imvanex smallpox vaccine for the prevention of mpox disease,[28] and the European Commission subsequently approved it.[29] (The vaccinations with Imvanex started earlier, depending on the federal state; in Lower Saxony they started on 3 July 2022[30] and in Berlin on 13 July.[31])

Till July 2022, the Federal Republic has received 40,000 doses (of the Imvanex smallpox vaccine) and distributed them to the federal states. Another 200,000 vaccine doses are expected for September. At the end of July, the Deutsche Aidshilfe e.V. (de) appealed to the German government to order 1 million vaccine doses in order to enable the (full) vaccination of up to 500,000 people.[32]

August 2022

Till 5 August 2022, 2887 confirmed cases were reported for the whole country and about half of the cases (1436) were reported from city-state of Berlin alone. In addition to the 9,500 vaccine doses Berlin already received, the federal government is expected give Berlin an additional 1,900 doses in the week of 8 August 2022.[33]

In Berlin where the highest number of reported new mpox infections occurred for a long time, this number has decreased significantly by mid-August.[34] By 19 August 2022, 6417 vaccinations (including 90 second shots) against mpox had been administered at the 28 vaccination sites in Berlin.[35]

Since September 2022

As of 9 September 2022, a total of 3530 cases of mpox have been reported to RKI, including 14 cases in females and 2 cases in children younger than 14 years. The weekly number of newly reported cases has been declining since early August.[36]

Since the number of cases reported each week has fallen to low numbers (quite persistently below 50), the RKI will provide information only once a week on Tuesday, starting in the second week of October 2022.[37]

Intervention

Vaccination

On 30 June 2022 − with pre-publication on 21 June − the RKI recommended Imvanex smallpox vaccine for post-exposure prophylaxis (PEP), for people with high risk of infection and for people with risk of a severe course of the disease. Due to the limited resources of Imvanex there are priorisations.[38] The Imvanex smallpox vaccine is administered subcutaneously.[39] (Unlike the first and second generation smallpox vaccines.)

On 21 July, the Standing Committee on Vaccination (STIKO) recommended to use only one dose per person (instead of two) of the Imvanex smallpox vaccine for the time being − so that more people can be vaccinated.[40]

See also: § July 2022

Since 19 August 2022, the

intradermal administration of the vaccine, which requires only one-fifth the dose amount (compared with subcutaneous administration) to induce similar antibody levels.[41]

Isolation

The RKI recommends that persons with diagnosed mpox isolate themselves at home for at least 21 days.[42] Isolation can be mandatory by ordinance of the "Gesundheitsamt" (local health authority).[43] This mandatory isolation period can also apply to close contacts that are vaccinated and show no signs of infection.[44]

Cumulative number of cases

In order to restrict the links for mere case numbers there are perhaps only some links for special days (like the end of a month or days that are not archived by the Wayback machine). The RKI reports data from Monday to Friday and German press relies on this data for the overall number, so there are no new cases on Saturday or Sunday. The data can be verified with the Internet Archive ("Wayback Machine") of the webpage from the RKI, see #RKI & CDC data.

Mpox cases in Germany  (
)
     Deaths        Confirmed cases
JunJunJulJulAugAugSepSepOctOctNovNov
Last 15 daysLast 15 days
Date
Cases (rise)
deaths
2022-06-07
80(n.a.)
2022-06-08
113(+33)
2022-06-09
131(+18)
2022-06-10
165(+34)
2022-06-11
165(=)
2022-06-12
165(=)
2022-06-13
189(+24)
2022-06-14
229(+40)
2022-06-15
263(+34)
2022-06-16
305(+42)
2022-06-17
338(+33)
2022-06-18
338(=)
2022-06-19
338(=)
2022-06-20
412(+74)
2022-06-21
469(+57)
2022-06-22
521(+52)
2022-06-23
592(+71)
2022-06-24
676(+84)
2022-06-25
676(=)
2022-06-26
676(=)
2022-06-27
767(+91)
2022-06-28
838(+71)
2022-06-29
874(+36)
2022-06-30
969(+95)
2022-07-01
1,054(+85)
2022-07-02
1,054(=)
2022-07-03
1,054(=)
2022-07-04
1,141(+87)
2022-07-05
1,242(+101)
2022-07-06
1,242(=)
2022-07-07
1,385(+143)
2022-07-08
1,490(+105)
2022-07-09
1,490(=)
2022-07-10
1,490(=)
2022-07-11
1,556(+66)
2022-07-12
1,636(+80)
2022-07-13
1,694(+58)
2022-07-14
1,790(+96)
2022-07-15
1,859(+69)
2022-07-16
1,859(=)
2022-07-17
1,859(=)
2022-07-18
1,924(+65)
2022-07-19
2,033(+109)
2022-07-20
2,110(+77)
2022-07-21
2,191(+81)
2022-07-22
2,268(+77)
2022-07-23
2,268(=)
2022-07-24
2,268(=)
2022-07-25
2,352(+84)
2022-07-26
2,410(+58)
2022-07-27
2,459(+49)
2022-07-28
2,540(+81)
2022-07-29
2,595(+55)
2022-07-30
2,595(=)
2022-07-31
2,595(=)
2022-08-01
2,677(+82)
2022-08-02
2,724(+47)
2022-08-03
2,781(+57)
2022-08-04
2,839(+58)
2022-08-05
2,887(+48)
2022-08-06
2,887(=)
2022-08-07
2,887(=)
2022-08-08
2,916(+29)
2022-08-09
2,982(+66)
2022-08-10
3,025(+43)
2022-08-11
3,063(+38)
2022-08-12
3,102(+39)
2022-08-13
3,102(=)
2022-08-14
3,102(=)
2022-08-15
3,142(+40)
2022-08-16
3,186(+44)
2022-08-17
3,213(+27)
2022-08-18
3,242(+29)
2022-08-19
3,266(+24)
2022-08-20
3,266(=)
2022-08-21
3,266(=)
2022-08-22
3,295(+29)
2022-08-23
3,329(+34)
2022-08-24
3,350(+21)
2022-08-25
3,387(+37)
2022-08-26
3,405(+18)
2022-08-27
3,405(=)
2022-08-28
3,405(=)
2022-08-29
3,422(+17)
2022-08-30
3,455(+33)
2022-08-31
3,467(+12)
2022-09-01
3,480(+13)
2022-09-02
3,493(+13)
2022-09-03
3,493(=)
2022-09-04
3,493(=)
2022-09-05
2022-09-06
3,505(n.a.)
⋮
2022-09-09
3,530(n.a.)
2022-09-09
3,530(=)
2022-09-09
3,530(=)
⋮
2022-09-12
3,533(n.a.)
2022-09-13
3,547(+14)
⋮
2022-09-16
3,556(n.a.)
2022-09-17
3,556(=)
2022-09-18
3,556(=)
2022-09-19
3,563(+7)
2022-09-20
3,570(+7)
2022-09-21
3,585(+15)
2022-09-22
2022-09-23
3,597(n.a.)
2022-09-24
3,597(=)
2022-09-25
3,597(=)
2022-09-23
3,607(+10)
⋮
2022-09-30
3,625(n.a.)
2022-10-01
3,625(=)
2022-10-02
3,625(=)
2022-10-03
2022-10-04
3,631(n.a.)
⋮
2022-10-07
3,645(n.a.)
⋮
2022-10-11
3,651(n.a.)
⋮
2022-10-18
3,656(n.a.)
⋮
2022-10-25
3,662(n.a.)
⋮
2022-11-01
3,668(n.a.)
⋮
2022-11-08
3,670(n.a.)
⋮
2022-11-22
3,672(n.a.)

References:


Weekly new cases[46]
Note: In early October 2022 change in the time period since RKI will now provide information only once a week on Tuesday.[37]

See also

External links

Wikimedia Commons has media related to 2022 monkeypox outbreak in Germany.
  • Our World in Data - Monkeypox (ourworldindata.org)
  • Affenpocken in Deutschland: Erste klinische Beobachtungen (www.aerzteblatt.de, 29 July 2022, in German)
    • Monkeypox in Germany: Initial clinical observations (English version)
      doi:10.3238/arztebl.m2022.0287
  • INFORMATION SHEET For Vaccination against Monkeypox – IMVANEX / JYNNEOS with Smallpox Vaccine from Bavarian Nordic (www.rki.de)
  • Bezirk Mitte startet Impfung gegen Affenpocken (www.berlin.de): Webpage contains the number of the telephone hotline of the "Beratungsstelle für sexuelle Gesundheit" (Sexual Health Counseling Center) of the municipality "Berlin-Mitte".
    (According to a press report the center serves in its day-to-day work primarily "people without health insurance and people who wish to remain anonymous".[31])

RKI data (German numbers)

CDC data (world map)

Notes

  1. International Committee on the Taxonomy of Viruses (ICTV), which is currently reviewing all orthopoxvirus species. As of March 2023, the official name of the virus remains "monkeypox virus".[4]

References

Some of the sources are witten in German language, they can be translated with services like Google Translate and its alternatives.

  1. ^ a b "Erster Affenpockenfall in Deutschland bestätigt" [First monkeypox case confirmed in Germany]. www.rnd.de (in German). 20 May 2022. Retrieved 24 June 2022.
  2. ^ a b "Germany, France, Belgium confirm first cases of monkeypox". www.dw.com. 20 May 2022. Retrieved 24 June 2022.
  3. ^ "Internationaler Mpox-/Affenpocken-Ausbruch: Fallzahlen und Einschätzung der Situation in Deutschland" (in German). 3 January 2023. Archived from the original on 11 January 2023. Retrieved 14 January 2023.
  4. ^ a b "WHO recommends new name for monkeypox disease" (Press release). World Health Organization (WHO). 28 November 2022. Retrieved 29 November 2022.
  5. ^ a b c d e "WHO Factsheet – Mpox (Monkeypox)". World Health Organization (WHO). 18 April 2023. Archived from the original on 21 April 2022. Retrieved 21 May 2023.
  6. ^ "Monkeypox". GOV.UK. 24 May 2022. Archived from the original on 18 May 2022. Retrieved 28 May 2022.
  7. ^ "Mpox Symptoms". U.S. Centers for Disease Control and Prevention (CDC). 2 February 2023. Archived from the original on 21 May 2023. Retrieved 21 May 2023.
  8. ^ a b c "Mpox (monkeypox)". World Health Organization. 12 May 2023. Archived from the original on 23 May 2023. Retrieved 24 May 2023.
  9. ^ "Monkeypox – United Kingdom of Great Britain and Northern Ireland". World Health Organization. 16 May 2022. Archived from the original on 17 May 2022. Retrieved 17 May 2022.
  10. ^ Pinkstone, Joe (17 May 2022). "Monkeypox 'spreading in sexual networks'". The Telegraph. Archived from the original on 17 May 2022. Retrieved 17 May 2022.
  11. ^ Nsofor, Ifeanyi (2 June 2022). "Opinion: Media coverage of monkeypox paints it as an African virus. That makes me mad". NPR. Retrieved 2 June 2022.
  12. ^ "Coronavirus: meet the scientists who are now household names". The Guardian. 22 March 2020. Retrieved 11 May 2023.
  13. ^ "Dem Virus voraus sein" [Get ahead of the virus]. www.charite.de. 2017. Retrieved 11 May 2023.
  14. ^ "Virologe Drosten: Das droht jetzt bei den Affenpocken" [Virologist Drosten: This is what is now at risk with monkeypox]. www.morgenpost.de. 7 May 2023. Retrieved 11 May 2023.
  15. ^ Vargas, Ramon Antonio (7 June 2022). "US raises monkeypox alert level but says risk to public remains low". The Guardian. Retrieved 9 June 2022.
  16. ^ "RKI: Inzwischen 33 bestätigte Affenpocken-Fälle in Deutschland" [RKI: There are now 33 confirmed cases of monkeypox in Germany]. www.rnd.de (in German). 31 May 2022. Retrieved 24 June 2022.
  17. ^ "Epidemiologe warnt vor Affenpocken: "Müssen das unter Kontrolle bringen"" [Epidemiologist warns of monkeypox: "Need to get this under control"]. www.focus.de (in German). 11 June 2022. Retrieved 25 June 2022. Das Robert-Koch-Institut nannte am Freitag 165 Fälle aus neun Bundesländern. [The Robert Koch Institute named 165 cases from nine federal states on Friday.]
  18. ^ "Experte rechnet mit bis zu 10.000 Affenpocken-Patienten" [Expert anticipates up to 10,000 monkeypox patients]. www.pharmazeutische-zeitung.de (in German). 24 June 2022. Retrieved 24 June 2022.
  19. ^ "Inzwischen 39 Affenpocken-Fälle in Berlin registriert" [39 cases of monkeypox have now been registered in Berlin]. www.zeit.de (in German). 3 June 2022. Retrieved 2 July 2022.
  20. ^ a b "Berlin startet in Kürze Affenpocken-Impfungen" [Berlin to start monkeypox vaccinations soon]. www.sueddeutsche.de. 28 June 2022. Retrieved 28 June 2022.
  21. ^ ""Nicht beunruhigend": Mehr als 1000 Fälle von Affenpocken in Deutschland" (in German). 1 July 2022. Retrieved 1 July 2022. Eine Gefährdung für die Gesundheit der breiten Bevölkerung in Deutschland schätzt das RKI nach derzeitigen Erkenntnissen als gering ein. [Based on current knowledge, the RKI estimates the risk to the health of the general population in Germany to be low.]
  22. ^ a b "Aktuell 761 registrierte Fälle: 8000 Affenpocken-Impfdosen da, aber geimpft wird nicht" [Currently 761 registered cases: 8000 monkeypox vaccine doses there, but vaccination is not carried out]. www.bz-berlin.de (in German). 5 July 2022. Retrieved 5 July 2022.
  23. ^ "Wartelisten für das Vakzin: Affenpocken-Impfstoff ist da – aber noch wird nicht geimpft" [Waiting lists for the vaccine: Monkeypox vaccine is here - but vaccination is not yet underway]. www.tagesspiegel.de (in German). 5 July 2022. Retrieved 5 July 2022.
  24. ^ a b "Berlin startet nächste Woche mit Affenpocken-Impfungen" [Berlin to start monkeypox vaccinations next week]. www.berlin.de. 8 July 2022. Retrieved 8 July 2022.
  25. ^ "Affenpocken: 2033 Fälle in Deutschland und 83 in Österreich gemeldet" [Monkeypox: 2033 cases reported in Germany and 83 in Austria]. www.tt.com (in German). 20 July 2022. Retrieved 24 July 2022.
  26. ^ a b "Berlin: Senat fordert mehr Impfstoff gegen Affenpocken vom Bund" [Berlin: Senate demands more vaccine against monkeypox from the federal government]. www.berliner-zeitung.de (in German). 22 July 2022. Retrieved 23 July 2022.
  27. ^ "Demand very high: Berlin is demanding more monkeypox vaccine from the federal government". europe-cities.com. 22 July 2022. Retrieved 23 July 2022.
  28. ^ "EMA recommends approval of Imvanex for the prevention of monkeypox disease". www.ema.europa.eu. 22 July 2022. Retrieved 30 July 2022.
  29. ^ "Monkeypox: EU approves use of Bavarian Nordic's Imvanex vaccine against virus". www.euronews.com. 25 July 2022. Retrieved 30 July 2022.
  30. ^ "Impfungen gegen Affenpocken in Niedersachsen gestartet". www.zeit.de. 3 July 2022. Retrieved 30 July 2022.
  31. ^ a b "Affenpocken-Impfung! Erste Berliner schon gespritzt" [Monkeypox vaccination! First Berliners already injected]. www.bz-berlin.de. 14 July 2022. Retrieved 14 July 2022. Das Zentrum betreut in seiner Alltagsarbeit vorrangig Personen ohne Krankenversicherung und Menschen, die anonym bleiben möchten.
  32. ^ "Bislang 240.000 Dosen bestellt: Aidshilfe fordert eine Million Impfdosen gegen Affenpocken" [240,000 doses ordered so far: Aidshilfe calls for one million vaccine doses against monkeypox]. www.tagesspiegel.de. 29 July 2022. Retrieved 30 July 2022.
  33. ^ a b c "Zusätzliche Dosen vom Bund: Berlin soll mehr "Affenpocken"-Impfstoff erhalten" [Additional doses from the federal government: Berlin to receive more "monkeypox" vaccine]. www.tagesspiegel.de (in German). 5 August 2022. Retrieved 6 August 2022.
  34. ^ a b c "Rückgang seit fast zwei Wochen: Weniger "Affenpocken"-Neuinfektionen in Berlin" [Decrease for almost two weeks: Fewer new "monkeypox" infections in Berlin]. www.tagesspiegel.de (in German). 18 August 2022. Retrieved 18 August 2022.
  35. ^ "Mehr als 6.000 Berliner haben sich gegen Affenpocken impfen lassen" [More than 6,000 people in Berlin have been vaccinated against monkeypox]. www.rbb24.de (in German). 22 August 2022. Retrieved 28 August 2022.
  36. ^ "Internationaler Affenpocken-Ausbruch: Fallzahlen und Einschätzung der Situation in Deutschland" [International monkeypox outbreak: case numbers and assessment of the situation in Germany]. www.rki.de (in German). 9 September 2022. Archived from the original on 9 September 2022. Retrieved 11 September 2022.
  37. ^ a b c "Internationaler Affenpocken-Ausbruch: Fallzahlen und Einschätzung der Situation in Deutschland" [International monkeypox outbreak: case numbers and assessment of the situation in Germany]. www.rki.de (in German). 11 October 2022. Archived from the original on 12 October 2022. Retrieved 15 October 2022.
  38. ^ "Beschluss der STIKO für die Empfehlung zur Impfung gegen Affenpocken mit Imvanex (MVA-Impfstoff)" [Decision of the STIKO for the recommendation for vaccination against monkeypox with Imvanex (MVA vaccine)]. www.rki.de (in German). 30 June 2022. Retrieved 9 July 2022.
  39. ^ "AUFKLÄRUNGSMERKBLATT: Zur Schutzimpfung gegen Affenpocken" [INFORMATION SHEET: For vaccination against monkeypox] (PDF). www.rki.de. 29 June 2022. Retrieved 9 July 2022.
  40. ^ "Pressemitteilung der Ständigen Impfkommission (STIKO) zu Affenpocken − Bei Impfstoffmangel sollte zur Verhinderung der Affenpockeninfektion zunächst eine Impfstoffdosis gegeben werden". www.rki.de. 21 July 2022. Retrieved 30 July 2022. Die STIKO rät daher dringend, alle verfügbaren Impfstoffe für die erste Impfung einzusetzen und die Gabe der zweiten Impfstoffdosis auf einen späteren Zeitpunkt, wenn ausreichend Impfstoff zur Verfügung steht, zu verschieben. [Therefore, the STIKO strongly advises to use all available vaccines for the first vaccination and to postpone the administration of the second vaccine dose to a later time, when sufficient vaccine is available.]
  41. ^ "EMA zu Affenpocken-Impfung: Impfstoff in statt unter die Haut" [EMA on monkeypox vaccine: Vaccine in instead of under the skin]. www.tagesschau.de (in German). 19 August 2022. Retrieved 21 August 2022.
  42. doi:10.25646/10097.2
    . Retrieved 25 July 2022. Die Isolation dauert, bis Schorf und Krusten abgeheilt sind bzw. abfallen, jedoch mindestens 21 Tage. [Isolation lasts until scabs and crusts heal or fall off, but at least 21 days.]
  43. ^ "VG München zur Absonderungsanordnung: Quarantäne bei Affenpocken ist rechtens" [VG Munich on isolation order: quarantine for monkeypox is legal]. www.lto.de. 7 July 2022. Retrieved 11 July 2022.
  44. ^ "Verwaltungsgericht: Antrag gegen Affenpocken-Quarantäne abgelehnt" [Administrative court: Application against monkeypox quarantine rejected]. www.spiegel.de (in German). 10 August 2022. Retrieved 10 August 2022. Weil er geimpft sei, hatte der Mitbewohner eines an Affenpocken Erkrankten einen Eilantrag gegen die Quarantäne-Anordnung gestellt – ein Düsseldorfer Gericht aber bestätigte die Entscheidung des Gesundheitsamts. [Because he had been vaccinated, the roommate of a monkeypox patient had filed an emergency appeal against the quarantine order - but a Düsseldorf court upheld the health department's decision.]
  45. ^ a b "Affenpocken: Länder erhalten diese Woche weitere Impfdosen" [Monkeypox: States to receive more doses of vaccine this week]. www.aerzteblatt.de (in German). 29 August 2022. Retrieved 30 August 2022.
  46. ^ from Friday before day d up to (and incl.) Thursday till 7 October 2022 resp. from Tuesday before day d up to (and incl.) Monday since 4 October 2022
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