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There are outbreaks of monkeypox (MPX) in non-endemic countries, and the World Health Organization (WHO) has declared the situation a public health emergency of international concern.

Community cases of MPX have been confirmed in Aotearoa New Zealand, and we can expect that there will be more cases. You can find current case numbers here. 

Based on the data from outbreaks in other countries we are seeing that gay, bisexual, and other men who have sex with men (GBM) are currently disproportionately affected by monkeypox. 

 

What is Monkeypox?

Monkeypox is a virus related to smallpox (which was eradicated in 1980), but less severe. It is normally found in Central and Western Africa. MPX was first found in monkeys, and it is carried by monkeys and rodents. However, it can be transmitted from these animals to people. Person-to-person transmission was previously thought to be rare, but the wide spread of the virus in the current outbreaks indicates the virus can spread more rapidly than previously recorded.

The cases in outbreaks overseas have been mainly among GBM. We should expect similar patterns here, so it is important that our communities are equipped with the information to protect themselves and others.

First rule to remember, and this also applies to other infections, including COVID-19: you should avoid close contact with others if you feel unwell and seek medical advice if you show symptoms like lesions and/or fever.   

It is important to remember that lesions and fevers may be signs of many common conditions, some of which are also infectious and require medical attention. If you have symptoms, do not panic, and talk to your doctor! Make sure to call ahead so they can assess you safely.

Signs and symptoms of monkeypox

The time from exposure to showing symptoms is normally 6-13 days but can sometimes take 5-21 days.  The first signs of infection are often swollen lymph nodes, fever, muscle aches, and fatigue. Typically, lesions or a rash form all over the body 1-3 days after the onset of early symptoms. The lesions are spots on the skin that fill with fluid, crust over, and eventually fall off. The lesions can be painful, and it can take around 3 weeks for them to heal.

According to the World Health Organization, the symptoms people with MPX are experiencing in the current outbreaks do not always look like a typical infection. For example, in some cases, the lesions have developed on the genitals and not spread to the rest of the body. Some people may develop lesions before other symptoms, such as fever. The reports of lesions around the anus and genitals indicate MPX has been spread during sexual contact. The variability of how MPX symptoms have presented means it may be difficult to recognise, which makes it especially important that people seek medical advice if they develop unusual symptoms, and particularly any new skin changes.

Illness from monkeypox can last 3-4 weeks. In most cases, people can treat MPX at home and fully recover. But it can be dangerous; some patients (10-15% based on early data) need hospitalization for pain management including for rectal pain, treating infection from the lesions, or managing lesions around the mouth and eyes.

Monkeypox transmission

Monkeypox is transmitted through skin-to-skin contact, contact with the skin lesions, and transfer of bodily fluids such as saliva. Contaminated objects such as sheets, clothing, or sex toys can also carry the virus. MPX is not classified as a sexually transmitted infection, but sex can make its transmission easy and is considered to be a common driver of transmission in the current outbreaks. Even so, we also know that non-sexual skin-to-skin contact can transmit the virus. People who come into close contact with people diagnosed with MPX such as healthcare workers or household members need to take strict precautions to avoid infection until the patients recover fully. Remember that it can take three weeks from exposure for a person to develop symptoms. A person can transmit MPX while they have lesions and possibly also when they only have earlier symptoms, such as fever.



Vaccine

The Australian Technical Advisory Group on Immunisation (ATAGI) identifies two vaccines that could be used for preventing MPX in Australia. A 3rd generation vaccine (JYNNEOS) and a 2nd generation vaccine (ACAM2000) are both likely to be effective in the prevention of MPX. However, JYNNEOS appears to have less adverse effects and is easier to administer by healthcare professionals. The vaccines may be effective as pre- and post-exposure prophylaxis (PrEP and PEP) for MPX. We understand that vaccines for MPX are in short supply worldwide and continue to advocate for their availability for those at risk in Aotearoa.

Why gay and bisexual men?

In the current outbreaks worldwide, monkeypox is disproportionately affecting GBM. Sex can make transmission easy because of skin-to-skin contact and the transfer of bodily fluids such as saliva during sex. Skin lesions may not be obvious or may be in places where they are not visible; some people infected with MPX may not realize they have it.

GBM communities are often closely connected through dense sexual networks corresponding to a relatively small population. We also know that cases of monkeypox among GBM were successfully identified thanks to vigilance about sexual health. Continuing to monitor symptoms and seeking medical advice when symptoms develop will help to protect our communities.

It is important that our conversations about monkeypox and GBM are not stigmatizing. It can be easy to associate the spread of infections with moral judgements about people’s sexual behaviours or sexualities. Such stigma is counterproductive to the collective need to identify cases and contain spread as it may cause people to avoid appropriate healthcare!

Remember to avoid physical or sexual contact with anyone else if you have lesions or rash until the lesions heal completely and the scabs fall off. The WHO recommends using condoms consistently during sexual activity for 12 weeks post-recovery from MPX as a precaution – we know that some viruses may persist in the testicles after the body has cleared the infection and there is some evidence that this may be the case for MPX.

When possible, avoid physical or sexual contact with a person if they have shared with you that they are experiencing any flu-like symptoms or a rash–remember to be empathetic and kind as nobody chooses to have a health condition and encourage them to have a check-up.

 

MPX and HIV

People living with HIV are not necessarily at increased risk of acquiring monkeypox or having a worse course of illness with monkeypox.

Evidence suggests that those who are virally suppressed and on antiretroviral treatment may experience the same course of illness as anyone else. People living with HIV who are not virally suppressed or have a low CD4+ Count are more likely to experience worse symptoms – so it is important that you speak with your healthcare provider about how you can keep yourself well and what to do if your symptoms are severe.

People living with HIV should keep in touch with their healthcare provider and check in regularly while they have monkeypox. If you feel particularly unwell and/or are experiencing severe symptoms and/or pain (particularly in the butt), it is important you seek medical attention as soon as possible. You may be able to access medicine such as Tecovirimat (available in New Zealand) to help treat monkeypox or other therapies that can help you feel better.

We do know that people living with HIV comprise around 40% of cases globally. Evidence is still emerging about this, but it does not seem that people living with HIV are more likely to acquire monkeypox than others.

People living with HIV can be vaccinated. We recommend all people living with HIV get vaccinated when possible to protect themselves against monkeypox.

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