Updated July 26, 2022: The World Health Organization declares the monkeypox outbreak a public health emergency of international concern (PHEIC) as current public health measures (or the lack thereof) have failed to curb the disease’s spread. Global cases have surpassed 18,000, with the US now leading case counts at ~3,850 (CDC).

This includes 2 cases in children who were reportedly in households with gay men, presumably a case of household transmission through holding, cuddling, feeding, as well as through shared items such as towels. As anticipated, homophobia is rising with ignorant responses like this, which (i) falsely think monkeypox is an STI/STD, and (ii) imply that homosexual men somehow had inappropriate contact with children:

Twitter reply to ABC7 story about 2 children contracting the monkeypox infection

Updated July 6, 2022: In just over 2 months, global case counts have crossed 7,000, and cases have spread to 52 countries.

On May 7, 2022 scientists in England confirmed a case of Monkeypox in a man who had recently returned from Nigeria. But as cases with no known travel links popped up in several countries, alarm bells went off. This meant we were now experiencing community transmission. Person-to-person infection is not how monkeypox has spread in the past, so epidemiologists believe there is cause for concern.

Case numbers are rising really quickly, and things might get a lot worse before they get better. I’m sure you’re wondering – should I be worried? Is this going to be another pandemic? What can I do to not get infected? Let’s dive in.

A primer on Monkeypox

The monkeypox virus

Monkeypox is a disease caused by the Monkeypox Virus. It is transmitted by close physical contact with an infected individual. It typically starts with flu-like symptoms (fever, chills, head and muscle aches, exhaustion). 1-5 days after initial symptoms, a rash appears on the face which can spread to other body parts. This rash transforms from red spots to pus-filled blisters (I’ll spare you photographs) that eventually scab and fall off. Most often, these symptoms go away on their own within a few weeks.
The strain spreading around the world is a West African strain, with an average mortality rate of ~3%, which for reference is twice that of Covid-19. Note: these are averages. Covid-19, for example, has a higher infection fatality rate (IFR) in older people.
Incubation period: 8 days, substantially higher than that for the nCoV-19. This will make it harder to detect in a timely fashion, and increase the chances of people unknowingly spreading the virus.
Tracing the path of this outbreak: Of the few thousand cases identified in this recent outbreak, most are among men, many of who self-identified as men who had sex with other men. Based on this important observation, a leading theory traces this outbreak to sexual activity among men at two recent (and massive) parties in Spain and Belgium. That said, monkeypox is by no means restricted to only men. Anybody can contract monkeypox through close contact – including through bodily fluids, and contaminated bed sheets and clothing.

If monkeypox was transmitted through sexual contact, is it a sexually transmitted infection?
Historically, monkeypox hasn’t been classified as an STI/STD because there was no evidence of the infectious agent (virus) being carried via semen, vaginal fluids, etc.
But, the latest data as of June 12, 2022 (Antinori, et al; reference below) suggests monkeypox virus DNA was found in 6/7 semen samples from infected patients. Importantly, one sample tested in the lab from a single patient suggested that the virus found in his semen was capable of infecting another person and replicating. This is not enough evidence to classify monkeypox as an STI but, like with all science, we’re constantly searching, researching, and learning.

Should I be worried?

The short answer is – probably not but precautions might be necessary as we learn more. There are a few important caveats to the “probably not”.
Transmission in LGBTQ+ community: This outbreak has largely been restricted to men who have sex with other men. If you’re part of this community, take extra precautions. Postpone big parties, avoid sex with strangers until we know more, spread awareness in your social circles, etc.
Airborne transmission: Unlike the coronavirus where tiny airborne air-droplets travel far, monkeypox spreads largely through close physical skin contact. The CDC says “The virus is not thought to spread during interactions, such as having a casual conversation, passing in the grocery store, or touching the same item such as a doorknob” That said, there is an important airborne component that we will learn more about through research in the coming months.
Severe illness: For most people, self-isolation for 3 weeks will resolve the disease with only mild symptoms. But, in severe cases, the disease is ruthless. Again, I will spare you the pictures.
Mutation: We saw this with Covid-19 – newer, more contagious variants spread like wildfire. We might start to see more contagious variants as the monkeypox virus circulates in the population.
There is some good news. Read on.

Are there vaccines or treatments for monkeypox?

Yes and yes, but again, there is always a caveat.
Vaccines: In 2019, the FDA approved a monkeypox vaccine called Jynneos, which prevents the disease or at least makes it less severe. We also have a smallpox vaccine which is 85% effective (CDC) based on data from previous outbreaks in Africa. As of now disease experts don’t believe you need to get preemptively vaccinated. The CDC also believes that vaccination after a monkeypox exposure may help prevent the disease or make it less severe. A monkeypox vaccine should not be taken 4 weeks before/after a Covid-19 vaccine.

Treatments: As of May 30, 2022, the World Health Organization has confirmed that the antiviral TPOXX, initially approved for smallpox, is effective against a monkeypox virus infection. Importantly – TPOXX has only been tested in humans for safety/side effects (Phase II trials). Due to ethical concerns (you can’t infect people with monkeypox), a large enough sample size has not been obtained for Phase III clinical trials. If vaccines are recommended for the general public, that will probably not be perceived well given that we’re still in the middle of a pandemic.
Other options include an antibody treatment called vaccinia immune globulin (VIG), and an antiviral called cidofovir (though it is cytotoxic (i.e. toxic to living cells) so it will only be used as a last resort).

Origins of monkeypox

Judging by its name, monkeypox originated in monkeys, right? Actually, that’s possibly not the case. The virus was first identified in lab monkeys in Denmark, but we don’t know the virus’s natural reservoir.
The first human case was identified in 1970 in an infant in the Democratic Republic of the Congo. From there, cases were identified in multiple parts of Central and Western Africa, likely spreading from animals to humans.
The first known monkeypox cases in the western hemisphere were identified in 2003. The 2003 Midwest monkeypox outbreak (reference below) started when a shipment of 800 small mammals (intended to be “exotic” pets) from Ghana to Texas was found to contain animals infected with the virus. These animals were shipped to an animal vendor in Illinois where the virus spread to over 200 prairie dogs at the facility. Prairie dogs are a common pet in the US, and contact with the animals and their bedding led to transmission to humans. Importantly, no human-to-human transmission was found during this outbreak. All cases were found to be the direct result of contact with infected prairie dogs.

Time for a new name?
As of June 15, 2022 the WHO has said it will rename the monkeypox virus. This decision comes after scientists are calling the name ‘inaccurate’ and ‘stigmatizing’. The scientists warn of “an increasing narrative in the media and among many scientists that are trying to link the present global outbreak to Africa or west Africa, or Nigeria” (reference below). We saw this with ex-US President Donald Trump’s usage of derogatory terms like “Kung-Flu” so can we not have a redo, please?
Anti-LGBTQ folks are also trying to use this outbreak to cancel Pride events across Europe. Given the inaccuracy of the current classification, and attempts to misuse and stereotype the disease, the name will be changed. My money is on hMPXV (human MonkeyPox Virus) being the new name.

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I will update this post with new developments on this outbreak. Stay tuned! Thanks for engaging, and please share this article if you learned something from A New Normal. I don’t monetize this space at all – safety, and love of science are my motivators. Don’t hesitate to reach out if you have questions, comments, concerns, or feedback. A special thanks to Chris Turnbull (Journalist at Enemy In A State) for his helpful comments.

A scientist

(1) Antinori A., Mazzotta V., Vita S., Carletti F., Tacconi D., Lapini E. L., D’Abramo A., Cicalini S., Lapa D., Pittalis S., Puro V., Rivano M.C., Giombini E., Gruber C. E. M., Garbuglia A. R., Marani A., Vairo F., Girardi E., Vaia F., Nicastri E., INMI Monkeypox Group. Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022. Euro Surveill. 2022; 27(22):pii=2200421. https://doi.org/10.2807/1560-7917. ES.2022.27.22.2200421
(2) Christian H., Ifedayo A., Placide M., Richard N., Emmanuel N., Anise H., Nnaemeka N., Oyeronke A., Gerald M., Trevor B., Richard A. N., Cornelius R., Emma H., Houriiyah T., Áine O., Andrew R., Oliver P., Moritz U. G. K., Eduan W., Joana I., Vítor B., Miguel P., João P. G., Cheryl B., Richard L., Ahmed E. O., Yenew K., Sofonias K. T., Tulio dO. Urgent need for a non-discriminatory and non-stigmatizing nomenclature for monkeypox virus. 2022. https://virological.org/t/urgent-need-for-a-non-discriminatory-and-non-stigmatizing-nomenclature-for-monkeypox-virus/853
(3) B.L. Ligon. Monkeypox: A review of the history and emergence in the Western hemisphere. Semin Pediatr Infect Dis. 2004. https://doi.org/10.1053/j.spid.2004.09.001

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