The Centers for Disease Control and Prevention is investigating five monkeypox cases in the United States, while the World Health Organization has now confirmed more than 90 cases in a dozen countries. So far, these cases have "mainly but not exclusively been identified amongst men who have sex with men," according to the WHO.
Experts stress that monkeypox does not spread as easily as COVID-19 and they do not expect a pandemic of that scale. While the outbreak has mainly affected gay and bisexual men so far, other groups are also susceptible.
"I expect we'll see more cases, but I think we can contain it," Dr. Peter Chin-Hong of UCSF told the Bay Area Reporter. "We can probably stamp it out by breaking the chain of transmission."
The monkeypox virus is transmitted through close personal contact, including skin-to-skin contact, kissing, contact with clothes or bedding, and respiratory droplets, but it does not appear to spread through the air at longer distances like the virus that causes COVID. It is not known whether it is directly transmitted through semen.
"Monkeypox is not a sexually transmitted infection in the typical sense, but it can be transmitted during sexual and intimate contact," CDC epidemiologist Dr. John Brooks explained at a May 23 media briefing. CDC officer Captain Jennifer McQuiston added that close personal contact can include household members and health care workers, "but not passing a person in a grocery store."
The San Francisco Department of Public Health is monitoring updates and guidance from the CDC and the California Department of Public Health, the agency said in a statement sent to the B.A.R.
"SFDPH systems are in place to receive reports of suspected cases from health care providers; identify and reach out to any individuals who have been in contact with cases during their infectious period; and ensure that clinicians remain well informed about testing, infection control and management of monkeypox as the situation develops," the agency stated. "Individuals who are concerned that they have symptoms of or may have been exposed to monkeypox should contact their clinical provider for evaluation and guidance."
Monkeypox, which is related to smallpox but less severe, typically causes flu-like symptoms, swollen lymph nodes, and a rash that can occur on the face, genitals, palms of the hands and soles of the feet, and elsewhere on the body. The rash may resemble herpes, syphilis, or chickenpox. The virus has an incubation period of up to three weeks before symptom onset, and the illness typically lasts two to four weeks. Transmission is most likely when a person is symptomatic, according to McQuiston.
A growing outbreak
Monkeypox is not a new disease. It is mostly seen in West and Central Africa, although sporadic cases in travelers are not uncommon elsewhere. In 2003, there was an outbreak in the Midwest linked to pet prairie dogs. The virus was believed not to spread easily between humans, so the extent of the new outbreak is unexpected.
The first nine cases were reported last week in the United Kingdom. One person had recently traveled to Nigeria, where the virus is endemic, but others appear to have contracted the disease locally. A large number of confirmed cases have since been reported in Spain, Portugal, and Canada, with smaller numbers in several other European countries, Australia, and Israel.
In the U.S., the CDC has confirmed one case in Boston, with four more presumptive cases in New York City, south Florida and Salt Lake City, McQuiston said at the briefing. All are men with a recent history of international travel. The Sacramento Bee reported Tuesday that health officials there are investigating a "likely" case of monkeypox in a traveler who returned from Europe.
Worldwide, all but one of the more than 250 confirmed or suspected cases for which the age and sex are known are young or middle-aged men. Many of the men identify as gay or bisexual or were seen at sexual health clinics. Several cases have been linked to a sauna in Spain and events including a fetish festival in Belgium.
While most cases are among gay and bi men so far, others should be aware that they, too, could be at risk.
"Close contact is not only sexual contact," said Dr. Boghuma Titanji, an infectious disease specialist at Emory University in Atlanta. "If you are at a crowded concert, bar, or club, body to body with other people, that's close contact too. All forms of sexual contact are close contact. Infectious pathogens flourish with the right timing and opportunity. That's how outbreaks occur."
Prevention and treatment
People with monkeypox usually recover without treatment, and the strain involved in the current outbreak has a fatality rate of around 1%. The new cases have so far been mild, with no deaths reported. The virus is more likely to cause severe illness in children and immunocompromised people. However, Brooks said that HIV-positive people with a suppressed viral load and a robust CD4 T-cell count should not be at increased risk.
Antiviral medications used to treat smallpox can also be used for monkeypox, and smallpox vaccination prevents monkeypox as well. In fact, monkeypox cases have risen over the past few decades since that vaccine was discontinued after smallpox was eradicated worldwide in 1980.
Smallpox vaccines are now being given to high-risk contacts of known cases as well as health care providers. Because the monkeypox incubation period is long, vaccines can be administered up to two weeks after exposure. At this time, experts do not advise vaccination for the population at large. An older vaccine, which is held in the national strategic stockpile in case of bioterrorism, can cause adverse events. A new, safer vaccine approved in 2019 is not yet widely available, but the U.S. has ordered more doses, officials said.
Health officials are urging gay and bi men and their providers, in particular, to be aware that monkeypox is circulating worldwide. Those experiencing symptoms are asked to contact their doctor or a sexual health clinic, isolate, and cooperate with contact tracing.
For those planning for Pride and other events in the coming weeks, Brooks said, "I don't think at the present time there is sufficient evidence of spread occurring so rapidly that we want to shut down any events or recommend that things be postponed. On the contrary, we want to empower people to take the initiative to hold themselves back from participating if they're feeling ill and to seek evaluation if, after an event, they start feeling ill."
A new disease outbreak that's primarily striking gay men has sparked fears that the community could again be subject to the kind of blame and stigma seen during the early years of the HIV epidemic.
"Infectious diseases don't care about borders or social networks," Brooks said. "Some groups may have a greater chance of exposure right now, but by no means is the current risk of exposure to monkeypox exclusively [limited] to the gay and bisexual community in the U.S."
Added UCSF's Chin-Hong, "At the end of the day, people really have to focus on the biology. Right now it's in men who have sex with men, but it really is an equal opportunity disease. Viruses don't care who you are — they just want to survive."
The California Department of Public Health has a page on its website about monkeypox.
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