How Serious Is Monkeypox?

This viral illness is not like Covid, but there is cause for concern. Here’s how experts are thinking about it now.

By Knvul Sheikh – Health News – 4 August

“Monkeypox cases are increasing worldwide, including in the United States, which has declared the outbreak a national health emergency. Since the disease was first detected in the U.S. in May, the Centers for Disease Control and Prevention have confirmed thousands of cases. Worldwide, there are more than 25,000 confirmed cases, and the World Health Organization has also activated its highest level of alert for monkeypox. 

After more than two years of a pandemic, it is understandable that the news of a new virus spreading across the globe could cause alarm, but health experts say that monkeypox is unlikely to create a scenario similar to that of the coronavirus, even as more cases are found. “As surveillance expands, we do expect that more cases will be seen. But we need to put this into context because it’s not Covid,” Dr. Maria Van Kerkhove, the W.H.O.’s technical lead on Covid-19, said in a live online Q. and A. on May 23.

Monkeypox is not a new virus, and it spreads primarily through close contact, so we asked experts for a better understanding of the pathogen — and how the disease it causes is different from Covid-19.

In the past, people typically caught monkeypox by coming into close contact with infected animals. That could be through an animal bite, scratch, bodily fluids, feces or by consuming meat that isn’t cooked enough, said Ellen Carlin, a researcher at Georgetown University who studies zoonotic diseases that are transmitted from animals to humans.

The virus was first discovered in laboratory monkeys in 1958, which is how it got its name, but scientists think rodents are the main carriers of monkeypox in the wild. It is primarily found in Central and West Africa, particularly in areas close to tropical rainforests — and rope squirrels, tree squirrels, Gambian pouched rats and dormice have all been identified as potential carriers.

“The virus has probably been circulating in these animals for a very, very long time,” Dr. Carlin said. “And for the most part, it has stayed in animal populations.”

The first human case of monkeypox was detected in 1970 in the Democratic Republic of Congo. Since then, the virus periodically caused small outbreaks, though most were limited to a few hundred cases in 11 African countries.

A handful of cases also made it to other continents in the past, brought by travelers or the import of exotic animals that passed the virus to house pets and then to their owners.

It is possible that the virus has evolved to become more transmissible in this outbreak. Researchers who have sequenced the monkeypox virus from recent cases have noted several mutations, but it may take some time to understand the role of these changes. Still, many experts believe that monkeypox can be contained. “Transmission is really happening from close physical contact, skin-to-skin contact. So it’s quite different from Covid in that sense,” Dr. Van Kerkhove said.

The virus can also spread by touching or sharing infected items like clothing and bedding, or by the respiratory droplets produced by sneezing or coughing, according to the W.H.O.

That may sound eerily familiar because in the early days of the pandemic many experts said that the coronavirus also had little human-to-human transmission beyond respiratory droplets and contaminated surfaces. Later research showed that the coronavirus can spread through much smaller particles called aerosols with the ability to travel distances greater than six feet. But that doesn’t mean the same will turn out to be true for the monkeypox virus, said Luis Sigal, an expert in poxviruses at Thomas Jefferson University in Philadelphia. 

Other routes of monkeypox transmission include from mother to fetus via the placenta or during close contact during and after birth.

A majority of cases this year have been in young men, many of whom self-identify as men who have sex with men.

It is difficult to disentangle whether monkeypox is transmitted sexually or just through close skin-to-skin contact, like kissing, touching or cuddling during sex. This ambiguity has led to fierce debate over not only how the virus is transmitted but also how to refer to it.

Some experts and academics are concerned about the stigma that comes with labeling monkeypox a sexually transmitted infection. Others argue that it is important to acknowledge sex as a possible risk factor in order to help those who are most vulnerable right now — men who have sex with men. But this debate has created confusion about how much of a risk monkeypox poses to other groups, including women and children.

“It’s a fine line that many people are walking right now,” said Perry Halkitis, dean of the Rutgers School of Public Health. “The minute you say it’s a disease that only gay men get, it can become stigmatized, because unlike heterosexual sex, homosexual sex tends to be stigmatized by a portion of the population the United States.”

Anyone can potentially catch and transmit monkeypox, but the number of cases in women and children has remained relatively small, even as testing has expanded around the globe.

Currently, the risk to the general population is pretty low. People are unlikely to get monkeypox in shared spaces like schools and offices, or by trying on clothes in stores, as some social media posts have suggested, said Dr. Seth Blumberg, an expert in infectious diseases at the University of California, San Francisco.

In a study of more than 500 cases that were reported in 16 countries between April and June, researchers found that 98 percent of monkeypox cases were among men who have sex with men. “We would expect to see more cases appear in other social networks if this was spreading by air, for example, or through more casual contact,” said Dr. Jay Varma, a physician and epidemiologist who specializes in infectious diseases at Weill Cornell Medical School in New York City.

Other evidence also points to sex as a likely route of transmission. Many cases in the recent outbreak have involved presentation of lesions or pustules on genital regions, rather than the classic flu-like symptoms of monkeypox followed by a body-wide rash. Several small studies have also found monkeypox virus DNA in semen and other bodily fluids collected from patients, although it is not clear yet whether the virus found there is able to replicate and infect another individual.

As a precaution, some public health experts have suggested that those at risk of monkeypox temporarily reduce their number of partners to reduce their risk and avoid sex if they do get sick, as well as abstain from kissing or touching other people’s bodies. The W.H.O. has also updated its guidance to recommend that those who have a confirmed or suspected monkeypox infection use condomsduring sex for 12 weeks after they have completely recovered to reduce the risk of spreading monkeypox to partners.

And health experts agree that, regardless of whether or not monkeypox is considered an S.T.I., there is an urgent need to get vaccines, tests and treatments to men who have sex with men — the group at highest risk for monkeypox.

Monkeypox is typically a mild and self-limiting condition, according to the C.D.C. On average, symptoms appear within six to 13 days of exposure, but can take up to three weeks. People who get sick commonly experience a fever, headache, back and muscle aches, swollen lymph nodes and general exhaustion.

About one to three days after getting a fever, most people also develop a painful rash that is characteristic of poxviruses. It starts with flat red marks on a patient’s face, hands, feet, mouth or genitals that become raised and filled with pus over the course of the next five to seven days. Many recent cases have only involved a single lesion or a few pustules on the genitals that do not spread to the rest of the body. (While chickenpox causes a similar-looking rash, it is not a true poxvirus, but is caused by the unrelated varicella-zoster virus.)

Once an individual’s pustules scab over and the scabs fall off, in two to four weeks, they are no longer infectious, said AngelaRasmussen, a virologist at the Vaccine and Infectious Disease Organization at the University of Saskatchewan in Canada.

Children and people with underlying immune deficiencies may have more severe cases, but monkeypox is rarely fatal. While one strain found in Central Africa can kill up to 10 percent of infected individuals, there have been no confirmed deaths reported outside Africa during the current outbreak.

The easily identifiable rash of monkeypox, as well as its earlier symptoms, could be considered beneficial. “One of the most challenging things about Covid has been that it can be spread asymptomatically or pre-symptomatically, by people who have no idea that they’re infected,” Dr. Rasmussen said. Most experts say that monkeypox generally becomes contagious after symptoms appear, though in some cases the symptoms may be mild. There are still plenty of opportunities to transmit monkeypox in the first few days of an infection, when symptoms are not as noticeable.

DNA viruses like monkeypox are generally very stable and evolve extremely slowly compared with RNA viruses like the coronavirus or Ebola, Dr. Sigal said. Scientists are trying to understand if the infectiousness, severity or other characteristics of the virus have changed based on genetic sequences collected from some patients, he said. “But my expectation is that they will not be any different.”

Nevertheless, experts have some explanations for the rise in frequency of outbreaks in Africa. Research has shown that incidences of humans contracting viruses from contact with animals — also known as zoonotic spillovers — have become more common in recent decades. Increasing urbanization and deforestation means that humans and wild animals are coming into contact more often. Some animals that carry zoonotic viruses, like bats and rodents, have actually become more abundant, while others have expanded or adapted their habitats because of urban development and climate change.

“There’s more opportunities for relatively rare pathogens to get into new communities, find new hosts and travel to new places,” Dr. Rasmussen said.

Despite a brief pandemic lull, people are also traveling more frequently and to more parts of the world than they did just a decade ago. And now that community transmission of monkeypox is occurring many parts of the world, new cases may not always have a history of direct travel to endemic countries in Africa.

“The main risk for people these days with regards to viruses remains Covid,” Dr. Rasmussen said. “The good news there is that a lot of the same measures that will reduce your risk of Covid — social distancing, wearing masks in public spaces, practicing good hand hygiene and surface disinfection — will also reduce your risk of getting monkeypox.”

If you get sick, the treatment for monkeypox generally involves symptom management. However, there is one antiviral drug, called tecovirimat or TPOXX, that occasionally can be used for severe monkeypox.

There is also a vaccine, called Jynneos, that the Food and Drug Administration approved in 2019, for people 18 and older, that protects against smallpox and monkeypox. Health officials stopped routinely vaccinating Americans against smallpox in 1972, when the disease was eradicated in the United States. But on June 28, federal health officials announced that states could get doses of Jynneos from the national stockpile and begin offering the vaccine to anyone who may have been exposed to the virus.

The vaccine can work both before and after exposure to monkeypox. If someone who has been in close contact with a known case gets the first dose of monkeypox vaccine right away, it may help reduce the symptoms of disease. According to the C.D.C., the first dose should ideally be taken within four days but can be taken up to two weeks after an exposure occurs. (Vaccination requires a total of two doses, with the second dose taken four weeks after the first).

If you have a new rash or are concerned about monkeypox, the C.D.C. urges you to contact your health care provider. The agency has asked doctors to be on the alert for signs of the telltale rash, and recommends that men who may have been exposed to monkeypox get vaccinated as soon as possible.

“It’s really hard to put a timeline on when this will be contained, or how easy it will be,” Dr. Rasmussen said. “But we have the pharmacological tools, in combination with the classic isolation and quarantine procedures that have helped contain monkeypox outbreaks in the past. We can contain it again. The key is going to be identifying all the cases.”

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