Have questions about monkeypox? We asked experts for answers

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As if COVID-19, inflation and the economy weren’t enough, the rise in monkeypox cases has given Californians yet another thing to worry about.

The disease — characterized by a rash and lesions that can look like pimples, bumps or blisters — primarily spreads through prolonged skin-to-skin contact with those lesions, which may be in hard-to-see places on the body or be mistaken for some other skin issue. Although rarely fatal, the disease can be quite painful.

Monkeypox has gained a foothold among men and transgender people in the LGBTQ community in Los Angeles. The Los Angeles County Department of Public Health has received a limited number of doses of monkeypox vaccine from the federal government, and is offering them only to people currently deemed at risk.

Right now, monkeypox cases are “approaching an exponential curve,” said Dr. Peter Chin-Hong, an infectious-disease expert at UC San Francisco. Nevertheless, for people outside the affected communities, the risk of catching monkeypox seems to be low at the moment. And if current vaccination efforts are successful, we may be able to wipe out monkeypox. But if it spreads to animals, the disease could become endemic in the United States.

How does monkeypox spread? How dangerous is it? How contagious is it? Can infected people with no symptoms pass on the disease to others? Can it be spread through the air? Who can get a vaccine? What can people do after they are fully vaccinated? What should people do to avoid getting monkeypox?

You have questions. We asked experts for answers.

Have more inquiries about monkeypox? Send us an email at [email protected]

UPDATED Aug. 11, 2022 | 3:42 PM

Who’s eligible for a monkeypox vaccine in L.A. County?

You must be an 18-year-old or older gay or bisexual man or transgender person and meet at least one of the following criteria to be eligible for the vaccination in L.A. County:

  • You’ve had multiple sex partners in the last 14 days, including (but not limited to) having sex in exchange for food, shelter or other goods or needs.
  • You are on HIV PrEP medication.
  • You’ve had anonymous sex or sex with multiple people within the last 21 days at a commercial sex venue or similar location. (Ward Carpenter, director of health services for the Los Angeles LGBT Center, said that would include such places as a sex party; a club, sauna or spa where people tend to engage in sexual activities; or an establishment where people pay money to gain entry and have sex.)
  • You’ve had high or intermediate exposure to monkeypox (the CDC has a list of what qualifies as exposure at those levels).
  • You’ve attended an event or venue where there was a high risk of exposure via skin-to-skin or sexual contact with people who have monkeypox.
  • You are experiencing homelessness and engaging in high-risk behaviors.
  • You’ve had gonorrhea or early-stage syphilis in the last 12 months.
  • You are in jail and have been identified as high-risk by clinical staff.
  • You are severely immunocompromised — for instance, you are undergoing chemotherapy, are on high-dose steroids or other immunosuppressants, or have advanced or uncontrolled HIV.

Eligibility criteria may change. The public health department‘s website maintains a list of the latest eligibility information. How do I get a monkeypox vaccine if I’m eligible?

To get the monkeypox vaccination in Los Angeles County, you need to sign up through the public health department. When vaccine appointments are available, the department lets you pre-register for an appointment at a clinic. When you pre-register, you’ll need to enter your name, phone number and email address and answer some questions. The confirmation notice says it will place you on a list, and you’ll be notified when it’s your turn to get vaccinated.

If there are no spots available, that pre-registration link will be closed. The department has an email newsletter that will alert you once more appointments open up. The place to sign up for the newsletter is on the yellow banner at the top of this page on the department’s website. Enter your email address in the box and click “submit.”

What do I do if I think I have monkeypox or have been exposed to it? What are the early symptoms of monkeypox?

Symptoms of monkeypox typically begin within five to 21 days of exposure. Early indicators include flu-like symptoms such as fever, malaise, chills, muscle aches and swollen lymph nodes, followed by a rash and the telltale monkeypox lesions. The department of public health has photos of what the blisters look like and more information on monkeypox symptoms.

“In many instances with the current outbreak, people are developing a rash with or without swollen lymph nodes that can occur in the genital region or anally as well,” said Dr. Leo Moore, the director of clinical services for the Los Angeles County Department of Public Health. “We’re also seeing the rash occur all over the body, including in the face.”

Symptoms are usually mild, although lesions can become quite painful for some patients, he said.

How dangerous is monkeypox?

Monkeypox is rarely fatal, and there have been no deaths in the United States from monkeypox during this outbreak. Globally, as of Aug. 11, there have been 31,665 cases of monkeypox and 12 deaths from it since May 2022, according to data from the World Health Organization. Though symptoms are usually mild, 36 people have been hospitalized for monkeypox as of Aug. 11 in California.

“Although we’re not seeing many deaths,” said UC San Francisco infectious diseases expert Dr. Peter Chin-Hong, monkeypox infections are “really causing a lot of suffering.” The pain can be excruciating and cause patients to have trouble sleeping, walking, eating, drinking or going to the bathroom. He said about 10% of monkeypox cases result in hospitalization, usually for severe pain or a super-infection (a second infection on top of an existing one).

Can only gay or bisexual men get monkeypox?

No. While the outbreak is spreading primarily among gay and bisexual men, as well as some transgender and nonbinary people, anyone — regardless of gender or sexual orientation — can become infected.

Dr. Stuart Burstin, the interim national director of infectious diseases for the AIDS Healthcare Foundation, said it was “by chance” that monkeypox first infected men who have sex with men. The virus has continued to spread in that group, as transmission can easily occur during sexual encounters.

Of the just over 700 confirmed and suspected monkeypox cases in Los Angeles County, 99% have been in men. 85% of people with a confirmed case of monkeypox identified as gay, bisexual, lesbian or a different term, according to data from the Department of Public Health. (2% of respondents in that group identified as straight or heterosexual, and for 14%, their sexual orientation was unknown.) State and national health officials have reported the same demographic trends, and for that reason, gay and bisexual men, as well as some other queer people, remain most at risk.

How does monkeypox spread?

“Its most efficient route of transmission is close, prolonged, skin-to-skin contact,” said Anne Rimoin, a professor of epidemiology at the UCLA Fielding School of Public Health and a member of the World Health Organization’s emergency committee on monkeypox. While the virus is capable of spreading via respiratory secretions and surface transmission on contaminated objects,that’s not what we are seeing as the primary mode of transmission in this outbreak. What we’re seeing is the vast majority of cases are from prolonged skin-to-skin contact, generally in the context of sex,” she said.

Unlike the coronavirus that causes COVID-19, experts say, there’s no evidence that monkeypox can spread through shared airspace.

“I think it’s really important for people to recognize monkeypox is not like COVID,” said Dr. Tomás Aragón, California’s public health director. “(Monkeypox) is very different in terms of transmission; you really have to have a close, physical contact.”

When will you know if you have monkeypox if you’ve been exposed, and how long does the infection last?

Symptoms can appear as early as five days after exposure. Dr. Leo Moore, director of clinical services for the Los Angeles County Department of Public Health, said people typically develop symptoms a week or two after being exposed, though it can take as long as three weeks for symptoms to appear.

Symptoms of monkeypox can last up to four weeks. The virus can be spread until lesions have healed completely and are covered by a new layer of skin, which can take weeks.

Can monkeypox spread asymptomatically?

“It does not, at this point, look like there’s risk from asymptomatic spread,” said Dr. Jay Gladstein, chief medical officer for APLA Health, an L.A. group focused on providing healthcare to the LGBTQ community.

But it’s possible that patients and clinicians may mistake early signs of a monkeypox rash for something like a pimple or an ingrown hair.

UC San Francisco infectious diseases expert Dr. Peter Chin-Hong said that even when there’s not a lot of skin disease, a person might have contagious legions in their rectum, urethra or mouth.

Is monkeypox considered an STD?

Not exactly. In this outbreak, monkeypox is spreading through prolonged skin-to-skin contact and shared clothing and bedding. Experts believe the current outbreak in North America and Europe likely started with people having sex at raves in Spain and Belgium. But it’s not a disease that specifically spreads through bodily fluids, like chlamydia or gonorrhea, and using a condom won’t prevent it from spreading.

So having sex is a very efficient avenue for the virus to spread, but not the only way. The San Francisco AIDS Foundation issued a safety warning about monkeypox noting that dancing and sex-adjacent activities including kissing could also be vectors for infection.

“There’s never been a better time to dress from top to bottom in latex or leather,” it reads.

What can I do after I get my monkeypox vaccine?

That’s unclear. You are not fully vaccinated until two weeks after your second dose. And right now, L.A. County is prioritizing getting first doses into arms over scheduling second shots.

The two-dose Jynneos vaccine has been tested for safety in humans, and it has proven effective in Petri dishes and in tests on animals. But we don’t have enough evidence yet to tell how effective it is at preventing monkeypox in humans.

“We just don’t have good data on vaccine effectiveness, especially as it relates to sexual transmission,” said Anne Rimoin, a professor of epidemiology at the UCLA Fielding School of Public Health and a member of the World Health Organization’s emergency committee on monkeypox. “That’s not to say it won’t work, we just don’t have enough data to make definitive statements.”

So it’s hard to say if and how your behavior should change two weeks after getting your second dose of the vaccine. We should know more soon.

“Even with the vaccine, as a physician, I am absolutely going to continue to encourage people to take precautions around skin-to-skin contact” for now, said Ward Carpenter, director of health services for the Los Angeles LGBT Center. “In a month or two, we’ll have a lot better idea on how well this is working to keep people safe.”

How does the state of emergency change things?

The state of emergency proclamation issued Aug. 1 makes it easier for the state to coordinate its monkeypox outbreak response by ordering all state agencies to follow directions from the Office of Emergency Services and the California Department of Public Health. The order also allows EMS workers to administer vaccines.

“That is helpful in that it adds bodies to this effort, it adds hands that can give vaccines,” said Ward Carpenter, director of health services for the Los Angeles LGBT Center. “We’re limited by the (vaccine) supply and also the sheer human capacity to handle this.”

What if I already got the smallpox vaccine?

The last routine shots for smallpox were given in the 1970s in the U.S. Georges Benjamin, executive director of the American Public Health Assn., said you would probably have some degree of protection from monkeypox if you got the smallpox shot pre-1980, but you should still get the Jynneos vaccine if you’re exposed or are otherwise eligible.

“Unless you were recently vaccinated for smallpox, like the last two to three years, most likely you probably want to go ahead and get vaccinated if you’re exposed,” he said.

Both smallpox and monkeypox are caused by orthopoxviruses. The symptoms are similar, though monkeypox is rarely fatal. The diseases are so similar, in fact, that the same vaccine is used for both: Jynneos. So the monkeypox vaccine is the smallpox vaccine; they are not different shots, although the dosages may differ — the U.S. Food and Drug Administration just authorized giving much smaller doses of the vaccine to stretch the supply.

What do I need to do to avoid monkeypox?

If you are not a member of the currently affected community — gay and bisexual men and transgender people — experts say you don’t need to change anything about your behavior right now.

If you are a member of the community that’s currently experiencing a rise in cases, any time you are in prolonged skin-to-skin contact — in bed, at a sauna, on the dancefloor, or anywhere else — with an infected person, you are at risk of catching the virus. But a blanket call for abstinence is justifiably controversial. Ward Carpenter, director of health services for the Los Angeles LGBT Center, said he recommends people consider moderating their own behavior in a way that’s workable for their lifestyle.

“We always take this from a harm reduction lens. I’m not going to tell someone that they can or can’t have sex, or should or shouldn’t,” Carpenter said. “The fact is with monkeypox, if you’re unvaccinated and lying next to someone, hugging someone, and neither of you is wearing clothing, there’s risk there and that’s unavoidable. The more we can do to reduce that risk, the healthier we all become. For some people, that may mean swearing off sex, for others that may mean shrinking their sexual network so they’re only having sex with one or a couple of people. For others that may mean changing to on-camera sex. Things where we can still have human interaction, but in a safer way.”

Will everyone have to get vaccinated for monkeypox eventually?

Right now, it doesn’t seem like that will be necessary, said Anne Rimoin, a professor of epidemiology at the UCLA Fielding School of Public Health and a member of the World Health Organization’s emergency committee on monkeypox.

“This is really spreading through specific sexual and social networks,” she said. “I would say that the risk to the general public right now is fairly low.”

With additional reporting by Rong-Gong Lin II, Luke Money, Taryn Luna and Melody Gutierrez.

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