This feature was created to provide information and resources focused on the monkeypox virus. Mary Beth Campbell is a public health professional with a background in infectious diseases, but this feature is not a substitute for advice or care provided by a licensed medical or health care professional. All information provided is current at the time of publication, but new information may arise as the outbreak continues to unfold.
As though we needed another public health crisis, the world now finds itself in the midst of an outbreak of monkeypox virus (MPXV). Though outbreaks of monkeypox in humans have occurred throughout the African continent since 1970, transmission outside of the continent has been rare. Since early May 2022, however, a global outbreak has begun. At the time of publication, over 47,000 cases of MPXV infection have been reported worldwide, with the majority reported in places that, historically, have not reported this disease. At present, over 17,000 of these cases have been reported in the United States; 162 of these infections are in Louisiana, with the majority (117) reported in the New Orleans area. On July 23rd, the World Health Organization finally declared the MPXV outbreak a Public Health Emergency of International Concern (PHEIC); the Biden-Harris administration declared the outbreak in the U.S. a national Public Health Emergency (PHE) on August 4th.
Though prevention and education efforts have been implemented worldwide, resources are still limited and many have found the current messaging confusing. It is important, especially as we head into Southern Decadence weekend, that comprehensive and clear information on the outbreak, the disease itself, and prevention resources are available to the public. And it is important that we don’t continue to make the same mistakes that we made with COVID-19.
The Monkeypox Virus (MPXV)
MPXV is an enveloped, double-stranded DNA virus of the Orthopoxvirus genus of the Poxviridae family, which includes cowpox and the more fatal smallpox virus (variola virus), which was eradicated in nature in 1980. Though these viruses are different, their similarities are considerable enough that the smallpox vaccine has been shown to be effective in prevention of monkeypox infection. Both viruses cause painful disease which manifests first as a rash, then as flat lesions (macules), to raised lesions (papules), then to fluid-filled blisters (vesicles) and pus-filled blisters (pustules) before eventually scabbing over.
Unlike smallpox, which is an exclusively human disease, MPXV is a zoonosis, or a disease which can be transmitted from other animal species to humans. The animal reservoir for MPXV is believed to be a rodent, and the virus can infect many animal species. This means that it is possible to transmit the virus to pets—and vice versa—via close physical contact (e.g., cuddling, hugging, kissing, petting, scratching, and sharing sleep spaces and food).
There are two known subtypes of MPXV (known as clades), the West African and Congo Basin clades. At present, the West African clade seems to be the virus in circulation worldwide, and is associated with less severe infection. Though the transmission rate of MPXV continues to increase over time, the outbreak can still be contained. Despite the growing number of cases, the risk of there being a true MPXV pandemic is low at the moment, though the possibility of it becoming endemic (consistently present in the population) if public health efforts do not improve is very real.
The Outbreak
The first human case of MPXV was described in 1970 in a 9-month-old baby in the Democratic Republic of the Congo. Multiple human outbreaks have occurred in the decades since, mostly across countries in western and central Africa. As climate change shrinks the space between human communities and habitats for wildlife these outbreaks have become more and more common and have begun to spread to non-endemic countries. In 2003 the first outbreak outside of the African continent occurred in the United States, linked to exposure to infected pet prairie dogs that had been housed with rodents imported from Ghana; a total of 47 confirmed and probable cases were reported from six states. The outbreak occurred between May and June 2003 and was quickly contained with effective contact tracing, laboratory testing, vaccine outreach, messaging, and an embargo on the importation of exotic animals.
Though the Western media only started reporting on the current outbreak in May, when the first cases in people from the U.S. and European countries were identified, the outbreak actually began in Nigeria in 2017. Perhaps unsurprisingly, despite their excellent surveillance efforts and expertise, the warnings of Nigerian scientists and physicians were not taken seriously until this disease affected people from the Global North. Though typically a childhood disease, the majority of identified cases in Nigeria and elsewhere have been young men in their 20s and 30s who identify as heterosexual.
In North America and Europe, the majority of these cases have been observed in the LGBTQ+ community, in particular gay and bisexual men, transgender, and non-binary people. The first cases identified in the West in May were linked to gay saunas and gay pride events in Europe and Canada. This has led some to (incorrectly) address this issue as solely an LGBTQ+ issue, with some messaging reminiscent of the early days of HIV/AIDS. The reality is, MPXV is spread efficiently through any closely knit social networks and events, and it is incredibly bad luck that the 2022 leg of the outbreak just happened to begin in the LGBTQ+ community and during summer Pride events. This is why we must take precautions seriously during events such as Southern Decadence, as well as be on top of preventive measures in general.
In a time where anti-LGBTQ+ messaging is ramping up, and the moral panic of queer individuals as “groomers” and “pedophiles” being perpetuated by right-wing politicians and groups is now extending to MPXV, it is very important to make sure that our messaging around MPXV is precise and not stigmatizing. The history of HIV/AIDS has taught us this. People who believe this to be solely a “gay disease” may not take proper precautions or ignore symptoms; doctors may also misdiagnose people if they do not fit into a certain risk group; and LGBTQ+ individuals may experience further harm.
MPXV Transmission
Though the recent MPXV outbreak appears to have been fueled by sexual contact (especially via infectious lesions on the genital and anal regions), it is very important to be clear that this is not the same as sexual transmission. At the time of this writing, there is no scientific evidence that the virus can be transmitted via semen or vaginal fluids. MPXV is not a sexually transmitted illness (STI), and one’s gender identity or sexual orientation does not make them biologically predisposed to be more at-risk than others. Thus, while it is important to focus on the groups who are currently most affected and at risk—both for health equity and disease control purposes—we must not lose sight of the fact that MPXV could spread more widely (e.g., in schools) and should also have strong measures in place for if and when this occurs.
Transmission occurs primarily through close physical contact with someone who has an MPXV rash or lesions, particularly if the lesions are opened and/or there is any damage to skin integrity. This is something that Dr. Susan Hassig, an infectious disease epidemiologist at Tulane University School of Public Health and Tropical Medicine, wants to emphasize. “Skin integrity is especially important for people with psoriasis, eczema, impetigo, pregnant people—everyone who is immunocompromised. Even a rug burn can be problematic.” Sex is one way that both transmission and disruption to skin integrity can occur, not only via contact with skin but also due to the friction caused by intercourse. Transmission is also possible with any other sort of skin-to-skin contact, as well as exposure to any surfaces, objects, and fabric in contact with MPXV lesions and respiratory secretions during prolonged face-to-face contact, though this does not seem to be the primary mode of transmission for this outbreak. Pregnant people infected with MPXV can transmit the virus to their fetus via the placenta. And, as discussed earlier, contact with infected animals may also lead to transmission and infection.
We must also be careful about self-inoculation, or when a person transfers a disease from one part of their body to another. “There’s the real possibility of self-inoculation,” especially with damage to skin and mucosal tissues, states Dr. Hassig. She is especially concerned about what will happen if MPXV spreads more among children as they “do not have self-control.” Self-inoculation to the mouth is possible as well as to the eyes, which could lead to blindness. This is why it is important to keep lesions covered (Dr. Hassig recommends small, circular bandages, which have a seal and are roughly the size of the largest MPXV blisters), as well as to practice proper hygiene and make sure that all materials that may have come into contact with someone with MPXV are disinfected.
Though the current strain in circulation has a mortality rate of only 1% (compare that to the approximate 10% mortality rate of the Central African strain), this does not mean that we should not be concerned—the disease is painful and debilitating and can lead to scarring—or that precautions should not be taken. For one thing, the more people who become infected, the larger number of people will be part of that 1%. Children and immunocompromised adults are at highest risk of severe disease and mortality. And, as is the case with all disease outbreaks, people who are already marginalized and face barriers to public health and medical resources will bear the greatest burden of disease.
The Disease
The incubation period (time between infection and symptom onset) for MPXV is approximately 3 to 17 days; during that time, people who are infected generally do not have symptoms and are currently not believed to be able to transmit the virus. As with many viral infections, the early symptoms (known as the prodromal period) are fairly standard and may be confused for other infections, including COVID-19: fever, chills, swollen lymph nodes, fatigue, muscle ache, headache. Respiratory symptoms (e.g., sore throat, nasal congestion, cough) may also occur. These symptoms may show up before a rash forms, after the rash appears, or, as is being observed with this current outbreak, not occur at all. In some cases, rectal symptoms (e.g., stools with blood or pus, rectal pain, or rectal bleeding) have been reported.
The next phase, known as the “skin eruption phase,” typically appears within 1 to 3 days of fever. These lesions are often described as being incredibly painful (especially if they are located in the genital or perianal regions of the body), and the pain may increase when the pustules become ulcers. Unlike in previous outbreaks, many of the cases that have been reported in the current outbreak do not involve a rash or lesions disseminated across the entire body. In fact, the rash and lesions may only be limited to a small number or even a single lesion. The lesions may also be in areas that make them hard to locate, including the genitals, anus, throat, and mouth. Lesions are going to look different on people with different skin tones, so be sure to get checked for anything that is not normal for your skin. Joe Hui, the Director of Communications at CrescentCare, emphasizes that “it’s important for the public and providers to educate themselves about what lesions look like with the current strain. It looks like a lot of other things—herpes, staph infections, pimples, and other common skin conditions.”
These lesions usually last for about two weeks. Eventually, the lesions scab over. As might be expected, these lesions and scabs also have a high risk of developing into permanent scars. A person is no longer considered to be infectious once the scabs fall off and the skin underneath heals. This whole process can last between 2 and 4 weeks, and isolation is strongly recommended. Naturally, this adds another layer of issues and inequities for people who are infected. As was (and still is) an issue with COVID-19, most people do not have the ability to isolate for that long, nor can they afford to take that much time off of work.
Prevention
So, what prevention efforts can be taken? Checking your skin and seeking medical attention for any rashes or blemishes that are not typical for you is an important step, says Dr. Hassig. Avoiding contact with infected pets or other animals is also a necessary prevention method. Disinfect surfaces and wash clothes and linens that have come into contact with lesion material (e.g., scabs, pus), body fluids, and/or respiratory secretions from infected individuals. And of course, there is the risk of exposure through close human contact, including sex, to address. Expecting people to abstain from sex is not realistic, so instead take a harm reduction approach, such as that outlined in the helpful guide CrescentCare created for their social media. If you find any lesions on your body and are not able to get tested or vaccinated right away, cover them with bandages and cover your skin as much as possible (admittedly, not ideal in the Louisiana summer or during Decadence, but better than transmitting or contracting MPXV).
If you are feeling ill, strongly consider staying in. If you experience symptoms and/or test positive, isolate (this might be challenging for many people). Make sure to disinfect surfaces and avoid sharing towels and clothing, and openly communicate with friends and sexual partners if you suspect you have symptoms or have been exposed. If you plan on going to large gatherings, be open with others about potential exposures and symptoms, and perhaps limit the number of events you go to. The risk of transmission is much lower in outdoor spaces than in indoor settings. Though MPXV is not most efficiently transmitted via respiratory secretions, it is still possible (and SARS-CoV-2, which is still very much an issue, can be as well); wear masks in large gatherings whenever possible. Finally, when engaging in sex with a partner, keep the lights on and take the time to explore each other’s bodies—it is possible to have fun with MPXV precautions and have good sex.
Testing is necessary for prevention—and unfortunately, not yet widely available. There is currently no rapid home test for MPXV, as there is for COVID-19, nor are there community testing events. Instead, if you notice any bumps, rashes, etc. on your skin, you need to go to a clinic to get checked out and request a test. The medical provider will swab the lesions and request an MPXV test, which is a PCR test (similar to that for COVID-19). There is still limited capacity for testing across the U.S. and most facilities have a couple days’ turnaround. Since the MPXV test requires infectious material from the lesions themselves, you also cannot get tested if you do not have any rash or lesion-like symptoms. This poses a problem for control and prevention efforts.
Vaccination
The very best prevention method is vaccination. Though there is no MPXV-specific vaccine, the virus is similar enough to smallpox that the smallpox vaccine has been shown to be at least 85% effective in preventing MPXV. If administered to individuals who have been exposed or who are infected, it might also help prevent disease, or at least prevent a person from developing a more severe case. In the United States, the JYNNEOS vaccine is being most commonly administered, as it has the least side effects and is safe to give people who are immunocompromised. Typically, two doses are needed, spaced four weeks apart, for a person to be considered fully vaccinated. However, due to supply chain issues which have limited access to JYNNEOS across the world, the U.S. has recently approved a new method of vaccine delivery to help stretch out the supply.
This is a fractional vaccination method, administering one-fifth of a normal dose of JYNNEOS intradermally (into the skin) to people ages 18 and older, instead of the more common ways of injecting it under the skin (subdermal) or into a muscle (intramuscular). Though this may seem strange, it is actually an approach that has been used before (this was how smallpox vaccines were typically delivered in the past), and it has been shown to be effective.
The limited JYNNEOS supply also means that, at present, individuals need to meet certain eligibility requirements to be vaccinated against MPXV. In Louisiana, the current vaccine eligibility requirements are as follows: individuals with known exposures (identified via contact tracing) and/or who have had a likely high-risk exposure in the last 14 days. Individuals who have had a likely high-risk exposure in the past 14 days specifically refers to:
*Gay, bisexual, other (cis or trans) men who have sex with men
Vaccine outreach events at gay bars and clubs have been occurring across New Orleans and are ramping up in time for Southern Decadence. Hui acknowledges that “Inconsistent access to the vaccine has been frustrating for so many people, especially for those at the highest risk.” But despite there being limited supplies, local clinics are starting to get more regular access to the vaccine and future outreach events by the New Orleans Health Department and other groups are expected to occur.
Unfortunately, there is no central database indicating which clinics have doses at any time, but Hui recommends calling 211 “to get a list of clinics who have received doses. You might have to call a few clinics before you can get an appointment, but for those who meet current LDH eligibility, it’s now much easier to find a dose.”
Aside from outreach events, calling 211, and checking in directly with clinics such as CrescentCare (call 504-821-2601 to schedule an appointment), people can also access vaccines (when supplies are available) at University Medical Center’s third floor clinic. The clinic is open Mondays, Wednesdays, and Fridays until 2 p.m., and vaccines are available both by drop-in visit and appointment. To check about appointments or vaccine supply, call 504-702-4243. All calls are directed to a phone tree. If you indicate that you have symptoms or have been tested you will not be considered eligible for an appointment at this time. If you meet the requirements, you will be transferred to a patient navigator who will help schedule your vaccination.
Treatment
While treatment for smallpox may also be effective for treating MPXV, this treatment is not dependable at this time due to limited supplies. Though it is still worth checking in with providers about whether they are able to access the drug, the best approach currently is still vaccination and other prevention efforts.
As with the COVID-19 pandemic, the MPXV outbreak has made clear that, once again, we were not prepared for another disease outbreak, and will not be in the future. This is not the last emerging zoonosis. Climate change will continue to force natural habitats into close contact with humans, and the interconnectedness of our world makes it easier for diseases to cross borders (not that they have ever recognized borders). With the addition of polio circulating in New York City and a call for the overhaul of the Centers for Disease Control and Prevention (CDC), we are in a very tenuous situation for public health, which is a tenuous situation for us all.
“We need to address [infectious diseases] much more effectively on a global scale.” states Dr. Hassig. “We haven’t begun to address the potential impact of climate on expansion of vector-borne disease [diseases transmitted by arthropods, such as mosquitoes, and which are much harder to contain].” This will require more robust public health structures, both in the U.S. and elsewhere. And, of course, this will also require that we address the inequities both here and elsewhere in the world. African countries, including those which have been handling MPXV outbreaks for years, have not had the same vaccine access as countries in the Global North. There are racial and socioeconomic disparities among people who qualify to receive the vaccine in the United States, even as recent data from Louisiana indicates that there is a racial disparity in cases. “This is an excellent example of disparity,” according to Dr. Hassig. “I’m concerned that our response to COVID and the disparities associated with it are being replicated in our response to monkeypox. The inequitable distribution of access to testing, vaccines, and therapies seems to be occurring once again,” and it continues to fuel these outbreaks.
We cannot directly control what is going on at higher levels of power, but that does not mean that we should give up. For our current situation with MPXV, in conjunction with the COVID-19 pandemic, it is important to continue to take all the necessary and recommended precautions. While vaccine resources are limited, focusing on the groups most immediately affected is a necessary strategy, but it is also important to have prevention and education efforts for other at-risk groups. Multiple approaches can and should occur simultaneously. Monitoring symptoms, communicating with loved ones about exposure, sharing information, and helping others gain access to resources such as vaccines and testing are actions that matter and keep our communities safe.
Illustrations by Kate Lacour