More than 11,600 cases have been reported in 65 countries so far.

Since May 13, at least 11,689 confirmed cases of monkeypox have been recorded in 65 countries, including 1,470 total in 42 states in the United States and the District of Columbia, according to the Centers for Disease Control and Prevention (CDC). In two weeks, the numbers have more than doubled worldwide and more than tripled in the United States.

The disease has the potential to cause serious illness — the World Health Organization (WHO) has recorded three deaths.

“We anticipate we may see an increase in cases throughout the month of July and into August,” said the CDC’s director, Rochelle Walensky, MD, MPH, at a press briefing on July 15. A rise in numbers is expected because there will be more exposures to the virus, the system for reporting cases has improved, and more people are getting tested.

Since July 6, the CDC’s Laboratory Response Network has seen a 76 percent increase in the number of tests, with testing rising from 6,000 samples a week to 70,000 samples per week.

Monkeypox numbers have been climbing worldwide. Spain currently has the largest outbreak, with 2,447 cases, followed by Germany (1,790), United Kingdom (1,735), and the United States (1,469), per the CDC.Professor Jimmy Whitworth, MD, of the London School of Hygiene and Tropical

Medicine, told The Guardian, “These numbers of new cases suggest that we are not yet getting the monkeypox epidemic under control.”

WHO IS MOST AT RISK

Based on the latest figures, the median age of those who are infected is 36, with a range of 18 to 76 years of age, and the vast majority of cases have been in people who identify as men who have sex with men (MSM).

Gay and bisexual men who have had sex with multiple partners are at particularly high risk of infection right now, according to the CDC. United Kingdom health services are advising individuals, particularly those who are gay, bisexual, or MSM, to be on the lookout for unusual rashes or lesions on any part of their body, especially their genitalia, and to contact a sexual health service if they have concerns.

Although the WHO has stressed that the general public is highly unlikely to get monkeypox, the international health agency is now pushing countries to act immediately and do everything possible to slow the transmission of this life-threatening disease.

While the WHO on June 25 said that the outbreak had not yet reached the level of global health emergency, the World Health Network, a coalition of citizens and experts who are committed to global action to protect public health, has declared monkeypox a pandemic.

The WHO warned that the public health risk could become high if the virus spreads to groups at higher risk of severe disease, such as young children and immunosuppressed persons.

“That scenario can be prevented,” said Tedros Ghebreyesus, PhD, the director general of the WHO. “The WHO urges affected countries to make every effort to identify all cases and contacts to control this outbreak and prevent onward spread.”

AN ABNORMAL OUTBREAK

The WHO called the situation “unusual” because this is the first time that monkeypox cases and clusters are being reported in widely different areas that have little or no association with West or Central Africa, where the disease primarily occurs.

“This is a very, very unusual infection in the United States and in the developed world,” said William Schaffner, MD, an infectious disease specialist and a professor of preventive medicine and health policy at the Vanderbilt University School of Medicine in Nashville, Tennessee. “Monkeypox virus lives in Africa, in a variety of different rodents, but occasionally gets into primates, such as monkeys, and hence the name, monkeypox.”

study published June 24 in Nature Medicine found that the latest strain of the monkeypox virus has far more mutations than would be expected — including several that increase transmission.

LEARN THE SYMPTOMS AND PREVENT TRANSMISSION

As monkeypox continues to spread, Dr. Walensky encourages all Americans to get educated about this disease, including how to prevent it, its symptoms, and how to get tested. “The classic presentation that we’ve seen in the past is that the rash first appears on the head or neck and then progresses in what’s called a centrifugal pattern. It leaves the center and it goes to hands, limbs, arms, legs, and soles of the feet,” said Rosamund Lewis, the technical lead for WHO’s monkeypox program in a YouTube webinar. Lesions then progress to the trunk and the genital area. The lesions themselves start as a macule (a slight red patch on the skin). They then advance to papules, which are raised firm bumps. And finally they become vesicles, which are like blisters, with fluid inside.

In the past, people with monkeypox first reported flu-like symptoms such as fever, body aches, and swollen glands, but during the current outbreak, some patients have developed a localized rash, often around the genitals, before any flu-like symptoms, and some had no flu-like symptoms at all.

Monkeypox has not previously been described as a sexually transmitted infection, but it can be passed on by direct contact during sex. Walensky noted that monkeypox cases may present similarly to some sexually transmitted infections and could be mistaken for other diagnoses.

“What we know right now is that monkey pox spreads primarily through close skin-on-skin physical contact — by touching objects like sheets or towels that may have been used by somebody with monkeypox, and through close face-to-face interactions like kissing,” said Walensky in the latest press briefing. The virus may also transmit between people through respiratory droplets in a close setting, such as the same household or a healthcare environment. Common household disinfectants can kill the virus. Dr. Ghebreyesus recently stressed that person-to-person transmission is ongoing and is likely underestimated. “In Nigeria, the proportion of women affected is much higher than elsewhere, and it is critical to better understand how the disease is spreading there,” he said in a speech on June 23. Walensky noted, however, that monkeypox is not thought to linger in the air and is not typically transmitted during short periods of shared airspace. “The virus is not thought to spread through interactions such as having a casual conversation, passing in the grocery store, or touching the same items, such as the doorknob,” she told reporters.

DEMAND FOR VACCINATIONS INCREASES

On June 28, the Biden administration announced that it would be immediately allocating 56,000 doses of the Jynneos vaccine from the strategic national stockpile, followed by 296,000 doses in the coming weeks. Over the next few months a combined 1.6 million additional doses will be made available.

The Jynneos vaccine is approved by the U.S. Food and Drug Administration (FDA) for protection against smallpox and monkeypox in individuals 18 years and older determined to be at high risk for smallpox or monkeypox infection.

Demand for the monkeypox vaccine has been rising. In San Francisco, city health officials say that as of July 13 they have received just under 3,000 vaccine doses but need the federal government to provide an additional 35,000, according to NBC News. In New York City, demand for the vaccine is so high that the NYC Department of Health and Mental Hygiene website crashed as people tried to make vaccine appointments.

“I want to acknowledge that at this time, the demand for vaccines from jurisdictions is higher than our current available supply,” said Walensky at the July 15 briefing. “We know that this is frustrating, [we are] actively working to increase supply and we continue to update our strategy to make sure we are using our current supply strategically to get the vaccine to those who need it most.”

HOW EFFECTIVE IS THE VACCINE?

Past data from Africa suggests that the Jynneos and smallpox vaccine is at least 85 percent effective in preventing monkeypox, according to the CDC.

Dr. Schaffner adds that the smallpox vaccine has “a degree of effectiveness” against monkeypox, but large-scale studies have not been done. He expects the best way to control the spread will be by identifying those with the illness and isolating them.

Administering the smallpox vaccine on a wide scale would pose many challenges, he adds. “Smallpox vaccine is not administered by a needle and syringe — it’s administered by a multiple puncture method,” said Schaffner. “It requires training in order to do that. We would have to train a whole bunch of people to administer this vaccine appropriately.”

The WHO does not recommend mass vaccination against monkeypox.  “In the few places where vaccines are available, they are being used to protect those who may be exposed, such as health workers and laboratory personnel,” said Ghebreyesus.

IT’S POSSIBLE TO GET THE ILLNESS FROM ANIMALS

Jennifer Horney, PhD, MPH, a professor of epidemiology and a core faculty member with the disaster research center at the University of Delaware in Newark, added that monkeypox is associated with unsafe domestication of wild animals and remains endemic in certain parts of the world. People can get monkeypox when they are bitten or scratched by an animal, prepare wild game, or have contact with an infected animal or possibly animal products. New CDC guidance includes avoiding close contact with sick animals.

“A large, 47-person outbreak of monkeypox impacted the United States in 2003,” said Dr. Horney. “That was traced back to contact with exotic mammals that were being kept as pets.”

Following that outbreak, the United States did not see any cases until last year, when Texas and Maryland each identified an infected person who had recently traveled to Nigeria.

SYMPTOMS TO WATCH FOR

While rare, monkeypox (which is in the Orthopox genus of viruses) has the potential to cause serious viral illness. It typically begins with flu-like symptoms (fever, headaches, muscle ache, chills, exhaustion) along with swelling of the lymph nodes. The illness then progresses to an itchy rash on the face and body — often noticeable on the palms of the hands and soles of the feet.

“The rash is initially just red blotches, but then they coalesce in blisters that fill with pus,” says Schaffner. “They’re really quite rubbery and firm; they’re not like the thin-walled blisters that we may be more familiar with. The fatality rate, however, is pretty low — around 10 percent.”

PEOPLE WHO SHOULD BE ESPECIALLY CAREFUL

The Massachusetts Department of Public Health says people may want to consult a physician about the possibility of monkeypox if they:

  • Have an unexplained rash.
  • Have traveled in the past 30 days to a country with recent confirmed or suspected cases of monkeypox.
  • Have had contact with a person or people with confirmed or suspected monkeypox.
  • Are a man who has sexual contact with other men

For more about this virus, visit the CDC’s dedicated page.

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