Monkeypox FAQ: How contagious? Are kids at risk? If you had chickenpox are you safe?
Since May, the number of monkeypox cases has grown to more than 16,000 across 75 countries and territories. The World Health Organization is worried about how quickly the virus is spreading among men who have sex with men — the group experiencing the vast majority of cases.
And there are no signs that the outbreak is slowing down. The overall numbers are now doubling every two to three weeks, with cases climbing a little faster in the U.S.
Over the weekend, WHO elevated monkeypox to its highest level of alert — a public health emergency of international concern. "We must act now," said Michael Ryan, executive director of the WHO Health Emergencies Program. "Like every effort in human science and human health, there are times when you must accelerate that effort."
It's a decision that some public health experts say should have come weeks ago — when cases were already surging and spreading in numerous countries — to encourage international coordination and accelerate the distribution of vaccines and treatments.
"Making the designation now is essentially a situation of better late than never," says Dr. Boghuma Titanji, an infectious disease physician at Emory University. "It's important [to] galvanize people [in] a coordinated global response [and] in a timely fashion to actually curtail a problem that has the potential to expand."
The WHO announcement and the virus itself raise a number of pressing questions. Here's what we know so far, based on interviews with global health experts and infectious disease physicians.
How does issuing a public health emergency of international concern help?
The primary function of this declaration is to sound a worldwide alarm, says Alexandra Phelan, a global health lawyer at Georgetown University. Health issues don't always cross the desks of governments and politicians with enough urgency, she adds, "There is a lot of value in bringing global political attention and ideally governments will perhaps provide money to WHO or directly to affected countries. Or even if it's happening in their own country, provide that financial and technical response."
Titanji says the WHO alert helps mobilize the tools necessary to address the outbreak. "And by that," she says, "I mean vaccinations, antiviral therapies, and availability and access to testing strategies to actually identify cases and promptly treat and contact trace."
So how will this play out in the real world?
"The declaration itself won't help contain the virus," says Dr. Preeti Malani, an infectious disease physician at the University of Michigan. But if the right resources are marshaled, she says, "there are procedures that can be put into place in terms of how are we taking care of patients, how the testing's being done, how the contact tracing [is] being done. We're still at a point where we can contain this and and get it to where it's not spreading out of control. And I would have hoped that we learned this in the last two years [with COVID] that we are all connected. What's happening in Europe, what's happening in Africa is very relevant to us here [in the U.S.]"
"It's not a magic wand," adds Titanji. "The WHO doesn't make this designation and then all of a sudden everything falls into place and it's guaranteed that the outbreak will be contained. It has to be backed by action — a concerted global response that is centered on equity. You cannot have a response that is dominated by wealthier countries essentially hoarding all the resources that are available to target the outbreak [because that would leave] a majority of the global population behind. If you don't address the problem simultaneously everywhere. then we are not going to be able to contain this."
How are things looking in the U.S.?
The outbreak is growing quickly. The CDC says there are nearly 3,000 confirmed cases, though Malani says many cases are likely unreported due to mild illness or lack of testing.
Testing has become more available in the U.S. since several commercial laboratories started testing for monkeypox this month. And last week, the CDC made it easier for doctors to prescribe TPOXX, the pills to treat monkeypox, by reducing some of the paperwork associated with it.
As for vaccines, the U.S. government has shipped over 300,000 doses and will be routing more to places where the most cases are being found. The Department of Health and Human Services says millions more are scheduled for delivery by the middle of next year.
Nonetheless, there are supply issues at present. In Washington, D.C. and New York City, instead of administering both doses of the vaccine to those who are interested, they're only offering a single dose and reserving the double dose for those at highest risk, such as the immuno-compromised.
"So things are getting better in the U.S.," acknowledges Titanji, "but there's still a lot to be done to actually get to where we need to be to make sure that we're making the best use of the tools that we have."
How contagious is monkeypox?
"Monkeypox is transmitted by close intimate contact with a person who is infected and has the classic rash on their body," says Titanji. "When outbreaks have happened in parts of west and central Africa, it was always thought that this was a virus that didn't transmit very well between humans." Indeed, a range of rodents and non-human primates serve as animal hosts to the virus.
"However, in the current outbreak, we know that close intimate contact facilitated through sexual networks and sexual activity appears to give the virus an ease of transmissibility that we were not aware of before. And as a result, we are seeing more cases of transmission from person to person. So it is transmissible, but it requires close intimate contact with someone who is infected.
"And besides the close contact, you can also get infected through droplets, as well as prolonged contact with contaminated objects [like] bedding, clothes and shared utensils."
"If traveling," Malani says, "use common sense. Sheets [and] towels should be clean. Don't share towels with others." She says it's reasonable to launder linens if you're unsure that they're clean. "As far as furniture goes, if [infected] people are sitting [on it] without clothing and then someone uninfected comes along later," she supposes infection is possible. But she underscores that these forms of exposure are lower risk than skin-to-skin contact.
If I do get monkeypox, how bad is it?
"I really think it's critical that we don't dismiss the pain and suffering that people who are experiencing this are actually going through," says Phelan. "This isn't just a rash. This can be an incredibly debilitating and painful disease. And I think that in of itself is an ethical duty to prevent that from occurring. And then when it is occurring, giving people access to appropriate treatments and medications."
How worried should I be?
"I think we should generally be worried," says Phelan, "whenever there are communities that are experiencing a disease that is causing them pain and suffering."
Malani says that she thinks people "should be aware more so than worried. I think they should know how to prevent infection. If you think may have monkeypox, isolate yourself from others (including pets). Keep the skin lesions covered to avoid contact with other people or surfaces." And go to your health care provider or an urgent care if you are concerned about exposure to monkeypox or signs of infection, she says.
Do I need to be concerned about asymptomatic and presymptomatic spread?
"Based on previous outbreaks," says Titanji, "generally people are most contagious when they have symptoms and when they have an active rash. And you would not expect that the highest period of contagion would be when people are completely asymptomatic and don't have any symptoms at all. But," she adds, "I think that there is a lot of research that is needed to clarify when exactly people become infectious after they have been exposed to the virus."
What do we know about potential risk to women and children?
"The overall risk of monkeypox to the general population remains low," Titanji emphasizes. And that's because "most spread is going to occur due to intimate contact," says Malani. "Thankfully, the risk of serious complications is low in most people."
However, "there are people who may be more vulnerable to develop complications if they do in fact develop the infection." These include "children under the age of eight, pregnant women and individuals who may be living with other immunocompromising conditions. We know that these individuals, if they are infected with monkeypox, are at a higher risk of developing complications and also at a higher risk of potentially fatal complications."
As for pregnant women, Titanji explains that transmission between a mother and fetus is possible and that the virus "can lead to miscarriages as well as other pregnancy-related complications. If we do not act quickly and contain it, we will see a spread of infection to other risk groups such as children."
If I have the smallpox vaccine, will I be protected?
The answer appears to be ... perhaps, but not as much as you might hope for.
"Monkeypox is a close relative of the virus that causes the now-eradicated smallpox," says Titanji. "The vaccines that we have at our disposal to protect against monkeypox are actually vaccines that were developed to prevent smallpox. So if you had been vaccinated against smallpox in the past, then that vaccination could provide a certain degree of protection against you acquiring monkeypox [now]."
However, since smallpox was eradicated in 1980, the bulk of the population under age 50 in the U.S. has never received a smallpox vaccine — and those who are vaccinated received their inoculation decades ago. It's unclear, says Titanji, just how long you're protected. "These are some of the research questions that we really need answers for," she says.
What are the biggest misconceptions about this outbreak?
"There's so many," says Titanji. She says one is that if you've had chickenpox, you're protected against monkeypox. That's not true, she says.
Malani says that "the biggest misconception is that this is only a risk for men who have sex with men And that's clearly not the case. The virus doesn't care. And so we do need to battle that misconception while also taking care of a very vulnerable group of individuals. There may also be stigma that's preventing people from getting the care they need.
"We should all remember that the virus doesn't care who you are, and monkeypox can infect any of us."
"I think threading that needle," adds Phelan, "between communicating to at-risk populations whilst not stigmatizing or discriminating against them" is especially important.
"Some misinformation has emerged that some of the monkeypox outbreaks that we see may be associated with some of the vaccines that have been used for COVID," adds Tintaji. "Again, no relationship whatsoever — completely separate viruses. COVID vaccination does not cause monkeypox. We know what causes monkeypox. It's a virus that we've been aware of for over 50 years."
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