As monkeypox cases continue to rise across the U.S. and the world, how is the virus being transmitted and where?
Already, the outbreak has been declared a global emergency by the World Health Organization.
A global emergency is WHO’s highest level of alert but the designation does not necessarily mean a disease is particularly transmissible or lethal.
“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."
According to the U.S. Centers for Disease Control and Prevention, 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.
So how is the virus spreading and who is most at-risk?
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 last 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.
Still, 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 they were aware of at least eight women among the more than 2,800 U.S. cases reported so far.
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.
CDPH Commissioner Dr. Allison Arwady said most cases "are coming from much more intimate skin-to-skin contact or kissing."
Here's a look at some potential activities and whether you're at-risk of contracting the virus:
Sexual or intimate contact: Likely
"The main source of spread is that direct skin-to-skin contact with rash or sores, and that can and has kind of very frequently among our cases included sexual or intimate contact," said Dr. Janna Kerins medical director for environmental health at CDPH.
The Centers for Disease Control and Prevention notes that pregnant people can spread the virus to their fetus through the placenta.
The close or intimate contact referred by health experts as a potential way to spread the virus can include kissing, Kerins said.
The Centers for Disease Control and Prevention also notes the virus "can be spread by respiratory secretions during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling, or sex."
Sharing a bed or other items such as towels: Possible
"We also recommend not sharing things like towels, bedding linens, and other things like fetish gear, sex toys, toothbrushes, because that is another potential way for spread to happen," Kerins said.
At a grocery store or coffee shop or on public transit: Unlikely
"MPV is not typically spread through just a casual conversation with someone, walking by someone," said Kerins. "It's not even as contagious as flu. And so it's really kind of that prolonged close contact, sharing bedding or clothing or direct skin-to-skin contact that results in spread. So overall, you know the grocery store, coffee, even public transit are not ways that we've seen this spread."
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 it's 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.”
Dancing on a crowded dance floor: It depends
The answer to this one is maybe.
"It really depends," said Dr. Massimo Pacilli, deputy commissioner of the Disease Control Bureau at CDPH. "Meaning that an event outside is certainly less risky than a crowded space indoors because of the opportunity for crowding and skimming and scanning. And then I introduced this element of like, it really depends on how much clothing you're wearing. So really, we have a disease where a very readily available intervention is a layer of clothing and I am aware that not all settings, you know, are suited to this but it's certainly readily available to remove sort of that risk by simply wearing more clothing. And I know it's summer and it's time to have a good time, but here is a readily available intervention... so avoiding that opportunity for direct contact, as well as the clothing, the barrier that we can provide is sort of the appropriate intervention. And as we think of events... the amount of crowding and the amount of personnel and the, you know, the amount of skin-to-skin contact that there is sort of then elevates the potential risk among groups where the disease is spreading."
Sharing drinks: Possible
Experts recommend avoiding sharing drinks or other items such as cigarettes or vape pens.
"Certainly avoiding sharing drinks with others," Pacilli said. "That is one of the ways in which the disease may transmit and sort of that is appropriate to avoid. And then a reminder that sort of the higher likelihood of spreading MPV - again this comes out clearly when we identified and investigate individuals who are infected - that really were their enclosed spaces such as back rooms, or sex clubs, or where really the front and center of the activity is the intimate sexual contact. That is what we're seeing spread occur."
Dr. Patrick Stonehouse, director of Public Health Operations at CDPH, said anything that gets put in someone's mouth should not be shared with others.
"It's not just that there's something about glass specifically that it would be the path of transmission. It's having something in your mouth and then giving that to someone else," Stonehouse said. "They put that in their mouth and so on and so on and so on. Right? So I'm thinking back like during the meningitis outbreak several years ago, there was some social media going around that was just 'Puff puff, don't give.'"
Through gym equipment or public restrooms: Unlikely
Public health experts said the risk of someone contracting monkeypox from an infected person via gym equipment or public restrooms is "highly unlikely" and no such cases have been reported so far.
They did stress that people should wipe down gym equipment before and after use and wash their hands after using a restroom.
In a swimming pool or hot tub: Unlikely
Experts said the monkeypox virus is not waterborne and therefore the risk of spread through water in pools or hot tubs, particularly those that are well-maintained and clean, is low.
They cautioned, however, against sharing towels or poolside clothing.
Trying on clothing at a store or touching a doorknob: Unlikely
"So the virus can potentially, you know, live in kind of body fluid that then has contact with something else, which is why we say it can potentially spread through things like, you know, wearing someone else's clothes or linens," Kerins said. "That all being said... the virus is also easily killed by things like disinfectants, by things like sunlight. I don't know off the top of my head like the exact amount of time that that takes, but it is very unlikely that spread would occur say through touching a doorknob. And although like kind of theoretically possible that someone who has MPV who had, you know, a sore, tried on clothing, then took that off and then another person tried it on that it could potentially be spread that way - I think also pretty unlikely that that will happen."
What about coworkers who may have been exposed? Unlikely
Public health officials said the risk of a potentially exposed coworker transmitting the virus to another coworker is low.
"So again, risk of spread to coworkers is low, unless you're having kind of one of the, like, other types of transmission - so sexual or intimate contact, direct skin-to-skin contact, you know, that you're like living with a coworker, you know, things along those lines," Kerins said. "What I can say too is in Chicago, we have not seen any spread between coworkers and what the health department does is we talk to individuals who've been diagnosed with MPV and we ask them about close contacts and then we evaluate their risk levels too, and coworkers we have not even seen the high risk really even needing kind of the vaccine because they've been exposed. So really risk of spread to coworkers is quite low."
What about through the air? No evidence so far
Experts have cautioned that there is no current evidence to suggest the virus is airborne.
What are the symptoms?
Monkeypox often begins with flu-like symptoms and swelling of the lymph nodes, and progresses to a rash on the face and body.
Virus symptoms range from fever, aches and rashes all over the body.
"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.
In the U.S., some experts have speculated whether monkeypox might be on the verge of becoming an entrenched sexually transmitted disease in the country, like gonorrhea, herpes and HIV.
“The bottom line is we’ve seen a shift in the epidemiology of monkeypox where there’s now widespread, unexpected transmission,” said Dr. Albert Ko, a professor of public health and epidemiology at Yale University. “There are some genetic mutations in the virus that suggest why that may be happening, but we do need a globally-coordinated response to get it under control."
What about vaccination?
Vaccine supply is extremely limited in Chicago, as only 5,400 doses are available across the city. More than 15,000 doses are soon expected from the federal government, along with another 2,600 from the state of Illinois.
"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.
As of last week, the U.S. had distributed 156,000 doses of the Jynneos vaccine to states and ramped up testing capacity to 70,000 tests per week. Many cities and states are offering vaccine doses to people with known or presumed exposure to the virus, including men who have sex with men and transgender, gender nonconforming or nonbinary residents with multiple sexual partners.