Does Everyone With Monkeypox Get a Rash? Here's What to Know About Symptoms

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With monkeypox cases continuing to spread in the Chicago area and the outbreak now declared a public emergency in Illinois, what symptoms should you watch for if you think you may have been exposed?

Experts warned that most who contract monkeypox experience flu-like symptoms before developing a rash, though some may develop a rash first followed by other symptoms, or no other symptoms at all.

Still, according to the Centers for Disease Control and Prevention, "most people with monkeypox will get a rash."

The flu-like symptoms may include fever, headache, muscle aches and backache, sore throat, cough, swollen lymph nodes, chills, or exhaustion.

"Suspected cases may present with early flu-like symptoms and progress to lesions that may begin on one site on the body and spread to other parts," CDPH previously stated.

Dr. Irfan Hafiz, an infectious disease specialist with Northwestern Medicine’s McHenry and Huntley hospitals, said the virus causes symptoms that are similar to several maladies, including chickenpox or smallpox.

“It can, to the layperson, look like chickenpox or warts,” he previously said. “But these (sores) tend to be in exposed areas.”

Health experts also stated the illness can be confused with a sexually transmitted infection like syphilis or herpes, or with varicella zoster virus.

Typically, symptoms start within three weeks of exposure to the virus, health officials said, with most infections lasting between two and four weeks long.

"Anyone with a new or unexplained rash or a rash that looks like monkeypox should talk with their healthcare provider, even if they don’t think they had contact with someone who has monkeypox," DuPage County health officials said in a statement. "Avoid close contact (including intimate physical contact) with others until a healthcare provider examines you."

Illinois has reported more than 530 cases in the state so far and on Monday, Illinois Gov. J.B. Pritzker declared monkeypox a public health emergency, classifying the state as a "disaster area" in regards to the disease.

"Chicago is very much the epicenter of the outbreak in the Midwest," Chicago Department of Public Health Commissioner Dr. Allison Arwady said Tuesday.

According to the CDC, more than 16,000 cases of monkeypox have been reported in 74 countries since about May. To date, monkeypox deaths have only been reported in Africa, where a more dangerous version of the virus is spreading, mainly in Nigeria and Congo.

The expanding outbreak is an “extraordinary” situation that qualifies as a global emergency, the World Health Organization chief said last month, a declaration that could spur further investment in treating the once-rare disease and worsen the scramble for scarce vaccines.

“We have an outbreak that has spread around the world rapidly through new modes of transmission, about which we understand too little,” WHO Director-General Tedros Adhanom Ghebreyesus said. “I know this has not been an easy or straightforward process and that there are divergent views."

So how does the virus spread and how can someone contract it?

In Africa, monkeypox mainly spreads to people by infected wild animals like rodents in limited outbreaks that typically have not crossed borders. In Europe, North America and elsewhere, however, monkeypox is spreading among people with no links to animals or recent travel to Africa.

WHO’s top monkeypox expert, Dr. Rosamund Lewis, said this week that 99% of all the monkeypox cases beyond Africa were in men and that of those, 98% involved men who have sex with men. Experts suspect the monkeypox outbreaks in Europe and North America were spread via sex at two raves in Belgium and Spain.

Person-to-person transmission is possible through "close physical contact with monkeypox sores, items that have been contaminated with fluids or sores (clothing, bedding, etc.), or through respiratory droplets following prolonged face-to-face contact," according to the Chicago Department of Public Health.

"Based on everything we know now, monkeypox is not spread through casual conversations, or by walking by someone with monkeypox like you might in a grocery store," Arwady said. "It is not as contagious as influenza or COVID. You don't become infected by just being around infected persons unless you have prolonged close contact or share bedding or clothing, for example, with someone who has MPV."

According to Dr. Sharon Welbel, director of hospital epidemiology and infection control at Cook County Health, the virus does not typically spread simply from "bumping up against somebody."

“The way it typically seems to happen is that there is a lesion and it bursts or its opened up and it gets into a scratch or something one can’t even see but a crack in the skin," she said. "It is not by bumping up against somebody, being in the same room as somebody, sharing a seat with somebody.”

She noted that it "generally takes prolonged contact."

Experts have cautioned that there is no current evidence to suggest the virus is airborne.

Dr. Amu Hazra, an infectious disease physician with Howard Brown Health, said that while a majority of cases have been in men who have sex with men, "the virus doesn't care how you identify."

Two children have been diagnosed with monkeypox in the U.S., health officials said Friday. In addition to the two pediatric cases, health officials said last week they were aware of at least eight women among the more than 2,800 U.S. cases reported so far.

Vaccine supply is extremely limited in Chicago and across the nation, in large part because the virus was a "pretty rare disease before this current outbreak," Arwady said.

"We're doing everything we can to prioritize vaccinations for those most at risk, but the truth is, given the very limited national supply... there will be tens of thousands of individuals that are eligible and won't gain access," said Howard Brown Health CEO and President David Ernesto Munar.

Currently, you are eligible for the two-dose vaccine if you have had close physical contact with a confirmed case or if you're a man who has had sex with another man and have done so in a social or sexual venue. Additionally, those who received money in exchange for sex or have had sex with anonymous partners are eligible.

The CDC has recommended the Jynneos vaccine for men who report more than four male sexual partners within the past 14 days.

NBC Chicago/Associated Press
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