Monkeypox has been in the news lately regarding its spread to numerous countries this year, including the United States, the United Kingdom, and Canada. Now identified in countries worldwide, monkeypox is understandably concerning to many. With over 9,000 cases (9,647 as of July 11th, 2022) in 63 locations, disease control centers (including the US CDC) are monitoring the outbreak to determine the best course of action to reduce the spread and ensure that people across the globe know how to protect themselves.
What is monkeypox (MPX)?
Monkeypox is a rare disease caused by an infection with the monkeypox virus. The virus belongs to the Orthopoxvirus genus in the family Poxviridae. This genus also includes the variola virus, which causes smallpox, vaccinia virus, which is used in the smallpox vaccine, and cowpox virus. However, monkeypox is not related to chickenpox.
History of monkeypox
As a viral zoonosis (a virus transmitted from animals to humans), monkeypox was first identified in humans in 1970 in the Democratic Republic of Congo in a 9-month-old boy in a region where smallpox had been eliminated since 1968. Since then, most cases have been reported from rural rainforest regions of the Congo Basin, particularly in the Democratic Republic of Congo, with human cases increasingly reported across central and west Africa.
Since the 1970s, human cases have been reported in 11 African countries. These include:
- The Central African Republic
- The Democratic Republic of Congo
- Cote d’ Ivoire
- The Republic of Congo
- Sierra Leone
- South Sudan
Where Has Monkeypox Been Identified?
While many of the past cases have been identified in Africa, this disease has global implications, as we have seen since May 2022. Viruses can spread more easily to different regions in a globalized world and economy. Authorities are seeing local transmission in non-endemic countries such as Canada, unlike the sporadic travel-related cases in the past. The first monkeypox cases were reported in Canada in May 2022 in Montreal, with British Columbia’s first case in June, with continuing additional cases across the globe. Prior to this year, most of the cases outside Africa were linked to international travel to where the cases occur more frequently or through imported animals. As such, surveillance was limited in non-endemic countries, though this is now changing.
In 2022, authorities have been tracking multiple monkeypox cases reported in several countries, such as the United States and Canada, that don’t normally report monkeypox. So far, monkeypox has been identified in 54 countries across the globe in every continent (except Antarctica).
Often clinical presentation resembles smallpox but is less severe. Symptoms can vary depending on several factors such as age, exposure characteristics, presence of conditions that may alter immune response, and previous immunity.
Monkeypox infection has two clinical phases:
- Prodromal illness that lasts between one and five days characterized by fever, intense headache, lymphadenopathy (swollen lymph nodes), back pain, myalgia, and fatigue. Other symptoms can include sore throat, cough, and possibly vomiting or diarrhea. Though in some cases, no prodromal symptoms are reported or occurred after the second phase (rash).
- A skin rash that begins one to five days after fever. The rash evolves, and the lesions can be painful and different stages of the rash can present at the same time. The number of lesions can also vary and can be found on all parts of the body, including the palms of the hands and soles of the feet.
The symptoms of monkeypox include:
- Muscle pains
- Swollen lymph nodes
- Low energy
- Skin rash (usually starts one to three days after the fever)
- Multiple lesions can be found on the face, palms of the hands, soles of the feet, mouth, or genitals
The rash can look like pimples or blisters that appear on the face, inside the mouth, and on other parts of the body like the hands, feet, chest, genitals, or anus. The rash goes through different stages before healing fully.
The current outbreak has seen cases of people experiencing painful anal and genital lesions, often before having a fever.
The illness typically lasts 2-4 weeks, and sometimes people get a rash followed by symptoms while others only experience a rash.
Thankfully, recent cases in Canada and western countries have been described as mild so far. Since May 2022, no deaths have been reported in these countries.
How is monkeypox transmitted?
The monkeypox virus is transmitted by close physical contact. Skin lesions, respiratory droplets, bodily fluids, and contaminated towels and bedding can all present a risk of exposure to the virus. Monkeypox is most infectious when a person has symptoms, and human-to-human transmission can result from close contact. Transmission via respiratory droplets usually requires prolonged face-to-face contact, putting healthcare workers, household members, and other close contacts of active cases at a greater risk.
In terms of community spread, the longest documented chain of transmission has risen in recent years from six to nine successive person-to-person infections, possibly due to the cessation of the smallpox vaccination. Transmission can also occur congenitally from the placenta from mother-to-fetus, or during and after birth from close contact.
In Africa, evidence of the monkeypox virus infection has been found in numerous animals such as rope and tree squirrels, Gambian pouched rats, dormice, and different monkey species.
The natural reservoir of monkeypox has not yet been identified, though rodents are the most likely. Eating inadequately cooked meat and other animal products is a possible risk factor. People living in or near forested areas may have indirect or low-level exposure to infected animals.
Scientists are currently investigating if monkeypox can be transmitted sexually or if it is from skin-to-skin contact with an infected sexual partner.
It is unclear how the current cases were exposed to monkeypox, but early data has suggested that sexual contact is a possible cause.
Who is affected?
Monkeypox can affect anyone, but as with many diseases and viruses, immunocompromised individuals are considered higher risk, as are children and pregnant women. The early data of the current outbreak in non-endemic countries has seen gay, bisexual, and other men who have sex with men (MSM) make up a high number of cases. Authorities stress that anyone can get monkeypox, and an individual that has had contact with someone with an infection is at risk. It is important not to stigmatize any group facing higher risk and that countries and health authorities work together to ensure that those most vulnerable to monkeypox have access to tools that help protect themselves. The virus can affect anyone, and all responses to this outbreak should avoid stigma or blame.
What should you do if you have symptoms or monkeypox is suspected?
If monkeypox is suspected, the individual should be tested by a health facility. PCR (polymerase chain reaction) testing is preferred given its sensitivity and accuracy. Generally, optimal samples are taken directly from skin lesions, or where possible, a biopsy is an option. As orthopoxviruses are serologically cross-reactive, antigen and antibody testing detection methods do not provide monkeypox-specific confirmation.
If a person suspects or has confirmed that they have monkeypox, it is important to avoid close contact (including intimate physical contact). It is important to stay isolated until the rash has healed, all scabs have fallen off, and a fresh layer of contact skin has formed.
Treatment and Vaccines
There are no treatments specific to monkeypox infections, but as the virus is similar to smallpox, antiviral drugs and vaccines developed to protect against smallpox may be used to treat and prevent monkeypox virus infections. Antivirals may be recommended for individuals who are more likely to get severely ill such as those who are immunocompromised.
Vaccines may be recommended for high-risk individuals and groups, someone who has had contact with someone who has monkeypox, or healthcare professionals who may have been or may be exposed to the virus.
The UK is considering a vaccine for those at higher risk of catching monkeypox. Due to the notable proportion of cases currently seen in MSM, they are considering a targeted vaccine program to help protect this group and others at a higher risk. The vaccine is also being offered to most healthcare workers caring for those suspected or confirmed with monkeypox.
It is important to know the symptoms and how the virus is transmitted to help increase protection against spreading the virus. Events such as festivals and concerts where attendees are generally fully clothed and unlikely to share much skin-to-skin contact are safer, but it is important to remain mindful of sustained close contact and of activities such as kissing that may spread monkeypox.
Other activities, such as raves or swim parties where there is likely to be more minimal clothing, have some risks, so it is good to be aware of rashes or sores you may see on others. Enclosed spaces such as saunas and smaller parties with tighter spaces are riskier, and it is important to remember there is a higher likelihood of monkeypox spreading. Regular handwashing with soap and water or alcohol-based sanitizer is recommended, similar to any virus or illness. Some other prevention tips include:
- Avoid going near wild or stray animals, including dead animals
- Do not touch or eat meat from wild animals or bush meat
- Do not share towels or bedding with individuals that are unwell and may have monkeypox
- Avoid close contact with those who are unwell or may have monkeypox
- Avoid sharing objects such as toothbrushes, sex toys, and drug supplies
- Talk to partners about sexual health and practice safe sex
- Clean and disinfect frequently touched surfaces such as door handles, countertops, and phones as well as fabrics such as bedding and clothes
- Stay home if you are sick and encourage others to do the same
- Wear a mask in indoor public spaces when possible
Remember, though anyone can catch monkeypox, it is highly unlikely to contract it if there has not been close contact (such as skin-to-skin contact or sharing bedding) with someone diagnosed with monkeypox, has symptoms, or there has not been travel to west or central Africa.
What do people living with HIV (or other serious illnesses) need to know about monkeypox?
Most people who contract and fall ill with monkeypox experience a mild illness and recover naturally. However, people with lowered immune systems may be at risk of more severe illness. All people living with HIV should contact their health professional if they develop symptoms or have contact with anyone with monkeypox. As with other viruses and illnesses (such as COVID-19), taking antiretroviral treatment (ART) as prescribed to reduce viral load, avoiding close contact with symptomatic people, and remaining as healthy as possible will help reduce the risk of falling ill.
If you do not know your HIV status, it is important to take an HIV test so that, if necessary, care and treatment can be started as soon as possible. For more information on testing, check out the INSTI® HIV-1/2 Antibody Self Test for options to test at home or contact your health center to speak to a professional about testing.
While part of the same smallpox family, monkeypox is less severe, and most people recover naturally with time. If someone has symptoms, they must get tested and isolate themselves until fully healed to help reduce the spread of the virus. Remember, though it is highly unlikely to contract monkeypox without close contact, take precautions in higher-risk situations, and be aware of and monitor for symptoms. Of course, if someone has questions or concerns, speaking to a healthcare professional for more information is always recommended.
Ottawa Public Health: https://www.ottawapublichealth.ca/en/public-health-topics/monkeypox-virus.aspx