What is Monkeypox?

Monkeypox virus (MPXV) was first discovered in 1958 during an outbreak in an animal facility in Copenhagen, Denmark. The first human case was recorded in 1970 in the Democratic Republic of the Congo (DRC), and since then the virus has been reported in a number of central and western African countries, with most cases being reported from the DRC and Nigeria.

It was first recorded in the US in 2003 when an outbreak occurred following the importation of rodents from Africa, and during this outbreak cases were reported in both humans and pet prairie dogs.

The first confirmed Monkeypox case in the UK was in 2018, and between 2018 and 2021 there had been a total of 7 cases of the virus in the UK. From 6 May 2022, a new outbreak of Monkeypox infection was confirmed in England, and up to 8 June 2022, 336 laboratory confirmed cases of Monkeypox had been reported in the UK.

Of those confirmed cases:

• 11 were in Scotland.
• 2 were in Northern Ireland.
• 3 were in Wales.
• 320 were in England.

Confirmed and highly probable cases of Monkeypox in the UK have now reached 2,859 as of 4 August 2022 according to the UK Health Security Agency (UKHSA).

The UK Health Security Agency (UKHSA) is a government agency responsible for protecting every member of every community in the UK from the impact of infectious diseases, chemical, biological, radiological and nuclear incidents, and other health threats. Their Chief Executive Dr Jenny Harries has played central roles in the UK’s response to COVID, Ebola, Zika, MERS, the Novichok attacks and, most recently, the current Monkeypox outbreak.

What is monkeypox?

Monkeypox is a viral zoonosis; that is, a virus transmitted to humans from animals. It is an infection caused by a virus similar to the Smallpox virus, although it is clinically less severe. There are two known strains of Monkeypox.

The strain that is endemic in several countries in West Africa, which has been seen in outbreaks outside of Africa in 2022, is less severe than the strain that occurs in the Congo Basin. So far, the strain in the current outbreak seems similar to the one seen in West African countries and has caused mild illness in most people infected with that virus.

With the eradication of Smallpox in 1980 and the subsequent cessation of the Smallpox vaccination, Monkeypox has emerged as the most important Orthopoxvirus for public health according to the World Health Organization (WHO).

How common is monkeypox?

Monkeypox is rare. Before April 2022, Monkeypox virus infection in humans was seldom reported outside African regions where it is endemic. Currently though, cases are occurring worldwide. The latest UK figures for Monkeypox infections are detailed above, and according to UKHSA, they appear to be plateauing; however, Dr Meera Chand, Director of Clinical and Emerging Infections, UKHSA, said “While the most recent data suggests the growth of the outbreak has slowed, we cannot be complacent.”

Outside the UK, from January 2022 to 15 June 2022, the WHO reported cases in 42 other counties including:

• Canada – 159 cases.
• USA – 72 cases.
• France – 125 cases.
• Germany – 263 cases.
• Portugal – 241 cases.
• Spain – 313 cases.
• Italy – 68 cases.
• Ireland – 14 cases.

And they state that “at present, transmission in apparently newly affected countries is primarily linked to recent sexual contacts. Given the number of countries across several WHO regions reporting cases of Monkeypox, it is highly likely that other countries will identify cases and there will be further spread of the virus.”

How can you catch monkeypox?

Animal-to-human (zoonotic) Monkeypox transmission can occur from direct contact with the blood, bodily fluids, or cutaneous or mucosal lesions of infected animals. In human-to-human transmission, Monkeypox is spread by close contact and exposure to an infected person’s respiratory droplets, skin lesions or other bodily fluids.

The longest documented chain of transmission in a community has risen in recent years from 6 to 9 successive person-to-person infections. This may reflect declining immunity in all communities due to the cessation of Smallpox vaccination worldwide.

Monkeypox could be caught through close contact with someone who has a Monkeypox rash, including through face-to-face, skin-to-skin, mouth-to-mouth or mouth-to-skin contact, or through sexual contact, and people with Monkeypox are generally considered infectious until all of their lesions have crusted over, the scabs have fallen off and a new layer of skin has formed underneath.

Although asymptomatic infection has been reported, it is not clear whether people without any symptoms can spread the disease or whether it can spread through other bodily fluids.

The virus can also spread from someone who is pregnant to the foetus, after birth through skin-to-skin contact, or from a parent with Monkeypox to an infant or child during close contact. If you have confirmed or suspected Monkeypox and you are breastfeeding, talk to your healthcare visitor or clinic for advice.

People who have confirmed or suspected Monkeypox should avoid close contact with animals, including pets such as cats and dogs, etc. livestock and wildlife, because although there are no instances of people with Monkeypox infecting animals documented, there is a potential risk.

Health organisations such as the WHO are still learning about this virus, and studies are underway to discover more about how long people with Monkeypox remain infectious. They are also examining the possible mechanisms of transmission of the virus through the air, as these are not yet well understood.

During research, fragments of DNA from the Monkeypox virus have been found in semen, but it is not yet known whether infection can spread through semen, vaginal fluids, amniotic fluids, breastmilk or blood. Research is underway to find out more about whether people can spread Monkeypox through the exchange of these fluids during and after symptomatic infection.

Signs and symptoms of monkeypox

The interval from infection to the onset of symptoms of Monkeypox is usually from 6 to 13 days but can range from 5 to 21 days.

Initial symptoms of Monkeypox include:

• Fever.
• Headache.
• Muscle aches.
• Backache.
• Swollen glands / swollen lymph nodes.
• Chills.
• Exhaustion.
• New unexpected or unusual spots.
• Ulcers, blisters and lesions, which can develop anywhere on the body, including the face and other parts of the body including the hands, pubis and genitals.

The spots can change and go through different stages. Areas of erythema (skin rash) and/or skin hyperpigmentation are often seen around discrete lesions and lesions of different appearances and stages may be seen at the same point in time.

They can look like Chickenpox, Anogenital Herpes or Syphilis, before finally forming a scab, which later falls off. Some people may have only had one or a few spots, but people remain infectious until all of the lesions have crusted over, the scabs have fallen off and a new layer of skin has formed underneath.

Symptoms are usually mild enough to not require hospital admission; they typically last two to four weeks and usually go away on their own or with supportive care, such as medication for pain or fever.

However, newborn babies, children and people with underlying immune deficiencies such as HIV, may be at risk of more serious symptoms and even death from Monkeypox.

How dangerous is monkeypox?

Monkeypox infection is usually a self-limiting rather than a life-limiting illness and most people recover within several weeks. However, severe illness can occur in some individuals, and can lead to medical complications and even death.

Complications from Monkeypox include:

• Secondary skin infections.
• Pneumonia.
• Confusion.
• Eye problems.

In the newly affected countries where the current outbreak of Monkeypox is taking place, there have been no deaths to date. In the past, between 1% to 10% of people with Monkeypox have died, but the WHO points out that death rates in different settings may differ due to a number of factors, such as access to healthcare. They also state that these figures may be an overestimate because surveillance for Monkeypox has generally been limited in the past.

Health professionals are currently trying to answer the question of whether having COVID-19 or the post-COVID condition long-COVID, makes someone more vulnerable to Monkeypox. If you suspect infection from Monkeypox and are suffering from COVID or long-COVID, talk to your GP.

Data from previously affected countries shows that children are typically more prone to severe disease than adolescents and adults and they should be closely monitored until they have recovered, in case they need additional care. There has been a small number of children with Monkeypox in the current outbreak.

How is monkeypox diagnosed?

Anyone who has or suspects that they may have symptoms that could be Monkeypox, or who has been in contact with someone who has Monkeypox, should call their GP or NHS 111 and seek their advice. You should isolate yourself whilst they arrange for you to be tested and then follow their instructions.

Clinical diagnosis of Monkeypox can be difficult, and it is often confused with other infections such as Chickenpox. A definite diagnosis of Monkeypox requires assessment by a health professional and specific testing in a specialist laboratory, so once you have been tested, your test will be sent for analysis. In the UK, the Rare and Imported Pathogens Laboratory (RIPL) at UKHSA Porton Down is the designated diagnostic laboratory.

If you test positive, the Health Protection Team at UKHSA will contact you to complete a questionnaire to collect information about close contacts that you have had in the past three weeks before your symptoms started.

This will include the people that you live with and any sexual partners including those you may have met recently. When contacted by the Health Protection Team at UKHSA, these close contacts will not be told any information about you; everything is kept fully confidential.

If you do test positive for Monkeypox you will need to continue to isolate until the last spot or ulcer has scabbed over and fallen off. Close contacts with symptoms should isolate for 21 days.

What treatment is available for monkeypox?

Although many cases of Monkeypox resolve on their own, people who are more ill from the virus may be treated with antiviral drugs. The main treatments for Monkeypox aim to relieve the symptoms, such as medication for pain (analgesics) and fever (antipyretics) which may be prescribed by your GP.

It is important for anyone with Monkeypox to:

• Stay hydrated.
• Eat well.
• Get enough sleep.

People who are self-isolating should also take care of their mental health by doing things that they find relaxing and enjoyable, such as staying connected to loved ones using technology, exercising if they feel well enough and can do so while isolating, and asking for support with their mental health if they need it.

Anyone with Monkeypox should avoid scratching their skin and take care of their rash by cleaning their hands before and after touching the lesions. They should keep their skin dry and uncovered, unless they are unavoidably in a room with someone else, in which case they should cover it with clothing or a bandage until they are able to isolate again.

The rash can be kept clean with sterilised water or antiseptic. Saltwater rinses can be used for lesions in the mouth, and warm baths with baking soda and Epsom salts can help with lesions on the body.

Many years of research on therapeutics for Smallpox have led to the development of products that may also be useful for treating Monkeypox and your GP may be able to advise you if any are recommended.

How to avoid getting monkeypox

Reduce your risk of catching Monkeypox by limiting close contact with people who have suspected or confirmed Monkeypox, or with animals who could be infected.

You should ensure that you:

• Wash your hands with soap and water regularly, or use an alcohol-based hand sanitiser as you may have come into contact with skin lesions or secretions which might have ended up on your hands.
• Regularly clean and disinfect environments that could have been contaminated with the virus from someone who is infectious.
• Do not share clothing, bedding or towels with people who are unwell and may have Monkeypox.

If you think you might have Monkeypox or suspect that you have been in close contact with someone who may be infectious, you can act to protect others by seeking medical advice and isolating yourself from others until you have been evaluated and tested.

If you have confirmed Monkeypox, you should isolate yourself from others until all of your lesions have crusted over, the scabs have fallen off and a new layer of skin has formed underneath. This will stop you from passing on the virus to others.

You should also:

• Avoid skin-to-skin contact with others, such as hugging and kissing.
• Refrain from sexual or intimate contact.
• Avoid international travel if possible; travel insurance may also not be valid for people advised not to travel.
• Avoid attending health or dental care appointments other than those required by UKHSA.
• Avoid close contact with children aged under 5 years, pregnant women and those who have an impaired immune system.

If you work with children aged under 5 years, pregnant women or those who have an impaired immune system, you may need to take time off from work. This decision will be based on a personalised clinical assessment by the UKHSA.

The World Health Organization (WHO) advises that people should use condoms whilst having sexual contact for 12 weeks after recovering from Monkeypox, as a precaution until more is understood about the virus transmission through sexual fluids.

Experts do not yet have a clear understanding of whether a previous Monkeypox infection gives you immunity against future infections and, if so, for how long. So even if you have had Monkeypox in the past, you should be doing everything you can to avoid getting re-infected.

Although there have not been any reports of Monkeypox being spread through blood transfusions, people should never give blood when feeling unwell, including if experiencing any symptoms of Monkeypox. To reduce the risk of anyone with an infectious disease giving blood there are strict protocols in place for when people can give blood, so if you don’t feel well, self-assess and monitor your health and reschedule the appointment.

Is there a vaccination for monkeypox?

There is a safe Smallpox vaccine which is available on the NHS and is currently being offered to close contacts of people diagnosed with Monkeypox, and to healthcare professionals who are seeing potential Monkeypox cases.

The vaccine reduces the likelihood of symptomatic infection and severe illness. Vaccination with the Smallpox vaccine can be used for both pre- and post-exposure to the virus and is up to 85% effective in preventing Monkeypox. People vaccinated against Smallpox in childhood may experience a milder disease if infected.

UKHSA has announced plans to make the Smallpox vaccine more widely available. Your doctor will be able to advise you about whether you should have the vaccine.

Final thoughts

Monkeypox is not as contagious as some other infections because for transmission it requires close contact; that is, face-to-face, skin-to-skin, mouth-to-skin or mouth-to-mouth with someone who has Monkeypox, or with a contaminated environment or with an infected animal.

Everyone can help to stop the spread of Monkeypox by knowing their own risk potential and by taking avoidance actions such as those listed above, to lower the risk of spreading it.