Monkeypox is a virus usually found in animals like squirrels and non-human primates. First identified in humans in 1970, hMPXV has similarities to the smallpox virus but is significantly less severe. (Of note, smallpox was eradicated in 1980 because of widespread vaccination.) Most cases of monkeypox resolve on their own in 2-4 weeks. Historically, about 3-6% of those diagnosed with this infection have died,but the circulating strain in the current outbreak appears to be a milder form. To date, there have been 6 deaths from hMPXV worldwide and no deaths in the U.S.

Infection occurs through direct contact with the skin or mucous membranes of an infected individual, or through prolonged face-to-face contact. This can happen directly through sex and other intimate activities, or indirectly through contaminated items like bed sheets or towels. Unlike COVID, the virus is not airborne and is much more difficult to transmit. It can be transmitted in large respiratory droplets from coughs and sneezes, but these generally cannot travel more than a few feet. Casual contact with people in daily life is not known to transmit hMPXV. However, any prolonged physical contact with an infected individual(particularly skin-to-skin contact without clothing) can lead to transmission. There is risk of transmission in all sexual encounters regardless of the gender or sexual orientation of the people involved.

Most cases of hMPXV take anywhere from 3 to 17 days from exposure to symptom onset. Early symptoms bear similarities to flu and COVID and include fever, headache, muscle aches, exhaustion, and swollen lymph nodes. However, people with monkeypox do not usually have the cough or nasal congestion commonly seen in flu and COVID. These early symptoms may be mild or may not occur at all. Usually within 1-3 days of the flu-like symptoms, patients develop a flat rash that soon progresses to raised bumps, then blisters, then pus-filled bumps. Lesions can occur anywhere on the body, including the mouth, genitals, and rectum, and can be associated with significant itchiness and pain. Over the course of 2-3 weeks, the rash scabs over and resolves. Of note, the rash and other symptoms can look very similar to syphilis, which is still very common in our community.

Anyone who develops concerning symptoms of fever and rash, especially if they have had a potential exposure such as recent sex, should isolate themselves at home or somewhere safe and away from other people and immediately call to speak with their medical provider. Do not walk into the office; call ahead to make sure you can be evaluated and seen without putting others at risk. If you must leave the house to seek urgent medical care, be sure to wear a mask and cover any visible lesions under clothing.

If you were exposed to hMPXV but do not have symptoms, you may be able to get the vaccine. The vaccine continues to be in very limited supply, so call your medical provider to see if doses are available. Once a person starts developing symptoms, you can no longer receive the vaccine (because it will not work and could worsen symptoms).

If you are experiencing skin lesions, your healthcare provider will likely be able to make a preliminary diagnosis by listening to your history and examining you. However, for a definitive diagnosis your medical provider will swab the skin lesions and send the samples to a lab for testing. Results are usually available in a few days.

If you are diagnosed with hMPXV or think you might have this infection, it is important not to touch any animals or household pets. The virus can shed and spread on soiled/shared clothing and furniture, so be careful to stay covered and avoid sharing a bed or linens with others. If you live with others, keep your silverware, cups, plates, etc. separate during your infection.

If you are living with other people or animals, you can decrease the risk of hMPXV exposure. The guidance below is from the CDC’s Isolation and Infection Control page.

• Isolate to the extent possible:
  • Avoid contact with unaffected individuals until the rash has resolved, the scabs have fallen off, and a fresh layer of intact skin has formed.
  • Isolate in a room or area separate from other household members and pets when possible.

• Frequent cleaning and disinfection:
  • Routinely clean and disinfect commonly touched surfaces and items, such as counters or light switches, using an EPA registered detergent in accordance with the manufacturer’s instructions.

• Hand hygiene:
  • People with monkeypox and household contacts should use an alcohol-based hand rub or wash their hands with soap and water after touching rash material, clothing, linens, or environmental surfaces that may have had contact with rash material.
• Mask and protective equipment:
  • When isolation is not possible, the person with hMPXV should wear long pants, long sleeves, socks and gloves (if hand lesions are present).
  • The person diagnosed with hMPXV should wear a tight-fitting medical mask when within 6 feet of others.
  • Other household members should wear a respirator or a tight-fitting mask when in close contact (e.g., within 6 feet) with the person with monkeypox for more than a brief encounter.
• Bathroom usage:
  • If possible, use a separate bathroom if there are others who live in the same household.
  • If there is not a separate bathroom in the home, the patient should clean and disinfect surfaces such as counters, toilet seats, and faucets using an EPA-registered disinfectant after using a shared space. This may include during activities like showering, using the toilet, or changing bandages that cover the rash. Consider disposable glove use while cleaning if rash is present on the hands.
  • Avoid shaving rash-covered areas of the body as this can lead to spread of the virus.
• Avoid sharing:
  • Limit use of spaces, items, and food that are shared with other household members.
  • Do not share dishes and other eating utensils. It is not necessary for the infected person to use separate utensils if properly washed. Wash soiled dishes and eating utensils in a dishwasher or by hand with warm water and soap.
• Laundry:
  • When possible, the person with hMPXV should do their own laundry. If illness prevents this, a caretaker should wear gloves at all times while handling the person’s laundry.
  • Other tips for doing laundry (taken from the NYC Department of Health):
    • Avoid shaking clothing/linens before putting in the washer.
    • Use hot water or the highest temperature setting.
    • Use regular detergent. You do not have to use chlorine or color-safe bleach, or another sanitizer.
    • Dry your clean, wet laundry at the highest temperature allowed. Check item labels for instructions.
    • Air-dry any items at home that cannot be dried in a machine.
  • For items that are not machine washable:
    • Wash them in a sink or bathtub with detergent.
    • Clean or disinfect those that came into contact with your rash or sores (such as watches, belts, and hats) using the appropriate disinfectant from the U.S. Environmental Protection Agency’s list (available at bit.ly/epa-disinfectants-list).
    • Put them in a sealed plastic bag for 21 days if they cannot be washed at home.
  • If you are in a laundromat or other shared laundry room:
    • Take your clean, dry laundry out of the dryer, put it directly in the clean bag and fold it at home.
    • Limit your time in public laundry spaces. If possible, go home between washing and drying your laundry, or go outside to avoid close contact with others.
  • Limit contamination within household:
    • Try to avoid contaminating upholstered furniture and other porous materials that cannot be laundered by placing coversheets, waterproof mattress covers, blankets, or tarps over these surfaces.
    • Additional precautions such as steam cleaning can be considered if there is concern about contamination.

The guidance below is from the CDC’s Isolation and Infection Control page.

• Considerations for isolating with animals in the home:
  • People with hMPXV should avoid contact with animals (specifically mammals), including pets.
    • If possible, friends or family members should care for healthy animals until the owner has fully recovered.
    • Keep any potentially infectious bandages, textiles (such as clothes and bedding), and other items away from pets, other domestic animals, and wildlife.
    • In general, any mammal may become infected with monkeypox. It is not thought that other animals such as reptiles, fish, or birds can be infected.
  • If you notice an animal that had contact with an infected person appears sick (such as lethargy, lack of appetite, coughing, bloating, nasal/eye secretions or crust, fever, rash) contact the owner’s veterinarian, state public health veterinarian, or state animal health official.

hMPX is usually self-resolving, which means that the infection will go away on its own. With this current outbreak, there have been no deaths and very few infections requiring hospitalization. Be sure to rest and drink plenty of fluids. However, the lesions can be very painful and depending on their location can make it hard to eat, urinate or have a bowel movement. Your medical provider can prescribe medications to help ease the discomfort.

For patients experiencing lesions that are not responsive to pain medications or other supportive measures, there is a medication being offered for treatment called tecovirimat, or TPoxx.

TPoxx was FDA approved to treat smallpox but not hMPXV. We have never had a smallpox outbreak (thankfully) so it has never been used in a large number of people experiencing this infection. TPoxx was tested in animals infected with smallpox and was shown to decrease symptoms, particularly if started early in the course of infection. However, it is not clear if these findings translate to humans with hMPXV. The medication was given to humans without either smallpox or hMPXV to assess its safety profile. In this study, TPoxx was shown to have mild side effects and was deemed safe for human use.

TPoxx is available under IND (investigation new drug) protocol from the CDC. Because it is not FDA approved for this indication, the CDC controls the use of this medication tightly. Medical providers prescribing and patients taking the medication must complete extensive paperwork and agree to several follow-up visits.

Though we know that TPoxx is safe, we still don’t know how much it will help an individual with hMPXV. Because of this and the amount of oversight required, TPoxx is still only being offered to patients with very severe symptoms. This may change as new data emerges.

For pain, people can alternate ibuprofen and acetaminophen every 3 hours. Patients can take 600-800 mg of ibuprofen and then take 500-1,000 mg of acetaminophen three hours later. Of note, an individual should not take more than 3,000 mg of acetaminophen and 3,200 mg of ibuprofen in a 24-hour period.

For lesions in the rectum, it is important to keep the stool as soft as possible. Drink plenty of water and fiber. If necessary, you can add a stool softener like Miralax or Colace. Avoid laxatives because these can stimulate the GI system.

If the lesions are itchy, patients can take an anti-histamine like Claritin or Benadryl. Soaking in a warm bath with colloidal oatmeal can also provide relief.

If the pain remains uncontrolled, call your medical provider to discuss further.

The same masks, gowns, gloves, frequent handwashing, and social distancing that are helping to keep us safe from COVID will also prevent transmission of monkeypox. If you must touch a potentially infected person for some reason, be sure to wear a mask, gloves, a disposal gown, and protective eye wear. Dispose of these immediately after contact in appropriate biohazard bags.

The risk of hMPXV can present a challenge for dating and sexual health. To decrease your risk, we advise honest conversations with potential partners regarding symptoms and potential exposures to hMPXV. Condoms are an important tool in decreasing STI risk. However, hMPXV lesions can appear on any part of the body, so condoms will not likely provide adequate protection from infection. Mutual masturbation and video/online play are low risk activities to consider.

There is one vaccine that is FDA-approved to prevent hMPXV, called Jynneos. However, this vaccine remains in short supply.

Originally, the guidance was two doses of Jynneos administered subcutaneously 28 days apart. However, the Los Angeles Department of Public Health, CDC and US Food and Drug Administration have issued new guidelines based on research showing that intradermal (into the skin) administration of this vaccine achieves the same level of immunity while using a much lower dose. http://publichealth.lacounty.gov/acd/monkeypox/Vaccine/#jynneos-admin

There is another vaccine, ACAM2000, that is FDA-approved to prevent smallpox. Because of the risk of adverse events associated with this vaccine, it is not being used in this outbreak.

Current guidance from the Los Angeles County Department of Public Health, CDC, and US Food and Drug Administration recommends two doses of Jynneos administered intradermally 28 days apart for eligible individuals over the age of 18.

The guidelines are based on research showing that intradermal (into the skin) administration of this vaccine achieves the same level of immunity while using a much lower dose. Making this change increases the available supply of vaccine by as much as five times and allows medical providers to resume offering second doses to those eligible.

  We acknowledge that the changes in these recommendations can be confusing and frustrating. There is still a lot that is unknown about this virus. As experts learn more about how to prevent and treat the hMPXV, guidelines will likely evolve. We will continue to provide you, our community, with the most up to date information and keep you informed of any developments.

Because of the limited number of hMPXV vaccines in the U.S., the Los Angeles County Department of  Health (LAC DPH) has advised that only those people meeting certain risk criteria are eligible. Currently, this includes:

1. Gay or bisexual men and transgender persons who:
   • Had multiple or anonymous sex partners in the last 14 days, including engaging in survival and/or transactional sex; or
   • Had a diagnosis of gonorrhea and/or early syphilis within the past 12 months; or
   • Are on HIV pre-exposure prophylaxis (PrEP); or
   • Attended or worked at a commercial sex venue or other venue where they had anonymous sex or sex with multiple partners within past 21 days).
2. Persons confirmed by LAC DPH to have high- or intermediate-risk contact with a confirmed monkeypox case (as defined by CDC and confirmed by LAC DPH).
3. Persons who attended an event/venue where there was high risk of exposure to an individual(s) with confirmed monkeypox through skin-to-skin or sexual contact. (Public Health will work with event/venue organizers to identify persons who may have been present and at risk of exposure).
4. Persons experiencing homelessness (PEH) with high-risk behaviors.
5. High risk cohorts identified by clinical staff in the LA County Jail system.

The Center is advocating for greater access to vaccines for our community. As soon as we receive doses from LAC DPH, we are utilizing all our staff resources to identify eligible patients and administer vaccines. Once we successfully administer those doses, we let LAC DPH know and request more. We will do our best to keep patients up to date regarding availability of vaccine at our sites, and we will continue this cycle until all patients at risk for hMPXV are vaccinated. 

See the latest update on our response to this current outbreak.

Monkeypox is usually found in central and west African countries including Cameroon, DRC, Gabon and Nigeria. Since May 18, 2022, an outbreak outside of these regions has caused over 28,000 cases in over 80 countries, with 7,500 cases in the U.S., 826 in California and 496 in Los Angeles. It is believed that these numbers are significantly under-counting the true number of cases. 

It is true that gay and bisexual men make up the vast majority of monkeypox cases worldwide. However, anyone who has skin-to-skin contact with an infected person can get this virus. We must avoid further shaming of LGBTQ+ people as our community continues to experience increased stigma related to sexuality and HIV/STIs. The Center will remain a source of judgement-free healthcare for anyone who is showing symptoms of monkeypox or any other stigmatized health condition.

This virus is nothing like COVID and has almost no chance of becoming a new global pandemic. Unlike COVID, hMPXV is transmitted only by prolonged physical contact with an infected individual. Casual contact like walking through a supermarket or spending time in a meeting is very unlikely to spread this virus. However, healthcare workers, household members, and sexual partners of infected patients are more at risk. Proper use of PPE can drastically reduce this risk even with known cases.

See the entire update.