Monkeypox: What we know about the smallpox-like virus spreading in Europe, the US and Canada
Suspected or confirmed cases of monkeypox, a rare viral infection related to smallpox, have now been reported in the United States, Canada and several European countries, marking an unusual international outbreak of a disease typically limited to Africa.
Canada is reportedly investi-gating a dozen suspected cases around Montreal, after Spain and Portugal spotted more than 40 possible and confirmed cases and the UK confirmed a total of nine.
In the US, the eastern state of Massachusetts confirmed on Wednesday a rare case of monkeypox in a man who recently travelled to Canada, and health officials are looking into whether it is connected to the cases in Europe.
The WHO says many cases re-ported have been in people identifying as gay, bisexual or men who have sex with men.
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All the cases reported in Portu-gal involve men, most of them young, authorities said. They have skin lesions and were said to be in stable condition.
Authorities did not say if the men had a history of travel to Africa or any links with recent cases in Britain or elsewhere.
Monkeypox has not previously been documented to have spread through sex, but can be transmitted through close contact with infected people, their clothing, or bedsheets.
How did this outbreak start?
The UK Health Security Agency (UKHSA) was the first health authority in Europe to publicly report a case of monkeypox on May 7, in a person who had recently flown into the UK from Nigeria. Since then, it has confirmed a total of nine cases.
"We are particularly urging men who are gay and bisexual to be aware of any unusual rashes or lesions and to contact a sexual health service without delay," said Dr Susan Hopkins, the agency's chief medical adviser.
The UKHSA recommended par-ticularly looking out for lesions on genitalia.
The agency said on Wednesday it had identified two new cases of monkeypox, one in London and another in southeast England, bringing the total to nine. It said neither case had previously travelled to Africa and that it was possible they were infected in the UK.
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The cases also had no known links to other previously confirmed patients, suggesting there may be multiple chains of monkeypox transmission already happening in the country.
Portugal on Wednesday con-firmed five cases of monkeypox in young men and was investigating another 15 suspected cases. All were identified this month around the capital Lisbon.
In Spain, the Madrid region was investigating 23 possible cases, all in young men, most of whom had sex with other men.
What are the symptoms of monkeypox?
Monkeypox is a relative of smallpox, a disease that was eradicated in 1980, but is less transmissible, causes milder symptoms and is less deadly.
The illness typically lasts for two to four weeks and symptoms can appear anywhere from five to 21 days after infection.
Monkeypox symptoms usually begin with a mix of fever, headaches, muscle aches, backache, chills, exhaustion, and swollen lymph nodes.
This latter symptom is typically what helps doctors distinguish monkeypox from chickenpox or smallpox, according to the World Health Organization (WHO).
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Once you have a fever, the key feature of monkeypox, a nasty rash, tends to develop one to three days later, often starting on the face and then spreading to other parts of the body.
The number of lesions may range from a few to thousands.
The lesions will go through an ugly ripening process, from macules (flat lesions) to papules (raised lesions), vesicles (fluid-filled lesions), then pustules (pus-filled lesions) and then finally scabs (crusty lesions) before eventually falling off.
Why is it called monkeypox?
Monkeypox virus belongs to the Orthopoxvirus genus in the family Poxviridae. It was first discovered in 1958 when two outbreaks of a pox-like disease occurred in lab monkeys kept for research, hence the name.
But monkeys might not be the ones to blame for outbreaks, and the natural reservoir of monkeypox remains unknown, though the WHO says rodents are the most likely.
“In Africa, evidence of monkey-pox virus infection has been found in many animals including rope squirrels, tree squirrels, Gambian poached rats, dormice, different species of monkeys,” says the UN health agency.
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Where is monkeypox typically found?
Human monkeypox primarily causes outbreaks in the tropical rainforest regions of Central and West Africa and is not typically seen in Europe.
The Democratic Republic of the Congo (DRC) had the first recorded human case of monkeypox in 1970.
Since then, cases have been re-ported in 11 African countries: Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Ivory Coast, Liberia, Nigeria, the Republic of the Congo, Sierra Leone, and South Sudan.
The first outbreak of monkey-pox reported outside of Africa was linked to the importation of infected mammals in 2003 in the United States, according to the US Centers for Disease Control and Prevention (CDC).
More recently, in 2018 and 2019, two travellers from the United Kingdom, one from Israel, and one from Singapore, all with travel history in Nigeria, were diagnosed with monkeypox following a large outbreak there, according to Europe’s own health agency, the European Centre for Disease Prevention and Control (ECDC),
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How do you catch monkeypox?
You can catch the virus from the bite or scratch of an infected animal, by eating bush meat, being in direct contact with an infected human or touching contaminated bedding or clothing.
The virus enters the body through skin lesions, the respiratory tract, or the mucous membranes (the eyes, nose, or mouth).
Human-to-human transmis-sion is thought to occur primarily through large respiratory droplets, which generally cannot travel more than a few feet, so prolonged face-to-face contact would be needed.
Some British experts com-menting on the recent UK outbreak said it was soon to conclude that monkeypox had spread through sexual contact, but that it was a possibility.
"The recent cases suggest a po-tentially novel means of spread," said Neil Mabbott, a disease expert at the University of Edinburgh, adding that related viruses were known to spread via sex.
Keith Neal, an infectious dis-eases expert at the University of Nottingham, said the transmission might not have occurred through sexual activity but just “the close contact associated with sexual intercourse".
The US Centres for Disease Control and Prevention (CDC) stressed in a statement that "anyone, regardless of sexual orientation, can spread monkeypox through contact with body fluids, monkeypox sores, or shared items (such as clothing and bedding) that have been contaminated".
Should I be worried?
Monkeypox “is usually a mild selflimiting illness and most people recover within a few weeks,” the UKHSA said in its statement.
“It is important to emphasise that monkeypox does not spread easily between people and the overall risk to the general public is very low,” said Dr Colin Brown, the agency’s director of clinical and emerging infections.
The patients infected in Eng-land contracted the West African clade of the virus, which health officials say is mild compared to the Central African clade and has a case fatality ratio of around 1 per cent.
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Although its symptoms are milder than those of smallpox, monkeypox has been shown to cause death in as many as 10 per cent of patients infected with the Congo Basin clade, compared to about 30 per cent for smallpox, according to WHO data.
Mortality is higher among chil-dren and young adults, and immunocompromised individuals are especially at risk of severe disease.
Monkeypox during pregnancy may also lead to complications, congenital monkeypox, or stillbirth, the WHO warned on Monday.
"Milder cases of monkeypox may go undetected and represent a risk of person-to-person transmission," it said in a statement.
Treatment and prevention
There is currently no specific treatment recommended for monkeypox, and it usually goes away on its own.
Common household disinfec-tants can kill the monkeypox virus, says the CDC.
Vaccination against smallpox is believed to be highly effective in preventing monkeypox, but because smallpox was declared eradicated more than 40 years ago, first-generation smallpox vaccines are no longer available to the general public.
A newer vaccine developed by Bavarian Nordic for the prevention of smallpox and monkeypox has been approved in the European Union, the United States, and Canada (under the trade names Imvanex, Jynneos and Imvamune), and antivirals are also under development.