Recently we’ve had to familiarize ourselves with yet another virus, monkeypox. As of June 9, 1,300 cases of the disease have been detected in 31 countries. Here in the US, 15 states have reported outbreaks. While the disease can be fatal, no one has yet died, due to this outbreak, director of the Centers for Disease Control and Prevention (CDC) Rochelle Walensky, MD, MPH, said in a June 10 telebriefing.
At the same conference, Raj Punjabi, MD, senior director for Global Health Security and Biodefense, emphasized, “We have the tools to protect people from this disease. We have tests for monkeypox. We have vaccines for monkeypox, and we have treatments for monkeypox.”
Still, it’s important to remain vigilant and seek out testing and care if you or someone close to you shows signs of having been exposed to monkeypox. Here’s what you need to know.
What Is Monkeypox?
Monkeypox is a viral disease related to smallpox, which causes pus-filled lesions on the skin along with fever, pain, chills and exhaustion.
The main difference between the two diseases is that smallpox tends to be more severe, but monkeypox causes your lymph nodes to swell, which doesn’t happen with smallpox.
Monkeypox is endemic to Africa, though small outbreaks, usually among people who have recently traveled to the continent, have happened before.
Symptoms start about one to two weeks after you’ve been exposed to the virus and last two to four weeks. Historically, the disease has been fatal in about 1% of those who are infected. So far, the current outbreak appears to be more mild than previous ones.
How Is Monkeypox Spread? Why Is the Virus an Issue Now?
The term “monkeypox” is a bit of a misnomer. Scientists first observed monkeypox in monkeys in 1958, but they now think rodents are more likely to carry the virus and transmit it to humans through bites or scratches. Between humans, the disease can spread through direct physical contact or touching surfaces or clothing that comes in contact with an infected individual’s sores. Close contact includes sexual activity, but also other types of contact like cuddling and dancing.
The CDC also says that part of the spread may be caused by respiratory droplets—large, wet droplets that sink on to floors and counters quickly— though it’s unclear how often this happens. Walensky explains that all the recent cases identified have included close physical contact, thus it’s extremely difficult to determine if the droplets played a role. Because of this finding, the agency first suggested wearing masks to help prevent infections from spreading, but quickly removed the advice from its website, to avoid causing confusion, according to the New York Times. “The virus is not thought to spread through interactions, such as having a casual conversation, passing in the grocery store or touching the same item, such as the doorknob,” said Walensky.
The CDC stated that most cases in the United States so far have been in people who have recently traveled or been in contact with someone who recently traveled to a Africa or an area with a larger outbreak. This observation suggests that the disease is not spreading in the community in the US, but the CDC emphasized that it may find community spread with increased testing. There does appear to be community spread in other areas, such as Montreal.
There have been previous outbreaks of monkeypox outside of Africa, but they’ve all been short-lived. Usually, an individual had traveled to Africa right before developing symptoms. One of the most notable outbreaks, in 2003, was caused by prairie dogs that had been stored near small mammals from Ghana. In that outbreak, 47 cases of the disease in humans were reported across six states. If a person can isolate themselves when they develop symptoms, they can avoid spreading the disease to others. The main reason scientists are concerned now is that cases are showing up in countries all over the world, all at once.
How is the 2022 Outbreak Different from Previous Monkeypox Outbreaks?
Previous outbreaks have caused rashes that cover large portions of the body and often start on the face, hands and feet. “All patients in the current US monkey pox outbreak in 2022 have experienced a rash, but the lesions have been scattered or localized to a specific body site,” explained Inger Daimon, MD, PhD, director of CDC’s Division of High-Consequence Pathogens and Pathology (DHCPP) in a June 21, 2022 briefing. In several cases, those body sites have been the genitals or anus, causing the disease to appear similar to sexually transmitted infections like herpes.
Many patients in the current outbreak have experienced mild fever or body aches or sometimes even no symptoms prior to developing the rash.
Global Monkeypox Case Tracking Count Map
Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP)
A World Health Organization (WHO) situation update from June 4, states, “The sudden and unexpected appearance of monkeypox simultaneously in several non-endemic countries suggests that there might have been undetected transmission for some unknown duration of time followed by recent amplifier events.”
US States Monkeypox Case Tracking Count Map
Who Is at Risk?
In previous outbreaks, children have often been the main ones to contract the virus. This time around, the outbreak seems to be concentrated in adult males who report having sex with other males. The virus is spread by close contact, but not exclusively sexual contact, with infected individuals.
A pre-print (a study that has not been peer-reviewed) posted in May 2022 in the Democratic Republic of Congo showed that out of four pregnant women who came to the hospital with monkeypox, three ended up having miscarriages. There were signs that the virus had crossed the placenta and infected the fetuses.
The CDC also states that children who are under 8 years old, people who are immunocompromised or those who have pox in areas such as the eyes, mouth, genitals or anus may be at increased risk for severe outcomes.
Typically about 1% to 10% of people who contract monkeypox end up dying from the disease, but so far the current outbreak hasn’t caused any deaths.
Are There Any Treatments?
No treatments have been developed specifically for monkeypox, however, the FDA has permitted compassionate use of several antiviral medications if a monkeypox outbreak occurs. Those treatments include:
- TPOXX (tecovirimat), an antiviral pill or injection originally approved to treat smallpox in both children and adults. It blocks a protein that smallpox and monkeypox both need to spread from cell to cell.
- Vistide (cidofovir), an antiviral designed to treat cytomegalovirus (CMV) in patients with HIV (human immunodeficiency virus) by preventing the virus from replicating. In patients with healthy immune systems, CMV rarely causes symptoms or illness, but it can be dangerous for patients with compromised immune systems, such as those with HIV.
- Vaccinia immune globulin intravenous (VIGIV) are antibody infusions approved to treat complications from the smallpox vaccine, such as infections and skin conditions. They are also permitted for use during a monkeypox outbreak.
- Tembexa (brincidofovir) was approved by the FDA in June 2021 to treat smallpox. It is incorporated into the viral DNA to slow its replication. The CDC hopes to make it available as a monkeypox treatment, but it does not currently have the authorization or an available stockpile.
What are the Side Effects of Antivirals Available to Be Used for Monkeypox?
Side effects of tecovirimat
The drug is generally well-tolerated, but you can experience:
- Nausea, vomiting or diarrhea
- Depression or irritability
- Abnormal heart rhythms
Warnings about Vistide, cidofovir
Cidofovir’s label carries a black box warning that the drug can cause kidney impairment, which may be fatal. It may also lead to birth defects, cancer and impaired fertility.
Other occasional side effects of cidofovir include:
- Blurry vision
- Nausea and vomiting
- Difficulty breathing
- Weakness and fatigue
- Hair loss
- Reduced white blood cell counts, which can leave you vulnerable to infections.
Warnings about vaccinia immune globulin intravenous:
Vaccinia immune globulin intravenous carries a black box warning stating that because the drug contains maltose, it can result in a number of ill effects. It can interfere with typical glucose monitoring, which can cause people to administer insulin when it’s not needed or allow life-threatening levels of low blood sugar to go overlooked. Blood sugar should be monitored using a monitor and test strips that detect glucose directly.
Other occasional side effects of vaccinia immune globulin intravenous include:
- Renal dysfunction that can be fatal
- Blood clots
Warnings about brincidofovir:
Brincidofovir’s label contains a warning that when the drug was tested for a disease other than smallpox in a clinical trial lasting 24 weeks, patients who took the drug were more likely to die than those who were given a placebo. This outcome didn’t happen in shorter trials for smallpox.
The drug may also cause birth defects and cancer. People who can become pregnant should use contraception for at least two months after taking their final dose. People whose partners can become pregnant should use condoms for at least four months after their last dose. Brincidofovir may also permanently impair fertility.
Other potential side effects of brincidofovir include:
- Liver damage
- Diarrhea and vomiting
- Abdominal pain
How Can I Avoid Getting Monkeypox?
Anyone who develops symptoms of monkeypox should isolate and report their symptoms to their physician. Avoid contact with anyone in your household who may have the illness and consider wearing a face mask at home, since it’s possible that the virus could spread through respiratory droplets.
Additionally, the FDA has approved one vaccine, Jynneos, to prevent monkeypox and is also offering ACAM2000, a vaccine approved for smallpox, for those at high risk of exposure. Both vaccines contain a live virus. While ACAM2000 is capable of replicating in your body, Jynneos is not, so it won’t cause an infection in immunocompromised patients.
Patients take Jynneos in two doses, 28 days apart. They don’t get their highest level of protection until two weeks after the second dose. ACAM2000, on the other hand, is a single-dose vaccine that provides peak protection after 28 days.
During a debriefing on June 10, Dawn O’Connell, assistant secretary for Preparedness and Response at the Department of Health and Human Services, said that the US has 100 million doses of ACAM 2000 available to prevent monkeypox, along with 72,000 doses of Jynneos. It has ordered another 300,000 doses of Jynneos and begun distributing both vaccines to 16 states and jurisdictions that need them.
What Are the Side Effects of the Vaccines?
Side effects of ACAM2000:
- Poxvirus infection, particularly in immunocompromised patients
- Myopericarditis (inflammation and swelling of the heart muscle)
- Skin issues, such as ulcers or eczema
- Spreading the infection to other unvaccinated individuals
Side effects of Jynneos:
- Injection-site reactions, like pain and redness
- Muscle pain
- Abnormal heart rhythms