Monkeypox: Separating the Fact from the Fiction

Image by Arek Socha:

On the 23rd July, the director-general of the World Health Organisation (WHO), Tedros Adhanom Ghebreyesus, declared a Public Health Emergency of International Concern due to the monkeypox outbreaks in many countries. This has only been issued 7 times since 2005 — and you’ll probably remember the last one… a virus called Covid-19 (1).

This is a very different kind of outbreak and monkeypox remains rare, but it is also a significant disease which warrants a serious response.

What is Monkeypox?

Monkeypox is the same type of virus as smallpox. Smallpox was a disease which is likely to have existed for thousands of years. It affected humans with a number of symptoms including characteristic fluid-filled lumps and was estimated to be fatal in ~30% of cases.

The smallpox vaccine was the first successful vaccine, developed by Edward Jenner in 1796, and many of us will remember it from school science lessons. Thanks to a global effort of vaccination this disease was eradicated in 1980: it no longer exists, except in some science laboratories (1).

Although monkeypox is the same type of virus as smallpox, the disease it causes is less severe. Since smallpox was eradicated, and therefore vaccination was stopped, monkeypox has spread more. This is because the vaccines against smallpox are also effective against monkeypox.

It is generally only found in Central and West Africa however, that has changed with the latest outbreak as cases have been found in more than 80 countries globally.

The first case of monkeypox in humans was found in 1970 in the Democratic Republic of Congo. Since then the majority of cases have been confined to regions within Africa, some of which have been dealing with cases ever since. There was a large outbreak in Nigeria which began in 2017 and cases continue to be reported here today (2).

There have also been outbreaks around the globe. For example, there were over 70 cases in the USA in 2003. However, these were linked to infected dogs which had been imported into the country from Ghana (2). The most recent outbreak is different, with hundreds of cases of the disease occurring in multiple countries where monkeypox doesn't usually exist — including the UK (2, 3).

Cases have been higher and more persistent with no clearly identifiable ‘source’ as in previous outbreaks.

Missed Warnings?

Prior to the outbreak in 2017, monkeypox was mostly restricted to rural areas and associated with contact with animals which harbour the virus. However, in 2017 experts began to warn that monkeypox was spreading in different ways. For example, the disease started to appear in urban areas and the distinctive fluid-filled ‘pox’ lesions sometimes appeared in genital regions — suggesting it might be being spread by sexual contact (2).

Did we miss the warnings of the changing threat of monkeypox?

We explore below how some countries, including the UK, are starting to offer a vaccine to parts of the population to help limit the spread and consequences of this disease. But, there are concerns that African nations, where rates of monkeypox have been increasing for a long time, will be ‘left behind’ in a similar way to that of Covid-19; under 20% of people in African countries have been vaccinated against Covid-19 (3).

What is the situation in the UK and how is it spread?

The latest data shows there have been 2,546 confirmed or highly probable cases of monkeypox in the UK — the majority of these in England and mostly in London (4).

According to the NHS website (5), monkeypox can be spread from person to person by:

  • Any close physical contact with monkeypox blisters or scabs (including during sexual contact, kissing, cuddling or holding hands)
  • Touching clothing, bedding or towels used by someone with monkeypox
  • The coughs or sneezes of a person with monkeypox when they’re close to you

A study in the New England Journal of Medicine has found that 98% of confirmed monkeypox infections were in gay or bisexual men and 95% were linked to sexual activity (6). The UK figures have also confirmed that the majority in gay, bisexual and other men who have sex with men (4).

This does not, however, mean that monkeypox is restricted to these communities or is considered a sexually transmitted disease. Anyone has the potential to catch the disease if they come into close contact with someone infected (5). Another concern is that if the disease is not contained then it could become established and more widespread in other populations.

Overall, the current risk in the UK remains low however there are people who are at higher risk and the disease remains a significant public health concern (7).

What are the symptoms and is there a vaccine?

It usually takes between 5 and 21 days before the symptoms of monkeypox appear once somebody is infected.

The first symptoms are similar to those of many illnesses including a high temperature, headache, shivering, exhaustion, joint pain and muscle aches.

It also has a rash which usually appears a few days after somebody begins feeling unwell which starts on the face and then spreads to other parts of the body which can include the mouth, genitals and anus (5).

It is usually a mild disease which resolves by itself within a few weeks, however, the symptoms can be very unpleasant and some cases are serious with deaths recently announced in Brazil and Spain (8).

Photo credit: (4)

The UK Health and Security Agency (UKHSA) is offering a vaccine known to be effective against smallpox to certain people. Because monkeypox is a similar virus to smallpox there is evidence to show it will give people a good immune response to the disease.

Currently, the UKHSA is recommending vaccination for specific groups, and initially only for one dose. According to the website (9), those who will be offered a vaccine include:

  • healthcare workers who are caring for and who are due to start caring for a patient with confirmed monkeypox
  • gay, bisexual and other men who have sex with men. Your clinician will advise vaccination for you if you have multiple partners, participate in group sex or attend ‘sex on premises’ venues
  • people who have already had close contact with a patient with confirmed monkeypox. Vaccination with a single dose of vaccine should be offered as soon as possible (ideally within 4 days but sometimes up to 14 days) (6)

There are concerns that the vaccine rollout isn’t going far enough — with some areas having to ‘ration’ doses due to a limited supply and in places such as London, demand is far outstripping supply (10).

It is clear that the government is once again in a position of needing to accelerate a vaccine rollout to limit the damage caused by a virus that is new to the UK.

TL;DR → Monkeypox is a virus which has spread for many decades in some African countries, but this year has seen multiple outbreaks in over 80 countries. There are thousands of cases in the UK, the majority in gay, bisexual and other men who have sex with men — a vaccine rollout has started but there are concerns it is not going quick enough.

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(1) WHO — Smallpox

(2) Nature — Monkeypox in Africa: Ignored Science

(3) Nature — Monkeypox Declared Global Health Emergency

(4) — UKHSA Monkeypox Case Numbers & Updates

(5) NHS — Monkeypox

(6) NEJM — Monkeypox Infections

(7) UKHSA — Monkeypox Vaccines

(8) BBC News — Monkeypox in Brazil & Spain

(9) UKHSA — Monkeypox Vaccines

(10) The independent — Monkeypox Vaccine Concerns



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