Questions and answers on monkeypox

What is monkeypox?

Human monkeypox (MPX) is a zoonotic viral disease caused by the monkeypox virus (MPXV). Since it was first recognised as a human disease in 1970, MPX cases have been increasingly reported in several African countries due to a combination of factors including both increased exposure (deforestation, conflict and displacement), as well as improved surveillance and laboratory capacity in the African region.

The first outbreak of MPX reported outside of Africa was in 2003 in the United States. More recently, in 2018 and 2019, two travellers from the United Kingdom, one from Israel, and one from Singapore, all with travel history to Nigeria were diagnosed with MPX. This was the first time that travellers were associated with MPXV transmission outside of an outbreak setting.

What is the origin of this outbreak?

Unlike previous monkeypox cases in Europe, most subsequent cases in the current outbreak have no travel history to parts of West- and Central Africa where monkeypox is endemic. Some of the current cases attended the same events in different EU countries, where they had close or sexual contact with others. Further investigations and sequencing are needed to determine the exact circumstances in which people have been infected.

How worried should we be about this outbreak?

The disease is more likely to spread through close contacts, for example during sexual activities, and in this group the risk can be considered high.  The likelihood of MPX spreading in people who have multiple sexual partners, including some groups of men who have sex with men (MSM), is considered high in the EU/EEA. However, it should be noted that the likelihood of spread to the broader population is low and that most cases in the current outbreaks have presented with mild symptoms. Public health authorities should currently prioritise the identification, management and contact tracing of monkeypox cases.

How is the monkeypox virus transmitted?

Monkeypox does not spread easily between people. Human-to-human transmission occurs through close contact with infectious material from skin lesions of an infected person, through respiratory droplets in prolonged face-to-face contact, and through fomites. The predominance, in the current outbreak, of diagnosed human MPX cases among men who have sex with men, and the nature of the presenting lesions in some cases, suggest transmission occurred during sexual intercourse.

What are the symptoms of monkeypox?

Human monkeypox often begins with a combination of the following symptoms: fever, headache, chills, exhaustion, asthenia, lymph node swelling, back pain and muscle aches. A rash commonly develops one to three days after the onset of fever, first appearing on the face and spreading to other parts of the body, including hands and feet. The cutaneous lesions often first present as macules, evolving to papules, vesicles, pustules, crusts and scabs.

How severe is the disease?

The clinical manifestation of monkeypox is usually mild, like in most of the cases reported in Europe to date. In Nigeria, the West African clade has been observed to have a case-fatality rate of 3.3%. Mortality is higher among children and young adults, and immunocompromised individuals are especially at risk of severe forms of the disease. Most people recover within weeks.

How can I protect myself and others against monkeypox?

Infected people should remain isolated until scabs fall off and should especially avoid close contact with immunosuppressed persons and pets. Abstaining from sexual activity and close physical contact is also advised until the rash heals. Cases should remain in their own room when at home, and use designated household items (clothes, bed linen, towels, eating utensils, plates, glasses), which should not be shared with other members of the household.

Close contacts of monkeypox cases should self-monitor for the development of symptoms for 21 days after the last exposure and should avoid close physical contact with young children, pregnant women and immunocompromised persons until MPX is excluded.

Caregivers and relatives should avoid touching skin lesions with their bare hands, wear disposable gloves, and observe strict hand hygiene.

Can condoms prevent the transmission of the monkeypox virus?

The use of condoms is consistently encouraged during sexual activities for prevention of HIV and other STIs. Condoms alone cannot provide full protection against transmission of MPXV as contact with skin lesions may be sufficient for transmission to occur.

Should persons who have recovered from monkeypox wear condoms?

It is currently unclear if transmission of the virus can occur through semen and, if so, for how long. Therefore, as a precaution, condom use is recommended during sexual activities for 12 weeks after recovery from monkeypox disease.

What is the risk of wider transmission in Europe?

Given the unusually high frequency of human-to-human transmission observed in the past weeks, and the probable community transmission without a history of travel to endemic areas, the likelihood of further spread of the virus through close contact, for example during sexual activities, is considered to be high. The likelihood of transmission between individuals without close contact is considered to be very low.

How is monkeypox treated? Is there a vaccine against monkeypox?

Treatment is mainly symptomatic and supportive, including prevention and treatment of secondary bacterial infections. The smallpox vaccine can provide cross-protection for the monkeypox virus. It can be used for pre- and post-exposure prophylaxis (PEP) of close contacts at increased risk for severe disease. Important information on the use of currently available smallpox vaccines is missing for groups at increased risk for severe disease. In addition, antivirals are potential treatment options for severe cases. The smallpox vaccine, if administered within the first four days after exposure to a confirmed monkeypox case can have a significant protective effect.

Why does ECDC recommend that cases should avoid contact with pets?

Mammalian pets, particularly rodents, are susceptible to the monkeypox virus. If these pets transmit the disease to wild animals, there is a risk that the disease could become endemic in Europe in those animal populations. Therefore, close collaboration between human and veterinary public health authorities is needed to prevent the disease from being transmitted to wildlife.

Monkeypox is an unusual disease but has appeared in Europe in the past - why is it attracting such attention now?

Before, cases were sporadically imported and were related to travel to endemic countries, whereas in these outbreaks, we see an unusual incidence of cases infected in the community without travel links. In addition, it is disproportionally affecting specific groups, i.e. men who have sex with men, probably because of close or sexual contact during recent events.