Q&A: What to know about monkeypox symptoms and how it spreads

Credit: Jack Kearse

Credit: Jack Kearse

Q: What does monkeypox illness look like in patients and is there a range in severity and symptoms?

A: There’s certainly a range but generally most patients are presenting with genital sores, and then they may be elsewhere on the body, anywhere from head to toe with as few as a single lesion up to dozens. Lesions may cause severe pain in the mouth, rectum or genital area. The other thing with these lesions is that they kind of evolve over time. They go from being kind of flat, looks like a rash, and that turns into kind of a bump that then looks like a little bit of a pimple and then becomes more of like what I think is now becoming recognized as a monkeypox lesion. That is what we call a vesicle. That’s kind of a fluid-filled lesion. And that will also vary and become kind of hard and then scab and then ideally heal over — but it can also leave scars.

These lesions can be excruciatingly painful, but not all are. It can be very painful to the point somebody needs to be hospitalized. Or if they don’t need hospitalization, they may need strong pain medicine. Locally, we’ve had a couple or so patients who needed to be hospitalized due to the pain being so severe.

In most cases with the illness, it will eventually get better on its own. But that doesn’t mean that the course of illness is easy by any stretch of the imagination. We have medications that may shorten the course of that illness.

Q: What do we know about how monkeypox is transmitted?

A: It’s transmitted primarily through prolonged, close skin-to-skin intimate contact, whether it’s kissing or cuddling or sharing the same bed. Sex is obviously an intimate activity. The vast majority of cases in the current outbreak are traced back to a sexual or otherwise intimate encounter.

In terms of surfaces or objects, sheets, towels or clothing that was in direct contact with infectious lesions could be a mode of spread. In this way, you would likely need the towel to be on your skin for a prolonged period of time.

We do not think there is a risk of getting this through other surfaces, in particular in the setting of casual contact or usual daily activities such as bank counters or public transportation.

So the New York outbreak is a really excellent example of this. New York is a place where folks from no matter what race, creed, gender identity, who they have sex with, socio economic status, everybody interacts on the subway. And in New York, we are still seeing this highly concentrated in men, and among those men, it’s largely men who have sex with men.

That’s not to say that there are not others who have had infections. If this was transmitted by holding a bar in the subway or by exchanging money we would be seeing lots more cases of individuals who don’t have some sort of intimate exposure. And we are just not seeing that.

Q: So is it a theoretical risk to get monkeypox from hard surfaces, handling cash?

A: You can never say there’s absolutely no chance, but based on the data we have, we would be seeing more cases if this was readily transmitted via surfaces.

I would remind people that hand hygiene is always important, right? If we are touching surfaces in public, if we are exchanging money, we transmit all kinds of viruses that way so you should be doing frequent hand washing when you are doing those activities.

But I am not aware of anybody acquiring monkeypox through these mechanisms, to date.

Q: How do health care professionals balance wanting to make sure that the information about vaccines and protecting oneself gets to the community most affected by monkeypox, but without stigma and framing this as a “gay disease?”

A: I think this is one of the most challenging issues for us all right now — to get this right. Let’s go to the facts. When you look at epidemiologic data, about 99% of the people infected thus far in this outbreak are men. And I think close to 94 to 98% of those are men who have sex with men.

Now, I think that it is a hard stop that this is not a gay disease. I don’t even really know what that means. But if it were a quote-unquote, a gay disease, only gay people could get it, and we know that is not true.

It doesn’t mean that those who are not in that community cannot get infected. But they are not at any really substantial risk at this point.

What I would ask from the communities outside of the gay, bisexual, transgender or otherwise men who have sex with men is that we need to have a tremendous amount of empathy and compassion right now, for the MSM (men-who-have-sex-with-men) community as this is the community principally affected at this time.

Q What do you think needs to happen to get this outbreak under control and stop it?

A: Well, I think it’s a multi-pronged approach. It starts with education. It’s important that the most affected communities — those seeing highest number of cases, the MSM community — are aware that this virus is around and that if individuals are engaging in intimate activities and sex that there could be risk, especially with anonymous or multiple partners. There may some value in temporarily adjusting sex lives and social lives to try to dampen that risk. The CDC has a good resource on this.

We need to get the vaccine to more people who fall into the groups being disproportionately affected.

For those individuals who develop lesions, I encourage them to seek care, as this is how we can diagnose and potentially initiate treatment, if warranted. This virus, unfortunately, is becoming stigmatized. It’s visible. We’re hearing stories, really heartbreaking stories, of people that have encounters in health care where they’re being shunned and being told ‘We don’t do testing, go away.’ And that is detrimental. We don’t want people to feel like they have to hide in their homes and not seek testing, treatment.

I think we need more efforts to get knowledge and best practices out to our colleagues here around metro Atlanta. There’s a lack of certainty and the other thing is that it is slightly challenging because it’s a slightly cumbersome testing process.

We’re not at the end, but we’re three years into another pandemic, where healthcare workers are burnt out. And then here we are, with a new illness that again, in the healthcare setting, can be challenging to operationalize care delivery. I want patients to know too, that we [Grady] will welcome them with open arms here, and they’re being received with compassion and empathy in our health system.