May 2022: 92 confirmed cases in 12 countries
July 2022: 4,000 cases in 47 countries. WHO declares a global health emergency.
August 2022: 31,000 cases in 75 countries; 10 deaths. U.S. declares public health emergency.
It’s not coming. It’s already here.
The U.S. has among the highest rates of Monkeypox infection in the world. Déjà vu?! Over 10,000 cases have been identified in the U.S. and the numbers are expected to continue to rise as testing and reporting improve.
How do you get it?
During monkeypox (MPX) outbreaks, close physical contact with infected persons is the most significant risk factor for monkeypox virus (MPXV) infection.
- Cases so far have been predominantly in men who have sex with men (MSM), particularly among those with multiple partners.
- Though there have also been cases in women and children, at this time the risk in the general population remains low.
- MPXV is transmitted from one person to another by prolonged exposure to respiratory droplets, sexual activity with infected partners, and contact with contaminated materials such as clothing and bedding. Close contact with the fluids from the lesions remains the highest risk factor for infection.
Is Monkeypox a sexually transmitted disease (STD)?
Yes and no. MPX is an infection that can be acquired with or without sexual activity. This makes it more similar to infections that are not considered to be typical STDs but can be sexually transmitted – like Zika virus, meningitis, mononucleosis, molluscum contagiosum, and hepatitis. Researchers are not sure if MPX is transmitted by the sexual activity or by the close proximity of an infected sexual partner over a prolonged period of time. The virus has been isolated in semen and may persist in semen for weeks. However, skin lesions contain exceedingly high amounts of the virus and skin-to-skin contact is now thought to be the primary route of transmission.
Because the virus can be acquired during sexual activity, close knit sexual networks of MSM have been affected. Because of the history of HIV, these communities tend to be well-educated about infectious disease and have closer ties to health care providers than heterosexual men. Their contact with the medical profession and their own public health messaging has helped describe the outbreak and foster public health awareness inside and outside of their communities.
Who is at risk:
- The infection will not continue to predominately affect the gay community. MPX is a risk to anyone, regardless of sexual orientation or sex/gender of sexual partners. Cases have been identified in women, children, and among transgender men and cisgender women. Sexual activity is but one scenario in which the virus can be passed from one person to another.
- MSM, especially those with multiple partners in close sexual networks, have been disproportionately affected.
- Health care workers caring for infected patients are at greater risk of acquiring the virus. It is recommended that health care workers who had been vaccinated against smallpox be assigned to care for patients with MPX.
- Household members of those infected are also at risk. Prolonged contact with respiratory droplets can result in transmission. But, unlike COVID-19, the MPXV can also be transmitted by contact with material (bedding, clothing) and surfaces contaminated with bodily secretions or respiratory droplets.
- Those at risk for severe infection and/or serious complications include:
- People with immunocompromising conditions (cancer, chronic liver, kidney, or heart disease, transplant recipients, people with HIV etc.)
- People with eczema or other chronic skin conditions
- Children under 8 years old
- TheMPX rash can be confused with other rash illnesses that are commonly seen in children, including varicella (chickenpox); hand, foot, and mouth disease; measles; scabies; and molluscum contagiosum. Any new rashes in children should be evaluated by health care providers.
- Daycare and school environments present conditions that facilitate contagion in young children (person-to-person close contact and access to body fluids (diapers, drooling, biting, sharing cups and toys).
Data is limited as to whether pregnant women are more susceptible to the virus or whether they might suffer from a more severe infection. Like other pox viruses, MPX can be transferred to the fetus during pregnancy or to the newborn during childbirth. Spontaneous miscarriages, stillbirths, and preterm births have been reported.
- The lesions can be excruciatingly painful.
- Waning smallpox virus immunity from childhood immunization probably played a role in monkeypox’s emergence now so many people are at risk
- Mutations of the MPXV that may make it more like the smallpox virus are of great concern. Mutations are already occurring, even though DNA viruses (which is what the MPXV is) do not normally mutate as quickly as RNA viruses (like COVID-19).
- As the infection continues to spread around the world at a rapid rate, concerns about inadequate supplies of vaccines for prevention and medications for treatment are a concern for governments, and public health organizations. Poorer communities in the U.S. and in other high income countries will disproportionately suffer as will middle- and low-income countries as the richer countries buy up the limited supplies.
- The general precautionary measures recommended against COVID-19 are also expected to largely protect from MPXV transmission in the general population, i.e., wearing masks in public and isolating people with the infection.
- The vaccine, Jynneos, provides protection (see Vaccines below).
Symptoms of infection
- The clinical presentation of monkeypox resembles that of a very mild case of smallpox, a related orthopoxvirus infection.
- About 70% of those infected experience early symptoms: swollen and tender lymph nodes in the neck, armpits, or groin, then a sudden onset of high fever >101o, chills, headache and muscle pain, weakness and fatigue.
- These symptoms are usually (96%) followed by skin lesions or rash on the face, arms and/or legs, and soles of hands and feet. Recent reports, however, suggest that, in some people, the onset of these symptoms may occur after the lesions or rash appear.
- The rash starts like pimples or red bumps, that then become small round pus-filled and very tender or itchy blisters. These eventually dry up and scab over and may leave a scar. The lesions can be extremely painful.
- People with MPX should isolate until their lesions have crusted, the scabs have fallen off and a fresh layer of skin has formed underneath.
- MPX symptoms last from 2 to 4 weeks and resolve on their own without treatment. An estimated 3–6% of infected people may die (as compared to 30% from smallpox).
Similarity to Smallpox
MPX is caused by the monkeypox virus, of the Orthopoxvirus group like smallpox (variola) and chickenpox (vaccinia). It has been endemic (fairly common) in west and central Africa for many years.
- MPX is much less contagious than smallpox and causes much less severe illness.
- Smallpox was declared eradicated worldwide in 1980.
- The U.S., China, and Russia maintain the smallpox virus in secure laboratories to enable the creation of vaccines in case it would be repurposed as a biological weapon. Vials of smallpox vaccine are also stockpiled.
- Vaccines used during the smallpox eradication program also provide protection against MPX. Among those immunized with smallpox vaccine, exposure to MPXV would likely result in prevention of infection or a mild case of infection.
- The administration of smallpox vaccine in the U.S. general population ended in 1972. So, people under 50 years-old are unlikely to have been vaccinated.
- Over 450,000 U.S. troops were vaccinated against smallpox in 2002-3 in preparedness against a bioweapon event. Rates of severe adverse events following vaccination were lower than expected.
- Due to our lack of attention to public health emergency preparedness and maintaining drug and vaccine stockpiles, 20 million doses of smallpox vaccine expired in the national stockpile. Now we are trying to catch up. (The U.S. has asked the makers of the vaccine to test the expired vials to ascertain if they might still be useable though it is thought to be unlikely.)
- What smallpox vaccine we have is currently being administered to:
- high-risk groups to prevent infection
- people who have been exposed to someone with the infection (post-exposure prophylaxis)
- treat symptomatic cases to lessen symptoms – though there is not a lot known about the efficacy of that yet.
- A newer vaccine called Jynneos has been developed in Denmark and is the only approved vaccine approved specifically for prevention of MPX in the U.S.
- The Food and Drug Administration recently issued an emergency use authorization allowing the vaccine to be injected intradermally, or into the skin, rather than by the standard injection that goes into the fat underneath the skin.
- Because there is a high concentration of immune cells just under the skin, this method allows lower doses (1/5 of the standard dose) of vaccine to be used. This stretches our current stockpile of vaccines to provide protection to more people.
- A new smallpox vaccine (ACAM2000) has been FDA approved for emergency use only because it causes more serious side-effects like myocarditis/pericarditis (swelling of the heart) and death. Being based on live virus technology, it is contraindicated in immunocompromised or pregnant people. It is reserved for people who are at high risk for MPX. (There are no contraindications to the smallpox vaccine. That’s because smallpox is so much more deadly and disfiguring than its vaccine.)
If you get infected
The World Health Organization (WHO) recommends that, if you think you have been in contact with someone who is infected or have symptoms of infection (described above) you should:
- Isolate at home. You can find more informationhere.
- Contact a health care provider for further instructions.
- Use pain relievers and fever reducers (Tylenol, Advil, etc).
- Cover your blisters or lesions to prevent spread in your household.
- Avoid contact with pets, especially those of the rodent variety. Yes, they can get monkeypox from you and pass it on to others.
- Seek immediate advice if your rash becomes more painful, shows signs of being infected (such as fever, nausea, or vomiting get worse), if you are unable to eat or drink, have difficulty breathing or if you feel dizzy or confused.
Contact tracing is a key public health measure to control the spread of infectious disease pathogens such as monkeypox virus. It allows for the interruption of transmission and can also help people at a higher risk of developing severe disease to more quickly identify their exposure.
- An antiviral agent, tecovirimat or Tpoxx, approved for the treatment of smallpox, has also been authorized for the treatment of MPX. CDC has recently streamlined the process for physicians to access the drug to make it more available for patients in need.
- The infection will clear up without treatment within 2 to 4 weeks. Remain sequestered until your skin is completely cleared of lesions.
Before you go, polio:
Depending on where you live, you may have to worry about polio, too. The first case of polio-induced paralysis in over a decade has just been identified. An unvaccinated 20-year-old man in New York state experienced paralysis due to infection with poliovirus in mid-July. Because only a fraction of people who get polio develop any symptoms, there may be many people unknowingly infected with polio in the area. Wastewater samples from the region tested positive for poliovirus, suggesting that the virus continues to spread among people in Rockland and Orange counties.
The virus that caused paralysis in the man likely came from a type of polio vaccine that has not been used in the U.S. for the past 20 years. Children here are vaccinated with an inactivated virus that can’t replicate. The polio strain found in the man and in the wastewater was derived from a vaccine made with attenuated (weakened) live virus, still in use in many countries. Rarely, that virus can cause the illness in vulnerable people.
In most communities, the polio vaccine is mandated for school attendance so most Americans are immune, but the polio vaccination rates are low in the New York counties where it has been detected in sewage. Polio vaccines are being offered to vulnerable people in the area.
Stay tuned here for more “viral posts” as they ‘evolve’…