Monkeypox has now been on the radar of most Americans — most gay Americans, especially — at least since late June, when news of the global outbreak coincided with LGBTQ Pride celebrations around the country. But still, for many, ideas around how the virus spreads, and which activities pose risk, remain confusing and misunderstood.
That’s especially concerning given that reported cases are still rising exponentially in the U.S. — up to nearly 11,000 on Aug. 11 from 4,639 on July 27, according to the Centers for Disease Control and Prevention (CDC), with 98% of cases occurring in gay or bisexual men. Last week the Biden administration declared a public health emergency over the mounting crisis, following the lead of local jurisdictions from New York City to Sacramento, and of the World Health Organization, which declared a global health emergency last month. WHO also advised men who have sex with men to temporarily limit their number of sexual partners, though the virus technically is not an STD (sexually transmitted disease), as it is not spread solely through sex.
So how does monkeypox spread?
Here’s what we know, according to medical and public health experts: Anyone can contract the virus, including children, because it is spread through bodily fluids such as saliva, sweat and pus from the pox’s skin lesions, mostly through extended skin-to-skin contact. Monkeypox symptoms include fever, headache, muscle aches, exhaustion and swollen lymph nodes, followed by the telltale skin rash that becomes oozing pustules.
Here’s what we don’t know: whether or not the virus can be spread by an exposed individual before experiencing any symptoms, including the very contagious pustules. That’s something “scientists are still researching,” according to the CDC.
And this is where understanding what is and what is not a risk can get complicated.
“This is an important question that we do not know the answer to,” epidemiologist Dr. Jay K. Varma, professor of population health sciences at Weill Cornell Medical College, tells Yahoo Life. “What we know is that people who have monkeypox may be infectious before they develop a rash. We know this from studies showing that the virus can be detected in the throat and blood before a rash develops and from investigations into outbreaks that suggested transmission may have occurred before the rash developed.” But, he adds, “this is all based on historical data.”
To find an answer within the context of the current outbreak, notes Dr. Céline Gounder, clinical assistant professor of medicine and infectious diseases at NYU Grossman School of Medicine, Kaiser Family Foundation senior fellow and host of the podcast Epidemic,“That’s going to require more testing — testing various different specimens, saliva, semen, feces — to have a better sense.” For example, she tells Yahoo Life, “We know there is virus in semen, but is that causing transmission? We don’t know. But it could explain why sexual contact is more efficient in terms of transmission.”
In the current outbreak, notes Varma, “many men are presenting with their first rash on their genitalia, anus or mouth in locations corresponding to sexual acts. This strongly suggests that transmission is occurring primarily through sexual intercourse or, in some cases, by prolonged skin-to-skin contact. There has been very little transmission to contacts of these cases in other settings [such as] offices, households, transportation, medical work, grocery stores,” he says. (It's why men who have sex with men and have had multiple partners are a high-risk group that should consider vaccination, says the CDC.)
“So, the best way to think of this is: There are many possible ways for monkeypox to transmit, but possible does not mean equally likely," Varma says, adding, “Receptive or insertive intercourse and prolonged skin-to-skin contact appear to be very high-risk activities.”
Beyond that, Varma cautions, there have not been enough current studies to yet put definitive risk percentages to specific types of exposure. But here’s what experts can ascertain about certain activities so far…
Greetings: casual hug, kiss, handshake with a friend
In the case of a casual physical greeting with a friend, says Gounder, if you have no lesions, "you're not shedding that way." Therefore, it's saliva that would be the most infectious route here. And unless you are deep kissing your pal, she says, monkeypox transmission is "very unlikely."
Saskia Popescu, infectious disease epidemiologist and assistant professor with George Mason University's Schar School of Policy and Government biodefense program, tells Yahoo Life: "What we’re seeing is that you need more close and frequent touching [for transmission]. So a casual touch is less likely to provide a substantial exposure, and I would say that kissing and direct contact with the rash is the bigger concern."
Something useful to keep in mind when weighing the risk of this or any other activity, Gounder suggests, is "the amount of time, times the dose of the virus," and in this case, since it's a quick greeting with little to no saliva involved, it's "a very minuscule time and dose."
Trying on clothes in a store
"This would be pretty unlikely, and I see it as lower risk," says Popescu. "We’re still learning more about contamination and spread through garments, but if you consider how little transmission has occurred through households, where linens and clothing are much more contaminated and exposure is far more substantial, trying on clothing is considered pretty low-risk, and I feel safe doing so right now."
Varma agrees, assessing the current case count to call this a "very low risk right now, because the percentage of people in the overall population with monkeypox is extremely low."
Perhaps the biggest thing to keep in mind is that monkeypox "is most transmissible when you have the lesions, so people in prodromal stage — where they don’t necessarily show symptoms and don’t have the lesions — are not highly infectious at that point," if at all, says epidemiologist Dr. Brian Mangum, associate dean and professor of medicine at the University of Health Sciences Antigua.
Then, he tells Yahoo Life, "the risk of going into a store and finding the one blouse someone with monkeypox happened to try on, with weeping blisters, is really, really remote," not to mention that "the number of people out there in the population is such a low number that the likelihood we’ll come into contact is pretty low."
Touching surfaces — in public restrooms, on public transportation or by handling cash
For starters, says Varma, as with trying on clothing, this is all "very low risk right now, because the percentage of people in the overall population with monkeypox is extremely low."
Also, if there does happen to be monkeypox on such a surface — similar to it being possibly alive on gym equipment or yoga mats — the virus is easy to kill with cleaning products and disinfectants, says Mangum, explaining, "Monkeypox is what's called an enveloped virus, which has to get into a host’s cells and replicate, so this envelope is like a protective coating … but things like laundry detergent, alcohol and bleach rapidly break down the envelope, then the monkeypox desiccates and dies."
Even if the virus gets onto your hands, he adds, sanitizer will do the trick; Popescu says thorough hand-washing will keep you safe, and notes that, on public transportation, her bigger concern at the moment is "people [not] wearing masks, given the COVID cases in the community right now."
Doing laundry, especially towels, and changing bedding, especially for housekeepers, health care workers
Mangum again stresses the use of hand sanitizer, which, if 70% alcohol, "rapidly destroys the envelope," and notes that, "even when there's someone in the home with monkeypox, as long as you run their clothes and beddings through a prolonged cycle with detergent and high heat setting," any lingering virus will be destroyed.
If you work in an industry where you’re changing bedsheets and towels, Popescu adds, "the big piece is to avoid shaking them, and just wear gloves or use hand hygiene after — and that’s the recommendation for contact with a known case, which is why you don’t see overarching public health guidance for the general public, as it’s considered lower risk."
Getting a massage, manicure/pedicure or haircut
"With skin-to-skin contact, again, really, the biggest thing to consider is when there are lesions, [which are] relatively obvious," says Mangum.
Gounder calls these activities "very low-risk," as it's "pretty easy to put on gloves," at least at a salon. Regarding respiratory secretions, she says, the biggest risk lies in "spraying saliva or snot while you’re coughing — I think of it more of a spray, like, that juicy sneeze. But if you’re sick, you probably shouldn’t be going to work, as it could also be COVID." Acknowledging a lack of paid sick and family medical leave, Gounder adds, "Ideally, if someone can stay home they should stay home, or then probably wearing a mask."
One case in New York she says she's been hearing about from a colleague, however, does appear to be one of monkeypox transmitted during a massage in the Philippines. "There's no contact tracing, but the patient does not have sex with men and has no genital, oral or anal lesions, just stuff on his general skin and near his eye," Gounder says. "We don’t really know what the deal is with that case. It’s hard to know — did the massage therapist have something on his hands? We don’t know. So there is stuff that is not totally clear."
Dancing inside a crowded club — especially at a gay club, shirtless
Varma calls this an "unclear risk," noting, "If you have exposed skin and are rubbing up against others with exposed skin, then there is a risk that you could be infected. It depends entirely on the area of the world that you are in. If you are in a neighborhood where there have been large monkeypox outbreaks, there is a possibility of being infected. If you are in a neighborhood where there is very little monkeypox, then your risk is very low."
Adds Popescu, "Direct and close contact is definitely where we can see spread, so I’d focus on trying to keep the shirt on and limiting skin-to-skin touching when possible. More importantly, stay home if you’re symptomatic."
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