Monkeypox and Traveling:

One of the Country’s Top Infectious Disease Doctors Weighs in

Zoom Vacations traveler, Dr. John O’Grady is board certified in both internal disease medicine and infectious disease medicine, and has been recognized as a Top New Jersey Doctor every year for more than a decade. Since he has traveled with us in numerous Zoom Vacations tours all over the world, we know him very well, and seized the opportunity to get more information on Monkeypox and how it may impact the world of traveler. Dr. O’Grady graciously accepted our request for an interview. We hope you find this interview as helpful as we did.

Zoom: How is Monkeypox different from Chickenpox or shingles?

John: Varicella (the virus which causes chickenpox as well as shingles) is similar to Monkeypox in that is also causes a vesicular (blister-like) rash and, in several outbreaks, it has been difficult to distinguish between the two viral infections. However, one feature which distinguishes between the two is LYMPHADENOPATHY (generalized swelling of lymph nodes) which is more distinctive of Monkeypox.  Diagnostic testing, such as a swab sample from an active lesion, would clearly differentiate between the two and confirm the diagnosis. 

Zoom: While traveling on planes, cruise ships, etc., is there any aspect that could make me susceptible to Monkeypox?

John: Human-to-human transmission of Monkeypox occurs through the following routes:

1. Close contact with infectious skin lesions; spread is thought to occur primarily through direct contact with infectious sores, scabs or body fluids. As such, Monkeypox can spread during activities that include close, personal contact with an infected individual. 

2. Mucous membrane micro-abrasions are a potential portal of entry (ie. deep kissing). 

3. Indirect contact with infectious fluid on contaminated linens.

4. Large respiratory droplets exposure… especially with prolonged face-to-face contact (within a six-foot radius for > 3 hours in the absence of PPE (mask)

5. Activities resulting in re-suspension of dried material from infected lesions (ie. shaking contaminated linens) may also present a risk.

Zoom: Should I be concerned if traveling to an area with a large Monkeypox outbreak?

John: If there are documented outbreaks in your geographic community there is obviously more risk of exposure to Monkeypox and more attention to mask-wearing and social distancing would be appropriate if possible). Not too dissimilar to the COVID issue precautions; although Monkeypox is MUCH LESS infectious via aerosolization.

Zoom: Can you tell us the ways someone can contract Monkeypox, besides close intimate contact?

John: Sure:

1. Transmission can also occur through contact with materials or fomites that have become contaminated with infected material, such as clothing,  linens or sex toys contaminated with infectious material from body fluids or sores.

2. Monkeypox virus is also  thought to spread through respiratory secretions, although prolonged face-to-face contact may be required for transmission to occur via this route. This can occur with prolonged face-to-face interaction such as kissing or cuddling for a prolonged period of time.

3. Activities resulting in re-suspension of dried material from lesions (eg. shaking contaminated linens) may also present a risk and should be avoided. 

4. The Monkeypox virus can be spread via a bite from an infected individual or infected animal (the classic example is a prairie dog which was responsible for a small outbreak in the mid-west US in 2003).

5. Finally, the Monkeypox virus can also be transmitted vertically (pregnant woman to fetus) and cause congenital infection. 

Zoom: How can you best safeguard yourself from Monkeypox?

John: Some good rules of thumb are:

1. Avoid close contact with anyone who might be suspected of having it (ie. has unexplained fevers, malaise, swollen lymph nodes and new/unexplained skin lesions

2. Any individual diagnosed with Monkeypox should self-isolate until their rash has healed.

3. If a partner has Monkeypox, avoid sex until their rash is completely healed, this includes anal, oral or vaginal sex. Continue to use a condom for 8-12 weeks after symptoms resolution. 

Zoom: I have heard that Monkeypox is much harder to spread than COVID-19. Is this true?

John: Monkeypox is NOT as contagious as the virus that causes COVID-19. You are unlikely to contract Monkeypox by being near someone unless you have direct contact with their skin or are face-to-face for a prolonged period of time. 

Zoom: Why is the world having a stronger response to COVID-19 than to monkeypox

John: On July 23, 2022, the WHO declared this Monkeypox outbreak a public health emergency of international concern. For most individuals, Monkeypox is a self-limited disease with the symptoms lasting from two to four weeks. Although some patients may develop severe disease, as of mid-July 2022, thousands of confirmed cases of Monkeypox in dozens of countries have been reported; yet no deaths (from Monkeypox) have yet been reported in non-endemic countries. Cases continue to emerge and this may change. However, unlike the SARS COVID-19 outbreak where tens to hundreds of thousands were dying within the first month of the outbreak, the outbreak of Monkeypox does not appear to require as drastic a response as was required with COVID-19. 

Zoom: In addition to bumps on the skin, travelers can get fever, headache, muscle aches, fatigue and swollen lymph nodes. Can you tell us more?

John: Monkeypox has traditionally caused systemic illness that includes fevers, chills and myalgias with a characteristic vesicular rash (similar to herpes simplex, chickenpox and smallpox). However, during the Monkeypox outbreak starting in May 2022, the prodrome typically lasts up to five days and is characterized by fever, intense headache, swollen lymph nodes, myalgia (muscle aches) and severe fatigue.  Some patients have presented with genital, rectal and/or oral lesions without the initial prodrome

Several complications of Monkeypox have been reported; these include secondary infections, bronchopneumonia, sepsis, encephalitis and infection of the cornea with ensuing loss of vision. 

Zoom: Is Monkeypox contagious and still able to be passed skin-to-skin even if the person displays no symptoms?

John: The potential for transmission from an individual with asymptomatic infection is uncertain. In a recent, yet-to-be-published study, at the beginning of the 2022 outbreak in Europe, stored anogenital and oropharyngeal specimens from 224 men who had been tested for gonorrhea and chlamydia were PCR tested for Monkeypox; three men had anorectal specimens positive for Monkeypox DNA despite absence of symptoms or known/reported exposure to a person with Monkeypox. Although the finding raises the concern that people with mild disease could contribute to ongoing transmission, none of the contacts of the three men developed clinical Monkeypox, and follow-up Monkeypox testing performed 21 to 37 days after the initial positive sample was negative

In short, it is unknown but doubtful that a person without skin lesions or symptoms is highly contagious. 

Zoom: Is there a reason that the bumps often start on the face?

John: The rash tends to be more concentrated on the face but often develops on the palms of the hands and soles of the feet. Other sites may include oral mucous membranes, conjunctivae, anus and genitalia. In the present outbreak, some patients have presented with proctitis (pain in the rectum) or with lesions located on the genital or perianal area alone. The lesions go through several stages:

1. The rash typically begins as 2 to 5 mm diameter macules (spots)

2. The lesions subsequently evolve to papules (bumps), vesicles (small blisters) and then pustules. They are well-circumscribed, deep-seated and often develop umbilication (a central depression on the top of the lesion).

3. The lesions eventually crust over, and these crusts dry up and then fall off. This usually occurs 7 to 14 days after the rash begins

4. The lesions typically begin to develop simultaneously and evolve together on any given part of the body. However, during the global outbreak of Monkeypox beginning in May 2022, not all lesions were in the same stage of development.

5. The rash associated with Monkeypox is often described as painful, but in the healing phase (when crusts develop) it can become itchy. Persistent scratching of the lesions can cause secondary skin infections. 

In addition to our interview, John also provided the following general information.

Monkeypox (The Basics)

What is monkeypox?

Monkeypox is an infection that causes fever and a painful rash. It was originally discovered in monkeys, which is where the name comes from.

For many years, monkeypox was uncommon. But in 2022, there has been an outbreak of new cases. These have happened in countries where people typically do not get monkeypox, including the US.

Health experts are concerned about monkeypox because of the sudden increase in cases. But most people who get monkeypox will not get seriously ill or die.

What are the symptoms of monkeypox?

Symptoms usually start between 5 and 13 days after a person is infected with the virus. Some people have a few days of feeling sick, similar to the flu. Symptoms might include fever, headache, feeling very tired and achy, and swollen lymph nodes. Then, a few days after these symptoms start, a rash appears.

●The monkeypox rash can look like pimples or blisters. It starts as a few small spots, then more appear.

●During the 2022 outbreak, some people have first noticed the rash in their genital or anal area.

●The rash can also affect the face, inside of the mouth, hands, feet, and other parts of the body.

●The bumps swell with fluid, then pop. Then, they dry up and form scabs, which eventually fall off.

●The rash can be painful, although it might become itchy when scabs start to form.

For some people, the rash is the first or only symptom they have, and they do not know they are sick until it appears. The rash usually lasts for about 2 to 3 weeks.

 

How does monkeypox spread?

In the past, the most common way for monkeypox to spread was from an infected animal to a person. This could happen from touching the animal’s body fluids or through a bite or scratch.

During the 2022 outbreak, the infection has been spreading from person to person. This can happen through:

●Touching an infected person’s rash, scabs, or body fluids – This seems to be the main way the infection is spreading during this outbreak. In many cases, this has happened through sexual activity. Experts are studying whether the infection can also spread through semen or vaginal fluids.

●Touching something that has touched an infected person – For example, if fluid from a person’s rash gets on clothing, bedding, or sex toys, it is possible for the infection to spread to others who touch these items.

●Through tiny droplets from the lungs – The infection can spread in this way if people are face-to-face, for example kissing or cuddling, for a long time.

It is also possible for a pregnant person to pass the infection to their baby.

A person is most likely to spread monkeypox while they have the rash. Experts do not yet know if a person is contagious before the rash appears.

Monkeypox is not as contagious as the virus that causes COVID-19. You are not likely to get it by being near someone unless you have direct contact with their skin, or are face-to-face for a long time.

Who is at risk for monkeypox?

Anyone can get monkeypox if they have close contact with someone who is infected. During the 2022 outbreak, many of the people who have been infected are men who have sex with men. But it’s important to know that anyone can get the infection, no matter their gender identity, sexual orientation, or sex practices. Thinking of monkeypox as something that only affects certain people or groups is inaccurate and harmful.

What should I do if I have symptoms?

If you have any symptoms of monkeypox, call your doctor or nurse. They will ask you questions and schedule an exam. If possible, avoid close contact or sex with others until you have been seen by a doctor or nurse.

What should I do if I think I was exposed?

If you had close contact with someone who had monkeypox, you should also tell your doctor or nurse, even if you don’t have any symptoms. They can tell you what to do next.

If you were exposed to monkeypox, you will need to monitor yourself for symptoms for 21 days. You should then call your doctor or nurse if you notice any symptoms such as fever, swollen lymph nodes, or any rash or sores.

In some cases, experts recommend vaccination in addition to monitoring. People who might benefit from the vaccine include those who:

●Were exposed to the virus – If you recently had close contact with someone who had monkeypox, getting the vaccine might lower the chances that you will get infected. Your doctor or nurse will help you figure out if you should get the vaccine. The decision is based on how and when you were exposed.

●Are at risk for being exposed – The vaccine might be an option for people who are at high risk for getting monkeypox. For example, your risk is higher if you had a sex partner who later found out they had monkeypox. It is also higher if you have had multiple sex partners and are in an area with a lot of monkeypox cases.

The goal of vaccination is to control the current outbreak. Your doctor, nurse, or local public health office can talk to you about the vaccine and your options.

Is there a test for monkeypox?

Yes. If your doctor or nurse thinks you might have monkeypox, they will use a swab to take a sample of fluid from your rash. They will look at the sample under a microscope and send it to a special lab for testing. In some cases, they might do blood tests, too.

How is monkeypox treated?

Most people with monkeypox will not get seriously ill, and will be able to stay home while they get better. This usually takes a few weeks.

In some cases, doctors might recommend treatment with “antiviral” medicines.

How can I avoid spreading monkeypox to others?

If you have monkeypox, there are things you can do to lower the risk of spreading the infection to other people.

The best way to avoid spreading the infection to others is to self-isolate:

●This means staying away from other people as much as possible, even the people you live with.

●Continue to self-isolate until your rash has fully healed. This means the scabs have fallen off and new skin has formed.

To protect others, you can also:

●Wash any clothing, bedding, or other items that have touched your rash. Do not shake out clothing or bedding around other people. If someone else needs to touch these items, or help care for you, they should wear gloves.

●Wash your hands often. Others in your home should also wash their hands often.

●Be extra careful if you do need to be around other people. Cover any parts of your skin that have a rash, and wear a face mask.

How can I avoid being exposed to monkeypox?

The best way to prevent monkeypox is to avoid close contact with anyone who might have it.

To lower your risk of being exposed:

●If a family member, friend, or partner has monkeypox, they should self-isolate until their rash has healed completely.

●Avoid close contact with anyone who has symptoms of monkeypox.

●If a partner has monkeypox, avoid sex until their rash is completely healed. This includes anal, oral, or vaginal sex. Virtual or phone sex are safe ways to be intimate without physical contact.

●Using condoms any time you have sex might help. But condoms probably cannot completely prevent the spread of monkeypox. This is because it can spread in a few different ways, as discussed above.

Where can I go to learn more?

As we learn more about monkeypox, expert recommendations will continue to change.

You can find more information at the US Centers for Disease Control and Prevention (CDC) website (www.cdc.gov/poxvirus/monkeypox).

John O’Grady, MD

Physician

Infectious Diseases and Travel Medicine

Morristown Medical Center

Morristown, New Jersey