Our Experts Weigh-In on Monkeypox

On July 23, the World Health Organization declared monkeypox a Public Health Emergency of International Concern, its most serious designation. Unlike previous monkeypox outbreaks that were mainly confined to countries in Central and West Africa, the current outbreak is much larger and more widespread. To date, there have been more than 18,000 confirmed cases in 75 countries, including the United States.

According to Columbia Mailman epidemiologists, the ongoing monkeypox outbreak is concerning but bears little resemblance to COVID-19, which spreads more quickly and has been responsible for millions of cases, hospitalizations, and deaths. Monkeypox infection, whose signature feature is painful skin lesions, is preventable and treatable. At the same time, they say this outbreak must be taken seriously to stop its further spread. 

More information on monkeypox is available on the CDC website. If you live in New York City, visit the NYC Department of Health and Mental Hygiene monkeypox webpage for information on transmission, prevention, and to check your eligibility for vaccination, and make an appointment.

What is monkeypox?

Stephen Morse: Monkeypox is a disease caused by monkeypox virus—a virus related to, but less dangerous than variola virus, the virus that causes smallpox. The name reflects its discovery as the cause of illness in monkeys in laboratories in the 1950s. However, this name is a misnomer as the virus mostly circulates among rodents. The first human cases were reported from Central Africa in 1970. Subsequent sporadic outbreaks were linked to people who came in close contact with wildlife. A limited outbreak in 2003 in the United States was traced to an Illinois pet distributor that imported rodents from Ghana who were co-located with prairie dogs that were sold as pets.

What do we know about how monkeypox presents and how the virus spreads?

Ian Lipkin: Traditionally, Monkeypox infection starts with non-specific symptoms, things like fever, headaches, feeling run down, and swollen lymph nodes. Its characteristic symptom is rash that can look like pimples or blisters that appears on the face, inside the mouth, and on other parts of the body. However, the current outbreak has had unusual features that include rash and sores appearing in the genito-anal area and rectal ulcers and lesions. The time from exposure to onset of symptoms is usually 7 to 14 days. The illness typically lasts between two and four weeks. It’s still too soon for us to be certain that we know all of the ways that monkeypox can spread.

Unlike SARS-CoV2, respiratory transmission does not appear to be a major factor for monkeypox infection. Most infections to date have been acquired through direct skin-to-skin contact, often in the context of sex or other intimate relations with people who are infected. However, people can also become infected through contact with contaminated surfaces including bedclothes. The majority of cases in the current pandemic have been reported among men who have sex with men. However, there is nothing intrinsic about the virus that makes men who have sex with men more susceptible to infection. And this does not mean that other groups of people are not at risk. There is also concern that the virus may spread to animals that could become sources of future human infections. 

How can we protect ourselves?

Wafaa El-Sadr: There are good reasons to be concerned about monkeypox, but no need for panic. Clear communication from public health officials, providers, and others with accurate information regarding this outbreak and how to prevent transmission is a priority. There is an urgency to reach those at risk in order for them to be aware of how to protect themselves from this infection. Most importantly, close contact with anyone who has a rash or sores should be avoided in someone diagnosed with monkeypox. The CDC recommends avoiding sharing eating utensils or cups or touching the bedding, towels, or clothing of someone diagnosed with monkeypox. For those who develop any symptoms of monkeypox, it is imperative that they contact their provider or seek care at a clinic for diagnostic testing and further management. For those with severe symptoms or who are at risk for severe complications with this infection, treatment should be promptly initiated.

Fortunately, there are two vaccines available to prevent monkeypox infection, although one is preferred due to its safety profile and ease of delivery. At this time, this vaccine is recommended for people who have been in contact with someone diagnosed with monkeypox and for people considered currently at risk for monkeypox. Useful guidance is available from the CDC at the following webpage guidelines on social gatherings for safer sex and monkeypox. As with any infectious disease, it is critical to avoid stigmatizing those diagnosed with monkeypox or at risk for this infection. We have learned again and again that viruses do not discriminate and that stigma and discrimination can drive people to delay diagnosis and shun needed services.

What is the future of this outbreak? 

Morse: Historically, in Africa, there might be some household or other limited transmission of monkeypox from an infected person, but if transmission to other people did happen to occur, the virus was not able to sustain itself in humans. If that holds true, the epidemic should subside, but the fact that it’s still going on is concerning. Although there is no evidence that the monkeypox virus has changed, the scale of the latest outbreak might allow new virus variants to evolve. If the virus does somehow become better adapted to human-to-human transmission, it could become entrenched—endemic in humans. Monkeypox may possibly also infect animals here and become endemic, similar to what it does in Africa. 

The best way to prevent these outcomes is to contain the virus, as quickly as possible. This really takes a multi-layered approach, as described by Dr. El-Sadr: effective communication about preventing infection and transmission, seeking immediate medical attention for anyone who thinks they may have become infected, testing, and vaccinating those at highest risk for infection.

Wafaa El-Sadr is an infectious disease specialist, director of ICAP at Columbia and leads the New York City Pandemic Response Institute at the Mailman School; Ian Lipkin, director of the Center for Infection and Immunity and the Global Alliance for Preventing Pandemics (GAPP), has worked on responding monkeypox outbreaks in Liberia and the DRC going back more than a decade; Stephen Morse is a professor of epidemiology and a leading authority on emerging infectious diseases.

[This article was first posted on May 26 and updated on July 29.]