What is Monkeypox?
Monkeypox is a viral disease, usually self-limiting and resolving in 2-4 weeks. It is similar to smallpox but is less infectious and much less lethal1. The incubation period is 4-20 days.
Like smallpox and chickenpox, the disease demonstrates a characteristic rash followed by eruptions.
The eruptions begin as macular (flat), which then become papular (raised), then vesicular (clear fluid blisters), and then pustular (pus filled). Finally, they scab and the crusts fall off. More reliably, the monkeypox rash differs from smallpox in that the monkeypox rash is accompanied by swollen lymph nodes in the neck and occasionally in the groin. These swollen nodes may sometimes measure several centimeters. Less reliably, the monkeypox rash spreads from the face and upper trunk to the rest of the body while the smallpox rash spreads from the trunk outward.
Other symptoms include fever, usually the first symptom, then chills, sweats, muscle aches, weakness, sore throat, cough, and shortness of breath.
Lastly, the evidence does not seem to suggest that monkeypox is a specifically sexually transmitted infection (STI).
Why “Monkey” pox
The name “monkeypox” is misleading since the connection with monkeys is minimal. Although first identified in laboratory monkeys in 19581, the disease seems endemic to rodents of central Africa and western Africa.
In 2003 an animal distributor transported prairie dogs, along with rodents from Ghana. The then-infected but pre-symptomatic prairie dogs spread the disease in the prairie dog population and a human outbreak occurred in the midwestern United States among those exposed to pet prairie dogs.
Transmission
Initial transmission from animals to humans seems to have occurred by respiratory transmission or by direct contact with skin or mucous membranes. Another possible route is by consumption of wild animals, “bush meat,” which is often undercooked.
Secondary transmission from human to human occurs by the respiratory route and by direct contact with skin or mucous membranes. Patients are considered infectious until the last scabs have fallen off.
Complications
The most common complication is pitted scars. However, there is also bronchopneumonia, blindness from corneal ulceration, septicemia, and encephalitis.
Lethality
Monkeypox is far less lethal than smallpox. Monkey pox lethality in Africa seems to have been at 1-10%, with more of these occurring in children and youth. On the other hand, the fatality rate from untreated smallpox is estimated to be 30%.2
Prevention and Treatment
Present data suggests that prior smallpox vaccination confers 85% immunity from monkeypox and that when infection does occur, it is milder. In fact, the Centers for Disease Control and Prevention (CDC) recommends smallpox vaccination even after exposure, ideally within 4 days, but also up to 2 weeks after exposure to a diseased animal or confirmed human case. The more recent discontinuation of routine smallpox vaccination may have contributed to the disproportionate frequency and severity of monkeypox in younger people.
In addition to the original smallpox vaccine, discontinued in the 1980s, and its successors, the Federal Drug Administration (FDA), in September 2019, approved a combined smallpox/monkeypox vaccine.
Finally, some antiviral drugs have shown evidence of effectiveness in the lab and in animal studies, but their effectiveness is still undocumented in human studies.
Social Implications
First, the World Health Organization (WHO) announced that it would rename monkeypox due to concerns that the name is “discriminatory and stigmatizing” because of the prevailing perception that the disease is endemic among people in some African countries. However, nearly all monkeypox outbreaks in Africa prior to 2022 have resulted from animal transmission to humans. Additionally, the Foreign Press Association of Africa has urged the global media to stop using images of black people in articles on the European outbreak.3 Finally, as of this writing, WHO has not yet determined a new name for monkeypox.
Second, several early European cases linked to a rave event in Spain and another in Belgium seem to have inspired a perception that monkeypox is a sexually transmitted infection (STI) among gay or bisexual men. However, the disease is, in fact, spread by physical contact, sexual or otherwise, with the skin eruptions of infected people.4
There sems to be nothing intrinsic to the monkeypox virus that would increase a proclivity for the gay or bisexual male population.
The false perception that monkeypox is an STI restricted to a circumscribed population can have both public health and clinical consequences. Regarding public health, the greater public outside the circumscribed population, feeling false security, may fail in their obligations to control the infection. Regarding the clinical arena, clinicians influenced by the false perception may be more alert to the diagnosis of monkeypox in the circumscribed population than in the greater public and so diagnose it more, resulting in a misperception becoming a self-fulfilling prophesy that narrows appropriate public health response.5
Monkeypox vs COVID-19 – The Good and the Bad
The appearance of monkeypox just now certainly prompts a comparison with COVID-19. Of course, comparisons must be tentative, as scientific conclusions evolve in accordance with the evolution of the evidence.
The Bad: Definitely troublesome is the fact that human-to-human spread of monkeypox has occurred in diverse locations almost simultaneously. This may result from global travel combined with a relatively long incubation period. Nevertheless, the phenomenon warrants caution.
The Good: Monkeypox seems less transmissible than COVID, with COVID spread primarily via the respiratory route and monkeypox spread primarily via direct contact.
Our experience with corona viruses spanned a few decades and with COVID-19 was nonexistent. On the other hand, our experience with pox viruses dates from the late 1700s, and with monkeypox specifically goes back 60 years.
The high transmissibility and difficulty in identifying mild cases of COVID made contact tracing difficult. However, the lower transmissibility and characteristic pox in even milder cases of monkeypox renders contact tracing easier and more effective.
Finally, in the darkest days of COVID, a vaccine was a vision. On the contrary, with monkeypox, a vaccine, and extensive experience with it, already exists.
Conclusion
We certainly do not need another epidemic. Although, currently cases are few, it is disturbing that human-to-human transmission has occurred at disparate places almost simultaneously. Additionally, scientific opinion evolves as the evidence upon which it is based develops; and this thought certainly inspires restraint in prediction.
However, we are cautiously optimistic about monkeypox not being a replay of our COVID nightmare. Monkeypox seems less transmissible, is more amenable to contact tracing, is much more familiar to us, and comes with a vaccine with which we already have extensive experience. We are in a much better position now than we were in January 2020!
Thomas Falasca, DO
References
1 Graham, M. B. (2022, June 16). Monkeypox. eMedicine Medscape. Retrieved June 26, 2022, from https://emedicine.medscape.com/article/1134714
2 Hussain, A. N. (2020, July 28). Smallpox Updated: Jul 28, 2020. Author: Aneela Naureen Hussain, MD, MBBS, FAAFM; Chief Editor: John L Brusch. eMedicine Medscape. Retrieved June 26, 2022, from https://emedicine.medscape.com/article/237229
3 Crist, Carolyn. (2022, June 15). WHO to rename monkeypox due to stigma concerns. eMedicine Medscape. Retrieved June 26, 2022, from https///www.medscape.com/viewarticle/975681
4 Heymann, D. (2022, May 24). Monkeypox spread likely "amplified" by sex at 2 raves in Europe, leading WHO adviser says. cbsnews.com. Retrieved June 26, 2022, from https://www.cbsnews.com/news/monkeypox-sex-raves-europe-world-health-organization/
5 Daskalakis, D., Mena, L., & McClung, P. (2022, June 16). Monkeypox: Avoiding the Mistakes of Past Infectious Disease Epidemics. ACPJournals.org. Retrieved June 26, 2022, from https://doi.org/10.7326/M22-1748