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For dozens of countries that do not typically encounter monkeypox, the fast-moving outbreak has caught both health officials and patients off guard. The World Health Organization declared monkeypox a global emergency on July 23. Nearly two weeks later, the United States issued a public health emergency declaration of its own in order to designate more resources and personnel to combat the escalating crisis.
“We’re prepared to take our response to the next level in addressing this virus, and we urge every American to take monkeypox seriously,” Health and Human Services Secretary Xavier Becerra said during a call with reporters on Aug. 4.
The U.S. currently has the most confirmed monkeypox cases — more than 14,000 — compared to any other country, according to the Centers for Disease Control and Prevention. The national declaration came days after several cities and states dealing with high case counts of the disease issued emergency declarations of their own. Existing data suggests that so far monkeypox is spreading overwhelmingly among men who have sex with men, and that people of marginalized races or ethnicities are disproportionately impacted.
READ MORE: The COVID lessons the U.S. still needs to learn to tackle monkeypox
Health officials are still learning about how the monkeypox virus, or MPV, is behaving during this outbreak. We know it spreads via close skin-to-skin contact and, in some cases, through certain objects or fabrics (think bedsheets, not doorknobs). But WHO Director-General Tedros Adhanom Ghebreyesus noted in a statement regarding that agency’s declaration that the current crisis is being fueled by “new modes of transmission, about which we understand too little.”
“One of the issues for epidemiologists is thinking about whether maybe [MPV] sustains itself better in the human population than we realize,” said Stephen Morse, an epidemiology professor at the Columbia University Medical Center.
The type of monkeypox that’s fueling the global outbreak is rarely fatal, but five deaths have been reported in countries that do not usually encounter it, according to the CDC. An Aug. 11 brief from the Africa CDC said that 104 deaths due to monkeypox have been reported on that continent since the start of 2022. A more lethal version of the virus is spreading in several African nations compared to the one circulating in non-endemic countries.
More than two years into the COVID-19 pandemic, we’re all a little too familiar with the ways that evolving information can seem murky in the early days of an infectious disease outbreak. MPV, however, isn’t a novel pathogen. There are resources available to treat and prevent monkeypox infection, but the effort to get those to everyone who needs them in a timely manner has so far been hampered by limited supplies and lingering logistical hurdles.
“I think we need to take swift action to address and ensure we get ahead of this outbreak,” said Anthony Fortenberry, chief nursing officer at Callen-Lorde community health center in New York City. “Unfortunately, no one feels the federal government is doing a good job with that at this time.”
Messaging on monkeypox has been uneven and at times confusing during the outbreak. That’s due in part to incomplete data and uncertainty about how to ensure those who are high-risk get the information and care they need to protect themselves without pigeonholing monkeypox as a disease that only affects certain demographics.
Men who have sex with men are currently at most risk of exposure and infection, which means that they are being prioritized for medical interventions that can prevent and treat monkeypox. But people of other identities and orientations can be infected and already have been, albeit at a much smaller scale. Sex appears to be the driving force of MPV transmission during this outbreak, but other forms of prolonged close contact have historically been known to spread the virus as well. Social stigma around infectious disease, particularly those that can be transmitted through sex, can be an enormous detriment to public health and ultimately could help this virus spread further.
“This is not a virus that will discriminate based on sexual orientation or gender identity. Anyone can catch this,” Fortenberry said. “Everyone should be aware of how it’s transmitted, and what to do in the event that there is an unexplained rash on yourself or your sexual partner, and how to be safe.”
Here’s a look at what we know about monkeypox, who is eligible to get vaccinated and what people can do to protect themselves and others.
Right now, gay, bisexual and other men who have sex with men make up the vast majority of confirmed monkeypox cases in the U.S. Data suggests that Black and Hispanic or Latino people have also been disproportionately infected thus far.
An Aug. 5 CDC report found that, in a subset of nearly 1,200 confirmed monkeypox cases with information on demographics, 99 percent were among men. For cases that included information on a patient’s sexual activity, 94 percent of those men reported male-to-male sexual or otherwise close intimate contact within three weeks of symptom onset, the agency said.
Among a sizable subset of cases with data on race and ethnicity, 41 percent of people were non-Hispanic white, 28 percent were Hispanic or Latino and 26 percent were non-Hispanic Black. Forty-one percent of people among a subset of cases with available data had HIV.
A separate analysis of 528 confirmed MPV cases across 16 countries found that 98 percent of people with infections were gay or bisexual men, 75 percent were white and 41 percent had HIV. Sexual activity was the suspected mode of transmission for 95 percent of cases among the group.
That’s why men who have sex with men and other groups who may be at increased risk of exposure to MPV due to sexual activity — including people of all genders and sexual orientations who have had multiple sex partners in the past two weeks, per Washington, D.C.’s guidance — are being prioritized to receive a vaccine that can both protect against MPV and stop or slow disease progression in people who have already been infected depending on when they get their first dose (see our section on “Who’s eligible to get vaccinated for monkeypox?” later on in this article for more information).
People who are infected with MPV develop rashes featuring lesions that range in severity and number, and can be excruciatingly painful. These lesions develop through specific stages, which are explained alongside photos on the CDC website (beware, it includes some graphic images). They can appear anywhere on the body, including near the genitals or anus, or the mouth, hands, face, feet or chest, the agency said.
Some patients — but not all — develop additional symptoms like a fever, muscle aches, headache and swollen lymph nodes during the first few days of infection before lesions appear, and may be contagious during that time. Evidence so far suggests that MPV is impacting people differently than it has in the past. During this outbreak, people with monkeypox infections appear to be comparatively less likely to develop those pre-rash symptoms and more likely to have genital lesions, according to the CDC. An Aug. 5 report from the agency found that of a subset of cases with available data, 46 reported one or more genital lesions during their illness.
Monkeypox infections can last between two and to four weeks, and people are no longer contagious once scabbed-over lesions fall off and heal, a process that can cause scarring.
READ MORE: To respond to monkeypox, health officials’ playbook informed by failures of the AIDS crisis
The incubation period for MPV can last up to 21 days, but symptoms are generally appearing in patients earlier than that, Fortenberry said. Data suggests that period is around seven to eight days.
A recent study which involved more than 500 monkeypox cases, reported that 95 percent of patients developed a rash, and a few dozen only had a single lesion. Nearly 75 percent had lesions around their genitals or anus. About one in 10 were hospitalized for pain, sometimes for a severely sore throat that limited their ability to swallow, though that was one of the less common reasons.
Fortenberry noted that those lesions could easily be mistaken for STIs by doctors who do not have MPV on their radar. (One example is herpes.)
Direct contact with lesions or scabs is the primary route of transmission. MPV can be spread during sex of all kinds and use of sex toys, plus hugging, cuddling, massaging, kissing and “talking closely,” said Sandra Fryhofer, a general internist based in Atlanta and chair of the American Medical Association Board of Trustees.
“You can get it from sharing objects with someone that has monkeypox, including objects that might be involved in intimate contact, or contact with respiratory secretions during prolonged face-to-face contact,” Fryhofer added. In some cases, MPV can also be spread by coming into close contact with an infected person’s clothing, bedding or towels.
Graphic by Jenna Cohen/PBS NewsHour
MPV is not transmitted through brief conversations and interactions with infected people or touching everyday items in public like doorknobs or elevator buttons, Fortenberry emphasized. According to the CDC, people who do not have monkeypox symptoms cannot transmit it to others, though Fortenberry cautioned the details on asymptomatic spread are not yet certain.
The CDC also notes that people can get MPV after being scratched or bitten by an animal that has the virus, or by preparing or eating meat from an infected animal.
Testing for MPV involves swabbing lesions on potentially infected patients. The CDC recommends that anyone who believes they may have monkeypox or has had close contact with someone with a confirmed case see a health care provider to discuss next steps.
“You really can’t get tested unless you have the lesion,” Fryhofer said. “But if in the past 14 days you’ve had close exposure with someone that has monkeypox, you’re considered high-risk and you would be one that would be considered to go ahead and get the vaccine prophylactically.”
A two-dose shot called JYNNEOS is available to protect high-risk recipients against monkeypox, or stop the disease from progressing if the first dose is administered within four days of exposure to the virus.
“Vaccination after monkeypox exposure can help prevent disease, or make it less severe if you get the vaccine later than four days,” Fryhofer said. “For example, if you get it between four and 14 days [after exposure,] it may reduce symptoms but may not prevent disease.”
More than 1 million doses of the vaccine have been distributed across the country as of Aug. 19, according to the Department of Health and Human Services’ (HHS) Administration for Strategic Preparedness and Response, but supplies are still considered limited. The second dose of JYNNEOS is typically administered four weeks after the first, and full protection kicks in two weeks after that. For now, providers are largely prioritizing getting first shots to people who have been exposed to MPV or who are at high risk.
Under an emergency use authorization, the FDA has said that JYNNEOS can be injected through an alternative route — intradermally, or through the skin, as opposed to subcutaneously, or through the fatty tissue beneath the skin. That method can allow providers to get up to five doses out of one vial, a move aimed at stretching limited supplies, according to an Aug. 15 press release from HHS.
A single-dose vaccine dubbed ACAM2000 can also prevent monkeypox, but it has a range of side effects and contraindications that limit who is eligible to receive it. Since JYNNEOS can be used for a wider array of recipients who are 18 years of age or older, including those who are immunocompromised or have skin conditions, and is associated with more minor side effects, it’s been the preferred choice during this outbreak.
The CDC’s recommendations prioritize people who suspect or know they have been exposed to MPV in the past two weeks — including those who know a recent sexual partner was diagnosed with monkeypox, have had multiple partners in an area where it’s known to be spreading or have been contacted by their local health department.
That includes men who have sex with men, who the agency notes have been primarily impacted during the outbreak thus far. Local eligibility guidelines vary but can include those who have had multiple sexual partners in the past two weeks regardless of their sexual orientation or gender, with an emphasis on cisgender men and transgender people who have sex with men, in the case of San Francisco, plus nonbinary and gender-nonconforming people, in the case of New York City. All sex workers and those who work in places where sex occurs, like bathhouses or sex clubs, are also listed in some guidelines, including those in San Francisco and Washington, D.C.
New York City’s guidelines particularly encourage people with immune system-weakening conditions like HIV or a history of skin conditions like eczema, plus those who met recent partners online or at large gatherings like clubs, who also fall under the above qualifications to consider getting vaccinated.
READ MORE: As resources go to fight European and American monkeypox outbreaks, some see inequity in African response
If you’re not sure about your eligibility, contact your local health department to discuss their guidelines or see a medical provider, whether that’s your primary care provider or someone at a community health center. Vaccines are available by appointment at sexual health clinics, medical centers and other places where health care is provided, and you can schedule them through your local or state health department.
Providers are largely focusing on getting first doses to recipients and delaying second doses until supplies increase, though those who are known contacts of cases or immunocompromised can be eligible for a second dose at the standard four-week interval following their first in some locations. Guidelines say that the second dose is still effective even if it’s administered beyond that window.
The CDC recommends waiting at least four weeks between receiving a monkeypox vaccine and a COVID-19 mRNA vaccine booster because of the risk of myocarditis (an inflammation of the heart muscle), especially in young men.
Getting a COVID-19 booster, as well as shots for flu and monkeypox at the time should be OK in theory because those diseases are all caused by three different pathogens, said Angela Rasmussen, a virologist at the Vaccine and Infectious Disease Organization at the University of Saskatchewan in Canada, but more evidence is needed to be sure.
READ MORE: Should I get the new COVID-19 booster? Here’s what you need to know
“That’s something that hopefully people are starting to collect data on — what it’s like to deploy JYNNEOS at population scale, to target monkeypox and what those immune responses are going to look like long term and what kind of protection that confers,” she said.
Certain antiviral medications can be used to treat MPV infections. But getting those drugs can be difficult, requiring extra time and effort on the part of medical professionals.
“You just can’t get a prescription to go to the pharmacy. They only can be obtained at the request of a patient’s local or state health department, and there’s a CDC number where physicians can request access to them,” Fryhofer said.
For Fortenberry and his colleagues, who have recently seen a multifold increase in the number of patients with confirmed monkeypox cases, it can take up to two hours to help coordinate one patient’s access to an antiviral called tecovirimat (TPOXX).
That medication is used to help treat severe cases of MPV, which come with risks of significant scarring and even tissue damage, Fortenberry said, and for high-risk patients, such as those who are immunocompromised. He added that the number of patients he’s seeing with severe symptoms who require TPOXX is on the rise, which is why he’s calling on the federal government to remove existing hurdles to allow for more straightforward distribution.
“We really need emergency use authorization from the FDA in order to eliminate the arduous administrative burden that is accessing this medication,” Fortenberry said.
On Aug. 18, the Biden administration announced that it would distribute 50,000 additional doses of TPOXX across jurisdictions based on how many confirmed MPV cases they have and the number of people considered high risk for contracting the virus locally.
Experts like Fortenberry are advising their patients to use a risk-reduction model that centers around clear and safe communication around sex and intimacy.
That process involves talking to your partners about their sexual histories, including any potential exposure to monkeypox, being aware of any unexplained sores or rashes on your own body or that of your partner and avoiding any type of intimate physical contact (including kissing, cuddling and sex) with someone who does have lesions on any part of their body.
Although condoms are generally a good option to ensure safer sex, the CDC emphasizes that they are likely insufficient on their own to prevent exposure to monkeypox, given that lesions can occur on any part of the body.
Fortenberry said it’s important to “lead with empathy” when pursuing conversations about monkeypox and sexual health in general to reduce stigma and empower yourself and others to be proactive about steps like getting tested or vaccinated.
“We’re all going through a scary time, we’re in it together. Don’t blame or shame anyone, including yourself. And don’t panic. Seek medical attention if you have any new or unexplained rash,” Fortenberry added.
If you know or suspect you have monkeypox, avoiding sex, crowds and other types of intimate contact with people is key, Fryhofer said. But given that monkeypox can also spread via other forms of close contact, like cuddling or sharing fabrics like clothing, towels or bedsheets, you should take precautions to protect others in your household as well. Keeping any rashes covered, wearing a mask and seeking prompt medical care if you haven’t yet is also crucial, she added.
If you have roommates, keeping your distance and making sure you don’t share any items like hand towels or dishware is a good idea. The same goes for any children in your home. Two kids in the U.S. have been diagnosed with monkeypox, which health officials suspect they contracted through household transmission. Avoiding close physical contact and preventing them from touching beds and other potentially contaminated fabrics can help reduce that risk.
READ MORE: 2 children diagnosed with monkeypox in the U.S., officials say
The CDC recommends that people with confirmed or suspected cases of monkeypox isolate at home until “all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed.”
Pets can also contract the virus. A recent report said that a couple who were diagnosed with MPV transmitted the virus to their dog, who routinely slept in the same bed as them. For pet owners who develop symptoms, the CDC recommends that if you didn’t have close contact with your pets prior to symptom onset, you should check whether someone you trust could care for them in a separate home until you fully recover.
Given that MPV infection often lasts weeks, a diagnosis can be extremely destabilizing for many patients, Fortenberry said.
“Our patients tend to not necessarily have stable housing, stable income, stable access to food. And so to have to take off work and isolate for two to four weeks as a result of this infection can cause people to lose housing, can cause people to lose their jobs,” Fortenberry said. “It really does undermine the stability for a lot of patients, [and] just general well-being.”
Providers like Fortenberry do not want to see a reality where MPV becomes endemic in any community. Increased access to treatment and vaccination is key to reducing transmission.
Fortenberry has dealt with other infectious disease outbreaks over the course of his career, including an Ebola and a meningitis outbreak. Pathogens cropping up and requiring immediate attention is nothing new, he said, but each one seems to require “reinventing the wheel” in the absence of sufficient federal support for the community medical providers and local health departments that respond to outbreaks.
He also noted that the federal government can ensure low-income patients will be able to access testing or treatment (federally qualified health centers do not turn patients away who cannot pay for services).
In concert with the ongoing COVID-19 pandemic, he said that the MPV outbreak is highlighting the dismal, under-funded state of public health infrastructure in the U.S. – something we knew before COVID, and the ramifications of which we have endured for almost three years during the pandemic, and yet to Fortenberry it still seems like “we’ve learned nothing.”
“We should not be, whenever an outbreak occurs, having to be so reactive to each issue that comes up,” Fortenberry said.
Dan Cooney and Matt Rasnic contributed reporting.
Bella Isaacs-Thomas is a digital reporter on the PBS NewsHour's science desk.
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