Auburn infectious disease expert explains monkeypox

With cases of monkeypox in the U.S. and across the globe increasing – a third case of the infectious disease was confirmed in Georgia on Friday – there are a number of questions regarding what the disease is, how it is transmitted, who is vulnerable and how it is treated. Marilyn Bulloch, associate clinical professor in the Harrison College of Pharmacy’s Department of Pharmacy Practice, provides comments on what is known about the virus.

Bulloch received her Doctor of Pharmacy from Rutgers University in 2007 and completed residencies at the University of Alabama at Birmingham and the Charleston (South Carolina) Area Medical Center. Her research interests include acute care pharmacotherapy, infectious diseases, internal medicine and medication use in older adults. She has spoken at the national, regional and local level on a variety of medicine related topics, including influenza and other concerning viral infections. She has been published in numerous medical and pharmacy journals.

What is monkeypox, and what are the symptoms?

Monkeypox is an orthopox virus, or orthopoxvirus, which is the same category or genus as smallpox and cowpox. It is rare but causes a pox-like syndrome. It was first identified in 1958 in Denmark, where an outbreak of a pustular disease occurred in a macaque colony that had been imported from Singapore for research purposes. The first human case was not documented until 12 years later in the Democratic Republic of Congo. Researchers do not know what the natural reservoir of the virus is. It is thought to be either African rodents or non-human primates.

Just as with every other virus, monkeypox is not one single strand of the virus. There are multiple versions, sometimes revered to as “clades.” The Congo Basin clade has a higher mortality rate than the West African clade in patients with normal immune systems.

If this has been around for a long time, why are we just now hearing about it?

There are several reasons that it has not been at the forefront. Those born in the mid-1970s and earlier most likely received the smallpox vaccine, which provides protection against other orthopox infections. The virus is known to circulate in animals, with sporadic appearance in humans over the years. Most of the human cases of the virus have been reported in Africa, with the most occurring in the Democratic Republic of the Congo. Cases outside of Africa in the past could be linked to travel to these areas.

Once smallpox was eradicated, routine smallpox vaccination ceased, although members of the military still receive it. This was when monkeypox cases really started to emerge in more frequency – in those not vaccinated against smallpox. Thirty to forty years ago, the vast majority of humans were vaccinated against smallpox, but today less than one-third are. The rate is much lower in developing nations. With the decreasing number of people with natural or vaccine-induced immunity, the virus has the opportunity to circulate.

Most chains of transmission reported in the past have been relatively short. Unlike what we might see with something like influenza, where large groups of people can be infected after exposure, transmission has stopped after one to three people, though slightly higher in some chains. Because the “outbreaks” are not the number of people that we have come to associate with an “outbreak” of any infection, infections that have been reported in the media or in the medical literature have not gained the amount of attention that an infection that impacts large numbers of people all at once will.

How did it make it to the United States, and how is it transmitted?

In the United States, monkeypox occurs in those who have traveled to countries where the virus naturally occurs or who have imported animals from those areas.

The virus can enter humans through the respiratory tract, mucous membranes of the eyes, mouth or nose or through broken skin, even very minor breaks. Human-to-human transmission mostly occurs, so far, through respiratory transmission. Unlike some viruses, the respiratory droplets carrying this virus do not travel very far; for the virus to be spread among humans, there must be extended, close, face-to-face contact.

Reports of human transmission through contact with lesion material has also been reported – for example, touching contaminated bedding. Currently, it is being investigated if the virus can be sexually transmitted. There have been clusters of cases among men who have sex with men. However, we don’t yet know if this is due to transmission through bodily fluid or if it is due to spread from genital and groin lesions. It is reasonable to think that if it could be spread in a similar way, regardless of sexual orientation.

What will happen if I get monkeypox?

Some people may be fearful of monkeypox because it seems new. From the human infections that have occurred since 1970, symptoms appear similar, but much milder than what was seen with smallpox. Many people may relate early symptoms to that of influenza (the flu): fever, headache, significant fatigue and muscle aches.

With monkeypox, people’s lymph nodes will swell. A rash appears a few days, on average one to three days, but can be longer, after the fever begins. The typical spread of the rash is from the face to other parts of the body. Almost everyone who gets infected has a fever and a rash. This can help distinguish it from other potential sources of infection.

Symptoms generally appear around one to two weeks (7 to 14 days) after exposure/infection, though some people have not shown symptoms until three weeks after infection. Lesions develop and progressively scab over before falling off. The duration of symptoms varies widely. Some people feel better within five days, while others may still be showing symptoms after three weeks.

Are there any precautions I can take against it?

It’s important to remember that transmission between humans requires direct and/or prolonged contact. The symptoms of monkeypox are much more specific than some other infections, and unless you are providing care to an infected person who cannot care for themselves, avoid contact.

What should I do if I feel I may have it?

After years of social distancing, it may be disheartening to hear that isolation is the first step in managing monkeypox. However, isolation should occur until all of the lesions have healed, and a new layer of skin has formed. Even after isolation has been stopped, infected people should not be in close contact with immunocompromised people until all of their lesion crusts are gone.

If you were exposed, you should self-monitor for symptoms. Unless symptoms develop, people can continue normal activities. If they appear, isolate yourself and contact the local health department. As mentioned before, almost everyone with monkeypox has a fever and a rash. However, a rare few will just have chills or swollen lymph nodes. If no fever or rash develops after 24 hours, they should be evaluated by a health care provider to rule out other causes.

Are there any treatments for monkeypox?

There are preventative measures. Smallpox vaccines have shown to be protective against monkeypox. There is also an FDA-approved vaccine called JYNNEOS, which is FDA approved for the prevention of monkeypox. It was developed to help prevent infection in those at risk for occupational exposure to the virus, such as those working in research labs with primates. 

Protection requires two doses given four weeks apart. Those who have previously received a smallpox vaccine may have slightly fewer side effects. Side effects seen in studies included injection site pain, redness, induration and itching. Some people experienced temporary muscle pain, headache, nausea, fatigue and chills. This is similar to what is seen with the routine vaccines that are given to the public. The vaccine has been studied in thousands of people in clinical trials.

To date, infection with the virus is mild in most people, even without therapy. However, as with any microorganism, it can and has caused severe disease and death in some cases. There is no treatment specifically for monkeypox. In previous outbreaks, people who were exposed, but not necessarily symptomatic, were offered the smallpox vaccine. It is proposed that medications that we have available to treat smallpox could be effective at treating monkeypox.