While the world continues to grapple with the impact of COVID-19, a different viral outbreak, monkeypox, is making headlines. As new infections pop up across the globe, should countries be bracing themselves for the next pandemic? We spoke with Saad Omer, PhD, director of Yale Institute for Global Health and professor of medicine (infectious diseases), to learn more about the public health implications of the monkeypox outbreaks.

What is monkeypox?

Monkeypox is an illness with characteristic skin lesions that is spread through close contact. The virus is closely related to the virus that caused smallpox, which was declared eradicated in 1980. Monkeypox has two variants, or clades. One is the so-called Central African clade, in which one in 10 people die. The other is the West African clade, which has a one percent case mortality—about one in 100 people die. Having said that, case mortality is very dependent on the location and situation—where people are being treated, how quickly they are diagnosed, and what therapies they receive. So the mortality may unfortunately be a function of a person’s circumstances.

The monkeypox virus is not like measles or Sars-CoV-2. It’s not known to be highly infectious, and it mostly requires a degree of intimate contact for transmission. Fortunately, the smallpox vaccine was documented to be approximately 85 percent effective in protecting against monkeypox, but this vaccination was stopped in the United States in 1972 and around the world in the early 80s. Therefore, not a lot of people have the smallpox vaccination. There is a monkeypox vaccine out there as well, but unlike the smallpox vaccine, it hasn’t been widely used.

How similar is monkeypox to smallpox?

In terms of deaths, smallpox was way more dangerous—monkeypox is the much less lethal cousin of smallpox.

Where did monkeypox get its name?

It’s called monkeypox because scientists in Denmark saw its manifestation in monkeys first. But it’s the rodents that we need to worry about in terms of actual transmission. It came to light when it was identified in monkeys, but monkeys are not a main source of transmission.

What are the signs and symptoms of monkeypox?

Usually the disease begins with fever, headache, mild muscle pain, palpable lymph nodes, chills, and extreme fatigue. Within 1 to 3 days, lesions appear as a rash, often but not always appearing on the face and spreading to other parts of the body. The Centers for Disease Control and Prevention (CDC) has a really nice description of the rash—I would refer you to that comprehensive description.

Monkeypox was first documented in humans in 1970. Why is it making headlines now?

Whenever you have an outbreak outside an endemic area [in this case, the portions of Africa I mentioned], it attracts attention. The other thing is that we are seeing multiple outbreaks at the same time outside the endemic area— monkeypox is circulating in multiple countries. Even before that, in areas where the virus is more prevalent, the rates were slowly going up over the years. So that’s why people are paying more attention now.

How does monkeypox spread?

Monkeypox spreads through close contact—living with someone, intimate contact like sexual activity. When people have sexual contact, they have to be in proximity to each other. So it’s not necessarily sexually transmitted, but that’s one kind of intimate contact. If you are living with someone, sharing a room or bed with someone, that’s the kind of stuff we are concerned about when it comes to transmission.

Should we worry about a monkeypox pandemic?

While it’s a cause for concern, it’s not likely to create close to the order of magnitude of disruption that was caused by COVID-19. At least that is our assessment at this time. But this certainly needs attention. It’s one of those things that should disturb the sleep of people who do this for a living, but not necessarily for the rest of the population. It requires attention, early follow up, and good shoe-leather epidemiology to figure out why these outbreaks are happening at the same time, and being prepared with preventative measures and vaccines if needed. But it does not need the level of concern that we showed for the new respiratory virus that was spreading in early 2020.

Numerous cases are occurring in the gay, bisexual, and other men who have sex with men (MSM) community, leaving many concerned about increased stigma. How can scientists communicate about monkeypox without stirring discrimination or panic?

All kinds of sexual contact are intimate contact by definition. It could be heterosexual contact, it could be MSM contact. Often, outbreaks get identified in certain communities, but that doesn’t mean that one specific type of sexual behavior is inherently more conducive to the transmission. An at-risk community gets identified because someone from that community travelled somewhere and started an outbreak. It’s a situation that occurs because of the intimacy of the contact, not the kind of sex people are having.

We need to treat this disease as a disease, not as a call for social judgment and stigmatizing. Because whenever we have done that, it has caused unwarranted stigmatization of communities. One example is HIV. It is unfair and unjust to stigmatize communities, and it is bad, bad public health policy to do that. If you want the trust of a community where initial cases are identified, you need to meet them with a level of trust, respect, and a non-stigmatizing approach.

So to clarify, it is the intimate contact, which may be of any kind that causes transmission. It just so happens that many of the cases identified are in the MSM community at this point.

There is already a vaccine for monkeypox. Should we make appointments to be vaccinated?

Not right now. But I think the government should be getting ready to identify trigger points, for example health care workers, in certain situations. I think initially that the administration of vaccines will be limited, in which case we would focus on the risk factors associated with exposure.

If you suspect you may have monkeypox, what should you do?

Seek care. The CDC has invested a lot of effort in informing the health care provider community. So pay attention to symptoms and reach out early on.

EDITOR’S NOTE: On June 9, Saad Omer led a one-hour virtual discussion on monkeypox with top experts, including two from Yale. You can watch the discussion here.

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