Monekypox has been declared a Public Health Emergency of International Concern, a precursor to a pandemic, by the World Health Organization. Approximately thirty-three thousand cases have been confirmed in ninety-one countries, including approximately ten-thousand in the United States. Neighboring New York appears to be the epicenter of a growing outbreak that now includes Connecticut. Several states and the federal government have declared states of emergency and are mobilizing additional resources. What little testing data is available is incomplete and open to interpretation, but appears to suggest a much larger outbreak than is widely acknowledged. Amid all of the headlines, you would not be blamed for feeling deja-vu from early 2020.

The difficulty in writing a “what you need to know” article is that it assumes what needs to be known is, in fact, known. In the case of Monkeypox, there is a great deal we do not yet know, and a great deal more that we think we know, but may very well be wrong about. This article will summarize what you need to know based on what we know now, but keep in mind that this is an evolving topic. New research is being released every day, and public health guidance is constantly changing because of that. In late July, the WCSU Health Services launched a new webpage, stating, “We are monitoring the local situation regarding Monkeypox and will continue to update as information becomes available” and referring to Connecticut Department of Public Health and Centers for Disease Control and Prevention for further information.

What is Monkeypox?

At its core, Monkeypox is a virus, but more specifically, a pox virus. It is from the genus Orthopoxvirus, the same as cowpox and smallpox, the latter of which the WHO describes as “one of the most devastating diseases known to humanity and caused millions of deaths before it was eradicated.” It is not specifically related to chickenpox, although symptoms and transmission may appear similar. It is completely unrelated to the so-called “Great Pox” known today as syphilis, which is caused by bacteria.

These two points of comparison, cowpox and smallpox, give us a very wide range of possible expectations. While it seems unlikely that the current strain will become as dangerous as smallpox, experts are still concerned about the possibility of more virulent, deadlier strains evolving from a prolonged outbreak like with COVID-19, hence the recommendations for aggressive efforts to contain the outbreak as early as possible. While Monkeypox is treatable with medical attention, it can also be deadly. Studies in Central Africa on a different strain of Monkeypox showed an 11% mortality rate without access to medical treatment. Estimates place the currently circulating strain at around a 1% mortality with treatment, which is in the same category as early variants of COVID-19. At time of writing, no deaths have been confirmed in the United States.

The distinguishing symptom of Monkeypox is a rash that initially looks like pimples or blisters, which may be painful or itchy, and evolves through several stages, such as scabs, over multiple weeks before healing. Other reported symptoms may resemble allergies, flu or COVID-19, including fever, chills, swollen lymph nodes, exhaustion, muscle and back aches, headache, sore throat, nasal congestion, and cough. Symptoms are highly variable. Some report no symptoms aside from the rash. Others report different timing for different symptoms.

How does Monkeypox spread?

Scientists are still pinpointing the exact mechanisms of spread, but current information suggests Monkeypox can spread in a variety of ways. Case studies and messages from health authorities emphasize direct contact with an infectious rash, scabs, or body fluids as the primary transmission vector However, there is also evidence of respiratory transmission during prolonged close contact, touching shared surfaces, pregnancy, and being scratched or bitten by an infected animal.

Much has been said about Monkeypox primarily being detected in men who have had sex with other men. It is worth noting explicitly that, according to the best of current information at time of writing, Monkeypox is not transmitted sexually. Research is still ongoing to determine whether Monkeypox can be spread through semen, vaginal fluids, urine, or feces at all, but current contact tracing focuses on direct and close contact, regardless of setting or context. In layman’s terms, it may not be sex itself, but physical closeness which happens during sex.

This means that anyone can be exposed in everyday life and catch Monkeypox, regardless of sexuality, gender, or lifestyle. It is likewise unclear as to whether the virus can be spread when someone is asymptomatic. We know that it can spread for the entire duration of the time a person has a visible rash, which is typically two to four weeks. The CDC currently recommends isolation for this entire period.

What can I do to stay healthy?

The CDC has a list of advice regarding “Safer Sex & Social Gatherings,” as well as “Congregate settings,” including dorms, and “Home Disinfection.” In general, the advice is common sense given the methods of transmission: cut down close and direct contact, especially with unfamiliar people and surfaces. Keep open communication with close contacts, including sexual partners and your doctor or Health Services. In particular, avoid contact with people with an unknown rash, and avoid sharing items like clothing, food, or vape pens. If you feel sick, isolate and seek medical attention. As always, wash your hands.

After the last two years, this advice may sound familiar. Most of these recommendations, with the exception of covering exposed skin, are redundant with existing recommendations to prevent the spread of COVID-19, and with regular advice during cold and flu season.

Although Monkeypox vaccines exist, vaccination is not recommended for the general public at this time, as supplies are limited. The CDC recommends vaccination only for those who have been exposed to the disease or are at high risk because of their job. In the United States, two vaccines for smallpox have been approved for Monkeypox, ACAM2000 and JYNNEOS. JYNNEOS, which is two doses four weeks apart and provides full immunity two weeks after the second dose, is the preferred vaccine. ACAM2000 is a single dose live vaccine that confers immunity in 28 days, but may also cause greater side effects, especially for those with underlying health conditions. Experts have stated that smallpox vaccination (standard in the US until 1972) should provide some immunity, but the precise extent of immune coverage is unknown.

Information on vaccine distribution in Connecticut, including eligibility criteria, can be found here. Campus Health Services have announced that Community Health Center Clinic is scheduling vaccine appointments for eligible individuals via calling the Middletown office at (860)-347-6971. The contact number for the Danbury location is (203)-797-8330.

What Happens Next?

Much like the early weeks of the COVID-19 outbreak in the United States, current Monkeypox testing gives us an incomplete picture. At the moment, with testing eligibility criteria based on existing symptoms, we cannot know whether asymptomatic transmission is a major factor in how Monkeypox spreads. This, plus the incubation period, means we only have a lower bound for how quickly the disease can spread. Likewise, we do not have a full picture of the severity, particularly in the long term, of the current strain.

Predicting the future with disease outbreaks can be dangerous. Given the trend of current cases, it seems reasonable to assume that numbers will continue to rise, but by how much is unclear. For political reasons if nothing else, it seems unlikely that any amount of spread short of completely shutting down hospitals will lead to a large scale quarantine so soon after COVID-19 restrictions are being lifted. What we know so far about the current strain of Monkeypox makes this kind of collapse seem unlikely, although a mass outbreak on top cold and flu season along with another wave of COVID-19 could still exacerbate existing staff shortages in and outside of healthcare.

Efforts to produce tests, vaccines, and antivirals are underway, but it remains to be seen whether vaccination or other forms of prophylaxis will be recommended for the general public, and when. In the meantime, it will be up to the public to individually take precautions to protect themselves and stop the spread.