Your essential guide to monkeypox

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 last week, but in the United States, where the federal response and communication around the crisis has a ways to go, many people don’t know how it spreads, what it looks like or what care they can get if they suspect they’ve been infected.

That’s true in part because we’re 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 on Saturday 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 U.S. currently has the most confirmed monkeypox cases — nearly 4,000 — compared to any other country, according to the Centers for Disease Control and Prevention.

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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.”

Crafting clear and concise messaging on MPV is hard because, right now, it’s affecting specific demographics more than others. Research suggests the virus is largely spreading among men who have sex with men, but other people of other identities and orientations can be and are already impacted, too. Sex appears to be a driving force of MPV transmission during this outbreak, but it’s just one of several forms of close contact that can spread the virus.

“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.”

The challenge for public health officials is ensuring that people who are currently high-risk have the information and care they need to protect themselves, but without inadvertently pigeonholing monkeypox as a disease that’s exclusive to men who have sex with men. 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.

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.

What symptoms are associated with monkeypox?

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. The illness 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.

The incubation period for MPV can last up to 21 days, but symptoms are generally appearing in patients earlier than that, Fortenberry said. A new study published in the New England Journal of Medicine found the median incubation period to be seven days.

That 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.)

How is it transmitted?

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.

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.

How does testing work?

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.”

What should I know about monkeypox vaccines?

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.”

Graphic by Jenna Cohen/PBS NewsHour

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.

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. The second dose of JYNNEOS is administered four weeks after the first, and full protection kicks in two weeks after that.

Who’s eligible to get vaccinated?

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.

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.

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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.

What are other monkeypox treatments?

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.

How do I protect myself from monkeypox?

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 I have monkeypox, how do I avoid spreading it to other people?

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.”

What happens if we don’t get a handle on the current outbreak?

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 declaration of a federal public health emergency in the U.S. would raise awareness and resources, and 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.