Understand Monkeypox
It's normal to freak out just a wee bit when yet another Public Health Emergency is announced—particularly as misinformation and fear-based messaging abounds.
The pandemic has been an exercise in anxiety management. And we’re being put to the test again, trying to thread the needle between caution and calm.
Anxiety is part of the human experience. So you’ll never hear me ask a patient “Do you have anxiety?” (That’s like asking “Are you alive?”) Rather, I ask about the degree of anxiety, the people or things to which the anxiety “sticks” (i.e. monkeypox, COVID, flying, public speaking, body image, an ex-boyfriend), the amount of brain space that the anxiety occupies, and the tools we might use to better manage it.
For me at least, mitigating anxiety starts with looking at the facts. So let's get to them.
What is Monkeypox?
Monkeypox (MPX) is a DNA virus. It is not new. It is rarely fatal. It is a cousin of smallpox which was eradicated in the 1980s through mass vaccination. MPX has been endemic in Western and central Africa. In 2003, the U.S. saw a smaller MPX outbreak of 47 cases, mostly in the Midwest. As of yesterday, we have approximately 8300 cases of MPX in the U.S. with zero fatalities.
How contagious is MPX?
MPX is significantly less contagious than COVID and is not airborne. Unlike the highly transmissible Omicron variant, a person infected with MPX typically infects zero or one other person, which is why this outbreak will likely die down relatively quickly.
It’s not exactly clear why, but transmission from one person to another seems to require a higher “dose” of virus. Contracting MPX seems to require prolonged and close contact with an infected person. In other words, contact with someone with MPX does not automatically lead to infection.
The upshot? MPX isn’t likely to cause a nationwide epidemic like COVID did. Nonetheless we need to take it seriously and remain humble about what we don’t know.
How is MPX spread?
The vast majority of cases are spread through close, extended, skin-to-skin contact, which naturally occurs during sex but can happen in other instances.
Though not the main mode of transmission, MPX can spread through respiratory secretions—for example during prolonged face-to-face contact with someone with active lesions in their mouth.
MPX can live on surfaces, but it is easily killed with soap and water. It also requires a significant “dose” of virus on the bed sheets or clothing of an infected person to infect and sicken another person. Thankfully, touching surfaces such as doorknobs or toilets in public places is extremely unlikely to spread MPX. As NPR put it, you are more likely to get hit by a bus than to get MPX on a bus.
Unlike COVID, MPX does not seem to spread from people who are asymptomatic. People are most contagious when they are actively sick—with fever and/or the classic rash. The incubation period (the time between exposure and infection) is long: somewhere between 5 and 21 days.
Who is most at risk?
Right now the vast majority of MPX cases are in men who have sex with men (MSM). This is not to say that MPX is a “gay” disease. Not at all. It can spread to anyone through non-sexual contact; it’s just a lot less common.
Young children are at very low risk, unless they happen to live with someone who has a case of MPX. This is why, out of the 8300 current cases, only a handful are in children, and they all reside with an adult who has MPX.
It’s important to be transparent about these facts while combating stigma against at-risk groups. As science reporter Kai Kupferschmidt wrote for the New York Times:
For now, the virus appears rather bad at using less intimate routes of transmission. Even close household contacts of people who have monkeypox have rarely gotten infected. Instead, the virus appears to be spreading mostly through very close and prolonged contact during sexual encounters, and it is doing so overwhelmingly in communities of men who have sex with men.
What are the symptoms of monkeypox?
MPX typically presents with a classic painful bumpy rash on or near the genitals or anus. The rash can also appear on other areas like the face, mouth, hands, feet, or chest. The rash is usually preceded by a fever and is often accompanied by body aches, swollen lymph nodes, fatigue, and flu-like symptoms.
The rash typically starts out as flat red spots then progresses to firm raised bumps then to fluid-filled blisters or pustules. The lesions can be extremely painful. When the rash crusts over and dries up, people are no longer shedding virus and are not contagious to others. This process usually takes two to four weeks.
How do we treat monkeypox?
As you savvy people know, vaccines are typically given well before an exposure in order to prevent disease. In the case of MPX, the vaccine also works to prevent disease soon after an exposure.
The preferred MPX vaccine is called JYNNEOS. It is safe even for immunocompromised people. If given within 4 days after an exposure to MPX, the vaccine works well to prevent disease. If given 4-14 days after an exposure, the vaccine may not prevent disease but may lessen the duration and/or severity of symptoms.
Jynneos is a two-dose vaccine given four weeks apart. It takes 14 days after getting the second dose to be maximally protected, but ongoing study will help us know if one dose is adequate when given immediately after exposure.
Antiviral medication
Usually the symptoms are self-limiting and resolve without any specific treatment, but there’s also an oral medication called TPOXX which is FDA approved to treat smallpox but can be used off-label to treat MPX. It is hard to get and is usually reserved for people at highest risk for severe outcomes.
Isolation while contagious
Usually the symptoms are self-limiting and resolve without any specific treatment, but there’s also an oral medication called TPOXX which is FDA approved to treat smallpox but can be used off-label to treat MPX. It is hard to get and is usually reserved for people at highest risk for severe outcomes.
Who is eligible for vaccination?
The CDC currently recommends vaccination for people who have been exposed to MPX and people who are more likely to get MPX, including:
People who have been identified by public health officials as a contact of someone with monkeypox
People who know one of their sexual partners in the past 2 weeks has been diagnosed with monkeypox
People who had multiple sexual partners in the past 2 weeks in an area with known monkeypox
So why aren’t we vaccinating everyone?
The short answer is that we don’t have enough vaccine doses. And until we have adequate doses, it’s important to surge resources to actively symptomatic and to high-risk patients and populations. In addition, most people are not at risk of getting MPX, so vaccinating everyone would be a waste of resources.
The bottom line?
In medicine, risk is almost never distributed evenly (often unfairly so). Just because something is possible doesn’t mean it’s probable. In the case of MPX, saying that everyone is at equal risk is not only dishonest, it deprives at-risk groups the tools and resources they need to reduce the burden of disease and the unfortunate stigma around it.
Transparency about risk helps reduce the burden of disease for people at higher risk and limits the burden of fear for people at lower risk.
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Speaking of risk and risk tolerance, check out this week’s episode of Beyond the Prescription.
Hamilton Leithauser is a rock star. He is also my first cousin. In this episode, we go behind the scenes of his rock-and-roll life. Ham opens up about the highs and lows of creating, performing, and navigating the whims of the music industry. We also reminisce about growing up across the street from each other—our strong family bonds and shared grief over the recent loss of Ham’s mom.
As always, my newsletter subscribers get early access to the pod every Monday night before the official Tuesday launch. Give it a listen now on Apple, Spotify, or wherever you find podcasts! Oh—and please rate and review!!
I will see you next week. Until then, be well.