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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 7,500 — 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 Black and Hispanic people are disproportionately impacted.
WATCH: Local health authorities race to contain the highly contagious monkeypox virus
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 four deaths have been reported in countries that do not usually encounter it — two in Spain, one in India and one in Brazil, according to the Center for Infectious Disease Research and Policy at the University of Minnesota. An Aug. 3 brief from the Africa CDC said that 103 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 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 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 sex workers of all genders, 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. 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 capacity for MPV, which involves swabbing lesions on potentially infected patients, has ramped up in the U.S. in recent weeks as capacity has expanded from public health labs processing the samples to commercial labs running results as well. 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.”
Two vaccines are available to protect people against MPV. But one, a two-dose shot called JYNNEOS, is being used far more widely during this outbreak. Getting vaccinated within four days of exposure can also help stop the disease from progressing.
“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.”
ACAM2000 is a single-dose, live replicating vaccine with a range of side effects and contraindications that can be serious, and recipients are considered fully protected after 28 days. It’s not recommended for people with immune conditions like HIV, those with skin conditions like eczema or those who are pregnant or lactating. The second dose of JYNNEOS is administered four weeks after the first, and full protection kicks in two weeks after that.
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 for eligible recipients.
The federal government has begun shipping doses of this vaccine to areas seeing high monkeypox transmission, with more than 300,000 distributed as of July 22, according to the Department of Health and Human Services’ Administration for Strategic Preparedness and Response. On July 27, U.S. health officials said nearly 800,000 doses would soon become available for distribution. The federal government also ordered 5 million additional doses, but they largely won’t be available until next year, according to the Associated Press.
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 health department guidelines in New York City and Washington, D.C. include transgender and non-binary people who self-identify as high-risk based on their sexual activity, plus all sex workers and those who work in places where sex occurs, like bathhouses or sex clubs, in the case of 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.
For now, vaccinations are only available at local health departments, meaning people cannot receive them from their primary care provider. In New York City, Fortenberry said, people are lining up outside those offices to get vaccinated, but there just aren’t enough shots for everyone who qualifies, and some are being turned away.
“We are pitifully under-resourced in preventing further MPV from getting out into the community,” Fortenberry said. He noted that he and his colleagues have been directly referring patients who are most at risk for poor health outcomes as a result of MPV infection directly to their local department of health for vaccination.
In Washington, D.C., which has the highest number of cases per capita in the U.S., rising cases combined with limited supplies have prompted health officials to start prioritizing getting first doses into high-risk residents’ arms. That strategy paved the way for thousands more people to be invited to get a first shot, DC Health said in a press release Monday, adding that research suggests the JYNNEOS vaccine is effective for at least six months after the initial dose.
With limited supply, medical professionals and activists are clamoring for the federal government to procure additional vaccines for those in need as soon as possible. More doses will be available in the coming weeks and months, according to the Administration for Strategic Preparedness and Response.
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.
Experts like Fortenberry are advising their patients using 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.
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. 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 that 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.
Isabella Isaacs-Thomas is a digital reporter on the PBS NewsHour's science desk.
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